Source: https://www.legalcrystal.com/case/103570/memorial-hosp-vs-maricopa-county
Timestamp: 2019-04-23 10:25:47+00:00

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This is an appeal from a decision of the Arizona Supreme Court upholding the constitutionality of an Arizona statute requiring a year's residence in a county as a condition to an indigent's receiving nonemergency hospitalization or medical care at the county's expense.
Held: The durational residence requirement, in violation of the Equal Protection Clause, creates an "invidious classification" that impinges on the right of interstate travel by denying newcomers "basic necessities of life." Shapiro v. Thompson, 394 U. S. 618 . Pp. 415 U. S. 253 -270.
(a) Such a requirement, since it operates to penalize indigents for exercising their constitutional right of interstate migration, must be justified by a compelling state interest. Shapiro v. Thompson, supra; Dunn v. Blumstein, 405 U. S. 330 . Pp. 415 U. S. 253 -262.
(b) The State has not shown that the durational residence requirement is "legitimately defensible" in that it furthers a compelling state interest, and none of the purposes asserted as justification for the requirement -- fiscal savings, inhibiting migration of indigents generally, deterring indigents from taking up residence in the county solely to utilize the medical facilities, protection of longtime residents who have contributed to the community particularly by paying taxes, maintaining public support of the county hospital, administrative convenience in determining bona fide residence, prevention of fraud, and budget predictability -- satisfies the State's burden of justification and insures that the State, in pursuing its asserted objectives, has chosen means that do not unnecessarily impinge on constitutionally protected interests. Pp. 415 U. S. 262 -269.
108 Ariz. 373, 498 P.2d 461, reversed and remanded.
opinion, post, p. 415 U. S. 270 . REHNQUIST, J., filed a dissenting opinion, post, p. 415 U. S. 277 .
This case presents an appeal from a decision of the Arizona Supreme Court upholding an Arizona statute requiring a year's residence in a county as a condition to receiving nonemergency hospitalization or medical care at the county's expense. The constitutional question presented is whether this durational residence requirement is repugnant to the Equal Protection Clause as applied by this Court in Shapiro v. Thompson, 394 U. S. 618 (1969).
claimed reimbursement from the County in the amount of $1,202.60, for the care and services it had provided Evaro.
residence requirement for providing free medical care to indigents.
The trial court held the residence requirement unconstitutional as a violation of the Equal Protection Clause. In a prior three-judge federal court suit against Pinal County, Arizona, the District Court had also declared the residence requirement unconstitutional, and had enjoined its future application in Pinal County. Valencano v. Bateman, 323 F.Supp. 600 (Ariz.1971). [ Footnote 4 ] Nonetheless, the Arizona Supreme Court upheld the challenged requirement. To resolve this conflict between a federal court and the highest court of the State, we noted probable jurisdiction, 410 U.S. 981 (1973), and we reverse the judgment of the Arizona Supreme Court.
"indistinguishable from each other except that one is composed of residents who have resided a year or more, and the second of residents who have resided less than a year, in the jurisdiction. On the basis of this sole difference, the first class [was] granted and second class [was] denied welfare aid upon which may depend the ability . . . to obtain the very means to subsist -- food, shelter, and other necessities of life."
Id. at 394 U. S. 627 . The Court found that, because this classification impinged on the constitutionally guaranteed right of interstate travel, it was to be judged by the standard of whether it promoted a compelling state interest. [ Footnote 6 ] Finding such an interest wanting, the Court held the challenged residence requirements unconstitutional.
Appellees argue that the residence requirement before us is distinguishable from those in Shapiro, while appellants urge that Shapiro is controlling. We agree with appellants that Arizona's durational residence requirement for free medical care must be justified by a compelling state interest, and that, such interests being lacking, the requirement is unconstitutional.
its ultimate scope, however, the right to travel was involved in only a limited sense in Shapiro. The Court was there concerned only with the right to migrate, "with intent to settle and abide," [ Footnote 8 ] or, as the Court put it, "to migrate, resettle, find a new job, and start a new life." Id. at 394 U. S. 629 . Even a bona fide residence requirement would burden the right to travel, if travel meant merely movement. But, in Shapiro, the Court explained that "[t]he residence requirement and the one-year waiting-period requirement are distinct and independent prerequisites" for assistance, and only the latter was held to be unconstitutional. Id. at 394 U. S. 636 . Later, in invalidating a durational residence requirement for voter registration on the basis of Shapiro, we cautioned that our decision was not intended to "cast doubt on the validity of appropriately defined and uniformly applied bona fide residence requirements." Dunn v. Blumstein, 405 U. S. 330 , 405 U. S. 342 n. 13 (1972).
intrastate travel, a question we do not now consider, such a distinction would not support the judgment of the Arizona court in the case before us. Appellant Evaro has been effectively penalized for his interstate migration, although this was accomplished under the guise of a county residence requirement. What would be unconstitutional if done directly by the State can no more readily be accomplished by a county at the State's direction. The Arizona Supreme Court could have construed the waiting-period requirements to apply to intrastate, but not interstate, migrants; [ Footnote 9 ] but it did not do so, and "it is not our function to construe a state statute contrary to the construction given it by the highest court of a State." O'Brien v. Skinner, 414 U. S. 524 , 414 U. S. 531 (1974).
