Document: 450 U.S. 221 101 S.Ct. 1074 67 L.Ed.2d 186 Richard SCHWEIKER, Secretary of Health and Human Services, Appellant,v.Charles Edward WILSON et al. No. 79-1380. Argued Dec. 2, 1980. Decided March 4, 1981. Syllabus The Supplemental Security Income (SSI) program, which is part the Social Act, provides a subsistence allowance to needy aged, blind, disabled persons. Inmates public institutions are generally excluded from this except that under § 1611(e)(1)(B) Act reduced amount SSI benefits provided otherwise eligible persons in hospital, extended care facility, nursing home, or intermediate facility receiving Medicaid funds for their care. Appellees, aged 21 through 64 residing mental do not receive care, brought class action Federal District Court challenging exclusion benefits. held such unconstitutional as violative equal protection guarantees Due Process Clause Fifth Amendment on ground "mental health" classification could withstand judicial scrutiny because it did have "substantial relation" object legislation light its "primary purpose." Held : Appellees' rights were violated by denying them Pp. 230-239. (a) In 1611(e)(1)(B), Congress made distinction between mentally ill group composed nonmentally ill, but residents funds. To extent statute has an indirect impact upon subset publicly institutionalized persons, record case presents no statistical support contention burdened disproportionately any other affected classification. deprivation worked appellees' class, whether considered "suspect," does not, absence evidence deliberately intended discriminate against move regard with heightened scrutiny. 230-234. (b) employed be judged rational-basis standard, allow substitute personal notions good policy those Congress. Under based legislative history, was irrational elect, view budgetary constraints, shoulder only burden supplying "comfort money" allowance, leaving States primary responsibility making available state-run institutions, decide recipients who most deserving 234-239. 478 F.Supp. 1046, reversed. Elliott Schulder, Washington, D. C., appellant. James Weill, Chicago, Ill., appellees. Justice BLACKMUN delivered opinion Court. 1 issue constitutionally may decline grant individuals they United Northern Illinois unconstitutional, Amendment, portion amended, excludes these supplemental Services taken direct appeal 28 U.S.C. 1252. 2 * October 1972, amended (Act) create federal effective January 1, 1974. 86 Stat. 1465, 42 1381 seq. This program "[t]o assist cannot work age, blindness, disability," S.Rep.No.92-1230, p. 4 (1972), "set[ting] guaranteed minimum income level persons," id., at 12.1 3 standards, Nation's disabled.2 Included within category "disabled" all "unable engage substantial gainful activity reason medically determinable physical impairment can expected result death lasted last continuous period if less than twelve months." 1614(a)(3)(A) 1382c(a)(3)(A). Although broad reach, coverage complete. From very inception, eligibility anyone "inmate institution." 1611(e)(1)(A) 1382(e)(1)(A).3 Also program's partial exception providing small money (not exceeding $300 per year) person "a payments (with respect individual spouse) State plan approved subchapter XIX [Medicaid] . ." 1382(e)(1)(B).4 thus, while excluding institution, explicitly tied residence institution individual. 5 Appellees suit challenge resulting detail Congress' having conditioned limited assistance Medicaid: ages resides stipend, even though meets requirements benefits, treatment age bracket funded Medicaid.5 6 attack statutory component Amendment's Clause.6 Their challenge, successful Court, twofold. First argue (and therefore disabled) bears rational relationship legitimate objective program. They assert, fact, inadvertently political powerlessness. Brief 6,32. Second, insist classifies basis illness, factor greatly resembles characteristics found inherently "suspect" means classification, special justification should required congressional decision exclude II 7 had somewhat complex procedural history. It initially instituted December 1973 injunctive declaratory relief schemes prevailed prior date See Wilson v. Edelman, 542 F.2d 1260, 1263-1266 (CA7 1976). then-existing state received, tuberculosis confined penal institution. Id., 1263, n. 2. plaintiffs later complaint include exclusion, then come into effect. 