*1 MARICOPA HOSPITAL MEMORIAL et al. COUNTY et al. 6, 1973—(cid:127) Argued November
No. 72-847. February 26, 1974 Decided J., opinion Court, delivered Marshall, Bren- joined. JJ., J., nan, Stewart, White, C. Powell, Burger, J., J., separate concurred the result. filed a Blackmun, Douglas, post, J., dissenting opinion, opinion, p. 270. filed Rehnquist, post, p. 277.
Mary appellants. M. argued Schroeder the cause for her Frank. With on the brief was John P. III
William J. Carter filed a brief argued cause and for appellees.* opinion delivered the
Mr. Justice Marshall Court.
This
presents
case
an
from a decision of the
appeal
Supreme
Arizona
an
upholding
Arizona statute
a
requiring
year's
residence
as a condition to
county
receiving nonemergency hospitalization or medical care
the county's expense.
question
The constitutional
presented is whether
require-
this durational
ment
is repugnant
to the Equal Protection Clause as
applied
Shapiro
this Court
v.
I Appellant Henry Evaro is indigent suffering an from a chronic asthmatic and In early bronchial illness. June 1971, Mr. Evaro moved from New Mexico Phoenix in Maricopa July Arizona. On County, Evaro 8, 1971, had a respiratory severe attack and was sent his attending physician to appellant Hospital, Memorial nonprofit private community hospital. Pursuant the Arizona governing statute medical care for indigents, Memorial notified the Maricopa County Super- Board of visors that it had in its an charge indigent might who qualify county for care and requested that Evaro be transferred to County’s public hospital facility. In approved accordance with the procedures, Memorial also *Sandor O. Shuch John J. Relihan filed a Legal brief for the Society County of Maricopa Aid as amicus urging curiae reversal. amount in the County from reimbursement claimed had provided and services for the care $1,202.60, Evaro. governments county individual law,
Under Arizona providing.nec- mandatory duty with the charged are sick.1 indigent their care for essary hospital medical resi- indigent to have been an requires But the statute order months County preceding for the dent of the medical care.2 nonemergency for free eligible public Evaro to its County to admit Maricopa refused because Evaro solely Memorial hospital or to reimburse preceding had not been a resident of the year. Evaro is an Appellees dispute do County.3 Maricopa or that he is a bona fide resident of *3 This was determine whether action instituted to appellee Maricopa obligated provide was to County medical care for Evaro or was liable to Memorial for the costs it incurred because of the refusal County’s do so. This controversy necessarily requires an ad- judication of the the constitutionality of Arizona dura- 1973-1974).
1 Ariz. (Supp. Rev. Stat. Ann. §11-291 2 (Supp. 1973-1974) provides part Section 11-297A in relevant that:
“Except emergency hospitalization when cases immediate or necessary preservation medical care is for of life limb no the or person provided hospitalization, outpatient shall be care medical relief provisions under the filing of this without first with article county supervisors member of the board of of the in which he in writing, resides a statement subscribed and sworn under oath, by that he is an regula- as shall be defined rules and department security, tions of the state unemploy- economic an totally dependent able upon county 'government the state or for support, financial employable or an low sworn income without sufficient provide necessary funds himself hospitalization medical care, and that county he has been a the resident the for preceding twelve (Emphasis added.) months.” 3Thus, question rights the oí transients to medical care is presented by this case. free medical providing residence requirement tional indigents. care to un- requirement
The trial held the residence court Protection Equal constitutional as a violation of the against In prior three-judge Clause. federal court suit had de- Arizona, Pinal the Court also County, District clared requirement the residence unconstitutional County. had its future in Pinal enjoined application Bateman, (Ariz. Valenciano v. Supp. 323 F. 1971).4 Supreme upheld Nonetheless, Arizona challenged conflict be- requirement. To resolve this State, tween highest a federal court and the court probable we jurisdiction, (1973), noted Supreme and we reverse the of the Arizona judgment Court.
II In determining challenged whether durational provision residence Equal violates the Protection Clause, we must first justification determine what burden of classification created thereby looking must meet, nature classification and individual inter- ests affected.5 The Court considered similar durational appellate Arizona’s intermediate court had also declared the Su durational in Board of unconstitutional pervisors, Robinson, Pima App. 238, 10 Ariz. 2dP. (1969), but its decision vacated as Arizona was moot *4 Supreme 280, Court. 105 (1970). Ariz. P. 463 2d 536 one-year
An requirement Arizona durational residence for care at state mental health facilities was declared unconstitutional in Vaughan Bower, v. Supp. (Ariz.), 313 F. 37 400 aff’d, U. S. 884 (1970). 11, See n. infra. one-year A Florida requirement durational residence for medical public expense care at in Arnold v. Halifax was found unconstitutional Hospital Dist., Crapps (MD F. Supp. 314 277 1970), and Fla. v. Hospital Auth., Duval Supp. (MD 1970). 314 F. 181 Fla. g., 5 E. Weber v. Surety Aetna Co., Cas. & 164, 406 U. S. 173 Blumstein, Dunn v. (1972); 405 (1972). U. S. 335
254 Shapiro assistance for welfare requirements
residence observed Court The U. 618 Thompson, v. S. needy resi two classes created requirements that those that one except from each other “indistinguishable dents more, year have resided who composed is of residents than a less resided who have of residents and the second differ of this sole jurisdiction. On basis year, class and second granted [was] the first class ence [was] abil may depend the upon denied welfare aid shelter, food, ity means to very .. . to obtain the subsist — Id., The at 627. life.” other necessities and on impinged this classification found that because travel, of interstate constitutionally guaranteed right pro whether judged it was to be the standard an such Finding interest.6 compelling moted state challenged residence wanting, the Court held interest unconstitutional. requirements before argue requirement residence Appellees that Shapiro, appel- while distinguishable us is from those urge Shapiro controlling. agree is We with lants require- appellants that Arizona’s durational justified by for free ment medical care must be a com- pelling that, being lacking, state interest and such interests unconstitutional.
Ill
repeatedly
has
interstate
travel
been
aas basic constitutional
recognized
freedom.7 Whatever
id.,
S.,
U.
at
642-644 (Stewart,
J.,
634. See also
concurring).
Blumstein, supra; Shapiro
Dunn v.
Thompson,
v.
394 U. S.
Wyman
Lopez,
Oregon
(1969);
(1972);
see
v.
255 ultimate scope, however, its the right was travel only involved a limited sense in Shapiro. The Court only was there concerned right migrate, with the “with 8 intent to settle and put abide” the Court “to or, it, migrate, find a new life.” resettle, job, and start new Id., at 629. Even a require- bona fide residence ment would burden the if meant travel travel, merely Shapiro, explained movement. the Court But, that residence requirement one-year and the wait- “[t]he ing-period requirement are independent distinct and pre- requisites” for assistance and the latter was held to Id., be unconstitutional. Later, at 636. in invali- dating a requirement durational residence regis- for voter tration on Shapiro, the basis of we cautioned that our decision was not intended to “cast doubt on validity of appropriately uniformly defined and applied bona fide requirements.” residence Dunn Blumstein, v. 405 U. S. 342 n. 13 330, (1972).