"An indigent who desires to migrate . . . will doubtless hesitate if he knows that he must risk making the move without the possibility of falling back on state welfare assistance during his first year of residence, when his need may be most acute."
Id. at 394 U. S. 629 . Second, the Court considered the extent to which the residence requirement served to penalize the exercise of the right to travel.
The appellees here argue that the denial of nonemergency medical care, unlike the denial of welfare, is not apt to deter migration; but it is far from clear that the challenged statute is unlikely to have any deterrent effect. A person afflicted with a serious respiratory ailment, particularly an indigent whose efforts to provide a living for his family have been inhibited by his incapacitating illness, might well think of migrating to the clean dry air of Arizona, where relief from his disease could also bring relief from unemployment and poverty. But he may hesitate if he knows that he must make the move without the possibility of falling back on the State for medical care should his condition still plague him or grow more severe during his first year of residence.
deterred [from moving] by residence requirements.' Indeed, none of the litigants had themselves been deterred."
" Shapiro did not rest upon a finding that denial of welfare actually deterred travel. Nor have other 'right to travel' cases in this Court always relied on the presence of actual deterrence. In Shapiro, we explicitly stated that the compelling state interest test would be triggered by 'any classification which serves to penalize the exercise of that right [to travel]. . . .'"
Finally, appellees seek to distinguish Shapiro as involving a partially federally funded program. Maricopa County has received federal funding for its public hospital, [ Footnote 18 ] but, more importantly, this Court has held that whether or not a welfare program is federally funded is irrelevant to the applicability of the Shapiro analysis. Pease v. Hansen, 404 U. S. 70 (1971); Graham v. Richardson, 403 U. S. 365 (1971).
determine whether these satisfy the appellees' heavy burden of justification, and insure that the State, in pursuing its asserted objectives, has chosen means that do not unnecessarily burden constitutionally protected interests. NAACP v. Button, 371 U. S. 415 , 371 U. S. 438 (1963).
"Absent a residence requirement, any indigent sick person . . . could seek admission to [Maricopa County's] hospital, the facilities being the newest and most modern in the state, and the resultant volume would cause long waiting periods or severe hardship on [the] county if it tried to tax its property owners to support [these] indigent sick. . . ."
108 Ariz. 373, 376, 498 P.2d 461, 464.
The County thus attempts to sustain the requirement as a necessary means to insure the fiscal integrity of its free medical care program by discouraging an influx of indigents, particularly those entering the County for the sole purpose of obtaining the benefits of its hospital facilities.
First, a State may not protect the public fisc by drawing an invidious distinction between classes of its citizens, Shapiro, supra at 394 U. S. 633 , so appellees must do more than show that denying free medical care to new residents saves money. The conservation of the taxpayers' purse is simply not a sufficient state interest to sustain a durational residence requirement which, in effect, severely penalizes exercise of the right to freely migrate and settle in another State. See Rivera v. Dunn, 329 F.Supp. 554 (Conn.1971), aff'd, 404 U.S. 1054 (1972).
"[T]he class of barred newcomers is all-inclusive, lumping the great majority who come to the State for other purposes with those who come for the sole purpose of collecting higher benefits."
"a State may no more try to fence out those indigents who seek [better public medical facilities] than it may try to fence out indigents generally."
Ibid. An indigent who considers the quality of public hospital facilities in entering the State is no less deserving than one who moves into the State in order to take advantage of its better educational facilities. Id. at 394 U. S. 631 -632.
by private hospitals, the costs of caring for indigents must be passed on to paying patients and "at a rather inconvenient time" -- adding to the already astronomical costs of hospitalization which bear so heavily on the resources of most Americans. [ Footnote 24 ] The financial pressures under which private nonprofit hospitals operate have already led many of them to turn away patients who cannot pay or to severely limit the number of indigents they will admit. [ Footnote 25 ] And, for those indigents who receive no care, the cost is, of course, measured by their own suffering.
"[Such] reasoning would logically permit the State to bar new residents from schools, parks, and libraries or deprive them of police and fire protection. Indeed, it would permit the State to apportion all benefits and services according to the past tax contributions of its citizens. The Equal Protection Clause prohibits such an apportionment of state services."
Shapiro, 394 U.S. at 394 U. S. 632 -633 (footnote omitted).
"[p]erhaps Congress could induce wider state participation in school construction if it authorized the use of joint funds for the building of segregated schools,"
but that purpose would not sustain such a scheme. See also Cole v. Housing Authority of the City of Newport, 435 F.2d 807, 812-813 (CA1 1970).
