*1 HEALTH AND HUMAN OF SECRETARY SCHWEIKER, v. WILSON SERVICES еt al. March 2, 1980 Decided Argued December
No. 79-1380. *2 J., opinion delivered the the Court, in which Blackmun, Burger, J., JJ., joined. C. and and J., Stewart, White, Rehnquist, Powell, dissenting filed a opinion, in which Brennan, Marshall, Stevens, post, JJ., joined, p. 239. Elliott argued Schulder the cause for appellant. With him on the briefs were Solicitor General McCree Deputy Solicitor General Getter. D.
James Weill argued the cause for appellees. him With on the Lehrer, brief were Robert E. Smigelskis, Marianne R. and Thomas J. Grippando.* opinion delivered Court.
Justice Blackmun issue constitutionally case is whether may decline to grant Supplemental Security Income benefits otherwise eligible class who are excluded individuals they aged through 64 and are institutionalized in public mental institutions that do not receive Medicaid funds for their care. The United District Court for States the Northern District Illinois held unconstitutional, * Briefsof amici curiae urging Abrams, by affirmance were Robert filed Attorney York, Shirley General of New Siegel, General, Adelson Soliсitor Rubinstein, Alan W. Harvey Attorney III, Assistant Bartel General, and Attorney General of Pennsylvania, al.; by for the State et of New York Judy Greenwood, Margaret F. Ewing, and Paul R. Friedman for the National Association for Mental ah; Health et A. William York, Carnahan for the New Pennsylvania, and Associations of California Psychiatric Hospitals. Private of the Fifth Amendment, portion
the Due Process Clause amended, Security Act, of the Social excludes these supplemental eligible persons from the otherwise benefits. Human Secretary of Health and Services has taken a under 28 U. appeal direct to this Court C. § S:
I 1972, Congress In amended Social Act Security October Security Supplemental (Act) create federal Income January 1, 1974. 86 Stat. (SSI) program, effective seq. et program C. This was intended U. S. “[t]o age, cannot blindness, assist those who work because disability,” p. 92-1230, (1972), “set[ting] guaranteed aged, blind, Federal minimum income level for *3 id., persons,” 12.1 and disabled SSI program provides a subsistence under аllowance, needy
federal to the standards, aged, blind, Nation’s and category disabled.2 Included within the under “disabled” any in program engage are all those “unable to substantial gainful activity any medically reason determinable physical or to impairment expected can be which Act, largely program, Security re
1 The SSI Title of the XYI Social placed prior system grants programs of federal assistance state-run aged, XIV, blind, I, and X, and disabled Titles XVI contained in Act, is, Assistance, 620, amended, 42 Age of the Old as 49 Stat. seq.; 645, amended, 42 Blind, U. S. et Aid C. to the 49 Stat. as §301 seq.; Permanently Totally Disabled, 1201 64 U. S. C. et Aid to the § seq.; Aged, amended, as to the Stat. 42 and Aid U. C. 1351 et S. § ed.). seq. (1970 Blind, Disabled, et or 76 Stat. 42 U. C. 1381 S. § Torres, Aznavorian, 435 (1978); ano ano 439 171 U. S. Calif Calif U. S. 2 2 is, 65 eligible “aged,” that person To be must be benefits, for SSI 1614 older, defined “blind,” “disabled,” or or or as terms are § those Act, amended, and resources 1382c, as his income U. S. C. § amended, 42 C. U. S. (a), specified must be below the as levels § (a). §1382 expected or can be or lasted to last in death which has
result period of not less than twelve months.” for a continuous S. 1382c Act, (a)(3)(A). § C. (a)(3)(A) U. § 1614 reach, coverage in its its program SSI is broad Although very program complete. inception, From its is anyone who an “inmate eligibility from of a excluded (1) (A) Act, amended, institution.” as from (e)(1)(A).3 program’s Also in- U. S. C. partial exception ex- ception, Congress has made a clusion providing money (not exceeding a small amount per any eligible person $300 in “a year) hospital, otherwise extended facility, nursing home, care or care intermediate facility respect receiving payments (with to such individual spouse) or State plan approved subchapter under a XIX ...” as (e)(1)(B), § 1611 amended, [Medicaid] §C. (e)(1)(B).4 thus, excluding while (e)(1)(A), amended, provides: Section 1611 as “(e) eligibility Limitation on of certain individuals
“(1) (A) Except provided subparagraph (B) as (C), person eligible shall be an eligible spouse purposes individual this sub- chapter respect any with throughout month if month he is an such inmate of a institution.” (e)(1)(B), 4 Section 1611 (e)(1)(A), as amended, modifying §1611 amended, states: “(B) (if In spouse case where an eligible eligible individual or his any) is, throughout any month, hospital, facility, in a care nurs- extended *4 ing home, (with or facility receiving respect intermediate care payments to such spouse) individual or plan approved title under a State XIX, the benefit under this title month shall for such for such individual payable— “(i) by at a in year (reduced $300 rate not excess the amount per of any of pursuant income (b)) not excluded of an to section 1612 in case individual who eligible spouse; does not have an
“(ii) in the of an if one eligible spouse, case individual who has month, of them is in hospital, facility such a throughout home such or not in rate excess of the sum of— “(I) any income, per year $300 the rate (reduced by of of amount
