Doe v. BusbeeDoe v. Busbee
ORDER
This is a civil action to obtain declaratory and injunctive relief brought pursuant to the Civil Rights Act of 1871,
*1328 I
The complaint alleges that plaintiffs Jane Doe 1 and Mary Roe 2 are eligible for medical assistance under Georgia’s Medicaid program. Doe and Roe, having been informed that they are pregnant and advised that given their conditions, an abortion is medically necessary, have each expressed a desire to obtain an abortion. However, neither is financially capable of obtaining an abortion without Medicaid reimbursement and neither qualifies for such reimbursement under the present rules promulgated by the Department of Medical Assistance regarding reimbursement for abortions. Plaintiffs Doe and Roe seek to bring this action as representatives of a class consisting of all present and future Medicaid enrollees who are now, or who may become, pregnant and who have decided, or who may decide, with their physicians, to have an abortion and for whom an abortion is “medically necessary”, but for whom an abortion is not necessary to prevent death or severe and longlasting consequences for their physical health, or where pregnancy did not result from rape or incest.
Plaintiffs Jacob B. Adams, M.D., Lawrence D. Baker, M.D., Charles Butler, M.D., Joel S. Engel, M.D., 3 James M. Freеmont, M.D., Steven Gordon, M.D., Otis T. Hammonds, M.D., Henry S. Kahn, M.D., William Mason, M.D., Harold W. Pitts, M.D., Edwin Portman, M.D., Joseph Randall, M.D., and Gerald Rehert, M.D. are all physicians who receive reimbursement from the Georgia Medical Assistance Program for medically necessary obstetrical, gynecological, psychiatric and anesthetic services which they individually provide to their Medicaid patients. These plaintiff physicians are seeking to bring this action on their own behalf, on behalf of their patients, and on behalf of all physicians and Medicaid providers who are certified by Georgia’s Department of Medical Assistance to obtain reimbursement for the provision of medically necessary services to persons eligible for benefits under the Georgia Medical Assistance Program, and who will perform medically necessary abortions for the plaintiff class of women in accordance with the exercise of their best medical judgjnent. 4
Plaintiff Atlanta Center for Reproductive Health, Inc. (“ACRH”), Atlanta Women’s Medical Center, Inc. (“AWMC”), and Feminist Women’s Health Center, Inc. (“FWHC”) are corporations which operate clinics which provide gynecological services, education and counseling, including first trimester abortions for women who are eligible for Medicaid.
Defendant George D. Busbee is the Governor of the State of Georgia. Defendant Richard Millsap is the Director of the Fiscal Division of the Department of Administrative Services for the State of Georgia. Defendant David B. Poythress is the Commissioner of the Georgia Department of Medical Assistance. Defendants D. Jack Davis, James E. Barnett, Vivian P. Hartman and Ronald Tigner are all members of the defendant Board of Medical Assistance, which is empowered to establish the general policy to be followed by the Georgia Department of Medical Assistance and approves all rules adopted by the Department. Defendant Arthur K. Bolton is the Attorney General of the State of Georgia.
At this stage of the action, the plaintiffs seek a preliminary injunction, pursuant to
There are four prerequisites which the Court must find are satisfiеd before granting a preliminary injunction: (1) a substantial likelihood that the plaintiffs will prevail on the merits, (2) a substantial threat that plaintiffs will suffer irreparable injury if the injunction is not granted, (3) that the threatened injury outweighs the threatened harm the injunction may do to the defendants, and (4) that granting the preliminary injunction will not disserve the public interest.
Morgan v. Fletcher,
II
In
Beal v. Doe,
Pursuant to the current rules promulgated by the Department of Medical Assistance of the State of Georgia, 6 Medicaid reimbursement for abortions is available only if one of the following conditions is met:
(1) The life of the mother would be endangered if the fetus were carried to term.
(2) Severe and longlasting physical health damage to the mother would result if the pregnancy were carried to term.
(3) The mother was a victim of rape or incest, and the incident was reported promptly.