[the County] uses the one-year requirement as a means to predict the number of people who will require assistance in the budget year. [The appellees do not take] a census of new residents. . . . Nor are new residents required to give advance notice of their need for . . . assistance. Thus, the . . . authorities cannot know how many new residents come into the jurisdiction in any year, much less how many of them will require public assistance."
394 U.S. at 394 U. S. 634 -635 (footnote omitted). Whatever the difficulties in projecting how many newcomers to a jurisdiction will require welfare assistance, it could only be an even more difficult and speculative task to estimate how many of those indigent newcomers will require medical care during their first year in the jurisdiction. The irrelevance of the one-year residence requirement to budgetary planning is further underscored by the fact that emergency medical care for all newcomers and more complete medical care for the aged are currently being provided at public expense regardless of whether the patient has been a resident of the County for the preceding year. See Shapiro, supra, at 394 U. S. 635 .
the case remanded for further action not inconsistent with this opinion.
THE CHIEF JUSTICE and MR. JUSTICE BLACKMUN concur in the result.
Ariz.Rev.Stat.Ann. § 11-291 (Supp. 1973-1974).
"Except in emergency cases when immediate hospitalization or medical care is necessary for the preservation of life or limb no person shall be provided hospitalization, medical care or outpatient relief under the provisions of this article without first filing with a member of the board of supervisors of the county in which he resides a statement in writing, subscribed and sworn to under oath, that he is an indigent as shall be defined by rules and regulations of the state department of economic security, an unemployable totally dependent upon the state or county government for financial support, or an employable of sworn low income without sufficient funds to provide himself necessary hospitalization and medical care, and that he has been a resident of the county for the preceding twelve months. "
Thus, the question of the rights of transients to medical care is not presented by this case.
Arizona's intermediate appellate court had also declared the durational residence requirement unconstitutional in Board of Supervisors, Pima County v. Robinson, 10 Ariz.App. 238, 457 P.2d 951 (1969), but its decision was vacated as moot by the Arizona Supreme Court. 105 Ariz. 280, 463 P.2d 536 (1970).
An Arizona one-year durational residence requirement for care at state mental health facilities was declared unconstitutional in Vaughan v. Bower, 313 F.Supp. 37 (Ariz.), aff'd, 400 U.S. 884 (1970). See n 11, infra.
A Florida one-year durational residence requirement for medical care at public expense was found unconstitutional in Arnold v. Halifax Hospital Dist., 314 F.Supp. 277 (MD Fla.1970), and Crapps v. Duval County Hospital Auth., 314 F.Supp. 181 (MD Fla.1970).
E.g., Weber v. Aetna Cas. & Surety Co., 406 U. S. 164 , 406 U. S. 173 (1972); Dunn v. Blumstein, 405 U. S. 330 , 405 U. S. 335 (1972).
394 U.S. at 394 U. S. 634 . See also id. at 394 U. S. 642 -444 (STEWART, J., concurring).
Dunn v. Blumstein, supra; Shapiro v. Thompson, 394 U. S. 618 (1969); see Wyman v. Lopez, 404 U.S. 1055 (1972); Oregon v. Mitchell, 400 U. S. 112 , 400 U. S. 237 (1970) (separate opinion of BRENNAN, WHITE, and MARSHALL, JJ.), 400 U. S. 285 -286 (STEWART, J., concurring and dissenting, with whom BURGER, C.J., and BLACKMUN, J., joined); Wyman v. Bowens, 397 U. S. 49 (1970); United States v. Guest, 383 U. S. 745 , 383 U. S. 757 -759 (1966); cf. Griffin v. Breckenridge, 403 U. S. 88 , 403 U. S. 105 -106 (1971); Demiragh v. DeVos, 476 F.2d 403 (CA2 19 73). See generally Z. Chafee, Three Human Rights in the Constitution of 1787, pp. 171-181, 187 et seq. (1956).
See King v. New Rochelle Municipal Housing Auth., 442 F.2d 646, 648 n. 5 (CA2 1971); Cole v. Housing Authority of the City of Newport, 435 F.2d 807, 811 (CA1 1970); Wellford v. Battaglia, 343 F.Supp. 143, 147 (Del.1972); cf. Truax v. Raich, 239 U. S. 33 , 239 U. S. 39 (1915); Note, Shapiro v. Thompson: Travel, Welfare and the Constitution, 44 N.Y.U.L.Rev. 989, 1012 (1969).
Appellees argue that the County should be able to apply a durational residence requirement to preserve the quality of services provided its longtime residents because of their ties to the community and the previous contributions they have made, particularly through past payment of taxes. It would seem inconsistent to argue that the residence requirement should be construed to bar longtime Arizona residents, even if unconstitutional as applied to persons migrating into Maricopa County from outside the State. Surely, longtime residents of neighboring counties have more ties with Maricopa County and equity in its public programs, as through past payment of state taxes, than do migrants from distant States. This "contributory" rationale is discussed infra at 415 U. S. 266 .