IV
The appellees argue
county
the instant
is distinguishable from the state residence
requirements in Shapiro, in that the former penalizes, not
interstate, but rather intrastate,
travel. Even were we to
draw a constitutional distinction between interstate and
Wyman Bowens,
v.
(1970);
Guest,
United States v.
intrastate judgment the support not would such distinction Appellant before us. in the case Arizona court effectively for his interstate penalized been Evaro has accomplished under the was although this migration, would What requirement. residence guise county can directly by the if done be unconstitutional county at readily accomplished by a no more be could Supreme Court the State’s direction. The Arizona apply waiting-period requirements have construed to the it did not migrants;9 to intrastate but not interstate but “it function a state so, do is our to construe given high- to construction the contrary statute Skinner, est court of a O’Brien v. State.” U. S. 531 (1974).
V Although any requirement residence im- durational pinges right travel, to some extent on the to the Court Shapiro did not requirement per declare such a to be se unconstitutional. The Court’s holding conditioned, was 394 U. S., at 638 n. caveat that some “wait- ing-period or residence requirements... penal- not be may ties upon the exercise of the constitutional of inter- state travel.” The impact amount of required give
9Appellees argue County that be apply should able to requirement preserve durational quality of services provided longtime its residents because of their ties to the commu nity previous and the they made, contributions particularly have through past payment of taxes. It would seem inconsistent argue that the residence be should construed to bar longtime residents, Arizona even if applied unconstitutional as persons migrating Maricopa County into from outside the State. Surely, longtime neighboring residents of counties have more ties with Maricopa equity public programs, in its through past payment taxes, migrants state than do from distant States. This “contributory” discussed, rationale infra, at 266. not made was rise to test compelling-state-interest in two requisite impact spoke clear.10 The period waiting ways. First, we considered whether migration: would deter migrate . . . will doubt-
“An who desires to making if less hesitate he knows he must risk back on possibility falling move without during year state welfare his first of resi- assistance Id., when dence, his need acute.” most at 629.
Second, the Court considered extent which the the residence requirement penalize served the exercise of right the to travel. appellees argue here that denial of non- the
emergency medical the is care, welfare, unlike denial of not apt migration; to deter far from clear but that challenged statute is unlikely any to have deterrent A person effect. afflicted with respiratory a serious ail- ment, particularly provide an whose efforts to living a family his have been inhibited his in- capacitating illness, might migrating well of think to the clean air dry Arizona, where relief from his disease could also bring relief from unemployment and poverty. But he hesitate if he that knows he make must move without possibility falling back on the State for medical care should his plague condition still him or grow more severe during year his first of residence.
It is true, as appellees argue, that there is no evidence in the record anyone before us that was actually deterred from traveling challenged restriction. But neither did majority in Shapiro any find reason dispute “to the 'evidence that few recipients welfare have in fact been 10Por a problems discussion of the posed by ambiguity, see Judge Coffin’s perceptive opinion Housing in Cole v. Authority of City Newport, 435 2d (CA1 1970). F. requirements.’ by residence moving] deterred [from been had themselves litigants none of Indeed, (citations Dunn, S., deterred.” 405 U. by urging Shapiro attempt distinguish An omitted). regis- for voter that a durational “funda- found to be a travel, was tration did not deter Dunn, supra, at law” in misunderstanding of the mental 339-340: that denial “Shapiro upon finding did not rest other travel. Nor have actually welfare deterred always relied on in this 'right to travel’ cases Shapiro In we presence of actual deterrence. explicitly compelling-state-interest stated that by 'any test would be classification which triggered penalize right serves to the exercise of that [to (Emphasis original; ....’” footnote travel] omitted.)
Thus, Shapiro and Dunn the proposition stand for “operates per- classification which penalize those sons . . . who have exercised their constitutional interstate migration,” justified by compelling must be state Mitchell, interest. Oregon v.
(1970)
(separate opinion of Brennan,
White,
JJ.)
(emphasis
added).
any
Although
Marshall,
durational residence requirement
imposes potential
cost
on migration,
Shapiro
Court in
cautioned that some
11 Vaughan
Bower,
In
v.
Supp.
(Ariz.),
313 F.
aff’d,
37
400 U. S.
(1970),
884
a federal court struck down an
permitting
Arizona law
the director of a state
hospital
mental
to return to the
prior
his
residence, any indigent patient who had not been a resi
dent of
year
Arizona
preceding
for the
his civil commitment.
It is
doubtful
challenged
any
law could have had
deterrent
effect on migration,
people
being
since few
consider
committed to a
hospital
mental
they
when
up
decide
take
to
residence in a new
State. See also
Whitcomb,
v.
Supp.
(ND
319 F.
69
Ind.
Affeldt
1970), aff’d,
(1972).
259 penalties.” S., . . 394 U. “waiting-period.[s] . Blumstein, In Dunn v. supra, at 638 n. 21. franchise, found that the denial of the “a fundamental Sims, political Reynolds 562 right,” 533, v. 377 S.U. penalty (1964), requiring application was a of the com- pelling-state-interest In Shapiro, test. the Court found denial of the penalty. basic “necessities of life” to be a Nonetheless, the Court has declined strike down state requiring statutes one year of residence as a condition to lower tuition at state institutions of higher education.12 parameters
Whatever the ultimate Shapiro pen- alty analysis,13 is at least clear that medical care is as much “a basic necessity of life” an indigent as welfare assistance.14 governmental or privileges benefits And, necessary to basic sustenance have often been viewed being greater significance constitutional than less essential forms of governmental entitlements. See, g., e. Shapiro, supra; Goldberg Kelly, 397 U. S. Family Sniadach v. Finance (1970); Corp., S. (1969). 340-342 It odd, would be indeed, to find that the State of Arizona was required to afford Evaro welfare assistance to keep him from the discomfort of inadequate housing pangs hunger but could deny him Kline, See Vlandis v. 441, 452-453, U. (1973). n. 9 example, For Shapiro Court cautioned that it meant “imply validity no view of waiting-period or residence re quirements determining eligibility to obtain a [inter license dial practice profession, fish, to hunt or S., and so forth.” 394 U. at 638 n. 21. 14Dept. of Health, Education, and (HEW) Welfare Report on Medical Resources Available to Meet the Needs of Public Assistance Recipients, House Ways Committee on Means, 86th Cong., 2d Sess., (Comm. 1961). Print Similarly, President Nixon has ob “ served : ‘It is health which wealth,’ real said Ghandi, 'and ” not pieces gold and silver.’ Health, Message from the President, 92d Cong., Sess., 1st H. R. Doc. 92-49, No. p. See also *9 4, materials supra. cited at n. 260 wheezing him from the to relieve necessary
medical care
his illness.15
for breath that attend
gasping
and
require
durational residence
Nor does the fact that the
emergency med
provision
inapplicable
ment is
from constitutional
challenged provision
ical care save the
appel
Supreme
observed,
doubt. As
Arizona
required
person
lant
who
con
“Evaro was an
preservation
tinued medical care for the
of his health
and well
if
being
,”
require
. . .
even
he did not
immediate
deny
care.16 The
could
Evaro care
emergency
15Reference to
tuition cases is
The lower courts
instructive.
way
have .contrasted
tuition
life” in a
in-state
with “necessities of
clearly
category.
that would
include medical
in
The
care
the latter
Malkerson,
Supp. 234,
(Minn.