In addition:
Written certification, verifying the above conditions will be required before payment can be made. In the case of the mother’s life being endangered, written certification of one physician is required. In the case of resulting severe and long-lasting health damage, written certification of two physicians is required.
In the case of rape or incest, signed documentation from a law enforcement agency or public health service stating that the rape or incest was reported within sixty (60) days of the incident is required.
Billing Procedures and Reimbursement Policies for Physicians Services — Appendix D *1330 (revised 12/1/78) (hereinafter cited as Physician’s Manual — Appendix D).
As a participating state, Georgia’s Medicaid Plan must meet certain minimum requirements as set out in Title XIX of the Social Security Act,
(1) inpatient hospital services;
(2) outpatient hospital services;
(3) laboratory and x-ray services;
(4) (A) skilled nursing facility services;
(B) early and periodic screening and diagnosis for persons under 21 years of age;
(C) family planning services and supplies;
(5) physicians services (whether furnished in the office, patient’s home, a hospital, skilled nursing facility or elsewhere).
The regulations promulgated by the Department of Health, Education, and Welfarе pursuant to Title XIX, which regulations have the force of law, 8 provide the following additional requirements of a state plan:
(a) The plan must specify the amount and duration of each service that it provides.
(b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.
(c) (1) The medicaid agency may not deny or reduce the amount, duration, or scope of a required service under §§ 440.210 [for the categorically needy] and 440.220 [for the medically needy] to an otherwise еligible recipient solely because of the diagnosis, type of illness, or condition.
(2) The agency may place appropriate limits on a service based on medical necessity or on utilization control procedures.
In summary, Title XIX and the regulations promulgated thereunder require that, as a minimum, a state plan for medical assistance must provide for all medically necessary services to the categorically needy which fall within the five general categories set out in Title XIX,
In response to plaintiff’s position, the defendants argue that given the nature of the statute creating the Department of Medical Assistance of the State of Georgia and the restrictions on the use of federal funds for abortions contained in the Hyde Amendment, Pub.L.NO.95-480, § 210, 92 Stаt. 1586 (1978), the Georgia Department of Medical Assistance is precluded from providing reimbursements for abortions except in those circumstances set out in the Physicians Manual — -Appendix D (see text, supra). Furthermore, the defendants argue that if the Court were to rule in favor of the plaintiffs, the Court would be required to reach a finding that the Hyde Amendment, is unconstitutional, which finding would be improper prior to joining the United States Department of Health, Education, and Welfare (“HEW”) and Joseph A. Califano, Secretary of HEW as parties to this action. 11
The Hyde Amendment in its present form reads as follows: 12
Provided, that none of the funds provided for in this paragraph shall be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term; or except for such medical procedures necessary for the victims of rape or incest, when such rape or incest has been reported promptly to a law enforcement agency or public health service; or except in those instances where severe and long-lasting physical health damage to the mother would result if the pregnancy were carried to term when so determined by two physicians. 13
Pub.L.95-205, § 101, 91 Stat. 1460 (Dec. 9, 1977).
It is the defendants’ contention that the regulations promulgated by the Georgia Department of Medical Assistance, restricting reimbursement for abortions to just those instances in which Federal financial participation is authorized under the language of the Hyde Amendment, are compelled by its authorization to maximize Federal financial participation. However, this contention is not explicitly supported by the language of the authorization, which does not limit serv *1332 ices provided by the State plan to those in which there is Federal financial particiрation; nor is it implicitly supported by resort to the general scheme by which each state’s share of Federal financial participation is computed, 14 absent a showing that reimbursement by the State for medically necessary abortions, outside those instances in which Federal funds are available, would result in the State’s loss of federal funds for which it would otherwise qualify.