For a discussion of the problems posed by this ambiguity, see Judge Coffin's perceptive opinion in Cole v. Housing Authority of the City of Newport, 435 F.2d 807 (CA1 1970).
In Vaughan v. Bower, 313 F.Supp. 37 (Ariz.), aff'd, 400 U.S. 884 (1970), a federal court struck down an Arizona law permitting the director of a state mental hospital to return to the State of his prior residence any indigent patient who had not been a resident of Arizona for the year preceding his civil commitment. It is doubtful that the challenged law could have had any deterrent effect on migration, since few people consider being committed to a mental hospital when they decide to take up residence in a new State. See also Afleldt v. Whitcomb, 319 F.Supp. 69 (ND Ind.1970), aff'd, 405 U.S. 1034 (1972).
See Vlandis v. Kline, 412 U. S. 441 , 412 U. S. 452 -453, n. 9 (1973).
"imply no view of the validity of waiting period or residence requirements determining eligibility [ inter alia ] to obtain a license to practice a profession, to hunt or fish, and so forth."
394 U.S. at 394 U. S. 638 n. 21.
Dept. of Health, Education, and Welfare (HEW) Report on Medical Resources Available to Meet the Needs of Public Assistance Recipients, House Committee on Ways and Means, 86th Cong., 2d Sess., 74 (Comm.Print 1961). Similarly, President Nixon has observed: " I t is health which is real wealth,' said Ghandi, and not pieces of gold and silver.'" Health, Message from the President, 92d Cong., 1st Sess., H.R.Doc. No. 92-49, p. 18 (1971). See also materials cited at n 4, supra.
"'While we fully recognize the value of higher education, we cannot equate its attainment with food, clothing and shelter. Shapiro involved the immediate and pressing need for preservation of life and health of persons unable to live without public assistance, and their dependent children. Thus, the residence requirement in Shapiro could cause great suffering, and even loss of life. The durational residence requirement for attendance at publicly financed institutions of higher learning [does] not involve similar risks. Nor was petitioner . . . precluded from the benefit of obtaining higher education. Charging higher tuition fees to nonresident students cannot be equated with granting of basic subsistence to one class of needy residents while denying it to an equally needy class of residents.''"
"special problems [are] involved in determining the bona fide residence of college students who come from out of State to attend [a] public university . . . ,"
since those students are characteristically transient, 412 U.S. at 412 U. S. 452 . There is no such ambiguity about whether appellant Evaro is a bona fide resident of Maricopa County.
108 Ariz. 373, 374, 498 P.2d 461, 462 (emphasis added).
See Valenciano v. Bateman, 323 F.Supp. 600, 603 (Ariz.1971). See generally HEW Report on Medical Resources, supra, n 14, at 73-74; Dept. of HEW, Human Investment Programs: Delivery of Health Services for the Poor (1967).
See HEW, Hill-Burton Project Register, July 1, 1947-June 30, 1967. HEW Publication No. (HSM) 72011, p. 37. Maricopa County has received over $2 million in Hill-Burton (42 U.S.C. § 291 et seq. ) funds since 1947.
Medicaid, the primary federal program for providing medical care to indigents at public expense, does not permit participating States to apply a durational residence requirement as a condition to eligibility, 42 U.S.C. § 1396a(b)(3), and "this conclusion of coequal branch of Government is not without significance." Frontiero v. Richardson, 411 U. S. 677 , 411 U. S. 687 -688 (1973). The State of Arizona does not participate in the Medicaid program.
Cf. Ely, Legislative and Administrative Motivation in Constitutional Law, 79 Yale L.J. 1205, 1223-1224 (1970); Note, Developments in the Law -- Equal Protection, 82 Harv.L.Rev. 1065, 1076-1077 (1969).
"[a]ppellants' attempted reliance on Dandridge . . . is also misplaced, since the classification involved in that case [did not impinge] upon a fundamental constitutional right. . . ."
Strict scrutiny is required here because the challenged classification impinges on the right of interstate travel. Compare Dandridge, supra, at 397 U. S. 484 n. 16, with Shapiro v. Thompson, supra.
Shapiro v. Thompson, 394 U.S. at 394 U. S. 629 .
See Cantor, The Law and Poor People's Access to Health Care, 35 Law & Contemp.Prob. 901, 909-914 (1970); cf. Catholic Medical Center v. Rockefeller, 305 F.Supp. 1256 and 1268 (EDNY 1969), vacated and remanded, 397 U. S. 820 , aff'd on remand, 430 F.2d 1297, appeal dismissed, 400 U.S. 931 (1970).
HEW Report on Medical Resources, supra, n 14, at 74. See generally Health, Message from the President, supra, n 14; E. Kennedy, In Critical Condition: The Crises in America's Health Care (1973); Hearings on The Health Care Crisis in America before the Subcommittee on Health of the Senate Committee on Labor and Public Welfare, 92d Cong., 1st Sess. (1971).