District Court
Starns v.
326 F.
1970), aff’d,
(1971), quoted
approval
U. S. 985
with
from Kirk v.
Regents,
Board
App.
430, 440,
Rptr.
273 Cal.
2d
78 Cal.
(1969),
266-267
appeal dismissed,
(1970) (emphasis
added):
“
fully recognize
we
higher education,
‘While
the value of
we cannot
equate
food,
Shapiro
its attainment
clothing
with
and shelter.
involved
pressing
preservation
immediate and
need for
of life
persons
health of
public assistance,
unable to live without
dependent
their
Thus,
requirement
Shapiro
children.
the residence
great
could cause
suffering and even loss of life. The durational
publicly
attendance at
financed institu-
higher learning
tions of
not involve
[does]
similar risks. Nor was
petitioner... precluded
obtaining higher
from the benefit of
educa-
Charging higher
tion.
tuition fees to non-resident students cannot be
equated
granting
with
of basic
needy
subsistence to one class of
”
denying
equally
residents while
it to an
needy class of residents.'
Note,
See also
Constitutionality
Tuition,
of Nonresident
Minn.
L. Rev.
1149-1158
Moreover,
supra,
Vlandis,
“special
Court observed
problems
involved in deter-
[are]
mining the bona fide residence of college students who come from out
public
State to
university
attend
,”
.
[a]
..
since those
are
students
characteristically transient, S., U.
at 452. There is no such
ambiguity about
appellant
whether
Evaro is a bona fide resident of
Maricopa County.
373, 374,
108 Ariz.
261 breath, he was just because, although gasping altogether. breathing danger stopping in immediate requires until To to untreated go allow a serious illness subject is the sufferer to emergency hospitalization to danger of a and irrevocable deterioriation substantial respiratory in his ill Cancer, disease, health. heart if irre ness, year, untreated for a become all but versible of life. paths pain, to and even loss disability, The denial of medical care is all the more cruel context, falling indigents it does on who are often without obtain means to alternative treatment.17
Finally, appellees
as in-
distinguish Shapiro
seek to
federally
volving
partially
Maricopa
funded program.
County has
funding
public
received federal
for its
hos-
pital18 but,
importantly,
more
this Court has held that
federally
whether or not a
funded
program
welfare
is
Shapiro analysis.
irrelevant
to
applicability
Hansen,
Pease v.
Not the Bible shall have of law, one manner as well for the for one stranger, as of your own country,” Leviticus 24:22 (King James Version), the right of interstate travel must be seen as new insuring right residents the same government to vital privileges benefits in the migrate States which they enjoyed as are by other residents. The State of Arizona's durational for free medical care penalizes indigents for exercising their migrate Bateman, 600, See Valenciano Supp. (Ariz. 1971). F. generally Report Resources, supra, See HEW on Medical 14, n. at 73-74; Dept. HEW, Human Investment Programs: Delivery of Health Services for the Poor 18 HEW, Project Register, July See Hill-Burton 1947-June (HSM) 1967. 72-4011, p. HEW Publication No. Maricopa 37. (42 $2 has received over million in Hill-Burton U. S. C. § seq.) et funds since 1947. the classifica- Accordingly, in that State.19 to and settle “unless shown requirement, the residence tion created compelling governmental necessary promote S., 634. Shapiro, 394 U. interest, is unconstitutional.” (Emphasis original.)
VI
*11
the State
of whether
question
We turn now to
is
requirement
residence
that
its durational
has shown
20 in
furthers a com-
defensible,”
that
it
“legitimately
A
are
purposes
number of
pelling state interest.21
must
requirement
be
we
asserted to
served
19Medicaid,
primary
program
providing
federal
medical
permit
indigents
public expense,
participating
to
not
care
at
does
a
apply
durational
as a condition
States to
eligibility,
(b)(3),
42
a
to
U. S. C. 1396a
and “this conclusion of
§
coequal
significance.”
branch
is
of Government
not without
Richardson,
677,
(1973).
v.
411
Frontiero
U. S.
687-688
The State
participate
program.
of Arizona does not
in the Medicaid
20
Ely, Legislative
Cf.
and Administrative Motivation in Consti
Note,
Law,
1205,
(1970);
Develop
79
tutional
Yale L. J.
1223-1224
Equal Protection,
1065,
in
1076-
ments
82 Harv. L. Rev.
Law—
(1969).
1077
21
Supreme
The Arizona
that
this case
Court observed
because
governmental
welfare,
involves a
akin
benefit
the “reasonable
Dandridge Williams,
v.
(1970),
basis” test of
A Supreme The Arizona Court observed: any “Absent residence requirement, sick indigent person . . . could seek [Maricopa admission to County’s] hospital, the facilities being the newest and most modern in the state, and the resultant volume would cause long waiting periods severe hardship on county if it tried tax its [the] property support owners [these] sick . . .” 373, . 108 Ariz. P. 2d 464. attempts thus require- sustain the *12 ment necessary as a means to insure the fiscal integrity of its free medical care an program discouraging influx of indigents, particularly those entering the County for the purpose sole obtaining of the benefits its hospital facilities.
First, may State not protect public drawing fisc an invidious distinction between classes of its citizens, Shapiro, at supra, 633, so appellees more must do than show that denying free medical care to new resi- dents money. saves The conservation of the taxpayers’ purse simply is not a sufficient state interest to sustain a durational residence requirement which, effect, severely penalizes exercise of the right freely migrate in another settle State. Dunn, See Rivera v. F. Supp. (Conn. 1971), aff’d, 404 U.
Second, extent the purpose of require- ment is to inhibit the immigration indigents gen- And, constitutionally impermissible.22 is goal erally, indigents those is to deter purpose extent to the its solely utilize in the up residence who take require- facilities, medical public new and modern challenged overinclusive. clearly issue is ment at every indigent, treats durational juris- he came to as if year residence, in his first a clas- care. Such free medical solely obtain diction waiting period than the no more defensible sification is said: Shapiro, supra, of which the Court all-inclusive, class of barred newcomers is “[T]he come to the majority who State lumping great the sole those who come for purposes for other with higher S., at purpose collecting benefits.” 631. try to fence out may “a no more
Moreover, public those who medical facili- indigents seek [better try generally.” than it to fence out indigents ties] Ibid. An quality who considers public hospital entering facilities in no less State is deserving than one who moves into in order to the State advantage Id., take of its better educational facilities. at 631-632.
