Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-15-05163/USCOURTS-caDC-15-05163-0/pdf.json

Parties Involved:
Florida Health Sciences Center, Inc.
Appellant
Secretary of Health and Human Services
Appellee

Document Text:

United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued March 22, 2016 Decided July 26, 2016

No. 15-5163

FLORIDA HEALTH SCIENCES CENTER, INC., DOING BUSINESS AS 

TAMPA GENERAL HOSPITAL,

APPELLANT

v.

SECRETARY OF HEALTH AND HUMAN SERVICES,

APPELLEE

Appeal from the United States District Court

for the District of Columbia

(No. 1:14-cv-00791)

Stephanie A. Webster argued the cause for appellant. 

With her on the briefs was Hyland Hunt.

Abby C. Wright, Attorney, U.S. Department of Justice,

argued the cause for appellee. With her on the brief were 

Benjamin C. Mizer, Principal Deputy Assistant Attorney 

General, Alisa B. Klein, Attorney, William B. Schultz, General 

Counsel, U.S. Department of Health and Human Services, 

Janice L. Hoffman, Associate General Counsel, Susan 

Maxson Lysons, Deputy Associate General Counsel for 

Litigation, and Jonathan C. Brumer, Attorney.

USCA Case #15-5163 Document #1626909 Filed: 07/26/2016 Page 1 of 14
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Before: GRIFFITH and KAVANAUGH, Circuit Judges, and

SENTELLE, Senior Circuit Judge.

GRIFFITH, Circuit Judge: Tampa General Hospital 

receives federal funds for serving patients who cannot pay for 

the healthcare they receive. To determine how much federal 

funding goes to each hospital for providing such care, the 

Secretary of the U.S. Department of Health and Human 

Services (HHS) makes certain “estimates” as required by the 

Affordable Care Act. Although the Act bars judicial review of 

the Secretary’s estimates, Tampa General seeks to challenge 

the data underlying them. We hold that the bar on judicial 

review of the Secretary’s estimates precludes review of the 

underlying data as well.

I

Tampa General Hospital serves a large share of Tampa’s 

low-income population. The federal government has long 

compensated hospitals like Tampa General for serving lowincome patients by disbursing funds through a system known 

as Disproportionate Share Hospital (DSH) payments. See 42 

U.S.C. § 1395ww(d)(5)(F) (1988). Historically, HHS 

calculated a hospital’s DSH payment based on the number of 

days per year that the hospital served Medicaid and lowincome Medicare patients. This calculation did not factor in 

the costs to the hospitals of “uncompensated care,” which 

they provide to patients who have no means to pay, whether 

through federal programs or otherwise. See Medicare Program 

Final Rule, 78 Fed. Reg. 50,496, 50,622, 50,634-35 (Aug. 19, 

2013).

The Affordable Care Act revised the process for 

calculating DSH payments. The new formula, which took 

effect in 2014, bases DSH payments largely on the 

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uncompensated care hospitals provide. See 42 U.S.C.

§ 1395ww(r) (2012); 78 Fed. Reg. at 50,622. HHS pays each 

hospital 25% of the amount it received under the old formula,

42 U.S.C. § 1395ww(r)(1), then adds more based in part on 

the Secretary’s “estimate” of the percentage of the nation’s 

overall uncompensated care that each hospital provides, id. 

§ 1395ww(r)(2)(C).

To implement this change, the Secretary issued a final 

rule describing HHS’s methodology for calculating DSH 

payments for 2014. 78 Fed. Reg. at 50,627-47. The Secretary 

decided to estimate each hospital’s amount of uncompensated 

care, one part of the DSH payment, by looking to the number 

of days spent in each hospital by Medicaid patients and lowincome Medicare patients who receive Supplemental Security 

Income benefits (Medicare SSI). Id. at 50,636-40. This 

number is then divided by the total number of days that such

patients spent in all eligible hospitals to determine each 

hospital’s share of the nation’s uncompensated care. In other 

words, the Secretary decided to use each hospital’s number of 

insured Medicaid and Medicare SSI patients as a proxy for its 

number of low-income uninsured patients. The Secretary 

reasoned that researchers often treat these two groups 

similarly, and that the proxy data was reliable because it had 

been “historically publicly available, subject to audit, and 

used for payment purposes.” Id. at 50,635-37.

Hospitals keep track of the number of Medicaid patients 

served by submitting annual reports to HHS. HHS decided to 

use data from the hospitals’ 2010/2011 reports, which offered 

“the most recently available” information. Id. at 50,638. If 

hospitals determine that the initial figures they submitted were

inaccurate, they can amend their annual reports. Mindful of 

this possibility, HHS picked the March 2013 updates as the 

most recent data it would use. Id. at 50,641-42. HHS would 

not use data submitted after the deadline when calculating 

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DSH payments for 2014 because there would not be enough 

time to ensure its accuracy with an audit. Id. at 50,647.