Cantor, supra, n 23; see E. Kennedy, supra, n 24, at 78-94; Note, Working Rules for Assuring Nondiscrimination in Hospital Administration, 74 Yale L.J. 151, 156 n. 32 (1964); cf., e.g., Stanturf v. Sipes, 447 S.W.2d 558 (Mo.1969) (hospital refused treatment to frostbite victim who was unable to pay $25 deposit). See generally HEW Report on Medical Resources, supra, n 14, at 74; Hearings on The Health Care Crisis in America, supra, n 24.
"[L]ack of timely hospitalization and medical care for those unable to pay has been considered an economic liability to the patient, the hospital, and to the community in which these citizens might otherwise be self-supporting. . . ."
HEW Report on Medical Resources, supra, n 14, at 73; Comment, Indigents, Hospital Admissions and Equal Protection, 5 U.Mich.J.L.Reform 502, 515-516 (1972); cf. Battistella & Southby, Crisis in American Medicine, The Lancet 581, 582 (Mar. 16, 1968).
See Green v. Dept. of Public Welfare of Delaware, 270 F.Supp. 173, 177-178 (Del.1967).
Ariz.Rev.Stat.Ann. § 46-292(1) (Supp. 1973-1974).
In addition, Pima County, Arizona, did not apply the durational residence requirement between August, 1969, when the requirement was found unconstitutional by the Arizona Court of Appeals, Board of Supervisors, Pima County v. Robinson, 10 Ariz.App. 238, 457 P.2d 951, and September, 1970, when that judgment was vacated as moot by the Arizona Supreme Court, 105 Ariz. 280, 463 P.2d 536.
The legal and economic aspects of medical care [ Footnote 2/1 ] are enormous, and I doubt if decisions under the Equal Protection Clause of the Fourteenth Amendment are equal to the task of dealing with these matters. So far as interstate travel per se is considered, I share the doubts of my Brother REHNQUIST. The present case, however, turns for me on a different axis. The problem has many aspects. The therapy of Arizona's atmosphere brings many there who suffer from asthma, bronchitis, arthritis, and tuberculosis. Many coming are indigent, or become indigent after arrival. Arizona does not deny medical help to "emergency" cases "when immediate hospitalization or medical care is necessary for the preservation of life or limb," Ariz.Rev.Stat.Ann. § 11-297A (Supp. 1973-1974). For others, it requires a 12-month durational residence.
"The requirement applies to all citizens within the state including long-term residents of one county who move to another county. Thus, the classification does not single out nonresidents nor attempt to penalize interstate travel. The requirement is uniformly applied."
108 Ariz. 373, 375, 498 P.2d 461, 463.
What Arizona has done, therefore, is to fence the poor out of the metropolitan counties, such as Maricopa County (Phoenix) and Pima County (Tucson) by use of a durational residence requirement. We are told that eight Arizona counties have no county hospitals, and that most indigent care in those areas exists only on a contract basis. In San Antonio Independent School Dist. v. Rodriguez, 411 U. S. 1 , we had a case where Texas created a scheme by which school districts with a low property tax base, from which they could raise only meager funds, offered a lower quality of education to their students than the wealthier districts. That system was upheld against the charge that the state system violated the Equal Protection Clause. It was a closely divided Court, and I was in dissent. I suppose that, if a State can fence in the poor in educational programs, it can do so in medical programs. But to allow Arizona freedom to carry forward its medical program, we must go one step beyond the San Antonio case. In the latter, there was no legal barrier to movement into a better district. Here a one-year barrier to medical care, save for "emergency" care, is erected around the areas that have medical facilities for the poor.
Congress has struggled with the problem. In the Kerr-Mills Act of 1960, 74 Stat. 987, 42 U.S.C. § 302(b)(2), it added provisions to the Social Security Act requiring the Secretary of Health, Education, and Welfare to disapprove any state plan for medical assistance to the aged (Medicaid) that excludes "any individual who resides in the state," thus eliminating durational residence requirements.
of Hill-Burton facilities. The regulations contain conditions that the facility to be constructed or modernized with the funds "will be made available to all persons residing in the territorial area of the applicant," and that the applicant will render "a reasonable volume of services to persons unable to pay therefor." [ Footnote 2/2 ] The conditions of free services for indigents, however, may be waived if "not feasible from a financial viewpoint."
"that there will be made available in the facility or portion thereof to be constructed or modernized a reasonable volume of services to persons unable to pay therefor. The requirement of an assurance from an applicant shall be waived if the applicant demonstrates to the satisfaction of the State agency, subject to subsequent approval by the Secretary, that such a requirement is not feasible from a financial viewpoint."
So far as I can ascertain, the durational residence requirement imposed by Maricopa County has not been federally approved as a condition to the receipt of Hill-Burton funds.
a professed inability to service indigents of all races because 42 CFR § 53.112(c) prohibits such discrimination in the operation of Hill-Burton facilities. It does not allow racial discrimination even against transients.