225 institution, explicitly public in a generally any person residing SSI of to eligibility for a reduced amount has tied benefits benefits for the receiving Medicaid in an institution residence eligible individual. care challenge de-
Appellees brought resulting this this suit having the limited assistance Congress’ of conditioned tail person ages for between the grant eligibility Medicaid: a 21 through 64 resides in a mental institution of who though not to receive eligible stipend, is small even this requirements person eligibility the other for SSI bene- meets fits, treatment in institution for a person in bracket not funded age under Medicaid.5 pursuant (b), not excluded section of the one in who is such home, hospital, facility), or
“(II) applicable specified (b)(1) (reduced by rate in subsection any the amount income, pursuant (b), of not excluded to section 1612 other); “(iii) year (reduced $600 at a rate per not in excess of the amount pursuant (b)) income not excluded to section the case of eligible spouse, an individual who has an if both them are such a home, facility hospital, throughout such month.” (C) implicated Subsection (e)(1), case, not further in this §1611 (e)(1)(A), modifies amended, by providing: §1611 “(C) in subparagraph (A), As used ‘public the tеrm institution’ does publicly include operated community more residence which serves no than residents.” Added 94-566, in 1976 (a), Pub. L. this subsec- Stat. § objections
tion met impeded reform de-institu- efforts to § groups tionalize certain handicapped individuals, such as the retarded. encourage determined of state- the establishment group run for people by homes such making residents these institutions eligible for SSI Rep. 94-1265, (1976); benefits. See p. H. R. pp. Conf. No. 94-1745, 27-28 5Federal funds pay program available under the Medicaid following (other “residential” “inpatient hospital services: services than in an services diseases),” institution for tuberculosis or mental § (a)(1), 42 (a) U. S. (1); C. 1396d nursing facility services “skilled (other than services in an diseases) institution for tuberculosis or mental years individuals age (4) or older,” (a) (A); “inpatient *5 226 of as violative statutory classification attack this
Appellees Amendment’s Fifth component protection equal in the Dis challenge, successful Their Process Clause. Due they argue exclusion First, is twofold. Court, trict disabled) persons therefore mentally (and ill of class of their of any legitimate objective relationship no rational bears their fact, in class was They assert, program. the SSI political powerlessness. of its inadvertently excluded they insist that because Second, 6, 32. Appellees Brief for illness, of mental a factor on the basis statute classifies services, nursing facility and intermediate care services, hospital skilled age facility years of or over in an institution individuals services for diseases,” (a) (14); “intermediate care mental for tuberculosis or (other facility in an institution for tuberculosis services than such services (a) diseases) care,” such or mental for individuals ... in need of (15); “inpatient psychiatric hospital services for individuals under certain 21,” (a) (16) (h). (17) (B) (a), age Subsection §1905 §§ provides any recog- funding for remedial care which other medical or “payments respect law, specifically nized under state excludes with years age care оr services for individual has not attained 65 who patient and who is a in an institution or mental diseases.” for tuberculosis 1950, assistance, In when Con- grants it first enacted federal for medical gress “any patient excluded individual . . . . . who is a in an institution . eligibility. mental diseases” from incor- exclusion was Stat 558. This porated 352, exceptions into the Medicaid statute in 79 Stat. but needy institutions, were made for the aged in for the care mental mentally persons general ill in the In medical facilities. Ibid. enacting bill program, the SSI bene- Medicaid further broadened mentally fits for the ill to include most children mental institutions. 86 Stat. 1461. A proposal Senate projects to investi- demonstration gate possibility extending be- Medicaid ill benefits to the ages tween the of 21 through 64 hospitals defeated at that was time. See S. 92-1230, p. (1972); Rep. No. Conf. H. R. 92-1605, p. 6 This repeatedly Court imposes has held that the Fifth Amendment on the Federal Government required legisla the same standard state Equal tion Protection See, Clause of the Fourteenth Amendment. g., Weinberger e. Salfi, (1975); S. 768-770 Richardson v. Belcher, *6 other that this
greatly resembles characteristics Court has inherently “suspect” as a means found classi- justification required be for con- fication, special should appellees. to gressional decision exclude
II
history.
complex procedural
had a
This case
somewhat
It
in December 1973 as a class action
initially was instituted
injunctive
declaratory
for
relief to
the federal
challenge
prior
prevailed
to,
and Illinois
schemes that
assistance
Edelman,
SSI
Wilson v.
program.
effective date of the
See
(CA7 1976).
then-existing
542 F.
The
2d
1263-1266
state
for
re-
program,
assistance
which federal funds were
ceived,
eligibility any
excluded from
who
person
residing
was
in a
mental or
institution or
con-
tuberculosis
who was
Id.,
penal
fined
at
n. 2.
plain-
institution.
The
tiffs later
complaint
challenge
amended their
include a
Id.,
the SSI exclusion, which
then
into
by
had come
effect.
three-judge
at 1266. A
court
under 28
was convened
U. C.
§§2281 and
(1970 ed.) (since
Pub. L. 94-
repealed
§§ and
1119).
consolidated
Stat.
