Low-Income Women of Texas v. Bost

• Citation: 38 S.W.3d 689
• Parties: (Tex.App.-Austin 2000) The Low-Income Women of Texas, as Represented by Robert Prince, M.D.; Curtis Boyd, M.D.; William Watkins West, Jr., M.D.; The Fairmount Center; The Routh Street Women's Clinic; and Reproductive Health Services, Appellants v. Eric M. Bost, Commissioner of Human Services, in his Official Capacity and his Successors; The Texas Board of Human Services; The Texas Department of Human Services; Charles E. Bell, Commissioner of Health, in his Official Capacity and his Successors; The Texas Board of Health; and The Texas Department of Health, Appellees NO. 03-98-00209-CV
• Decision Date: 07 December 2000
• Court: Court of Appeals of Texas

Page 689

38 S.W.3d 689 (Tex.App.-Austin 2000)

The Low-Income Women of Texas, as Represented by Robert Prince, M.D.; Curtis Boyd, M.D.; William Watkins West, Jr., M.D.; The Fairmount Center; The Routh Street Women's Clinic; and Reproductive Health Services, Appellants v. Eric M. Bost, Commissioner of Human Services, in his Official Capacity and his Successors; The Texas Board of Human Services; The Texas Department of Human Services; Charles E. Bell, Commissioner of Health, in his Official Capacity and his Successors; The Texas Board of Health; and The Texas Department of Health, Appellees

NO. 03-98-00209-CV

TEXAS COURT OF APPEALS, THIRD DISTRICT, AT AUSTIN

December 7, 2000

FROM THE DISTRICT COURT OF TRAVIS COUNTY, 126TH JUDICIAL DISTRICT NO. 93-02823, HONORABLE PAUL DAVIS, JUDGE PRESIDING

[Copyrighted Material Omitted]

Before Justices Jones, B. A. Smith and Yeakel

OPINION

Justice Bea Ann Smith

The Low-Income Women of Texas¹ filed a lawsuit ² against the State to challenge funding restrictions placed on abortion services provided by the State's medical programs for low-income Texans. The restrictions prohibit state funding for abortions except in cases of rape or incest or when necessary to save the life of the mother; funding for essentially all other necessary medical procedures is available if the procedure is "medically necessary." Low-Income Women seek a declaratory judgment that the challenged provisions restricting state funding of medically necessary abortions violate the Texas Constitution. They also request injunctive relief enjoining enforcement of the challenged provisions, as well as costs and attorneys' fees. Competing motions for summary judgment were filed; the trial court granted the State's motion and denied Low-Income Women's motion. Low-Income Women appeal, claiming that the abortion-funding restrictions violate three provisions of the Texas Constitution: (1) the equal protection clause; (2) privacy guarantees; and (3) the Equal Rights Amendment (ERA). We will vacate the judgment and dismiss any claim concerning the currently unfunded Maternal and Infant Health Improvement Act (Maternal/Infant Health Act). Because we agree that the Medicaid funding restrictions violate the ERA, we will reverse the judgment of the trial court and render judgment granting Low-Income Women's motion for summary judgment. We will remand the cause to the trial court solely for consideration of the Low-Income Women's request for costs and attorneys' fees.

FACTUAL AND PROCEDURAL BACKGROUND

Statutory Framework

The lawsuit filed by Low-Income Women challenges funding restrictions on two Texas programs that subsidize health services for the poor. At issue are the Texas Medical Assistance Program, which is Texas's Medicaid program, and the programs created by the Maternal/Infant Health Act.

The federal Medicaid program was established in 1965 when Congress enacted Title XIX of the Social Security Act. 42 U.S.C.A. §§ 1396-1396v (West 1992 & Supp. 2000). Medicaid is a joint federal-state indigent-assistance program that provides federal funds to each state to furnish medical assistance to certain categories of needy persons. Id. § 1396 (West 1992). The federal government pays a percentage of the total cost that a participating state incurs in providing these services. Id. § 1396b (West Supp. 2000). Federal law establishes mandatory and optional categories of services a participating state may provide under Medicaid. Id. §§ 1396a, 1396d(a) (West Supp. 2000).

Congress has restricted federal matching funds available for abortions by the annual enactment of the Hyde Amendment. Named for its sponsor, Representative Henry Hyde of Illinois, the Hyde Amendment is a rider to the Labor-HEW Appropriations Act that has been passed every year since 1976.³ The specific terms of the amendment have varied over the years, but the versions presently in place and in place when this lawsuit was filed prohibit federal reimbursement for abortion services except in cases of rape or incest or where the pregnancy threatens the mother's life.⁴ Though the Hyde Amendment prevents states from receiving federal matching funds for most abortion services, states are free to subsidize at their own expense abortions for which federal reimbursement is not available. Harris v. McRae, 448 U.S. 297, 311 n.16 (1980); Omnibus Consolidated and Emergency Supplemental Appropriations Act of 1999, Pub. Law 105-277, sec. 509(b), 112 Stat. 2681-385 ("Nothing in the preceding section shall be construed as prohibiting the expenditure by a State . . . of State funds (other than a State's . . . contribution of Medicaid matching funds).").