1266. A three-judge court convened §§ 2281 2282 (1970 ed.) (since repealed Pub.L. 94-381, 90 1119). consolidated another challenged pretrial detainee. Relying Weinberger Salfi, 422 749, 95 2457, 45 522 (1975), granted Secretary's motion dismiss both cases lack subject-matter jurisdiction failed exhaust administrative remedies 1631(c)(3) 1383(c)(3). F.2d, 1267-1268.7 8 On appeal, appellees abandoned claims statutes. 1271. Appeals Seventh Circuit reversed dismissal, holding (then Patricia Harris) waived requirement exhaustion her submission summary disposition.8 1272. Because dropped request relief, remanded single-judge 1269. That court, remand, certified class9 judgment, 1382(e)'s members guarantee Amendment. Sterling Harris, 1046 (ND Ill.1979).10 reasoned "creates three classifications: (1) (2) public, (3) health hospital." 1050. ruled use first two factors need justified demonstration "rational relationship" interest." Ibid. classifications withstood use, however, deemed require closer examination possess significant indicia suspect recognized cases." 1052. recognizing demonstrate denoting suspicious classifications, race national origin,11 believed politically impotent, insular minority" "have been subject 'history unequal protection.' " concluded legislatively disfavor 1611(e) did, passes "intermediate scrutiny," 1053, is, "classification evaluated "in purpose" scheme part. adjudged monthly stipend enable purchase comfort items Rejecting proposed justifications exclusion,12 said, revealed intent class; conceive "possible unexpressed purpose exclusion"; "aged, blind inmates would similar needs." Upon we noted probable jurisdiction. Harris Wilson, 446 964, 100 2938, 822 (1980). III A. 9 obligation imposed provide best governance possible. necessary different institutional competences, reasons obvious. Unless employs invidious impinges fundamental rights, areas judiciary duty intervene democratic process, properly exercises review power over Congress, appropriate representative body makes choices among alternative solutions social economic problems. San Antonio School Rodriguez, 411 93 1278, 36 16 (1973). At level, consistently classify affects manner rationally related governmental objectives. See, e. g., Dandridge Williams, 397 471, 1153, 25 491 (1970); Mathews De Castro, 429 181, 97 431, 50 389 (1976). assert particular here, "be subjected standard review," 39, "historically purposeful treatment; relegated position powerlessness; prejudice curtails participation pluralist system strips discriminatory legislation." (Footnote omitted.) 41, S.Ct., 1301. 10 We occasion reach conclude directly health.13 distinguishes groups whom meet basic requirements: "public institution" full benefits; certain nature ("hospital, spouse ) )" (emphasis added), isolate them, discrete group, subordinate treatment. most, incidentally denies benefit number suffering illness; so doing imposes equivalent same time benefiting numbers ill. 11 thus singled out entirely includes, sizable proportion total population large people.14 Further, congruent class. Among nonmedical institution," prison, residential operate;15 institution; medical provider.16 subsection, also chose afflicted alcoholism drug addiction undergoing treatment, 1611(e)(3)(A), spend more specified outside States, 1611(f). Califano Aznavorian, 439 170, 99 58 435 (1978) (upholding constitutionality 1611(f)); Torres, 98 906, 55 65 Puerto Rico). Thus, 1611(e), 12 certainly draws line (in part) individuals: hospitals hospitals. These shifting population, one can, often do, pass group.17 13 note produce health. admit exists; indeed, rely explicit proof "inattention" needs therefore, them. 39. As Jefferson Hackney, 406 535, 92 1724, 32 285 without us Cf. Personnel Administrator Massachusetts Feeney, 442 256, 2282, 60 870 (1979). B 14 pertinent inquiry advances goals fashion. said that, although "not toothless one," Lucas, 427 495, 510, 96 2755, 2764, 49 651 (1976), our Congress: 15 "In area economics welfare, violate Equal Protection [and correspondingly Government Amendment] merely laws imperfect. If some 'reasonable basis,' offend Constitution simply 'is mathematical nicety practice results inequity.' Lindsley Natural Carbonic Gas Co., 220 61, 78 [31 337, 340, L.Ed. 369]." U.S., 485, 1161. said: "This relatively relaxed reflecting Court's awareness drawing lines distinctions peculiarly task unavoidable one. Perfection neither possible nor necessary." Bd. Retirement Murgia, 307, 314, 2562, 2567, 520 Railroad Fritz, 449 166, 453, 66 368 long classificatory chosen reasonable identifiable objective, must disregard existence methods allocation we, individuals, perhaps preferred. 