The case was
with another that challenged
exclusion from SSI
benefits
of any pretrial
Relying
Weinberger
Salfi,
detainee.
on
On abandoned their the prior claims federal Id., statutes. Court States United three-judge court also found that state statute classified on age, basis health, was and constitutional. rational Appeals The Court of declined holding review that on constitutional ground review from the three-judge court could had Edelman, Wilson Court. 2d, F. at 1276-1282. dismissal, reversed the for the Seventh Circuit hold- Appeals Patricia ing Secretary (then Harris) had waived that the by her submission of the requirement of exhaustion case Id., summary disposition.8 at 1272. the District Court request their plaintiffs dropped injunctive Because the had to the single-judge was remanded District Court. relief, the case Id., court, remand, certified the class at 1269. That holding granted summary judgment, motion for appellees’ *7 members the (e)’s equal of the class violated § 1382 exclusion of the Due Process Clause the Fifth guarantee protection Harris, Ill. Sterling Supp. (ND 478 F. Amendment. 1979) .10 The District Court reasoned that the statute “creates (1) age, public, three classifications: residence in a (2) and Id., (3) It hospital.” health at 1050. ruled that mental justified only by first two need be Congress’ use factors only Appeals plaintiffs, The Court of also held that two the named Turney, minimum, Maudie Simmons and John Kiernan had satisfied the requirement may (g) party nonwaivable of 42 U. S. C. 405 that a seek only Secretary” denying, terminating, of a “final decision of the review suspending program. plaintiffs, the SSI The other named benefits under denied, including Wilson, eligible for, sought or had and been Charles were prior programs, only cooperative benefits under the state-federal they parties. therefore were dismissed as have as a We retained Wilson case, however, party caption in did the District named of this as remand, uniformity. Court for the sake of persons residing Region The class was defined as “all in V who HEW XVI, applied have been terminated from benefits or who have under Title Supplemental Security have XVI and been Income benefits Title they benefits, January 1974, solely such denied on or after ages hospitalized of 21 institu between and 65 and App. tion.” to Juris. Statement 21a. denied, however, pretrial The District of the detainees Court claim monthly stipend, applying relation” standard find “rational ing necessarily the exclusion rational detainee status is because “[t]he temporary nature, [Secretary] legitimately could wish with hold these in a payments extra-subsistence while the detainee housed Supp., institution F. and until his future status is determined.” 478 at 1055.
demonstration of their relationship” legitimate “rational to “a state interest.” Ibid. Under that standard, these classifica- scrutiny. tions withstood Congress’ use, however, a “mental require health” classification was a closer deemed examina- tion because “mental health classifications possess signifi- cant of the suspect recognized indicia classifications other Id., Although cases.” at 1052. recognizing that the mentally ill as group do demonstrate all the characteristics this Court has considered as denoting inherently suspicious classifi- such cations, as race and origin,11 national the District Court mentally believed that the ill politically were “a in- impotent, minority” sular subject ‘history that “have been to a un- ” equal protection.’ Ibid. The court therefore concluded legislatively could disfavor the ill, 1611 (e) did, statutory if the passes classification “intermediate level of judicial scrutiny,” id., is, only if the “classification bears relation” to the a substantial object legislation of the “in light primary evaluated purpose” of the scheme of part. which it is a Ibid. The court adjudged “primary the small purpose” of *8 monthly stipend was needy purchase to enable the comfort to provided by items the Rejecting the Secre- institution. tary’s proposed justifications for exclusion,12 the the District scrutiny. Court held that the classification could not withstand problem, person’s The District Court noted that health especially one institutionalization, likely that has led to ‘"bear to [a] is ” ability Id., perform to society.’ relation to at 1051- to contribute Frontiero 1052, quoting Richardson, The v. U. S. acknowledged also court that and to what is debatable whether “[i]t solely extent the mental illness is an ‘immutable determined characteristic Fron quoting the accident of Supp., again birth.’” 478 F. tiero, S., at 686. Secretary argued The statutory purposes: that three has exclusion “1) 2) resources; conservation of federal that federal funds the concern qualified institutions; 3) on the fact received behalf residents of plaintiffs ‘similarly in terms patients that are not situated’ with Medicaid of federal interest and control.” Supp., at F. to said, revealed intent exclude history, “possible of no could conceive un- court class; the
appellees’
the court
exclusion”;
reasoned
purpose
expressed
of all
institu-
inmates
and disabled
“aged, blind
Upon
Ibid.
Secretary’s
needs.”
similar
would have
tions
probable jurisdic-
noted
this
we
judgment,
from
appeal
direct
Wilson,
Ill
A imposed the Due Process equal obligation protection obligation provide not an of the Fifth Amendment Clause necessary possible. This is a result governance the best its competences, different institutional reasons obvi- a classification that is inher- employs ous. Unless a statute ently impinges rights, or that fundamental areas invidious judiciary duty in which the then has intervene properly democratic this a limited process, Court exercises power Congress, appropriate representative review over body through which the choices democratic makes problems. alternative solutions social and economic among See San Rodriguez, Antonio School District v. 411 U. S. (1973). At level, consistently the minimum Court required classify legislation persons it affects manner rationally to legitimate objec- related governmental Williams, See, g., Dandridge tives. e. (1970); S. 471 Mathews v. De Castro, 429 181 (1976). Appellees U. S. assert particular grant of federal benefits under review however, here, subjected heightened should “be to a standard review,” Brief for Appellees 39, because the ill “historically have been subjected purposeful unequal treat- ment; they have been relegated position political to a *9 powerlessness; and prejudice against par- them their curtails ticipation in the pluralist political system strips them political protection against discriminatory legislation.” (Footnote omitted.) Id., at 41. this
We have occasion to reach issue because we conclude classify directly this statute does not the basis of distinguishes program mental health.13 The SSI among three groups of all of whom meet persons, the basic eligibility re- quirements: not in a persons “public institution” may re- ceive full benefits; persons “public in a institution” of a cer- tain nature (“hospital, facility, extended care nursing home, or facility receiving intermediate care payments (with respect to such [Medicaid])” or . . under spouse) (em- individual . phasis added), may (e)(1)(B), receive reduced bene- fits; any persons “public may other institution” receive benefits. statute does not the men- isolate tally subject ill or as a discrete them, group, special At subordinate treatment. the most, legislation inci- dentally monthly denies a small comfort benefit to a certain persons number of suffering illness; from mental but in so it doing imposes equivalent deprivation groups on other who mentally are not while at the ill, benefiting same time sub- numbers of the mentally stantial ill. group singled thus out for special treatment not entirely mentally does exclude the In fact, ill.