Even so, Tampa General sought to give the Secretary 

new data in April 2013. When the Secretary refused to use the 

data, Tampa General filed suit in district court, arguing that 

the Secretary’s reliance on “obsolete” data rather than “the 

most recent data available” violated the Administrative 

Procedure Act and the Medicare statute. Fla. Health Scis. 

Ctr., Inc. v. HHS, 89 F. Supp. 3d 121, 126 (D.D.C. 2015). 

Tampa General claimed that the data submitted in April 2013 

established that it was entitled to $3 million more than the 

Secretary originally calculated. Id. at 129. 

The district court dismissed the hospital’s claim for lack 

of subject matter jurisdiction, holding that 42 U.S.C. 

§ 1395ww(r)(3), which precludes judicial review of the 

Secretary’s “estimate” of a hospital’s amount of 

uncompensated care, bars review of the Secretary’s choice of 

data used in determining that estimate. The district court 

reasoned that any other conclusion would be an end run 

around the bar on review. Florida Health, 89 F. Supp. 3d at

129.

Tampa General timely appealed, and we have jurisdiction 

under 28 U.S.C. § 1291.

II

We review de novo the district court’s dismissal for lack 

of subject matter jurisdiction, taking Tampa General’s 

allegations as true and drawing all reasonable inferences in its 

favor. Council for Urological Interests v. Sebelius, 668 F.3d 

704, 713 (D.C. Cir. 2011). Although it is Tampa General’s 

burden to establish subject matter jurisdiction, Lujan v. 

Defenders of Wildlife, 504 U.S. 555, 561 (1992), we apply a

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presumption in favor of judicial review of agency action and 

read statutory bars on judicial review narrowly. El Paso Nat. 

Gas Co. v. United States, 632 F.3d 1272, 1276 (D.C. Cir. 

2011). But the presumption in favor of review can be 

overcome by “specific language” in the statute that is a 

“reliable indicator” of Congress’s intent to bar review. Tex. 

Alliance for Home Care Servs. v. Sebelius, 681 F.3d 402, 408 

(D.C. Cir. 2012) (quoting Block v. Cmty. Nutrition Inst., 467 

U.S. 340, 349 (1984)). 

We find such a reliable indicator here and affirm the 

district court.

A

Tampa General seeks to challenge the Secretary’s refusal 

to use the most recent available data to estimate the hospital’s 

2014 DSH payment. But the Affordable Care Act bars 

“administrative or judicial review” of “[a]ny estimate of the 

Secretary” or “[a]ny period selected by the Secretary” to 

determine each hospital’s DSH payment. See 42 U.S.C. 

§ 1395ww(r)(3).

1 We recently held that virtually identical 

language in another statute “unequivocally precludes review”

of the agency action that falls within the bar. Texas Alliance, 

681 F.3d at 409 (“[T]hat there be ‘no administrative or 

judicial review’ under the . . . statutes ‘or otherwise’ 

unequivocally precludes review of the Secretary’s actions 

[listed in the judicial-review bar].”). Accordingly, we cannot 

review the Secretary’s choice of data here if that decision “is 

 1 The judicial review bar provides in full: “There shall be no 

administrative or judicial review under section 1395ff of this title, 

section 1395oo of this title, or otherwise of the following: (A) Any 

estimate of the Secretary for purposes of determining the factors 

described in paragraph (2). (B) Any period selected by the 

Secretary for such purposes.” 42 U.S.C. § 1395ww(r)(3).

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of the sort shielded from review.” Id. (quoting Amgen, Inc. v. 

Smith, 357 F.3d 103, 113 (D.C. Cir. 2004)). We conclude that 

it is.

Tampa General concedes that the Act bars judicial review 

of the Secretary’s “estimate” of the hospital’s “amount of 

uncompensated care.” 42 U.S.C. § 1395ww(r)(2)(C)(i)

(providing that this “amount” is to be “estimated by the 

Secretary”). But Tampa General argues that we can review 

the underlying data on which the Secretary relied, because an 

“estimate” is not the same thing as the “data” on which it is 

based. The estimate is an output, and the data are an input. 

Tampa General notes that the statute requires the Secretary to

base her estimates on “appropriate” data, id., and urges that its 

challenge is to the Secretary’s reliance on inappropriate data, 

not her methodology for estimating uncompensated care. 

