# Azar v. Allina Health Services
## Dissenting Opinion

    Breyer
Syllabus
NOTE: Where it is feasible, a syllabus (headnote) will be released, as is being done in connection with this case, at the time the opinion is issued. The syllabus constitutes no part of the opinion of the Court but has been prepared by the Reporter of Decisions for the convenience of the reader. See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337.
SUPREME COURT OF THE UNITED STATES
Syllabus
AZAR, SECRETARY OF HEALTH AND HUMAN SERVICES v. ALLINA HEALTH SERVICES ET AL.
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT
No. 17–1484. Argued January 15, 2019—Decided June 3, 2019
The Medicare program offers additional payments to institutions that serve a “disproportionate number” of low-income patients. 42 U. S. C. §§1395ww(d)(5)(F)(i)(I). These payments are calculated in part using what is called a hospital’s “Medicare fraction.” The fraction’s denominator is the time the hospital spent caring for patients who were “entitled to benefits under” Medicare Part A, while the numerator is the time the hospital spent caring for Part-A-entitled patients who were also entitled to income support payments under the Social Security Act. §1395ww(d)(5)(F)(vi)(I). Congress created Medicare Part C in 1997, leading to the question whether Part C enrollees should be counted as “entitled to benefits under” Part A when calculating a hospital’s Medicare fraction. Respondents claim that, because Part C enrollees tend to be wealthier than Part A enrollees, counting them makes the fraction smaller and reduces hospitals’ payments considerably. In 2004, the agency overseeing Medicare issued a final rule declaring that it would count Part C patients, but that rule was later vacated after hospitals filed legal challenges. In 2013, it issued a new rule prospectively readopting the policy of counting Part C patients. In 2014, unable to rely on either the vacated 2004 rule or the prospective 2013 rule, the agency posted on its website the Medicare fractions for fiscal year 2012, noting that they included Part C patients. A group of hospitals, respondents here, sued. They claimed, among other things, that the government had violated the Medicare Act’s requirement to provide public notice and a 60-day comment period for any “rule, requirement, or other statement of policy . . . that establishes or changes a substantive legal standard governing . . . the payment for services,” §1395hh(a)(2). The ​court of appeals ultimately sided with the hospitals.
Held: Because the government has not identified a lawful excuse for neglecting its statutory notice-and-comment obligations, its policy must be vacated. Pp. 5–17.
(a) This case turns on whether the government’s 2014 announcement established or changed a “substantive legal standard.” The government suggests the statute means to distinguish a substantive from an interpretive legal standard and thus tracks the Administrative Procedure Act (APA), under which “substantive rules” have the “force and effect of law,” while “interpretive rules” merely “advise the public of the agency’s construction of the statutes and rules which it administers,” Perez v. Mortgage Bankers Assn., 575 U. S. 92, ___. Because the policy of counting Part C patients in the Medicare fractions would be treated as interpretive rather than substantive under the APA, the government submits, it had no statutory obligation to provide notice and comment before adopting the policy.
The government’s interpretation is incorrect because the Medicare Act and the APA do not use the word “substantive” in the same way. First, the Medicare Act contemplates that “statements of policy” can establish or change a “substantive legal standard,” §1395hh(a)(2), while APA statements of policy are not substantive by definition but are grouped with and treated as interpretive rules, 5 U. S. C. §553(b)(A). Second, §1395hh(e)(1)—which gives the government limited authority to make retroactive “substantive change[s]” in, among other things, “interpretative rules” and “statements of policy”—would make no sense if the Medicare Act used the term “substantive” as the APA does, because interpretive rules and statements of policy—and any changes to them—are not substantive under the APA by definition. Third, had Congress wanted to follow the APA in the Medicare Act and exempt interpretive rules and policy statements from notice and comment, it could have simply cross-referenced the exemption in §553(b)(A) of the APA. And the fact that Congress did cross-reference the APA’s neighboring good cause exemption found in §553(b)(B), see §1395hh(b)(2)(C), strongly suggests that it “act[ed] intentionally and purposefully in the disparate” decisions, Russello v. United States, 464 U. S. 16, 23. Pp. 5–12.
(b) The Medicare Act’s text and structure foreclose the government’s position in this case, and the legislative history presented by the government is ambiguous at best. The government also advances a policy argument: Requiring notice and comment for Medicare interpretive rules would be excessively burdensome. But courts are not free to rewrite clear statutes under the banner of their own policy concerns, and the government’s argument carries little force even on its own terms. Pp. 13–16. ​(c) Because this Court affirms the court of appeals’ judgment under §1395hh(a)(2), there is no need to address that court’s alternative holding that §1395hh(a)(4) independently required notice and comment. Nor does this Court consider the argument, not pursued by the government here, that the policy did not “establis[h] or chang[e]” a substantive legal standard—and so did not require notice and comment under §1395hh(a)(2)—because the statute itself required the government to count Part C patients in the Medicare fraction. Pp. 16–17.
863 F. 3d 937, affirmed.
GORSUCH, J., delivered the opinion of the Court, in which ROBERTS, C. J., and THOMAS, GINSBURG, ALITO, SOTOMAYOR, and KAGAN, JJ., joined. BREYER, J., filed a dissenting opinion. KAVANAUGH, J., took no part in the consideration or decision of the case.
This work is in the public domain in the United States because it is a work of the United States federal government (see 17 U.S.C. 105).
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