Lewis v. Grinker

• Citation: 111 F.Supp.2d 142
• Decision Date: 19 January 2000
• Docket Number: No. CV-79-1740-CPS.,CV-79-1740-CPS.
• Parties: Lydia LEWIS, etc., et alia, Plaintiffs, v. William GRINKER, etc., et alia, Defendants.
• Court: United States District Courts. 2nd Circuit. United States District Court (Eastern District of New York)

111 F.Supp.2d 142

Lydia LEWIS, etc., et alia, Plaintiffs, v. William GRINKER, etc., et alia, Defendants.

No. CV-79-1740-CPS.

United States District Court, E.D. New York.

January 19, 2000.

COPYRIGHT MATERIAL OMITTED

Richard Elliot Blum, Scott A. Rosenberg, The Legal Aid Society Civil Appeal & Law Reform Unit, New York City, for Plaintiff.

Joan Weiner Margiotta, Corporation Counsel of the City of New York, New York City, Mary Fisher Bernet, Attorney General, State of New York, for Defendants.

MEMORANDUM AND ORDER

SIFTON, Chief Judge.

On March 14, 1991, this Court entered a permanent injunction in this class action enjoining the defendants from denying Medicaid coverage for prenatal care to otherwise eligible pregnant aliens on the ground that they were not permanently residing in the United States under color of law. Lewis v. Grinker, 794 F.Supp. 1193 (E.D.N.Y.1991), aff'd, and reh'g denied, 965 F.2d 1206 (2d Cir.1992). Those decisions held that the language of the federal Medicaid statute then at issue, which limited Medicaid coverage for undocumented aliens, should not be interpreted as applying to the provision of Medicaid benefits for prenatal care in the absence of clear evidence of Congress' intent to deny coverage for such benefits.

This action is once again before this Court on the federal defendant's motion to vacate the permanent injunction. The federal defendant contends that the permanent injunction must be vacated because Congress has now provided evidence of its specific intent to deny Medicaid coverage for prenatal care to undocumented aliens through its enactment of Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Welfare Reform Act"), Pub.L. No. 104-193, 110 Stat. 2105, 2260.

For the reasons set forth below, the federal defendant's motion to vacate the permanent injunction is denied. What follows sets forth the findings of fact and conclusions of law on which this determination is based.

BACKGROUND

Statutory Framework

Medicaid was originally enacted in 1965 as Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq. The Second Circuit has described Medicaid as a "cooperative federal/state cost-sharing program designed to enable participating states to furnish medical assistance to persons whose income and resources are insufficient to meet the costs of necessary medical care and services." DeJesus v. Perales, 770 F.2d 316, 318 (2d Cir.1985). States that choose to participate in the Medicaid program are subject to the requirements of the applicable federal statutes, see 42 U.S.C. § 1396a, and to the regulations promulgated by the Secretary of the Department of Health and Human Services (the "Secretary") pursuant thereto.

The Medicaid statute requires participating states to provide coverage to two basic categories of individuals: the "categorically needy," 42 U.S.C. § 1396a(a)(10)(A), and the "medically needy," id. § 1396a(a)(10)(C). See also 42 C.F.R. § 435.4; DeJesus, 770 F.2d at 318.¹ "Roughly speaking, the categorically needy are those who earn no more than that necessary to cover the necessities of life; the medically needy differ in that it is only the expense of necessary medical care that strains their ability to pay for basic necessities." Lewis v. Gross, 663 F.Supp. 1164, 1174 (E.D.N.Y.1986).

Prenatal Care Under Medicaid

Under current law, pregnant women seeking prenatal care may be eligible for Medicaid under any one of three categories, depending on their financial status. First, participating states must provide Medicaid coverage to a subgroup of the categorically needy, called the "mandatory categorically needy." 42 U.S.C. § 1396a(a)(10)(A)(i) (West Supp.1999). Included in this subgroup are "qualified pregnant women," id. § 1396a(a)(10)(A)(i)(III), defined as any woman with a "medically verified" pregnancy whose household would have been eligible for benefits under the Aid to Families with Dependent Children ("AFDC") program "if her child had been born and was living with her in the month such aid would be paid," or who "meets the income and resource requirements" of the AFDC program, as in effect as of July 16, 1996.² 42 U.S.C. § 1396d(n)(1)(A), (C).

Second, participating states may, at their option, choose to provide Medicaid coverage to individuals called the "optional categorically needy." 42 U.S.C. §§ 1396a(a)(10)(A)(ii), 1396a(d). This subgroup includes "pregnant women" in general, id. § 1396d(a)(viii), and "women during pregnancy" whose household incomes are between 133% and 185% of the federal poverty line, id. § 1396a(l)(1)(A), (2)(A).³

Third, the states may, at their option, choose to provide coverage to "medically needy" individuals. Id. § 1396a(a)(10)(C). This subgroup includes the same groups of individuals that the states may cover as "optional categorically needy" but applies less stringent financial and resource requirements. While medically needy coverage is generally optional with the states, once a state chooses to provide any type of medical coverage to some medically needy individuals, it must provide, inter alia, prenatal and delivery services to medically needy pregnant women. Id. §§ 1396a(a)(10)(C)(ii)-(iii), 1396d(a)(viii).