We rejected a similar argument in Texas Alliance. 681 

F.3d at 409-10. There, HHS deemed suppliers of certain 

healthcare products ineligible for a Medicare contract because 

they had failed to meet the financial standards HHS had set 

forth in a regulation. Although the statute precluded judicial 

review of, among other things, “the awarding of contracts,” 

the suppliers brought a challenge to the financial-standards 

regulation. Id. at 409 (quoting 42 U.S.C. § 1395w3(b)(11)(B)). The suppliers argued that they could challenge 

the financial standards, even though those standards affected 

the Secretary’s decision whether to award a contract, because 

only the ultimate contract decision was barred from review. 

Id. at 410. In other words, the suppliers sought to challenge an 

input (the financial standards), contending that only review of 

the output (the awarding of contracts) was expressly off 

limits.

But we rejected the categorical distinction between inputs 

and outputs that the suppliers urged. Instead, we held that the 

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scope of the congressional directive that there be “no 

administrative or judicial review” turned on the relationship 

between the challenged decision and the agency action

shielded from review. Id. at 409-11. We reasoned that the 

financial standards that determined a bidder’s eligibility for a 

contract were “indispensable” to the ultimate contract 

decision, which could not be challenged in court. Id. at 409-

10 (“If a bidder is found financially ineligible, its bid is 

rejected[.]”). Additionally, the statute barred judicial review 

of “the bidding structure” for such contracts, and the financial 

standards were “integral” to and “inextricably intertwined” 

with the Secretary’s bidding structure. Id. at 411 (identifying 

each step in the bidding process that involved the challenged 

financial standards). In sum, we could not review a decision

that was “indispensable” or “integral” to, or “inextricably 

intertwined” with, the unreviewable agency action. Id. at 409-

11.

Following that reasoning, we cannot review the data that 

underlie the Secretary’s estimate of Tampa General’s amount 

of uncompensated care in 2014. As already described, to 

determine that amount, the Secretary used the number of 

Medicaid and Medicare SSI patients as a proxy for the 

population of uninsured low-income patients. 78 Fed. Reg. at 

50,636. No other data factored into the Secretary’s estimate of 

uncompensated care. A challenge to the data would 

“eviscerate the bar on judicial review.” El Paso, 632 F.3d at 

1278. Just like the financial standards in Texas Alliance, the 

underlying data here are “indispensable” and “integral” to,

and “inextricably intertwined” with, the Secretary’s estimate 

of Tampa General’s amount of uncompensated care. 681 F.3d 

at 409, 411. Indeed, the data are the entire basis for the 

estimate. The bar on judicial review in section 1395ww(r)(3) 

therefore “expressly preclude[s]” Tampa General’s challenge

to the data, id. at 411, and we lack jurisdiction to consider it.

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Tampa General’s efforts to distinguish Texas Alliance fall 

short. First, the hospital invokes the canon of statutory 

interpretation that cautions against interpreting one provision 

in a way that renders another redundant. Marx v. Gen. 

Revenue Corp., 133 S. Ct. 1166, 1176-77 (2013) (discussing 

the surplusage canon). Tampa General contends that the 

statutory provision that bars judicial review of “[a]ny period 

selected by the Secretary” for the purpose of calculating 

Tampa General’s DSH payment, 42 U.S.C. 

§ 1395ww(r)(3)(B), would do no work if “estimate” were 

interpreted to bar review of anything that affects the estimate. 

This is so, Tampa General claims, because the period affects 

the estimate as well. According to Tampa General, Texas 

Alliance did not involve two such separate provisions, one of 

which would be deprived of “all meaning and effect” by the 

government’s interpretation. Reply Br. 9 (emphasis omitted).

But our interpretation of “estimate” does not deprive the 

“period” provision of all meaning and effect. To be sure, in 

the part of the statute at issue, the period that the Secretary 

chooses affects her estimate. See 42 U.S.C. 

§ 1395ww(r)(2)(C) (requiring the Secretary to “estimate” the 

“amount of uncompensated care” provided by each hospital 

“for a period selected by the Secretary”). But the statute’s bar 

on judicial review of “[a]ny period selected by the Secretary” 

also encompasses two additional parts of the statute that are 

not at issue in this case. See id. § 1395ww(r)(2)(A)-(B). As 

applied to one of these provisions, the bar precludes review of 

periods that have nothing to do with any estimate the 

Secretary makes. See id. § 1395ww(r)(2)(B)(i) (requiring the 

Secretary to “calculate[]” the number of uninsured people 

nationwide “in the most recent period for which data is 

available” by looking to “estimates” from the Congressional 

Budget Office—not estimates made by the Secretary).