It also useful to look the other side of the coin—at who will bear the cost of if indigents’ illnesses the County provide does not needed treatment. For newly those arrived residents who do receive at least hospital care, the cost is often by private borne nonprofit hospitals, appellant like many of which are Memorial — already precarious financial straits.23 When absorbed *13 22Shapiro Thompson, v. S., at 629.
23 Cantor, See The Law People’s and Poor Care, Access to Health 35 Contemp. 901, Law & (1970); Prob. 909-914 cf. Catholic Medical Rockefeller, Center v. Supp. 305 (EDNY F. 1969), 1256 and 1268 remanded, vacated and 820, 397 U. S. remand, aff’d on 430 F. 2d 1297, appeal dismissed, 400 (1970). U. S. 931 by private hospitals, caring indigents costs of for passed patients must be on to and “at a rather paying adding already inconvenient astronom- time” — hospitalization heavily ical costs of bear so on the resources pressures of most Americans.24 financial private nonprofit hospitals under which operate have already away led many patients them turn who pay severely or indigents cannot limit the number of they And, will admit.25 for those who receive indigents care, no is, the cost measured course, by their own suffering.
In addition, the County’s claimed savings may fiscal well illusory. timely The lack could medical care cause patient’s condition point to deteriorate to a where more expensive emergency hospitalization (for which no durational applies) is needed. And, the disability may result from un- letting an treated condition deteriorate well in pa- result tient family and his becoming a burden on the State’s wel- fare rolls for the duration of his care, emergency if permanently, his capacity to work impaired.26 Report Resources, supra, HEW 14, on Medical n. at 74. Health, generally Message See President, supra, 14; from the n. Kennedy, E. In Critical Condition: The Crises America’s (1973); Health Hearings Care on The Health Care Crisis in America before the Subcommittee on Health Com Senate on Welfare, mittee Labor and Cong., Public 92d 1st Sess. 25Cantor, supra, 23; supra, n. Kennedy, See E. 78-94; n. at Note, Working Assuring Rules Hospital Nondiscrimination Administration, 151, 156 (1964); Yale J. cf., g., L. n. 32 e. Stanturf Sipes, (Mo. 1969) S. W. 2d (hospital refused treatment to frostbite victim who pay deposit). gen $25 was unable to See erally Report Resources, HEW supra, on Medical 74; n. Hear ings on The America, supra, Health Care Crisis n. 24. timely hospitalization “[L]ack and medical care for those pay unable been has liability considered an economic to the patient, hospital, community and to the in which these citizens *14 dura- appellees argue eliminating also quality tional residence would dilute the fostering an provided longtime by services residents County’s influx of and thus requiring newcomers public expanded pool limited health resources to serve an recipients. Appellees assert that the should protect able to its of their longtime residents because contributions the community, particularly through past payment of taxes. rejected “contributory” We Kline, Shapiro rationale both in and in Vlandis v. U. 441, 450 n. 6 (1973), observing: reasoning would logically permit the State to
“[Such] bar new residents from schools, and libraries or parks, deprive police them of In- protection. and fire deed it permit would all apportion State benefits and services according past to the tax contri- butions of its Equal citizens. The Protection prohibits Clause such an apportionment of state services.” Shapiro, 394 S., (footnote U. at 632-633 omitted).
Appellees express a concern that the threat of an influx of indigents would discourage development “the of modern and [public effective facilities.” It medical] is suggested that whether or not the durational residence requirement actually deters migration, the voters think protects that it them from low income families’ being at- tracted county hospital; hence, the requirement is necessary for public support of that medical facility. A not employ an invidious discrimination to political sustain the viability of its programs. As we might otherwise be self-supporting . . . .” Report HEW on Medical Resources, supra, 14, 73; n. Comment, Indigents, Hospital Admis Equal sions and Protection, 5 U. Mich. J. 502, L. Reform 515-516 (1972); Southby, Crisis,in cf. Battistella & American Medicine, The Lancet (Mar. 16, 1968). Shapiro, supra, “[p]erhaps Congress observed at participation could induce wider state school construc- if joint building tion it authorized the use of funds *15 of segregated schools,” purpose but that would not sus- a Housing Authority tain such scheme. v. See also Cole City 2d Newport, (CA1 435 F. 812-813 807, 1970).
B The appellees argue also that the challenged statute objectives. serves some They administrative claim that the one-year waiting period is a convenient rule of thumb to determine bona fide residence. not being Besides factually certainly defensible, test is overbroad to accomplish its avowed A purpose. mere re quirement accomplish would objective of limiting public the use of medical to bona fide residents facilities County without sweeping prohibitions within its those bona fide residents who had moved into the State period. within the qualifying Less drastic means, which do not on impinge are travel, interstate avail employed27 able and an ascertain individual’s true intentions, protracted without a exacting period waiting have dire economic and consequences health for certain Tucker, citizens. See Shelton v. 364 S.U. 479, 488 The Arizona State agency welfare applies criteria than other of residency duration determine applicant whether an a bona fide resident.28 The Arizona Medical Aged Assistance to the law provides public medical care for certain senior citizens, conditioned on residence.29 Pinal County, Arizona, operated public has its hospital without benefit of the Dept. See Green Public v. Delaware, Supp. F. Welfare of (Del. 1967). 177-178 (1) 28 Ariz. Rev. Stat. Ann. (Supp. 1973-1974). § 46-292 (3) 46-261.02 (Supp. 1973-1974). § requirement application since durational residence enjoined a challenged statute in that was Bateman, Supp. F. federal court Valenciano 1971).30 (Ariz. is a useful allege waiting period appellees valid has a Certainly, fraud. preventing
tool for for medical by any applicant preventing interest in fraud resident, Shapiro, or oldtime care, whether newcomer is ill- provision challenged but 394 U. S., intent on An purpose. indigent applicant, suited to that having been a committing fraud, easily could as swear to being resident of as to county preceding year for the currently. one is no the State And, there need for to rely safeguard on the durational against when pur fraud other mechanisms to serve that *16 pose are available which impact would have a less drastic on constitutionally protected NAACP v. interests. , Button, 371 U. example, 438. at For state S. law it a makes crime to file an “untrue . . . statement for purpose the of obtaining medical care hospitalization, or outpatient relief” county expense. at Ariz. Rev. Stat. Ann. 11-297C (Supp. 1973-1974). Dunn, § S., See 353-354; at U. S. Dept. Agriculture Moreno, v. of U. S. 528,
Finally, appellees assert the waiting period is for necessary budget predictability, but what was in said Shapiro is equally applicable to the case before us:
“The records . . .
utterly
are
devoid of evidence that
addition,
In
County,
Pima
Arizona,
apply
did not
the dura-
requirement
tional residence
August
between
1969,
require
when the
ment
by
was found unconstitutional
Appeals,
Arizona
of
Board
Supervisors,
Pima
Robinson,
App. 238,
10 Ariz.
951,
457 P.
September
2d
judgment
when that
was
vacated as moot
Supreme
the Arizona
Court,
105 Ariz.
[the number who will predict people means year. appellees budget assistance require [The new Nor do census of residents .... take] new advance required give are notice residents for . . Thus, of their need . . assistance. . . many authorities cannot know how new residents jurisdiction year, come into the much less any how of them will many require public assistance.” (footnote omitted). U. at 634-635 S., projecting many Whatever difficulties in how new- jurisdiction comers to a welfare require assistance, will it could be an even more and speculative difficult task to estimate how those many newcomers will require during medical care year their first jurisdiction. one-year The irrelevance residence requirement to budgetary planning is further under- scored that emergency fact medical care for all newcomers and complete more aged medical care for the currently provided are being public expense regardless of whether the patient has been a resident of the County for preceding year. Shapiro, supra, See at 635.