17 believe incorporate standards deliberate, choice. record, sparse, appears unequivocal. Both House Senate Reports initial bill uncertain terms. Report stated: 18 "People homes getting funds, get up $25 month (reduced nonexcluded income). For people met needed. Some payment people, though, needed supplied No will paid H.R.Rep. 92-231, 150 (1971), U.S.Code Cong. & Admin.News 5136. 19 followed House's language almost identically. S.Rep. 92-1230, 386 (1972). find passages, least, clear expression understanding smaller eligible, people. bill's section-by-section analysis contained laid terms precisely supports conclusion aware included group. 334. 20 unnoticed enacting established considered, passed, amendment Medicaid, inpatient services juvenile institutions.18 1905(h) 1396d(h); 280-281; H.R.Conf.Rep. 92-1605, Also, proposal projects feasibility extending cover simultaneously defeated. 281; 65. process considering wisdom limitations provisions. escape controversy. Committee hearings testimony advocating extension institutions. Amendments 1971, Hearings H.R. before Finance, 92d Cong., 1st 2d Sess., 2180, 2408-2410, 2479-2485, 3257, 3319 history shows aware, when added restrict deliberate inadvertence ignorance. Maine Thiboutot, 448 8, 2502, 2505, 555 Having adoption intentional, deem logical infer further subsidiary lies behind which, party denies, adopted "traditional" institutions.19 Secretary, emphasizing desire economize disbursement argues limit distribution "is avoid spending resources behalf whose being fully local government units" "may implement choice financial already form coverage." Appellant 27-28. say belief continue withholding general welfare funds.20 22 understand inclined sympathetic appelle$s' supporting amici assertions beneficial effects patient's legislative, legal, argument. elect recipients, assumed major expense.21 gratuity represents solution far problem,22 legitimately assume would, should, equivalent, either Baur Mathews, 578 228, 233 (CA9 1978). "strong presumption constitutionality" conferring monetary 185, 434, believes discretion deciding how expend necessarily resources. Awarding type inevitably involves kind line-drawing leave comparably favored circle.23 constraints,24 supplement. Boles, 443 282, 296, 2767, 2776, 61 541 (1979); Jobst, 434 47, 53, 95, 99, 54 228 (1977); 768-770, 2468-69, (1975); Richardson Belcher, 404 78, 83-84, 254, 258, 30 231 (1971). 23 supplementary benefit. judgment 24 ordered. POWELL, BRENNAN, MARSHALL, STEVENS join, dissenting. 26 holds denied allowance" solely previously my view, thoughtlessly applied developed serving needs. wholly dependent minimal interest. violates 27 comprehensive cash indigent disabled. 171, 472, (1978). Section 1382(e)(1)(A), operates reduce substantially, month, reside reduction understandable: "For 29 qualified hospital receives his behalf. 1382(e)(1)(B). unless he compensable separate 1382c(a)(3)(A), (C). 65, ineligible 1396a(a)(17)(B).1 reason, none other, including patients private institutions.2 31 refusal pay lengthy development programs. Legion Richardson, 354 456 (SDNY), summarily aff'd sub nom. Weinberger, 414 1058, 94 564, 38 465 Initially, broadly refused aid diagnosed ch. 809, 303(a), 343(a), 351, 549, 554, 557-558. Subsequent enactments, illness homes, 1396d(a)(1), (4) (1976 ed. Supp.III), 1396d(a)(14), (16). Moreover, defined operated community center residents. 1382(e)(1)(C). various contexts. residual rests principles: traditionally burdens administering distrusted therapeutic efficiency 404, 89th (1965), reprinted 1965 1943, 2084. 1396d(h)(1)(B) (persons utility met). sheds why coextensive payments.3 might allowances appellees, bear paying 27. accepting justification, adds ever have, irrelevant rationality supposed judgment. Ante, 237, 20. 