includes, proportiоn population in a sizable re the total ceiving benefits, SSI ill large mentally people.14 numbers of applies We therefore intimate no view as to of review what standard legislation expressly classifying group. discrete ill as a Security Social Administration of all blind statistics show that 30.7% persons and disabled adult (109,509 persons) awarded benefits in SSI disorders, were deemed disabled con and the Administration disability cluded that illness was the most common cause of “[m]ental Kochhar, Federally 1975.” Ad Blind and Disabled Awarded Persons Payments, 1975, (June ministered SSI Security Social Bulletin 1979). Half of this number men suffered rather than from mental illness retardation, tal any persons prior these statistics did not with include Ibid. entitlement to benefits. Further, study as a recent indicates, also of men- a substantial number tally people actually ill in institutions Social Secu- receive SSI benefits. rity Administration, Representative Payments Program, the SSI *10 appellees’ congruent with is not excluded Further, group any of inmates other are the excluded those Among class. prison, penal a other institution,” such as “public nonmedical program funded residential publicly institution, other and residing a tuberculosis persons operate;15 may the State not institution certified of a medical institution; residents and Although not the same sub provider.16 as a Medicaid from eligibility to exclude SSI chose section, also Congress not drug or addiction and persons with afflicted alcoholism (A), persons treatment, (3) and who undergoing § States, specified outside the United spend more than a time Asnavorian, ano v. (1978) S. 170 (f). U. § 1611 See Calif Tones, ano constitutionality (f)) ; (upholding § 1611 Calif constitutionality Congress’ (1978) (upholding Rico). Puerto eligibility from SSI residents of exclusion (e), not Thus, § 1611 made a distinction between composed .nonmentally ill, ill and a but group in public receiving between residents institutions Medicaid August 1977, 16, 1980). (Sept.. Research and Statistics Note No. 9 study population receiving This established that of the total SSI 15% (for reasons, including blindness, benefits age, disability) all had “representative (а payees” person “appointed manage of an benefits beneficiary” beneficiary’s inability adult manage “the adult Id., funds”). his own 184,133 1. Out of total of institutionalized persons who receiving August were through SSI benefits such “representative payees,” 76,494, approximately 41%, were institution- Id., (Table (Table 1). alized because 6) of mental disorders. at 7 Thus, incomplete even data, on this recipients sizable SSI number of persons were institutionalized for mental illness. 15Appellees appear rationality Congress’ general concede the ex publicly clusion of persons institutionalized from full benefits. SSI 16An eligible otherwise person does receive benefits is not SSI if he receiving long-term facility treatment in a medical certified under Medicaid standards provider. Act, 1861 of U. C.S. 1395x. These many strict standards exclude facilities work but to the ultimate benefit Town receiving of those O’Bannon Medicaid Cf. Nursing Court Center, S. 773 in such institutions not care residents
funds their funds. receiving Medicaid *11 impact upon an indirect
To the statute has the extent that per- of mentally рublicly institutionalized ill as a subset certainly support no statistical for a sons, presents this record mentally ill class are burdened dis- contention that aas proportionately by other class affected the classification. only composed exclusion draws a line between groups (in part) public ill in of individuals: those mental hospitals hospitals. not in mental and those These groups shifting population, in and members of group one do, can, and pass group.17 often the other We note appellees produce any also that have failed evidence intent of that was to on the classify average inpatient stay hospitals in mental Re short. cently stay county collected data for 1975 reveal a median in state and hospitals days. mental of Witkin, 25.5 Characteristics of Admissions Facilities, to Selected Mental Health 1975: An Book Charts Annotated of and Tables, National Institute of Mental Health DHHS Publication (ADM) (1981). study young 80-1005 This also showed elderly patients periods had longer stay patients middle-age of in than Id.., group. rapidity inpatients at 95. The from with which are released public institutions has increased of all since the 1950’s. In 75% patients hospitals admitted to state the first mental within were released months, Ozarin, three while were released within the first six months. 87% Redick, Taube, Quarter Century Care, & A Psychiatric A 1950-1974: Review, Hospital Statistical Community Psychiatry 515, & propor from Data the National that the Institute of Mental Health show “patient episodes” tion of (admissions during year plus care residents beginning at the at state year) inpatient treatment attributable to county hospitals This declined in 1977. from in 1955 to 9% 49% hospitals dramatic in percentage persons decrease to these admitted paralleled commu growth through was in outpatient treatment nity facilities; 1955 to in percentage grew health from 23% Health Witkin, Episodes 1977. Trends in in Mental Patient Care 76% Facilities, Health 1955-1977, Health, Mental National Institute Mental p. time, total 1980). Statistical Note No. (Sept. At the same “patient episodes” approximately number of fourfold, care from increased Id., million in 1.7 1955 to 6.9 million in 1977. 1. admit such evi- Appellees mental health.