In support of their argument that a ruling by this Court in favor of the plaintiffs would require a finding that the Hyde Amendment is unconstitutional, the defendants rely on
Preterm, Inc. v. Dukakis,
Alternatively, the defendants argue that given the neutrality of
The common premise crucial to the success of each of defendants’ arguments is the proposition that the Hyde Amendment substantively alters Title XIX as held in
Preterm, Inc. v. Dukakis,
In support of its conclusion that the Hyde Amendment substantively affects Title XIX, the
Preterm
court looks to the legislative history of the Amendmеnt, which in this case consists solely of debates and insertions in the Congressional Record. Before it can justify exploring legislative history, however, the
Preterm
court, unable to find that the words of the amendment themselves are unclear,
18
must find that the plain meaning of the amendment produces a result “ ‘plainly at variance with the policy of the legislation as a whole.’ ”
United States
v.
American Trucking Associations, Inc.,
This Court has difficulties with this conclusion. To begin with, it is to take too narrow a view of the overall Medicaid scheme to find that any obligations are “imposed” on states where their participation in the Medicaid program is voluntary. It must be conceded that the minimum requirements for state plans set out in Title XIX and discussed above represent “obligations”, but they аre obligations which each state chooses to accept when it exercises the option of participating in the Medicaid program. Indeed the very issue before the Court in the instant case is whether the funding of all medically necessary abortions is one of those obligations.
Additionally the
Preterm
court seems to confuse the basic policy of Title XIX, the enabling of each state to furnish medical assistance to the needy, with the basic mechanism by which Congress seeks to effect that policy, the provision of federal funds on a cooperative basis with participating states. But even so, it is not the case, nor is it required by Title XIX, that there be federal financial participation in every service necessarily provided by a participating state. Indeed, in the instant case it has been stipulated that the State of Georgia provides 100% of the premiums for the insurance program established by part B of Title XVIII,
The Court notes further that, in its discourse on statutory construction, the Supreme Court in
United States v. American Trucking Associations, Inc.,
However, even assuming that exploration of the legislative history of the Hyde Amendment were justified, this Court does not find support therein for the proposition that the Hyde Amendment represеnted a clear, substantive limitation on Title XIX. Without repeating in detail each of the statements considered by the Preterm court, this Court finds that the statements made by the proponents of the amendment expressed their regret that their efforts to change substantive law on abortions languished in committee and their hopes that restrictions on the use of federal funds *1334 would accomplish a “working of their will”, 123 Cong.Rec.H. 6083 (June 17, 1977) (Rep. Hyde), while those statements made by the opponents of the amendment expressed predictions of the praсtical effect of the amendment, which in their opinion would be dismal. 123 Cong.Rec. at S. 11031 (June 29, 1977) (Sen. Packwood).
The
Preterm
court’s reliance on these statements effectively makes self-fulfilling prophecies of them. While it may well be manifest that the Hyde Amendment was “calculated to stop the provision of abortional services from public funds”,
McRae v. Matthews,
In summary, the Court finds the language of the Hyde Amendment unambiguous, obviating resort to the legislative history for its construction. The Hyde Amendment on its face clearly operates merely to restrict the use of federal funds for abortions. Furthermore, a review of that legislative history, as presented in
Preterm, Inc. v. Dukakis,
In conclusion, the Court finds, on the basis of the apparent merit of the plaintiffs’ arguments and the lack of merit of the defendants’ position, that there is a substantial likelihood that the plaintiffs will prevail on the merits.
III
The defendants have not argued the absence of irreparable injury 22 or that the threatened injury outweighs whatever threatened harm thе injunction may do to the defendants. It is conceded that the abortions sought by plaintiffs Doe and Roe are medically necessary due to their age, health, and familial circumstances.
The Court finds a substantial threat that plaintiffs Roe and Doe will suffer irreparable injury for which there is no adequate legal remedy if the injunction is not granted, and further that the balance of harms weighs in favor of the plaintiffs.