Texas has participated in Medicaid almost since the program's inception, passing enabling legislation in 1967 establishing the Medical Assistance Program. See Medical Assistance Act of 1967, 60th Leg., R.S., ch. 151, §§ 1-24, 1967 Gen. Laws 310 (Tex. Rev. Civ. Stat. Ann. arts. 695j, 695j-1, since repealed and codified at Tex. Hum. Res. Code Ann. §§ 32.001-.052 (West 1999 & Supp. 2000)). The program covers all "health care and related services and benefits authorized or provided under federal law for needy individuals of this state." Tex. Hum. Res. Code Ann. § 32.003 (West Supp. 2000). Services are limited, however, to those for which the State can receive federal matching funds. See id. § 32.024(e) (West Supp. 2000). The Texas Medical Assistance Program therefore tacitly adopts the limits set forth by the Hyde Amendment, and physicians are reimbursed with Medicaid funds only for abortions necessary to save the woman's life or when the pregnancy has resulted from rape or incest. By the State's own admission, every other reproductive health service provided by a doctor with the Texas Medical Assistance Program is reimbursed if it is medically necessary; with one minor exception, abortion is the only service of any kind covered by the program that requires a showing of something more than mere medical necessity.⁵

In addition to their Medicaid challenge, Low-Income Women have challenged the abortion funding restrictions found in the Maternal/Infant Health Act. See Tex. Health & Safety Code Ann. §§ 32.001-.045 (West 1992 & Supp. 2000). This program was created in 1985 to provide medical and educational services to low-income women and infants. See Maternal and Infant Health Improvement Act, 69th Leg., R.S., ch. 592, 1985 Tex. Gen. Laws 2224 (Tex. Rev. Civ. Stat. Ann. art. 4447y, since repealed and codified at Tex. Health & Safety Code Ann. §§ 32.001-.045). Under the Maternal/Infant Health Act, no funds may be used to provide abortion services unless the woman's life is in danger. Tex. Health & Safety Code Ann. § 32.005 (West 1992). With no exception for women who are victims of rape or incest, abortion coverage under the Maternal/Infant Health Act is even more restricted than under the Texas Medical Assistance Program.

The Parties

Low-Income Women are represented in this action by physicians and health clinics that provide abortion services. Doctors Robert Price and Curtis Boyd are both Texas-licensed physicians who divide their time between their private practices and the Fairmount Center, a Dallas health center that provides low-cost, outpatient abortions to Medicaid-eligible women. The physicians and the clinic each assert their own interests and those of their patients, claiming that because of the funding restrictions on medically necessary abortions, many women are forced to delay obtaining an abortion until their second trimester, when the procedure poses greater health risks, because of the time required to find money to pay for a non-subsidized abortion.

Doctor William Watkins West is also a Texas physician who specializes in abortions. He provides services at the Routh Street Women's Clinic in Dallas, also a plaintiff-appellant in this case. Between five and ten percent of Dr. West's Routh Street patients are Medicaid-eligible, and the clinic offers reduced-fee abortions to those women. Finally, Reproductive Health Services is a non-profit clinic located in Austin that provides abortions, family planning, prenatal care, and other gynecological services. It provides abortions to Medicaid-eligible women. Like the other plaintiffs in this lawsuit, Reproductive Health Services claims that the clinic and the patients it treats are irreparably harmed by the abortion-funding restrictions.

The defendants/appellees in this action are Commissioner of Health Charles E. Bell, the Texas Department of Health, and the Texas Board of Health. While the Human Services Department is designated by statute as the administrator of the Medical Assistance Program, the legislature has also provided that the program may be administered in cooperation with other state agencies. Tex. Hum. Res. Code Ann. §§ 32.003, .021, .023 (West 1990 & Supp. 2000). By Rule 11 agreement eliminating as defendants the Human Services Department, Board, and Commissioner, the parties apparently agree that it is the Department of Health that oversees the Medical Assistance Program and that the Department of Human Services is not involved in the administration of the program. See Tex. R. Civ. P. 11.

Medically Necessary Abortions

At issue in this case are abortions that fall in the zone between purely elective abortions and those sought because the pregnancy resulted from rape or incest or jeopardizes the mother's life.⁶ Low-Income Women do not argue that low-income Texans have a right to funding for all abortions. Instead, they urge that the same standard of medical necessity that applies to all other reproductive health care treatments should apply to abortion services as well.

While abortions are funded when a physician determines that the mother's life is threatened by the pregnancy, they are unfunded in other cases, absent rape or incest, in which the physician deems an abortion medically necessary and advisable because of health problems faced by...