33 employ impinge upheld purpose. U. S. Independent 17, 1288, (1973); (1970). stated test firmly principles tension. wise fair duly elected representatives Vance Bradley, 440 93, 109, 939, 949, 59 171 Dandridge, supra, 485-486, 1161-62, place substantive power. minimum, legislature arbitrarily citizens. E. Johnson Robison, 415 361, 374-375, 1160, 1169, 39 (1974); Strange, 407 128, 140, 2027, 2034, 600 (1972); Weber Aetna Casualty Surety 164, 175, 1400, 1406, 768 Enforcing prohibition avoiding unwarranted incursions difficult task. bright divides foolish arbitrary law.4 Given difficulty, enjoys rationality, particularly strong where apportionment scarce accordance criteria requires painful line-drawing. DeCastro, 34 deference accommodation conflicting interests entitled principle majoritarian democracy responds wishes Accordingly, important touchstone statutes readily discerned serve. Dept. Agriculture Moreno, 413 528, 536-538, 2821, 2826-27, 37 782 McGinnis Royster, 410 263, 270, 1055, 1059, 35 282 When implicit itself, assurance conscious Our serve discernible respectful deference. McRae, 297, 2671, 784 (1980); Maher Roe, 432 464, 479, 2376, 2385, 53 484 (1975). Yet, question discriminates divorced enacted suggested ingenuity lawyer litigating statute, reviewing presented much absence.5 skepticism post hoc hypotheses about purpose, unsupported history.6 indication current "fair asserted F.S. Royster Guano Co. Virginia, 253 412, 415, 40 560, 561, 989 (1920). marginally demanding indirectly plausibility tendered preserve something mere tautological recognition fact what do." 180, 462 (STEVENS, J., concurring judgment). Neither structure 1611 identifies suggests plausibly served allowance. above, identified goal depriving 3, supra. offers guidance drawn reference policies rather SSI. By mechanically applying avoided still payment. importation creates risks equally Murry, 508, 514, 2832, 2835, 767 Medora Colautti, 602 1149 (CA3 1979). argues, agrees, units." present allowance; concedes "the [appellees] thought needy." 32.7 Nor suggest necessities life hospitals, inmate Indeed, probability patient increase refuses relieve cost apparently recognizes this, states actually irrelevant. institutionalized, patients. But, argued, make There link, responsibilities. Residence subsidize questions policy. Supra, 241-242. But opposed relation pays expenses, beyond "other programs." 96-451, pt. 153 relating maintenance care; patients' remains same, likelihood fulfilled same. I refusing numerous identically situated indigents. unexplained difference oversight. dissent. Title XVI largely replaced grants programs Titles I, X, XIV, Old Age Assistance, 620, 301 seq.; Aid Blind, 645, 1202 Permanently Totally Disabled, 555, 1351 Aged, 76 197, ed.). (1978); 907, "aged," older, "blind," "disabled," 1614 1382c, below levels 1611(a), 1382(a). 1611(e)(1)(A), provides: "(e) Limitation "(1)(A) Except subparagraph (B) (C), shall purposes throughout modifying states: "(B) (if any) title XIX, payable— "(i) rate excess year pursuant section 1612(b)) spouse; "(ii) spouse, home sum of— "(I) income, 1612(b), facility), "(II) applicable subsection (b)(1) other); "(iii) $600 month." Subsection (C) 1611(e)(1), implicated case, modifies providing: "(C) used (A), term 'public institution' serves residents." Added 1976 94-566, 505(a), 2686, objections impeded reform efforts de-institutionalize handicapped retarded. determined encourage establishment 94-1265, (1976); 94-1745, pp. 27-28 1976, 5997, 6032. following "residential" services: "inpatient (other diseases)," 1905(a)(1), 1396d(a)(1); "skilled diseases) years older," 1905(a)(4)(A); services, skilled diseases," 1905(a)(14); care," 1905(a)(15); psychiatric 21," 1905(a)(16) (h). (17)(B) 1905(a), funding remedial law, specifically "payments attained diseases." 1950, assistance, "any diseases" eligibility. 558. incorporated 1965, 79 352, exceptions facilities. broadened children 1461. investigate possibility defeated time. 281 4989, 5370. repeatedly Fourteenth g. 81, 257, classified health, constitutional. declined constitutional 1276-1282. named plaintiffs, Maudie Simmons John Kiernan Turney, satisfied nonwaivable 405(g) seek "final Secretary" denying, terminating, suspending Charles for, sought denied, cooperative state-federal programs, dismissed parties. retained caption sake uniformity. "all HEW Region V terminated XVI, after 1974, hospitalized App. Juris. Statement 21a. claim detainees finding "[t]he detainee status temporary nature, [Secretary] wish withhold extra-subsistence housed until future determined." F.Supp., 1055. person's problem, especially led institutionalization, likely 'bear [a] ability perform contribute society.' 