basis of of explicit on the absence rely indeed, they exists; dence and, to their needs “inattention” Congress’ proof intent as Appellees Brief for them. against prejudice therefore, its the indirect Hackney, (1972), As in Jefferson appellees’ class, upon legislation deprivation worked does not “suspect,” with- considered or not the class is whether scrutiny. heightened regard it with out more move us Feeney, Massachusetts Administrator Cf. Personnel U. S. 256
B the classification is whether Thus, pertinent inquiry legitimate legislative employed (e)(1)(B) advances although that, The Court has said goals a rational fashion. *12 Mathews “not a toothless one,” this rational-basis standard is not to Lucas, 495, 510 does allow us (1976), v. 427 U. S. it personal public policy for those good substitute our notions Congress: welfare, a State “In the of economics social area cor- Equal not violate the Protection Clause does [and not violate respondingly the Federal Government does equal protection component of the Fifth Amendment] merely by its laws are because the classifications made imperfect. If some ‘reasonable the classification has simply because basis,’ it does not offend Constitution nicety the classification not with mathematical ‘is made inequity.’ or in practice results some Lindsley 78.” Co., v. Natural Carbonic Gas 220 U. Williams, Dandridge 397 U. S., relatively employs The Court also said: “This inquiry relaxed standard the Court’s awareness reflecting legisla- drawing of lines peculiarly that create distinctions is making tive task unavoidable one. Perfection necessary necessary.” nor possible classifications is neither S. 307, Murgia, Massachusetts Bd. Retirement v. 314 (1976). See also United States Railroad Retirement Bd. Fritz, (1980). long U. S. 166 As the classificatory as by Congress scheme chosen rationally advances a reasonable and identifiable objective, disregard we must governmental the existence of other methods of allocation in- we, dividuals, perhaps preferred. would have
We believe incorporate the decision the Medicaid to eligibility standards into the SSI must scheme be considered Congress’ deliberate, considered choice. The rec- ord, although sparse, appears to unequivocal. be Both House Reports and Senate on the initial SSI bill noted the exclusion in no uncertain terms. The Report House stated:
“People who are residents of certain institutions, or hospitals nursing homes which getting Medicaid funds, get would up $25 benefits of (reduced a month income). nonexcluded For people these sub- most sistence needs are met full the institution and bene- fits are not payment needed. Some people, these though, purchase would needed to them enable small supplied comfort by the institution. No items paid penal assistance benefits will be to an in a individual institution.” H. Rep. No. 92-231, p. R. Report Senate language followed the almost iden- House’s
tically. See S. find 92-1230, p. We these passages, very at the least, expression be a clear *13 Congress’ to understanding stipend was be grant that the limited to group smaller of other- population than the total wise eligible, sec- people. institutionalized That the bill’s tion-by-section analysis Report laid contained in the House out terms of the conclu- precisely supports exclusion Congress sion that in was was included that aware who group. Rep. limited R. No. 92-231, at 334. H. pass The limited eligibility nature Medicaid did enacting unnoticed In bill that Congress. the same Congress considered, passed, established the SSI program, inpatient coverage of Medicaid, providing to an amendment needy in juvenile of the number large services to a Act, S. C. (h) of the See § institutions.18 mental 280-281; Rep. H. R. Conf. at Rep. 92-1230, S. (h); 1396d No. § proposal demon Senate Also, a (1972). 92-1605, p. No. to extending Medicaid feasibility of on thе projects stration institu in provided inpatient cover all services 92-1230, No. Rep. defeated. See simultaneously tions was Congress was at 65. 92-1605, H. 281; R. Conf. limitations considering the wisdom these process provi the SSI incorporate them into to at the time it chose controversy. The not escape do so did sions. decision testimony extension advocating contained hearings Committee needy SSI benefits all residents of both Medicaid and Amendments Security See Social public mental institutions. on R. before the Senate Committee 1971, Hearings H. Sess., 2180, 2408-2410, 1st 2d Finance, Cong., 92d history This shows 2479-2485, 3257, to the Congress aware, § was when added Act, program Medicaid that would the limitations benefits; restrict for the reduced SSI we decline to eligibility regard such deliberate action as the of inadvertence result ignorance. v. Thiboutot, See Maine S. adoption found the of the in-
Having Medicaid standards tentional, logical we deem it to infer from Congress’ deliberate action an intent to further subsidiary purposе the same lies behind the exclusion, which, party denies, Medicaid adopted was believed the States to have a “traditional” responsibility to care for those institutionalized eligible To be services, for Medicaid inpatient reimbursement men tally persons age ill being of 21 treated in mental institutions receiving must be “active treatment” prescribed that meets standards Secretary reasonably that “can expected improve be the condi tion, by reason of which necessary, such services are extent eventually longer (h)(1)(B) such services will no necessary.” (h) Act, (1) (B). 42 U. S. C. 1396d *14 emphasizing Secretary, public