VII The Arizona durational
eligibility for free nonemergency medical care creates an “invidious impinges classification” that on the *17 interstate travel denying newcomers “basic necessities of life.” Such a classification can sustained on a of a showing compelling state interest. Appellees have heavy not their met burden of justification, or demon- State, strated that in pursuing legitimate objectives, has chosen means which unnecessarily do not impinge on constitutionally protected interests. Accordingly, judgment of the Supreme Court of Arizona is reversed and inconsistent for further action not the case remanded with opinion.
So ordered. Blackmun and Mr. Justice The Chief Justice concur the result. Douglas. Justice
Mr. care1 are aspects The economic of medical legal and I enormous; Equal doubt if decisions under the Fourteenth are Protection Clause of the Amendment equal to the task of with these matters. So far dealing I per travel se considered, interstate share Rehnquist. my present Brother case, doubts The however, prob- turns for me on a different axis. The many lem aspects. therapy has The atmos- Arizona’s phere many brings there who suffer from bron- asthma, chitis, arthritis, Many and tuberculosis. are coming or become indigent after arrival. Arizona does deny help medical to “emergency” cases “when immediate hospitalization necessary or medical care is preservation of life or limb,” Ariz. Rev. Ann. Stat. (Supp. § 11-297A 1973-1974). For it requires others, 12-month durational residence.
The Act is not aimed at interstate travelers; applies even to long-term resident who county moves from one another. As Supreme stated Court Arizona present case: “The requirement applies to all citizens within the state including long term residents of one county who move to another county. Thus, the classification does not single out non-residents nor attempt penalize interstate travel.
is uniformly applied.” 108 Ariz. 373, 375, 498 P. 2d 463. appendix opinion, post,
1 See to this p. 274. *18 poor What Arizona fence done, therefore, has out of the metropolitan Maricopa such as counties, County (Phoenix) County (Tucson) by and Pima use a durational requirement. We told that are eight Arizona counties no county hospitals have and that only most care in those on a areas exists contract In San Antonio Independent School Dist. v. Rod- basis. riguez, 1, we had a case where Texas created a scheme which school districts with low tax property base, from they could raise meager funds, offered a lower quality of education to their students than the wealthier system districts. That upheld was against the charge that system state violated Equal Pro- tection Clause. It a closely was divided Court I and was in I suppose dissent. if a State can fence poor in educational programs, can do so medical programs. But to allow Arizona carry freedom to for- ward its medical program we go must one step beyond San Antonio case. In the latter there was no legal barrier to movement into better district. aHere one- year barrier to medical care, save for “emergency” care, is erected around the areas that have medical facilities poor. for the
Congress has struggled problem. with the In the Kerr-Mills Act of 1960, 74 Stat. 42 U. S. §C. 302 (b)(2), provisions it added to the Social Security Act requiring Secretary'of Health, Education, and Wel- fare to disapprove any plan state for medical assistance to the aged “any that excludes individual who (Medicaid) resides the state,” thus eliminating durational resi- dence requirements.
Maricopa County has received $2 over million in federal funds for hospital construction under the Hill- Burton Act, U. S. C. 291 seq. et § Section 291c (e) authorizes the of regulations issuance governing op- *19 con- regulations The Hill-Burton facilities. of eration or facility to be constructed tain conditions that to be made available the funds “will modernized with appli- area of the residing in the territorial persons all reasonable render “a applicant will cant” and-that pay to therefor.”2 unable persons volume of to services however, indigents, for The conditions of free services from financial be waived if “not feasible viewpoint.” must obtain application agency
Prior to the the state applicant from the an “that there will be made assurance facility portion available in the thereof to be con- structed or modernized reasonable of services volume persons pay requirement to unable to therefor. applicant an assurance from an shall be waived if the applicant demonstrates to the satisfaction of the State subject by subsequent approval Secretary, to agency, requirement that such a from a is feasible financial viewpoint.” (c)(1).3 42 CFR § 53.111 I
So far as can the durational residence re- ascertain, quirement imposed by Maricopa County has not been federally approved as a condition Hill- receipt to the Burton funds.
Maricopa County does argue that it is not financially provide feasible to free nonemergency medical care to new residents. Even so, federal regulatory framework does not leave the uncontrolled in determining which indigents will receive the benefit the resources which are available. It clear, is for example, that County could hot limit service to such whites out of 2Title 42 (b) (8) 53.111 CFR defines term to mean § “a level uncompensated services which meets a need for such services applicant area served an and which within the financial ability applicant provide.” of such The waiver of such a requires notice opportunity and. public hearing. (c) (2). CFR 53.111 § of all races indigents service professed inability discrimina- such (c) prohibits because 42 53.112 § CFR It does facilities. operation tion of Hill-Burton transients. against not allow racial discrimination even are guided Hill-Burton Act donees Moreover, the crite- CFR 53.111 which sets out m some detail (g), § persons ria which unable identifying must used patient’s pay for such services. The criteria include personal and medical insurance and fam- coverage, health ily resources, income, obligations financial Maricopa “similar County, pursuant factors.” county employs length state law here resi- challenged, *20 indigent dence as an additional criterion in identifying recipients uncompensated nonemergency of medical care. recog- The federal do seem to regulations, however, nize that an acceptable criterion.
And, Thorpe Housing Authority, held in as we v. Service, v. 268; Mourning Family U. S. Publications 356, U. S. these to fed- federal conditions attached grants eral are valid when related to the “reasonably purposes of the enabling legislation.” at S., 280-281.