IV
The defendants argue that granting plaintiffs the injunctive relief they seek would disserve the public interest by channeling funds, which would otherwise be avаilable to all Medicaid recipients, to benefit the relative few who need medically necessary abortions. However, this argument fails in light of the fact that Medicaid payments are made in support of prenatal and childbirth services and in light of the stipulations in the instant case that the cost of childbirth exceeds the cost of abortion, and indeed, that the cost to the state of a childbirth, for which the state receives federal financial participation, exceeds the cost of a fully state-funded abortion.
The Court finds that the grant of preliminary injunctive relief to the plaintiffs will not disserve the public interest.
*1335 V
Having found that all the prerequisites to the grant of preliminary injunctive relief have been met in this action, the Court will enter a preliminary injunction in favor of the named plaintiffs.
ACCORDINGLY, the defendants, their agents, employees and attorneys are enjoined from refusing to provide Medicaid reimbursements for the medically necessary abortions of plaintiffs Doe and Roe.
SO ORDERED, this the 4th day of June, 1979.
Notes
. Pseudonyms have been adopted to preserve the anonymity of the plаintiffs seeking Medicaid funding for their own medically necessary abortions.
. Plaintiff Roe was added as a named party to this action by an amendment to the complaint, which amendment was filed as a matter of course prior to the filing of any answer to the complaint.
. Dr. Engel voluntarily withdrew as a named plaintiff on May 21, 1979.
. Both the plaintiff women and the plaintiff group of physicians have moved for certification of their respective classes, but these motions will be addressed by the Court at a later date.
. As will be seen, this Court finds adequate stаtutory grounds for granting the relief sought, therefore the Court will not address the constitutional arguments of the parties.
See Hagans v. Lavine,
“It is inappropriate to address constitutional issues without determining whether statutory grounds . . . are dispositive.”
Regents of the University of California v. Bakke,
.
.
See
. It has been established in a variety of contexts that properly promulgated, substantive agency regulations have the “force and effect of law."
Chrysler Corp. v. Brown,
- U.S. -, -,
. Title XIX does not explicitly mandate that all medically necessary services within the five general categories be provided by a state plan, however, this Court does find such a mandate in the promulgation of
Preterm, Inc. v. Dukakis,
. The purpose of Title XIX with which this action is directly concerned is “the purpose of enabling each State, as far as practicable under the conditions in such State, to furnish (1) medical assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resourcеs are insufficient to meet the costs of necessary medical services . . . .
. The defendants have pending a motion to join these federal parties which the Court will address at a later time.
. The original Hyde Amendment affecting HEW appropriations for FY 77 restricted the use of federal funds for abortions “except when the life of the mother would be endangered if the fetus were carried to term.” Pub.L.94 — 439, § 209, 90 Stat. 1418 (Sept. 30, 1976).
. This same language has been incorporated in the Departments of Labor and Health, Education, and Welfare Appropriations Act, 1979, Pub.L.95 — 480, § 210, 92 Stat. 1586 (Oct. 18, 1978).
.
See
. The
Preterm
decision has been followed in this respect by the Seventh Circuit in
Zbaraz v. Quern,
. The defendants have not expressly articulated this argument but the Court presumes its adoption by defendants’ reliance on
Preterm, Inc. v. Dukakis,
. The defendants cite
Woe v. Califano,
. If the words of a statute are clear, there is no need to resort to extrinsic aids of statutory construction.
See TVA v. Hill,
. While the defendants argue that the State of Georgia pays these premiums in order to receive the direct benefit of increased federal funding which the state would otherwise lose, the requirement to pay these premiums is no less an “obligation” in the Preterm sense than would be requiring the states to fund the total cost of non-Hyde Amendment therapeutic abortions. All that could be said is that in the latter case, the state benefits less directly.
. The Court notes one further distinction between the facts of
U. S. v. Amer. Trucking Ass’ns, Inc.,
. “It is emphatically the province and duty of the judicial department to say what the law is.”
Marbury v. Madison,
. The issue of imminence was made less crucial at the hearing on a TRO in this case by the defendants’ agreement to reimburse plaintiffs should they have an abortion prior to the Court’s grant of injunctive relief, and of course, conditioned on such grant.