in institutions.19 mental in dis- to economize congressional desire then-existing the decision to limit that funds, argues of bursement federal of in- monthly public stipend to inmates distribution of the rationally funds “is Medicaid receiving who stitutions are spending desire to avoid to the legitimate related whose care and federal behalf of individuals resources fully for and local being provided treatment state government “mаy implement congres- to units” and be said supplemental to policy provide sional choice financial assist- already ance for of who those residents institutions in support receive the form Medicaid significant federal for coverage.” Appellant say Brief 27-28. We cannot that to primary belief that the States continue should have responsibility money” small “comfort making this allow- residing ance available to those in state-run institutions is an from withholding irrational basis for them general federal welfare funds.20 assumption The Medicaid Congress’ limitation was based on that persons
care of in mental properly responsibility institutions was Rep. (1949) the States. See H. R. Cong., No. 81st Sess., 1st (enacting funding federal needy blind, to aged, services and dis provided in public abled institutions, excluding medical but assistance to “public private those or tuberculosis, institutions for mental illness and provided since the generally cases”); States have for medical care such Cong., pt. S. 89th (1965) (enact 1st Sess., 1, pp. 144-147 providing coverage only ment Medicaid aged needy to institutions; noting tuberculosis was reason for this exclusion “[t]he long-term hospitals care in such traditionally accepted had as a been responsibility States,” id., 144). upheld This was exclusion Legion Richardson, Supp. 354 F. summarily nom. (SDNY), aff’d sub Legion Weinberger, 414 (1973), Weinberger, U. S. 1058 and Kantrowitz v. Supp. (DC 1974), F. aff’d, App. F. 2d U. S. D. C. denied, cert. 819 (1976), appellees disavow intention dispute holding. Appellees Brief for 26-27; Arg. Tr. Oral Whether State chooses provide elect or elect equivalent monthly stipend to patients institutionalized mental does not rationality Congress’ alter the decision. *15 238 sympathetic inclined to be and are understand
Although we amici’s assertions as supporting their to and appellees’ with receiving patient’s of a reduced effects sti- the beneficial argument. and not a legislative, legal, pend, find this a we may part to shoulder rationally elect Congress may allowance, rationally and this limit supplying burden recipients, whose care the grant to Medicaid Federal major portion already has assumed Government represents partial gratuity limited solution expense.21 The Congress problem,22 legitimately general to a far more would, may should, provide that the States or assume funds or in basic care. Baur equivalent, either in v. Mathews, 228, (CA9 1978). F. 578 2d 233 Court has This constitutionality” granted legisla- to presumption a “strong conferring monetary Castro, tion Mathews v. De benefits, 429 S., Congress U. it that believes have should deciding expend necessarily discretion in how to re- limited type Awarding inevitably sources. of benefits involves line-drawing the kind of will leave comparably some needy person outside say the favored circle.23 We cannot 21 Secretary interpreted (e)(1)(B) require to that at §1611 least of the cost of services be reimbursed Medicaid before the 50% (b) (5) reduction of benefits becomes 20 effective. CFR §416.231 22Congress investigate continues to general other more solutions and 'propose (e). Rep. pt. alterations 1611 96-451, See H. R. p. (1979); Cong. 31349-31350, 31354-31355, (1979) Rеc. (remarks Rep. Corman, Rep. Pepper, Bingham) (proposing amendment to forestall of benefits until reduction after eligible individual has been institutionalized in Medicaid institution months); three Staff of the Finance, Supple Senate Committee on Security Program, Cong., Sess., (Comm. Income 95th 1st 109-115 1977) (advocating legislative Print standardizing monthly amendments stipend persons). to institutionalized legal determined, “When a distinction is may as no one doubts that it be, night day, maturity, between childhood and or other ex tremes, a point has be fixed gradually or line has drawn, irrational of in view of Congress, budgetary was cons
traints,24 to
recipients
decide that
it is the Medicaid
in public
needy
institutions
that are the most
and the most deserving
g.,
e.
See,
monthly supplement.
small
v.
Califano
Boles,
Jobst,
(1979);
v.
S.
Califano
Salfi,
(1977); Weinberger
U. S. 749, 768-770
Belcher,
Richardson (1975);
It is so ordered. Justice with whom Justice Powell, Justice Brennan, Marshall, Justice dissenting. Stevens join,
The Court Congress rationally holds that has a denied small “comfort monthly eligible allowance” to peo- otherwise ple solely previously it them rationally denied Medic- aid benefits. In my Congress thoughtlessly applied view, picked by decisions, out change place. successive to mark where the takes by Looked at regard necessity itself without to the behind it the line or point seems'arbitrary. might It nearly as well or as well be a little more to one side or the point other. But when is seen that line or there it a be, must fixing and that there logical way is of it no mathematical precisely, the legislature decision of the accepted must unless we can say very is wide of Co. v. reasonable Louisville Gas mark.” Coleman, (1928) 277 U. S. (Holmes, J., dissenting). 24The amount money, involved, of people potentially and the number of are not Although Secretary inconsiderable. appellees agree, do not estimates that implementing annual cost of order the District Court’s approximаte Ap $30 nationwide would Beply million. Memorandum 3. pellant receiving In people total of almost 2.2 million were January disabilities, SSI benefits for 900,000 of increase over from Security Further, (Table M-24) 1979). Social (June See Bulletin 49 January all the applied disabled adults who 1974 and for benefits between July 1975, eligibility were denied reason of their residence 1.1% Bep. 95-1312, p. (table) institution. See S. developed legitimate to further statutory goals classification program to another welfare program serving welfare one wholly is an
entirely needs. result exclusion different benefits, serving from minimal dependent people Gov- This irrational classification violates the ernment interest. component the Due Process equal protection Clause of Fifth Amendment.