It is difficult to impute to of Congress approval durational implications for of requirement, such a decision would weighty protection involve equal Bolling considerations Federal Government, Sharpe, v. 347 U. S. as well States, as the bound. are political processes4
The protection rather than equal litigation are the ultimate of present prob- solution lem. But in the setting of case the invidious dis- against crimination poor, Harper Virginia Board 4 For the impact of private “free” on hospitals care and paying patients Dept, Health, their see Education, of and Welfare (HEW) Report on Medical Resources Available to Meet the Needs of Recipients, Public Ways Assistance House on Committee and Means, Cong., (Comm. 86th 2d 1961). Sess. Print inter- travel not the Elections, U. critical issue. my in view the state, DOUGLAS, J. OF OPINION APPENDIX TO and Food—A Fable5 Gourmand They ate good loved Gourmand people food. research, cooking restaurants, money in donated good for matters all safeguard government their instructed industry Long ago, the do with- having to food food. restaurants, many chaos. There were had been total Anyone could call very some small. chef himself restaurant, one could choosing a restaurant. In open A commis- good. meal would be never be sure that the sion distinguished studied the situation chefs recommended that no one be to touch allowed food qualified “Food to be except important is too for chefs. amateurs,” they Qualified were said. left chefs licensed by penalties anyone with severe state engaged cooking. else who were exceptions Certain preparation made person but a home, for food could family. Furthermore, serve his own qualified chef, become a man least complete had to twenty-one years training (including years four *21 college, years cooking school, one year and four of of All apprenticeship). cooking schools had to be first class.
These did in raising succeed the quality reforms of cooking. But a restaurant meal became substantially expensive. more A second commission observed not everyone could to eat one,” out. “No they afford said, “should be denied good a meal because his of 5Foreword to an article on Medical Care Delivery: and its An Appraisal Economic Judith R. Lave and Lester B. Lave in 35 Contemp. & Law Prob. should argued that Furthermore, th&y
income.” chefs “complete goal everyone giving work toward the of physical For those psychological and satisfaction.” out, government to people who could not eat afford declared that should be allowed to do so they as often as they government liked and would For pay. it them- others, they organize was recommended that groups selves in and pay part pool into their income of that would undertake mem- pay to the costs incurred by dining greatest bers out. To insure satisfaction, groups were set so member up that a could eat out anywhere liked, and as he could as have elaborate often desired, a meal as he and nothing would have to pay percentage small the cost. joining The cost such prepaid dining clubs rose sharply.
Long ago, most restaurants would have one chef prepare the A restaurants were more elabo- food. few rate, salads, with specializing roasting, fish, chefs sauces, things. and other many rarely People went these elaborate restaurants since were they expensive. so With the clubs, establishment prepaid dining everyone wanted eat at these fancy restaurants. At the same young time, going school disdained cook in chefs small restaurant they where would have to cook every- thing. higher The was pay and pres- much more was tigious to specialize cook at a really fancy restaurant. Soon there not enough were to keep the small chefs open. restaurants
With prepaid clubs and many meals the poor, free for people started eating their three-course meals elaborate restaurants. they Then began to increase the number courses, directing the to “serve the chef best thought with no the bill.” (Recently a 817- course meal was served.) eating costs out rose A new faster faster. *22 (1) Noting reported as commission
government follows: potatoes being peel used to were licensed that chefs that these recommended lettuce, commission wash (whose licensed dishwashers over to be handed tasks cooking training included dishwashing years three of courses) Con- (8) category personnel. or some new of overworked, were cluding many that licensed chefs be ex- cooking recommended that schools commission length training shortened, and that panded, of be admitted. qualifications that with lesser applicants also that were (3) The commission observed chefs people to be more concerned unhappy because seemed about the decor and service than about (In food. test, could one not tell patron recent taste vintage between a 1930 and but he difference distinguish also could not between white and red wines. explained vintage He he ordered always that the 1980 only really good because he knew that would restaurant expensive stock such an wine.) agreed weighty commission that problems faced the nation. They recommended pre- that a national payment group be established which everyone join. must They recommended that continue to be on paid chefs the basis the number they dishes They prepared. recommended every given Gourmandese be anywhere to eat he chose and as elaborately as he chose and pay nothing.
These recommendations were adopted. Large num- bers people spent all their time ordering incredibly elaborate meals. Kitchens became marvels new, expensive equipment. All those who were not consum- ing restaurant were in the kitchen preparing it. food Since no one in Gourmand did anything except prepare meals, eat the country collapsed. *23 Rehnquist, dissenting.
Mr. Justice
I free for provides The of Arizona medical care State indigents. in common with its 49 sister Confronted, with and welfare spiraling the assault health States, limited felt upon costs state it has bound to resources, require recipients of eligibility.1 three standards meet they First, indigent, unemployable, must be or unable provide they their own care. must be resi- Second, in Third, dents of the aid. county they seek they period must have maintained their for year. apply one standards, however, These persons seeking exception An is nonemergency aid. specifically provided for immedi- “emergency cases when ate hospitalization is for the necessary or medical care preservation life . or limb . . .”
Appellant Evaro moved from New Mexico to Arizona suffering June 1971, from a “chronic and asthmatic bronchial illness.” In July experienced 1971 he respiratory attack, and obtained facili- treatment appellant ties of Hospital, Memorial a privately operated (Supp. Rev. 1973-1974) 1 Ariz. Stat. 11-297A Ann. reads as § follows: emergency
“Except hospitalization cases when immediate or necessary preservation medical care is of life or limb no person provided hospitalization, outpatient shall medical care relief provisions under filing of this without first with a article supervisors member of county the board of of the in which resides he writing, a statement oath, subscribed and sworn under that he an shall regulations be defined rules and department state security, unemployable totally economic an dependent upon county government the state or sup- for financial port, employable or an of sworn low income without funds sufficient provide necessary hospitalization himself care, and medical that he county has been a resident of the preceding for the twelve months-.” expenses hospital to recover sought
institution. its Maricopa County appellee provisions from under the Ariz. Rev. Ann. (Supp. 1973-1974), § Stat. 11-297A county asserting that Evaro was entitled to receive care. he satisfy eligibility requirements Since did not dis- above,2 appellee responsibility cussed declined to assume care, for his suit was instituted in the then Superior Court. *24 there is
Appellants not, not, did and could claim that nonemergency constitutional medical care at right county expense state or right a constitutional reim- by private hospital.3 bursement for extended care They asserted, however, that having the state legislature, give decided to free care to persons, certain classes of must give that care to upholds Evaro as well. The Court that claim, holding eligibility that Arizona requirements burdened Evaro’s “right to travel.” many
Unlike traditional such government services, police or fire protection, care provision health has commonly been by per- undertaken private facilities and private sonnel. But as strains on become services and greater, care obtaining costs increase, federal, state, governments and local been pressed have to assume larger Reasonably role. enough, me, it seems to those governments which now hospital find in the themselves operate seek to that business primarily business for those 2 parties stipulated that Mr. Evaro was “an who recently changed his residence from New Mexico Arizona and who resided in the state of has Arizona for less than twelve months.” App. 10. Therefore Mr. Evaro failed to meet the third discussed in text. This has noted that have citizens no constitutional See, g., welfare e. Dandridge benefits. v. Williams, U. S. (1970); Independent San Antonio School Rodriguez, Dist. v. U. by both financing locality persons dependent on the association need. argue case nevertheless