1051-1052, quoting Frontiero 677, 686, 1764, 1770, 583 acknowledged "[i]t debatable 'immutable characteristic accident birth.' 1052, again Frontiero, 1770. argued purposes: "1) conservation resources; 2) concern received institutions; 3) 'similarly situated' interest control." 1053. intimate applies expressly classifying Administration statistics show 30.7% adult awarded 1975 (109,509 persons) disorders, "[m]ental common cause disability 1975." Kochhar, Blind Disabled Persons Awarded Federally Administered Payments, 1975, Bulletin 13, (June Half suffered retardation, entitlement recent study indicates, Administration, Representative Payments Program, August, 1977, Research Statistics Note (Sept. 16, 1980). 15% (for reasons, disability) "representative payees" (a "appointed manage beneficiary" beneficiary's inability own funds"). 1. Out 184,133 August 1977 payees," 76,494, approximately 41%, disorders. (Table 6) 1). incomplete data, illness. appear concede An long-term provider. 1861 1395x. strict many facilities ultimate Medicaid. O'Bannon Town Nursing Center, 447 773, 2467, 506 average stay short. Recently collected data reveal median county 25.5 days. Witkin, Characteristics Admissions Selected Mental Facilities, 1975: Annotated Book Charts Tables, National Institute DHHS Publication (ADM) 80-1005 (1981). showed young elderly longer periods middle-age 95. rapidity inpatients released increased since 1950's. 1971 75% admitted months, 87% six months. Ozarin, Redick Taube, Quarter Century Psychiatric Care, 1950-1974: Statistical Review, Hospital Community Psychiatry 515, 516 Data "patient episodes" (admissions during plus beginning attributable 49% 1955 9% 1977. dramatic decrease percentage paralleled growth outpatient facilities; grew 23% 76% Trends Patient Care Episodes 1955-1977, Health, 154, time, fourfold, 1.7 million 6.9 reimbursement treated "active treatment" prescribed "can reasonably improve condition, necessary, eventually 1905(h)(1)(B) 1396d(h)(1)(B). limitation assumption States. 1300, 81st (1949) (enacting tuberculosis, cases"); 144-147 1943 (enactment noting accepted States," 144, (1973), Kantrowitz 388 1127 (DC 1974), aff'd, 174 U.S.App.D.C. 182, 530 1034, cert. 819, 64, disavow intention dispute holding. 26-27; Tr. Oral Arg. 19. Whether chooses alter decision. interpreted least 50% reimbursed becomes effective. CFR 416.231(b)(5) continues propose alterations 1611(e). 125 Cong.Rec. 31349-31350, 31354-31355, 31356 (1979) (remarks Rep. Corman, Pepper, Bingham) (proposing forestall months); Staff 95th 109-115 (Comm. Print 1977) (advocating amendments standardizing persons). "When legal determined, doubts be, night day, childhood maturity, extremes, point fixed drawn, gradually picked successive decisions, mark change takes place. Looked itself necessity seems arbitrary. well nearly little side other. seen there way fixing precisely, wide mark." Louisville Coleman, 277 32, 48 423, 426, 72 770 (1928) (Holmes, dissenting). money, potentially involved, inconsiderable. agree, estimates annual implementing order nationwide approximate $30 million. Reply Memorandum 3. 1979, 2.2 disabilities, 900,000 M-24) adults 1974 July 1.1% 95-1312, (table) Other classes tubercular prison inmates. too quickly dispatches argument While true benefit, inescapable Only agree punish slight demonstrates disinclination involve infra, page 242. irrational, suggest. "No furthers formulations basis" test. 176-177, 10, 460, Members hold divergent views clarity appear, see 180-181, 461-462 judgment); 187-188, 465-466 (BRENNAN, dissenting), degree afforded suiting ends, compare 78-79, 369 (1911), failure judgments distort separation powers encouraging branches essentially decisions. Cannon University 441 743, 1946, 1981, 560 (POWELL, actual irrelevant, Flemming Nestor, 363 603, 612, 80 1367, 1373, 1435 (1960), "if facts conceived justify" discrimination, McGowan Maryland, 366 420, 81 1101, 1105, 393 (1961). caution, describe importance analysis. recognize rarely acts single mind compromises blur Therefore, accord executive's intent, similarly consistent construction agency charged enforcement. Udall Tallman, 380 85 792, 801, 616 (1965). Ascertainment feasible, essential step protection. concession accept decided "Medicaid supplement." 239.

Category: 1