I Security program Income (SSI) is a Supplemental of minimal cash program federal welfare ben comprehensive blind, aged, for the and disabled. 86 Stat. indigent efits seq. generally et v. Azna C. Califano vorian, (e)(1)(A) Section 1611 439 U. S. (е)(1)(A), operates 42 U. S. reduce Act, C. per SSI month, the benefits available substantially, $25 who eligible persons otherwise reside institutions. for this The reason reduction benefit understandable: people “For these most subsistence are met needs *17 pay- and full benefits are not needed. Some institution needed people, though, ment to these to enable would supplied them to comfort not purchase small items (1971). p. the institution.” 150 Rep. H. R. No. 92-231, See comfort 92-1230, p. also S. 386 This provided if the allowance residents institution qualified person or that public hospital resides in a institution 1382 § receives Medicaid on his 42 U. S. C. funds behalf. (e)(1)(B). Thus, no paid comfort allowance will be he individual unless the form treatment of institutionalized is compensable program. receives Medicaid separate under the illness, Appellees indigent mental are people disabled 42 thus eligible payments and otherwise are for SSI public S. C. U. 1382c As residents (C). §§ (a)(3)(A), 65, how- mental and ages institutions between of 21 ever, they fоr their ineligible are benefits to receive Medicaid
241 (a)(17)(B).1 For this reason, § treatment. 1396a and none may not monthly receive the reduced other, appellees SSI institutions, payments to inmates of other available medical in patients public hospitals private medical and including mental institutions.2 pay public
The refusal to for treatment mental institu- history lengthy development tions has a in the of the federal Richardson, Legion medical programs. assistance Supp. F. summarily Legion aff’d sub nom. (SDNY), Weinberger, U. Initially, S. 1058 Congress broadly refused federal aid individuals diagnosed as men- tally ill, (a), (a), §§303 ch. Stat. however,
557-558. Subsequent enactments, have extended Medicaid coverage treatment of mental illness in or private or hospitals nursing homes, medical S. C. (a)(1), (4) (1976 Supp. Ill), §§ 1396d ed. to treat- ment mental illness those under and 65 or over in institutions, (14), (a) (16). Moreover, mental 1396d §§ Congress “public has defined institution” not to include publicly operated community residence serving center Thus, more than 16 residents. (e) (1) (C). federal medical benefits have been ill for mentally to the extended
1 Other classes of people institutionalized denied the reduced allow SSI patients ance include prison tubercular institutions inmates. quickly dispatches too argument Court that classi mentally fies on the basis mental illness. While is true all people benefit, ill are denied the the benefit people and that some denied mentally ill, inescapable are not it is appellees the benefit are denied they patients mentally Only ill institutions. are treated in mental agree is no institutions. I there While would ill, indication that punish slight intended to *18 history of Medicaid Congress’ the demonstrates disinclination involve Federal Government state treatment institu of mental illness in infra, tions. See at page this I and 242. find the classification Because irrational, question I not part do reach whether classifications drawn on the of require scrutiny appellees basis mental heightened health suggest. of exclusion The residual contexts. in various
treatment finan- ill from federal for the institutions large state States tradi- principles: related rests on two cial assistance form administering this of burdens tionally assumed have distrusted long Government Federal and the care, large mental institu- efficiency therapeutic economic Sess., 1st Cong., (1965). 404, 89th No. Rep. S. tions. See (persons under re- (h)(1)(B) C. § U. S. 1396d See also 42 in mental institutions treatment for Medicaid benefits ceive met). utility are only standards when why history light sheds §of legislative The coex- from reduced SSI benefits made exclusion from Medicaid payments.3 the exclusion tensive with Congress might rationally con- argues have Secretary responsibility the primary States have cluded that appellees, of comfort making payments allowances they already paying for their treat- responsibility bear the In accepting justifica- Brief for this Appellant ment. tion, do, the Court adds that whether the States ever have, provide large will benefit to in- ever this residents Congress’ sup- rationality stitutions is irrelevant Ante, posed judgment. n. 20.
II
A Social legislation and economic not sus that does employ pect rights classifications or impinge on must fundamental be upheld the equal Fifth protection component of the Amendment when rationally related means are legitimate to a purpose. Government Retire U. Railroad ment Bd. Fritz, Antonio In S. 166 San indication congressional intent “No assistance states: paid will benefits to an penal individual in a institution.” H. R. 92-231, p. hospital penal A mental institution. Secretary argues Neither appellees nor the Court the exclusion of from the rationally comfort purpose. allowance furthers
243 Rodriguez, v. 411 U. 1, School District S. 17 pendent (1973); Williams, (1970). 471 Dandridge v. 397 U. S. simply- This firmly established principles stated test holds two in tension. legisla The Court must substitute its view of wise or fair duly representatives for that of the elected policy tive Bradley, 93, Vance v. 440 U. S. people, Dan (1979); dridge, supra, 485-486, equal at but protection require does place legislаtive power. ment a substantive limit At minimum, legislature arbitrarily cannot discriminate Robison, g., Johnson among 361, citizens. v. U. S. E. (1974); Strange, James 128, (1972) 374-375 v. 407 U. S. ; Casualty Surety v. Weber Aetna & 406 U. S. Co., (1972). prohibition Enforcing avoiding this while unwar power legislative incursions on the difficult presents ranted merely task. No line foolish bright divides the ar from legislation bitrary difficulty, enjoys properly law.4 Given presumption of which is rationality, particularly strong legislation apportionment welfare where the of scarce benefits complex requires painful accordance with un criteria but Castro, line-drawing. avoidable Mathews v. De S.U. (1976). 181, 185