Appellants are be, efforts, though they may admirable State’s excluded impressive But others simply enough. sim- by eligibility requirements certainly could make many protests. Maricopa ilar residents of paying support public years, taxes to both construct hospital facilities, be for their may ineligible care because slightly marginal are for inclu- incomes above level sion. These people have been excluded the State, on public not because their claim limited resources merit, without but because it has been deemed less meri- torious than the need. greater claims those even today’s Given a finite amount Arizona resources, after decision well conclude that indigency its threshold should elevated provide since its counties must migrants out-of-state as well longer as for residents These standing. stringent more need requirements deny would then care persons to additional who until now *25 qualified would for have aid. presently
Those excluded because above marginally indigency may State’s those standards, who be excluded in the because of more future indi- stringent gency requirements by today’s necessitated decision, appellant Evaro, have plausible all govern- claim to ment-supported medical care. choice The between them by a necessitated finite amount of a classic resources is example of determination of priorities to accorded be and would in conflicting claims, past recent have been be a thought particularly to matter compe- within the tence of the state to legislature decide. As this Court Dandridge Williams, stated in U. S. “the
(1970), Constitution empower does not Court this to second-guess state officials charged with the difficult funds welfare public limited allocating
responsibility potential recipients.” myriad among barred was that the State holds, however, The Court bur- because it made the choice making from to travel.” “right placed upon Evaro’s den its choice hardly “right” definition this the Court’s Although right interstate does state: precise, the Court “[T]he residents the same insuring new must be seen as travel in the privileges benefits and right government vital other enjoyed by they migrate to which as are States This merits further attention. residents.” rationale
II to travel the Nation been right throughout has century of this for over a in the decisions recognized Nevada, Court.4 See Crandall v. Wall. concept right
But the of that has not been static. To right see how distant a cousin the to travel enunciated right this case is to the declared Court Crandall, reference need language made to the speaking Mr. Justice Miller, Court: “But if government rights has these on her own account, the citizen rights. also correlative He has has to come right to the seat of government any may claim he upon assert govern- have any or to ment, transact business he have with it. To protection, seek its its share offices, engage administering its functions. He has right to free access to its sea-ports, through operations all the of foreign trade and commerce are 4 Although to travel recognized has been *26 century, origin right over a the of the still remains somewhat majority opinion obscure. The in this case makes no effort identify source, simply relying the on recent cases which state such right a exists. offices, land sub-treasuries, to the conducted, justice and courts of offices, revenue in its nature inde- and this is right several States, he any whose soil pendent of will of over State Id., 44. pass must in the exercise it.” no to free right Crandall The Court established the traveler every through from benefits might modestly the State could pass, but more held that power not use travel its taxing impede its across borders.5 con- quite
Later also defined this to travel right cases servatively. Fears, v. example, For Williams 179 U. S. 270 (1900), upheld a statute Georgia taxing the Court out- “emigrant agents” persons for work hiring labor — side the although agents hiring for local work State — went untaxed. The Court recognized right travel existed, stating:
“Undoubtedly right right locomotion, place remove from one according to another to incli- personal an attribute of nation, liberty, and the ordinarily, of right, free from or through transit territory any State is secured the Four- teenth and by provisions Amendment other Id., Constitution.” at 274. on, Court went however, to decide that the statute,
despite the cost added against exported assessed labor, affected freedom of egress “only incidentally remotely.” Ibid.6 The tax upon levied State of every person Nevada was
leaving the noted, State. As Court has since the tax was a direct tax on travel was charge intended to be a for the use Airport state facilities. See Evansville Airlines, Delta 405 U. S. rejected The Court equal protection also an argument, conclud ing: say “We are unable to that such discrimination, if it existed, *27 California, Edwards v. case, earlier leading
The the support little equally provides (1941), U. S. Court Edwards the In here. holding expansive Court’s to crimi- subjected which statute a California invalidated in bring- or assists brings “that any person nal penalties not a is who any person indigent the State ing into indigent him to be an knowing State, of the resident found Id., of the 171. Five members at person.” Clause, Commerce under the unconstitutional the statute attempts on against “prohibition finding in the Clause diffi- itself from to isolate any single the State part the trans- restraining by to all of them culties common borders.” property across its portation persons and a better Id., concurring found at 173. Four Justices result in the Fourteenth Amendment’s justification for the citizenship.”7 “privileges the of national protection of definition, and right’s precise source Regardless the invalidated in Edwards was it is clear that statute per- and deter specifically designed would, indigent to, imposi- the of California. The entering from sons penalties persons assisting tion of criminal on all the surely entry indigent ingress of an served to block as posted had at border to turn guards if the State the away. operation It made no difference to the indigents indigent, statute that once the State, inside by supported payments.8 would be federal Furthermore, grounds, did not rest on reasonable was within the discretion legislature.” S., state 179 U. 276. at Douglas concurring opinions (with of MR. See whom Justice Murphy joined), S., Mr. Justice Black and Mr. Justice 314 U. at Jackson, id., Mr. Justice at 181. 8The Court in Edwards arriving observed: “After California indigent] Security was aided Administration, Farm [the wholly government.” ... financed S., Federal 314 U. express at 175. The Court did not a view that time as to whether a different result would have been reached if State bore the finan Shapiro cial burden. But v. Thompson, cf. intend require did not statute up residence within the State. take continuous remote barrier not therefore an incidental or statute was an purposeful effective and but fact migration, was *28 from attempt indigents. insulate present comparable no The statute case raises desiring to Admittedly, indigent persons barrier. some may possible reside in Arizona choose to detri- weigh the their care ment of own health providing nonemergency the total during against first of their residence year location gained benefits to be from within continuing State, entry but their mere into the State does penalties. invoke criminal To the contrary, indigents are State, free live within the welfare bene- receive necessary fits for food shelter,9 and to receive free emergency medical care if needed. once Furthermore, the indigent has a for county year, settled within a he becomes for full eligible county medical care expense. at To say, therefore, indigents Arizona’s treatment of compares with California’s during treatment the 1930’s would border on the frivolous. those
Since older cases discussing right to travel unhelpful are to Evaro’s cause here, reliance be must placed A elsewhere. careful reading Court’s opinion discloses that entirely decision rests almost on two cases of recent vintage: Shapiro Thompson, U. S. 618 and Dunn v. (1969), Blumstein, 405 U. S. In Shapiro the Court struck down statutes requiring one year’s prior residence to receiving welfare In Dunn benefits. the Court struck down a statute requiring year’s a residence before receiving the right to In vote. placing reliance on these two cases, the Court Ariz. See Rev. Stat. (Supp, 1973-1974), Ann. § 46-233 provides that eligible recipient general an assistance must have “established at the application.” residence time of necessarily recent cases distinguish
must
discredit
year’s
upholding
requiring
this
statutes
important question for lower in-state tuition.10 The
analysis,
Court’s
is whether
according
purpose,
“ 'operates
penalize
persons
a classification
to'
those
. . .
who have exercised their constitutional
of interstate
”
(Emphasis in
migration.’
opinion.)