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Even if our interpretation of “estimate” creates some 

overlap with the “period” provision in the specific paragraph 

at issue in this case, at times Congress “drafts provisions that 

appear duplicative of others—simply, in Macbeth’s words, ‘to 

make assurance double sure.’” Shook v. D.C. Fin. 

Responsibility & Mgmt. Assistance Auth., 132 F.3d 775, 782 

(D.C. Cir. 1998); see also Fort Stewart Sch. v. Fed. Labor 

Relations Auth., 495 U.S. 641, 646 (1990) (recognizing that 

Congress sometimes includes terms that are “technically 

unnecessary, and were inserted out of an abundance of 

caution”).

Tampa General invokes another canon of statutory 

interpretation that applies where the context suggests that 

Congress’s “mention of one thing” reasonably “impl[ies] the 

preclusion of alternatives.” Shook, 132 F.3d at 782

(discussing the expressio unius canon). Tampa General 

contends that the bar on review of the period, which is one 

component of the estimate, shows that Congress left other 

components of the estimate, like the data, subject to review.

This argument fails for the same reason as the argument

that the Secretary’s interpretation creates redundancies within 

the statute. Although the period is a component of the 

Secretary’s estimate in some provisions of the statute, in 

others it is not a component of any such estimate. Thus, 

“looking at the structure of the statute,” id., we doubt that by 

explicitly barring review of the period, Congress intended to 

allow review of the data underlying the Secretary’s estimate. 

Instead, “a normal draftsman” would have foreclosed review 

of the period to emphasize that the period cannot be reviewed 

in challenges to calculations under any of the relevant 

statutory provisions—whether or not the period is connected 

to an estimate made by the Secretary. Id. 

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Finally, Tampa General argues that Texas Alliance is 

distinguishable because the bar on judicial review we 

considered there worked much differently than the bar on 

judicial review before us. In Texas Alliance, the statute 

precluded courts from reviewing the agency’s ultimate 

decision whether to award a contract. By contrast, Tampa 

General argues, the statute here creates no bar to a court

reviewing the Secretary’s ultimate decision as to the amount 

of a hospital’s DSH payment, but only her intermediate 

determination as to the estimate of a hospital’s share of 

uncompensated care. To illustrate this difference, Tampa 

General suggests that a hospital could challenge a DSH 

payment that failed to take into account required statutory 

factors other than the estimates or periods chosen by the 

Secretary.

This is a distinction without a difference. The critical

factor in Texas Alliance was not whether the statute barred 

from review the agency’s ultimate determination or merely an 

intermediate step in reaching that decision. Rather, we were 

concerned with the close connection between the element 

being challenged and the decision that could not be 

challenged in court. Texas Alliance, 681 F.3d at 409-11. That 

analysis applies with equal force here. The dispositive issue is 

whether the challenged data are inextricably intertwined with 

an action that all agree is shielded from review, regardless of 

where that action lies in the agency’s decision tree. Because 

the data here are inextricably intertwined with the Secretary’s 

estimate of uncompensated care, Tampa General cannot 

challenge the Secretary’s choice of data in court.

Tampa General makes a similar argument that we should 

read the bar here narrowly because Congress shielded from 

judicial challenge only two components of HHS’s 

methodology—the estimates and periods—rather than the 

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entire methodology or the ultimate determination. In contrast, 

Tampa General points to other parts of the Affordable Care 

Act where Congress broadly precluded judicial review of 

ultimate payment amounts or entire methodologies for 

determining payments. See, e.g., 42 U.S.C. 

§ 1395ww(o)(11)(B)(i) (barring review of “the determination 

of” the “amount of the value-based incentive payment”); id.

(barring review of the “methodology used to determine the 

amount of the value-based incentive payment”). But even 

viewing the bar here narrowly, the selection of data fits

squarely within it. The data and the estimate are so closely 

intertwined that we cannot review either. As a result, we have 

no jurisdiction to review the Secretary’s choice of data.

B

Tampa General also seeks to reframe its challenge as an 

attack on something other than an estimate by the Secretary. 

We are not persuaded.

Relying on our decision in ParkView Medical Associates

v. Shalala, 158 F.3d 146 (D.C. Cir. 1998), Tampa General 

asserts that we should construe its complaint as a challenge to

HHS’s general rules leading to the estimate rather than as a 

challenge to the estimate itself. In ParkView, we said that 

even if judicial review of a decision is barred, “hospitals [are] 

free to challenge the general rules leading to” that decision.

Id. at 148. This principle, according to Tampa General, allows 

the hospital to challenge the Secretary’s refusal to use the data 

that Tampa General thinks most accurate.