The deference to con- which accommodation of flicting interests is part upon principle entitled rests in political process majoritarian of our democracy re- sponds impor- to the people. wishes of the Accordingly, tant touchstone for is how equal protection review statutes readily a in- can be discerned which the policy legislature employed The Court has numerous the “rational formulations Fritz, test. U. S. Railroad Retirement basis” Bd. v. S. 176-177, divergent n. hold Members of the continue to Court id., clarity appear, views on the legislative purpose with must see which a (Stevens, id., J., 180-181 concurring judgment); at 187-188 (Brennan, J., dissenting), degree about of deference afforded Lindsley legislature Carbonic suiting Natural compare means to ends, v. Co., Royster Gas F. Guano Co. (1911), v. S. U. S. 78-79 with Virginia, 253 U. S. Agriculture Dept. g., See, e. to serve. tended Royster, McGinnis (1973); Moreno, 528, 536-538 413 U. S. *20 purpose legitimate When a (1973). 263, S. 270 410 U. implicit or is legislative history in the appears a statute some assurance that court has itself, a statutory scheme choice. Our dem policy made conscious a legislature to serve a intended system requires legislation ocratic deference. respectful most receive purpose discernible Roe, v. McRae, (1980); 297 Maher 448 S. v. U. See Harris Salfi, 422 v. S. 749 (1977); Weinberger 464, 479 S.U. statutory classifica of whether (1975). Yet, question from whether arbitrarily cannot be divorced tion discriminates leg When a purpose. an identifiable enacted to serve it was suggested by be the ingenuity can purpose islative of a stat government lawyer litigating constitutionality much with a may presented be not so reviewing court ute, a legislative as its absence.5 policy choice my skepticism view,
In the Court should receive with some post hypotheses legislative purpose, unsupported hoc about history.6 legislative legislative no indication of by the When system Congress’ judgments policy failure to mate can distort our essentially powers encouraging separation of branches to make other 677, University legislative Chicago, 441 U. S. decisions. v. See Cannon (1979) (Powell, J., dissenting). purpose of a statute suggest Some our cases the actual Flemming irrelevant, Nestor, (1960), and that 363 U. S. reasonably may con upheld any statute must be “if state of facts Maryland, justify” discrimination, U. S. ceived to its McGowan v. caution, (1961). important Although preserve these cases they in our importance legislative рurpose do not describe the of actual analysis. single rarely recognize legislative body with We that a acts compromises Therefore, appropriate mind and that it is purpose. blur intent, as legislative accord some deference to the view of executive’s similarly of a statute we accord deference to the consistent construction g., Udall agency E. charged administrative its enforcement. with Tollman, purpose of actual Ascertainment equal step protection. feasible, however, the extent remains an essential purpose appears other than the current position of the Secre tary, require the Court should the classification bear a substantial purpose. “fair and relation” the asserted Royster Virginia, F. S. Co. v. Guano 253 U. S. 415 scrutiny This marginally demanding more indirectly would plausibility test purpose, the tendered preserve equal protection something review as more than “a mere tau tological recognition fact that did what it in Fritz, supra, tended do.” at 180 (Stevens, J., concurring in judgment).
B Neither the structure of nor its history identifies even suggests policy plausibly intended to *21 be by denying appellees served the small SSI allowance. As above, only purpose noted the identified in the House and Reports Senate is the goal irrelevant of depriving inmates penal institutions of all benefits. n. See The supra. structure of the no guidance statute offers to purpose as be cause is drawn in policies reference the Medicaid rather than to policies By the of SSI. mechani cally applying the criteria for developed Medicaid, Congress appears to have avoided considering what criteria would appropriate for deciding which institutions a per son can reside and still be eligible for some SSI payment. The importation of eligibility criteria from one statute to another significant creates risks that irrational distinctions will be made between equally Dеpt. needy people. U. S. Agriculture v. Murry, 413 Medora (1973); U. Colautti, v. 602 F. 2d 1979). (CA3 Secretary argues, ex- and the that agrees, Court clusion “is rationally related to the legitimate desire to spending avoid on behalf of in- federal resources dividuals whose fully provided care and treatment are being for by state and Appel- local Brief for government units.” lant 27. The Secretary argue appellees does not are not he concedes allowance; indeed, comfort present need [appellees] not exclude statutory does classification that “the Id., needy.” be less at 32.7 they thought were because provides that because a suggest State Secretary Nor does inmates of life to of mental the necessities health care and with com- will the inmate provide the State also hospitals, pay State probability that a will Indeed, fort allowance. increase when the does patient a comfort allowance of the cost of part to relieve it Government refuses Federal recognizes apparently The Court patient’s medical care. actually provides not State this, states whether Ante, n. Ap- a comfort allowance is irrelevant. simply provided denied to other institu- pellees a benefit patients. tionalized, disabled make Congress rationally
But, argued, judg it is could responsibility ment bear the for the States should already allowance, they responsi comfort have providing and minimal care. There is bility treatment responsibilities. no logical link, however, between these two Murry, See U. S. Dept. Agriculture supra. Residence in a mental hospital related to whether rationally Legion pay patient’s should treatment. v. Richardson, summarily Supp. (SDNY), aff’d F. Legion sub Weinberger, nom. S. 1058 judgment whether the Government should subsidize Federal *22 care for ill in institutions involves large public questions difficult policy. Supra, of medical and economic 241-242. But institution, op residence in a public mental posed tо hospital private residence in or a a state medical hospital, SSI any policy bears relation to program. monthly per $25 for small pays allowance sonal expenses, beyond pro the minimal treatment care and 7 This concession makes accept it conclusion that difficult to the Court’s Congress rationally could recipients in have decided that “Medicaid institutions . . . needy deserving most of the small and the most monthly supplement.” Ante, at 239.
vided programs.” Medicaid or “other H. R. No. 96- 451, pt. p. If pays SSI a cash benefit relating to personal needs other than maintenance and medical care, it is irrelevant whether the or the State Federal Government paying for the maintenance and medical care.; patients’ same, need remains the the likelihood that the policies of SSI will be fulfilled remains the same.
I conclude that had no rational reason for refus- ing pay a comfort allowance to appellees, while paying identically numerous otherwise situated disabled indigents. This unexplained difference in treatment must have been a I oversight. therefore dissent.