Moreover, Hill-Burton Act donees are guided by 42 CFR § 53.111(g), which sets out in some detail the criteria which must be used in identifying persons unable to pay for such services. The criteria include the patient's health and medical insurance coverage, personal and family income, financial obligations and resources, and "similar factors." Maricopa County, pursuant to the state law here challenged, employs length of county residence as an additional criterion in identifying indigent recipients of uncompensated nonemergency medical care. The federal regulations, however, do not seem to recognize that as an acceptable criterion.
And, as we held in Thorpe v. Housing Authority, 393 U. S. 268 ; Mourning v. Family Publications Service, 411 U. S. 356 , these federal conditions attached to federal grants are valid when "reasonably related to the purposes of the enabling legislation." 393 U.S. at 393 U. S. 280 -281.
It is difficult to impute to Congress approval of the durational residence requirement, for the implications of such a decision would involve weighty equal protection considerations by which the Federal Government, Bolling v. Sharpe, 347 U. S. 497 , as well as the States, are bound.
of Elections, 383 U. S. 663 , not the right to travel interstate, is, in my view, the critical issue.
APPENDIX TO OPINION OF DOUGLAS, J.
The people of Gourmand loved good food. They ate in good restaurants, donated money for cooking research, and instructed their government to safeguard all matters having to do with food. Long ago, the food industry had been in total chaos. There were many restaurants, some very small. Anyone could call himself a chef or open a restaurant. In choosing a restaurant, one could never be sure that the meal would be good. A commission of distinguished chefs studied the situation and recommended that no one be allowed to touch food except for qualified chefs. "Food is too important to be left to amateurs," they said. Qualified chefs were licensed by the state, with severe penalties for anyone else who engaged in cooking. Certain exceptions were made for food preparation in the home, but a person could serve only his own family. Furthermore, to become a qualified chef, a man had to complete at least twenty-one years of training (including four years of college, four years of cooking school, and one year of apprenticeship). All cooking schools had to be first class.
income." Furthermore, they argued that chefs should work toward the goal of giving everyone "complete physical and psychological satisfaction." For those people who could not afford to eat out, the government declared that they should be allowed to do so as often as they liked and the government would pay. For others, it was recommended that they organize themselves in groups and pay part of their income into a pool that would undertake to pay the costs incurred by members in dining out. To insure the greatest satisfaction, the groups were set up so that a member could eat out anywhere and as often as he liked, could have as elaborate a meal as he desired, and would have to pay nothing or only a small percentage of the cost. The cost of joining such prepaid dining clubs rose sharply.
Long ago, most restaurants would have one chef to prepare the food. A few restaurants were more elaborate, with chefs specializing in roasting, fish, salads, sauces, and many other things. People rarely went to these elaborate restaurants, since they were so expensive. With the establishment of prepaid dining clubs, everyone wanted to eat at these fancy restaurants. At the same time, young chefs in school disdained going to cook in a small restaurant where they would have to cook everything. The pay was higher, and it was much more prestigious to specialize and cook at a really fancy restaurant. Soon there were not enough chefs to keep the small restaurants open.
The commission agreed that weighty problems faced the nation. They recommended that a national prepayment group be established which everyone must join. They recommended that chefs continue to be paid on the basis of the number of dishes they prepared. They recommended that every Gourmandese be given the right to eat anywhere he chose, and as elaborately as he chose, and pay nothing.
These recommendations were adopted. Large numbers of people spent all of their time ordering incredibly elaborate meals. Kitchens became marvels of new, expensive equipment. All those who were not consuming restaurant food were in the kitchen preparing it. Since no one in Gourmand did anything except prepare or eat meals, the country collapsed.
See appendix to this opinion, post, p. 415 U. S. 274 .
"a level of uncompensated services which meets a need for such services in the area served by an applicant and which is within the financial ability of such applicant to provide."
The waiver of such a requirement requires notice and opportunity for public hearing. 42 CFR § 53.111(c)(2).
For the impact of "free" indigent care on private hospitals and their paying patients see Dept. of Health, Education, and Welfare (HEW) Report on Medical Resources Available to Meet the Needs of Public Assistance Recipients, House Committee on Ways and Means, 86th Cong., 2d Sess. (Comm.Print 1961).
Foreword to an article on Medical Care and its Delivery: An Economic Appraisal by Judith R. Lave and Lester B. Lave in 35 Law & Contemp.Prob. 252 (1970).
The State of Arizona provides free medical care for indigents. Confronted, in common with its 49 sister States, with the assault of spiraling health and welfare costs upon limited state resources, it has felt bound to require that recipients meet three standards of eligibility. [ Footnote 3/1 ] First, they must be indigent, unemployable, or unable to provide their own care. Second, they must be residents of the county in which they seek aid. Third, they must have maintained their residence for a period of one year. These standards, however, apply only to persons seeking nonemergency aid. An exception is specifically provided for "emergency cases when immediate hospitalization or medical care is necessary for the preservation of life or limb. . . ."
institution. The hospital sought to recover its expenses from appellee Maricopa County under the provisions of Ariz.Rev.Stat.Ann. § 297A (Supp 1973-1974), asserting that Evaro was entitled to receive county care. Since he did not satisfy the eligibility requirements discussed above, [ Footnote 3/2 ] appellee declined to assume responsibility for his care, and this suit was then instituted in the State Superior Court.