As Tampa General recognizes, however, since our 

decision in ParkView we have clarified that judicial review is 

not permitted “when a procedure is challenged solely in order 

to reverse an individual . . . decision” that we otherwise 

cannot review. Palisades Gen. Hosp. Inc. v. Leavitt, 426 F.3d 

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400, 405 (D.C. Cir. 2005). “The proposition that hospitals 

may challenge the general rules leading to denial” is 

“inapplicable” where “the hospital’s challenge is no more 

than an attempt to undo” a shielded determination. Id. That 

fits what Tampa General is trying to do in this case. Tampa 

General has not brought a challenge to any general rules 

leading to the Secretary’s estimate. Tampa General is simply 

trying to undo the Secretary’s estimate of the hospital’s 

uncompensated care by recasting its challenge to the 

Secretary’s choice of data as an attack on the general rules 

leading to her estimate. 

Finally, Tampa General attempts to repackage its 

arguments to fall within a line of cases in which we have 

found jurisdiction to review an agency’s action that is ultra 

vires, i.e., beyond the scope of its lawful authority. See Sw. 

Airlines Co. v. TSA, 554 F.3d 1065, 1071 (D.C. Cir. 2009). 

Because we presume Congress “rarely intends to foreclose 

review of action exceeding agency authority,” we typically 

construe bars on judicial review to extend “no further than the 

Secretary’s statutory authority” to make the challenged 

determination. Amgen, 357 F.3d at 112. Tampa General thus 

contends that because the statute directs the Secretary to base 

her estimates on “appropriate” data, 42 U.S.C. 

§ 1395ww(r)(2)(C)(i), any estimate based on inappropriate 

data is ultra vires.

To challenge agency action on the ground that it is ultra 

vires, Tampa General must show a “patent violation of agency 

authority.” Indep. Cosmetic Mfrs. & Distribs., Inc. v. U.S. 

Dep’t of Health, Educ. & Welfare, 574 F.2d 553, 555 (D.C. 

Cir. 1978); see also Qwest Corp. v. FCC, 482 F.3d 471, 476 

(D.C. Cir. 2007) (defining “ultra vires” action as “patently in 

excess of [the agency’s] authority” (quoting Wash. Ass’n for 

Television & Children v. FCC, 712 F.2d 677, 682 (D.C. Cir. 

USCA Case #15-5163 Document #1626909 Filed: 07/26/2016 Page 12 of 14
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1983))). A violation is “patent” if it is “[o]bvious” or 

“apparent.” BLACK’S LAW DICTIONARY (10th ed. 2014).

Tampa General’s claimed violation is neither.

Tampa General relies heavily on our decision in 

Southwest Airlines v. TSA, but that decision does not help the 

hospital. The statute at issue in Southwest Airlines authorized 

the Transportation Security Administration (TSA) to charge 

airlines certain fees, but capped those fees at the amount that 

airlines paid “for screening passengers and property” in the 

era before the agency was formed. 554 F.3d at 1068 (quoting 

49 U.S.C. § 44940(a)(2)(B)(i) (repealed)). Congress barred 

judicial review of “[d]eterminations of the Under Secretary” 

regarding the fee limitations. Id. at 1069 (quoting Pub. L. No. 

107-71, 115 Stat. 597, 625 (2001)). But when TSA calculated 

the fees, it included the screening costs for non-passengers as 

well as for passengers. Even though we could not review the 

fee determinations made “for screening passengers and 

property,” we could and did invalidate the fee determinations 

insofar as they included costs for screening non-passengers, 

because those cost calculations patently fell outside TSA’s 

statutory authority. See id. at 1071-72.

Here, the Secretary’s choice of data is not obviously 

beyond the terms of the statute. It is far from apparent that 

choosing March instead of April as the cutoff date for 

hospitals to update their Medicaid data was “[in]appropriate.” 

42 U.S.C. § 1395ww(r)(2)(C)(i). By asking us to review the 

appropriateness of the data the Secretary used to calculate 

Tampa General’s DSH payment, Tampa General urges us to 

engage in the kind of “case-by-case review of the 

reasonableness or procedural propriety of the Secretary’s 

individual applications” that Congress intended to bar.

Amgen, 357 F.3d at 113. We will not permit Tampa General 

to “couch[]” this type of reasonableness challenge “in terms 

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of the agency’s exceeding its statutorily-defined authority.” 

Nw. Airlines, Inc. v. FAA, 14 F.3d 64, 73 (D.C. Cir. 1994). 

IV

We affirm the district court and hold that 42 U.S.C. 

§ 1395ww(r)(3) bars Tampa General’s challenge.

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