Court’s
the Court concedes that
'waiting-peri-
Since
“some
”
.
penalties,’
ante,
. .
not be
one
258-259,
od[s]
expect
would
opinion
distinguish
to learn from the
how to
waiting period
penalty
which is a
from one which is
Any expense imposed
not.
crossing
on citizens
state
lines but not imposed
put
on those staying
could theoret-
ically
deemed
penalty
on
the toll
travel;
exacted
persons
from
crossing
from
Jersey
Delaware to New
inter-,
the Delaware Memorial Bridge
“penalty”
is a
on
*29
state travel
in the most literal sense of all. But such
charges,11 as well as
transportation
other
fees
use of
facilities such as
on airport
taxes
been
users,12 have
upheld by this Court against
upon
attacks based
the
right
to travel.
It seems
me
that
the line to be
derived from
prior
our
cases is that some
im-
financial
positions on interstate travelers have such
indirect
inconsequential
impact on
they
travel
simply
that
do
not constitute
type
of direct purposeful barriers
struck down in Edwards and Shapiro. Where the im-
pact is that remote, a State can reasonably require that
the citizen bear some proportion of the State’s cost in
its
I
facilities.
would think that
this standard is not
only supported by this Court’s decisions, but would be
10
Starns Malkerson,
See
v.
326
Supp.
(Minn.
F.
234
1970), aff’d,
401
(1971);
U.
S.
Kline,
v.
Vlandis
412 U.
441 (1973).
S.
11See,
g.,
e.
Interstate
Corp.
Busses
v. Blodgett,
“Whatever ultimate parameters it medical is at clear that penalty analysis, least indi- necessity is as much basic to an care ‘a life’ gent governmental And, assistance. welfare privileges or benefits to basic sustenance necessary often being greater have been viewed as consti- significance tutional than less essential forms of g., Shapiro, e. governmental See, entitlements. supra; Goldberg Kelly, 254, (1970) ; v. S. U. Family Sniadach v. Corp., Finance 395 U. S. Ante, (1969).” 340-342 (Emphasis added; at 259. omitted.) footnotes
However clear majority, this conclusion be to the certainly not clear to me. solicitude the Court has involving shown cases vote,13 denial entry virtual inherent in denial of welfare very benefits —“the live,” means which to Goldberg U. Kelly, 397 (1970) ought— be so casually extended to alleged deprivation here. Rather, examine, should as it has done past, whether the challenged requirement erects a *30 purposeful real and barrier to movement, or the threat barrier, such a or whether the effects on travel, viewed realistically, merely are incidental and remote. As the above discussion shown, has the barrier hardly here is 13See, g., Cornman, e. Evans v. Cipriano 398 419 (1970); U. S. v. City Houma, S. earlier cases. condemned to the barriers counterpart a traditional its observe so, the Court should being That financial of its limited respect for the State's allocation its own imposing unjustifiably than resources rather preferences.
Ill state proffered Court, its examination that those the contention categorically rejects interests, time fixed county period who have in the resided facilities than greater community stake in may have a rejection accomplished newly But arrived. by by principal more than One of the factual fiat reason. Malkerson, Supp. v. 326 F. between Starns distinctions (Minn. 1970), (1971), aff’d, U. S. 985 Kline, Vlandis U. both of which (1973), upheld requirements durational for in-state university tuition,14 Shapiro, which struck them down for welfare is the nature of the aid which recipients, county provides. State or benefits, Welfare whether in cash in kind, or are from commonly funded current tax revenues, which supported very well newest arrival as well as longtime resident. But universities and hospitals, although demanding operat- ing support from current revenues, require extensive capital facilities which cannot possibly be funded out of current tax revenues. Thus, entirely apart from the majority’s conception of whether nonemergency health care is more less important than continued education, 14 Vlandis, In striking while down a Connecticut statute effect prevented a new state resident obtaining from lower tuition rates for period the full enrollment, we stated that the decision should not “be construed deny impose on a student, as one element in demonstrating residence, bona fide reasonable durational residency requirement, which can be met while in student status.” 412 S.,U. at 452. Starns support was cited as position. for this *31 capital in residents established longer of the interest to the contribution financial greater their facilities and indisputable.15 seems such facilities construction support its by the State Other interests advanced virtually rejected are also statutory eligibility criteria county The protection out hand the Court. that “[t]he economies is dismissed with the statement a suffi- not simply taxpayers’ purse conservation out that points .” Court cient state interest . . . The Government, may be if care, the cost of not borne Memorial by private hospitals appellant borne such as in Hospital. true observation is doubtless While this large problem any part, present and is bound to private to me that thus hospital, it does seem becomes determinant. The Court also constitutional money by may pro- observes that save fact viding waiting medical nonemergency care rather than deterioration an illness. However valuable a qualified analysis might cost to legislators drafting be eligibility requirements, and this specu- however little lation may bear on (which Evaro’s condition record does not indicate to deteriorating have been a illness), this sort of judgment has traditionally been confided legislatures, rather than to courts charged with de- termining questions. constitutional
The rejects likewise all arguments based on 15This distinction particularly important in a State such as Arizona where the provides Constitution for limitations on state and county Const., debt. (State); See Ariz. Art. Art. § (County). generally Comment, Dulling Edge See §8 of Hus bandry: Special Arizona, Fund Doctrine in 1971 L. & Soc. (Ariz. J.) O. St. L. 555. 16The appellees in this case filed an indicating affidavit acceptance appellants’ position impose would an added burden property taxpayers on Maricopa $2.5 of over million year first alone. App. 12-17. the asser- accept Refusing objectives. administrative *32 rule “convenient period is a one-year waiting that a tion majority the residence,” fide determine bona to of thumb analysis is alternatives. Similar own simply suggests its the based on argument appellees’ in applied rejecting an that declaration for fraud. potential The Court’s could as fraud, committing on applicant “intent county for been a resident easily having to swear currently” ignores year being one preceding for State fabricating presence obvious fact that fabricating year surely more difficult than is remain. present intention to simply whether case is legal question The arbitrarily determining acted of Arizona has medi- nonemergency hospital to local facilities access they have persons denied to until cal care should be impediment The year. established residence for one on placed quite which this rational determination has appellant “right Evaro’s to travel” is so remote as so far as the record indicates Evaro moved negligible: years and has ago from New Mexico Arizona three remained ever has eligibility since. not the resemblance to the actual barriers to slightest ingress protected of free and Con- egress and down in Crandall struck cases such as stitution, an And, Shapiro, Edwards. unlike it does involve need for the necessities of life or a benefit funded urgent from current revenues claimant well contributed. It a substantial broadening have of, all departure from, of these all the remark- holdings, more explanation able for the lack of which accompanies the I can result. Since subscribe neither to the method I nor result, dissent.