Appellants did not, and could not, claim that there is a constitutional right to nonemergency medical care at state or county expense or a constitutional right to reimbursement for care extended by a private hospital. [ Footnote 3/3 ] They asserted, however, that the state legislature, having decided to give free care to certain classes of persons, must give that care to Evaro as well. The Court upholds that claim, holding that the Arizona eligibility requirements burdened Evaro's "right to travel."
persons dependent on the financing locality both by association and by need.
Appellants in this case nevertheless argue that the State's efforts, admirable though they may be, are simply not impressive enough. But others excluded by eligibility requirements certainly could make similar protests. Maricopa County residents of many years, paying taxes to both construct and support public hospital facilities, may be ineligible for care because their incomes are slightly above the marginal level for inclusion. These people have been excluded by the State not because their claim on limited public resources is without merit, but because it has been deemed less meritorious than the claims of those in even greater need. Given a finite amount of resources, Arizona after today's decision may well conclude that its indigency threshold should be elevated, since its counties must provide for out-of-state migrants as well as for residents of longer standing. These more stringent need requirements would then deny care to additional persons who, until now, would have qualified for aid.
responsibility of allocating limited public welfare funds among the myriad of potential recipients."
"[T]he right of interstate travel must be seen as insuring new residents the same right to vital government benefits and privileges in the States to which they migrate as are enjoyed by other residents."
This rationale merits further attention.
conducted, to the sub-treasuries, the land offices, the revenue offices, and the courts of justice in the several States, and this right is, in its nature, independent of the will of any State over whose soil he must pass in the exercise of it."
Id. at 73 U. S. 44 .
"Undoubtedly the right of locomotion, the right to remove from one place to another according to inclination, is an attribute of personal liberty, and the right, ordinarily, of free transit from or through the territory of any State is a right secured by the Fourteenth Amendment and by other provisions of the Constitution."
"prohibition against attempts on the part of any single State to isolate itself from difficulties common to all of them by restraining the transportation of persons and property across its borders."
the statute did not require that the indigent intend to take up continuous residence within the State. The statute was not therefore an incidental or remote barrier to migration, but was, in fact, an effective and purposeful attempt to insulate the State from indigents.
The statute in the present case raises no comparable barrier. Admittedly, some indigent persons desiring to reside in Arizona may choose to weigh the possible detriment of providing their own nonemergency health care during the first year of their residence against the total benefits to be gained from continuing location within the State, but their mere entry into the State does not invoke criminal penalties. To the contrary, indigents are free to live within the State, to receive welfare benefits necessary for food and shelter, [ Footnote 3/9 ] and to receive free emergency medical care if needed. Furthermore, once the indigent has settled within a county for a year, he becomes eligible for full medical care at county expense. To say, therefore, that Arizona's treatment of indigents compares with California's treatment during the 1930's would border on the frivolous.
eminently sensible and workable. But the Court not only rejects this approach, it leaves us entirely without guidance as to the proper standard to be applied.
"Whatever the ultimate parameters of the Shapiro penalty analysis, it is at least clear that medical care is as much'a basic necessity of life' to an indigent as welfare assistance. And governmental privileges or benefits necessary to basic sustenance have often been viewed as being of greater constitutional significance than less essential forms of governmental entitlements. See, e.g., Shapiro, supra; Goldberg v. Kelly, 397 U. S. 254 , 397 U. S. 264 (1970); Sniadach v. Family Finance Corp., 395 U. S. 337 , 395 U. S. 340 -342 (1969)."
a counterpart to the barriers condemned in earlier cases. That being so, the Court should observe its traditional respect for the State's allocation of its limited financial resources, rather than unjustifiably imposing its own preferences.
Other interests advanced by the State to support its statutory eligibility criteria are also rejected virtually out of hand by the Court. The protection of the county economies is dismissed with the statement that "[t]he conservation of the taxpayers' purse is simply not a sufficient state interest. . . ." [ Footnote 3/16 ] The Court points out that the cost of care, if not borne by the Government, may be borne by private hospitals such as appellant Memorial Hospital. While this observation is doubtless true in large part, and is bound to present a problem to any private hospital, it does not seem to me that it thus becomes a constitutional determinant. The Court also observes that the State may, in fact, save money by providing nonemergency medical care, rather than waiting for deterioration of an illness. However valuable a qualified cost analysis might be to legislators drafting eligibility requirements, and however little this speculation may bear on Evaro's condition (which the record does not indicate to have been a deteriorating illness), this sort of judgment has traditionally been confided to legislatures, rather than to courts charged with determining constitutional questions.
administrative objectives. Refusing to accept the assertion that a one-year waiting period is a "convenient rule of thumb to determine bona fide residence," the majority simply suggests its own alternatives. Similar analysis is applied in rejecting the appellees' argument based on the potential for fraud. The Court's declaration that an indigent applicant "intent on committing fraud, could as easily swear to having been a resident of the county for the preceding year as to being one currently" ignores the obvious fact that fabricating presence in the State for a year is surely more difficult than fabricating only a present intention to remain.