Prior to 1981, pregnant women were not identified as a special eligibility group under the Medicaid statute.⁴ Instead, the Secretary gave participating states the option to extend Medicaid benefits directly to the fetus under the assumption that fetuses were optional categorically needy "persons under the age of 21." See Lewis v. Grinker, 965 F.2d 1206, 1209 (2d Cir.1992) ("Lewis IV-A").⁵

In the 1980's, Congress adopted a series of laws that greatly expanded access to prenatal care while at the same time shifting the analytical focus from the fetus to the pregnant mother. In the Omnibus Budget Reconciliation Act of 1981 ("OBRA '81"), Pub.L. No. 97-35, 95 Stat. 357, 853, in place of direct AFDC coverage for the fetus, Congress permitted the states to provide AFDC benefits to women in their third trimester of pregnancy if they would be eligible for AFDC based on the constructive birth of their fetuses — if they would be eligible had their children been born and living with them at the time the benefits were provided. OBRA '81, § 2312(a), 95 Stat. 357, 853. OBRA '81, in order to provide pregnant women with prenatal care under Medicaid, also amended the Medicaid statute to authorize states to "deem" a pregnant woman an AFDC recipient for Medicaid purposes, and thus mandatorily eligible for Medicaid, if the woman would be eligible for AFDC based on the concept of the constructive birth of her fetus. OBRA '81 § 2312(b), 95 Stat. 357, 853. OBRA '81 also required states that provided coverage to medically needy individuals to provide prenatal care to medically needy pregnant women as well. Thus, states had the option to supply Medicaid coverage for prenatal care to a pregnant woman either as mandatory categorically needy or as medically needy. See 42 U.S.C. § 1396d(a)(viii) (adding pregnant women as a separate eligibility group). At the same time, the Secretary continued to give the states the option of providing Medicaid coverage directly to the fetus by considering the fetus to be an individual under age of 21.

In the Deficit Reduction Act of 1984, Pub.L. No. 98-369, 98 Stat. 494 ("DRA '84"), Congress further expanded access to prenatal care by requiring the states to provide Medicaid benefits to "any qualified pregnant woman or child" as mandatory categorically needy. The statute defined a "qualified pregnant woman" as a pregnant woman who would be eligible for AFDC "if her child had been born and was living with her in the month such aid would be paid, and such pregnancy has been medically verified." DRA '84 § 2361(b), 98 Stat. 494, 1104 (codified as amended at 42 U.S.C. § 1396d(n)). The qualified pregnant woman provision expanded access to prenatal care because, while OBRA '81 merely gave the states the option to employ the constructive birth analysis to deem pregnant women AFDC recipients for the purposes of providing Medicaid coverage for prenatal care, DRA '84 required the states to do so. By mandating coverage for "qualified pregnant women," the statute also eliminated categorical barriers in the AFDC program that had arbitrarily limited access to Medicaid for poor pregnant women such as those without any "dependent children."⁶ DRA '84 also ensured that Medicaid coverage would follow the fetus after birth by providing that an infant born to a woman eligible for and receiving Medicaid benefits on the child's date of birth was automatically covered by Medicaid at birth. DRA '84 § 2362(a), 98 Stat. 494, 1104 (codified as amended at 42 U.S.C. § 1396a(e)(4)).

In the Consolidated Omnibus Budget Reconciliation Act, Pub.L. No. 99-272, 100 Stat. 82, 201 (1985) ("COBRA"), Congress again made it easier for pregnant women to qualify for prenatal care by breaking the link between AFDC eligibility and Medicaid eligibility. After COBRA, a prospective qualified pregnant woman only had to demonstrate that she was sufficiently poor to qualify for Medicaid benefits. Because the Secretary interpreted the constructive birth analysis to apply to all three sections of the definition of qualified pregnant woman, the fetus' interest could be considered in determining whether the woman was financially needy. In February 1985, in Program Memorandum # 853, for the first time the Secretary did not list fetuses as one of the categories of people under age 21 to whom the states could, at their option, provide Medicaid. This omission completed the shift from fetal-centered to maternal-centered analysis of coverage for prenatal care.

In the Omnibus Budget Reconciliation Act of 1986 ("OBRA '86"), Pub.L. No. 99-509, 100 Stat. 1874, Congress removed the categorical eligibility rules from the Medicaid prenatal scheme and began to expand prenatal coverage by raising financial eligibility ceilings...