The legal question in this case is simply whether the State of Arizona has acted arbitrarily in determining that access to local hospital facilities for nonemergency medical care should be denied to persons until they have established residence for one year. The impediment which this quite rational determination has placed on appellant Evaro's "right to travel" is so remote as to be negligible: so far as the record indicates, Evaro moved from New Mexico to Arizona three years ago, and has remained ever since. The eligibility requirement has not the slightest resemblance to the actual barriers to the right of free ingress and egress protected by the Constitution, and struck down in cases such as Crandall and Edwards. And, unlike Shapiro, it does not involve an urgent need for the necessities of life or a benefit funded from current revenues to which the claimant may well have contributed. It is a substantial broadening of, and departure from, all of these holdings, all the more remarkable for the lack of explanation which accompanies the result. Since I can subscribe neither to the method nor the result, I dissent.
"Except in emergency cases when immediate hospitalization or medical care is necessary for the preservation of life or limb no person shall be provided hospitalization, medical care or outpatient relief under the provisions of this article without first filing with a member of the board of supervisors of the county in which he resides a statement in writing, subscribed and sworn to under oath, that he is an indigent as shall be defined by rules and regulations of the state department of economic security, an unemployable totally dependent upon the state or county government for financial support, or an employable of sworn low income without sufficient funds to provide himself necessary hospitalization and medical care, and that he has been a resident of the county for the preceding twelve months."
The parties stipulated that Mr. Evaro was "an indigent who recently changed his residence from New Mexico to Arizona and who has resided in the state of Arizona for less than twelve months." App. 10. Therefore, Mr. Evaro failed to meet only the third requirement discussed in the text.
This Court has noted that citizens have no constitutional right to welfare benefits. See, e.g., Dandridge v. Williams, 397 U. S. 471 (1970); San Antonio Independent School Dist. v. Rodriguez, 411 U. S. 1 , 411 U. S. 33 (1973).
Although the right to travel has been recognized by this Court for over a century, the origin of the right still remains somewhat obscure. The majority opinion in this case makes no effort to identify the source, simply relying on recent cases which state such a right exists.
The tax levied by the State of Nevada was upon every person leaving the State. As this Court has since noted, the tax was a direct tax on travel, and was not intended to be a charge for the use of state facilities. See Evansville Airport v. Delta Airlines, 405 U. S. 707 (1972).
"We are unable to say that such a discrimination, if it existed, did not rest on reasonable grounds, and was not within the discretion of the state legislature."
179 U.S. at 179 U. S. 276 .
See the concurring opinions of MR. JUSTICE DOUGLAS (with whom Mr. Justice Black and Mr. Justice Murphy joined), 314 U.S. at 314 U. S. 177 , and Mr. Justice Jackson, id. at 314 U. S. 181 .
"After arriving in California, [the indigent] was aided by the Farm Security Administration, which . . . is wholly financed by the Federal government."
314 U.S. at 314 U. S. 175 . The Court did not express a view at that time as to whether a different result would have been reached if the State bore the financial burden. But cf. Shapiro v. Thompson, 394 U. S. 618 (1969).
See Ariz.Rev.Stat.Ann. § 4233 (Supp. 1973-1974), which provides that an eligible recipient of general assistance must have "established residence at the time of application."
See Starns v. Malkerson, 326 F.Supp. 234 (Minn.1970), aff'd, 401 U.S. 985 (1971); Vlandis v. Kline, 412 U. S. 441 (1973).
See, e.g., Interstate Busses Corp. v. Blodgett, 276 U. S. 245 (1928); Hendrick v. Maryland, 235 U. S. 610 (1915).
See Evansville Airport v. Delta Airlines, 405 U. S. 707 (1972).
See, e.g., Evans v. Cornman, 398 U. S. 419 (1970); Cipriano v. City of Houma, 395 U. S. 701 (1969).
"be construed to deny a State the right to impose on a student, as one element in demonstrating bona fide residence, a reasonable durational residency requirement, which can be met while in student status."
412 U.S. at 412 U. S. 452 . Starns was cited as support for this position.
This distinction may be particularly important in a State such as Arizona, where the Constitution provides for limitations on state and county debt. See Ariz.Const., Art. 9, § 5 (State); Art. 9, § (County). See generally Comment, Dulling the Edge of Husbandry: The Special Fund Doctrine in Arizona, 1971 L. & Soc. O. (Ariz. St.L.J.) 555.
The appellees in this case filed an affidavit indicating that acceptance of appellants' position would impose an added burden on property taxpayers in Maricopa County of over $2.5 million in the first year alone. App. 117.

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