Case Name: David KONG, Plaintiff-Appellant, v. Thomas SCULLY, in his official capacity as director of Center for Medicare and Medicaid Services; Tommy Thompson, in his official Capacity as Secretary of the United States Department of Health and Human Services, Defendants-Appellees, The First Church of Christ, Scientist, Defendant-Intervenor-Appellee
Court: United States Court of Appeals for the Ninth Circuit
Jurisdiction: United States
Decision Date: 2003-09-02
Citations: 341 F.3d 1132
Docket Number: No. 02-15057
Parties: David KONG, Plaintiff-Appellant, v. Thomas SCULLY, in his official capacity as director of Center for Medicare and Medicaid Services; Tommy Thompson, in his official Capacity as Secretary of the United States Department of Health and Human Services, Defendants-Appellees, The First Church of Christ, Scientist, Defendant-Intervenor-Appellee.
Judges: Before NOONAN, McKEOWN, and RAWLINSON, Circuit Judges.
Reporter: Federal Reporter 3d Series
Volume: 341
Pages: 1132–1148

Head Matter:
David KONG, Plaintiff-Appellant, v. Thomas SCULLY, in his official capacity as director of Center for Medicare and Medicaid Services; Tommy Thompson, in his official Capacity as Secretary of the United States Department of Health and Human Services, Defendants-Appellees, The First Church of Christ, Scientist, Defendant-Intervenor-Appellee.
No. 02-15057.
United States Court of Appeals, Ninth Circuit.
Argued and Submitted April 9, 2003.
Filed Sept. 2, 2003.
Robert J. Bruno, Brunsville, MN, for the plaintiff-appellant.
Lowell V. Sturgill, Jr., Department of Justice, Washington, DC, for defendants-appellees Thomas Scully and Tommy Thompson.
Stephen M. Shapiro, Chicago, IL, for the defendant-intervenor-appellee.
Before NOONAN, McKEOWN, and RAWLINSON, Circuit Judges.

Opinion:
Opinion by Judge NOONAN; Concurrence by Judge McKEOWN; Concurrence by Judge RAWLINSON
OPINION
NOONAN, Circuit Judge.
David Kong appeals the judgment of the district court upholding as constitutional on its face and as applied section 4454 of the Balanced Budget Act of 1997. This law effected amendments to 42 U.S.C. § 1320 and 42 U.S.C. § 1395 in order to permit payments under Medicare and Medicaid Acts for the nonmedical care of persons whose religious tenets lead them to reject medical services. The district court held that these amendments were not an establishment of religion. We affirm the district court.
THE AMENDED STATUTES
42 U.S.C. § 1320c-ll, as amended by the Balanced Budget Act, reads:
Exemptions for religious nonmedical health care institutions The provisions of this part shall not apply with respect to a religious non-medical health care institution (as defined in section 1395x(ss)(l) of this title).
42 U.S.C. § 1395x(e), as amended in its definitions, defines "hospital" to include
a religious nonmedical health care institution (as defined in subsection (ss)(l) of this section), with respect to items and services ordinarily furnished by such institution to inpatients, and payment may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements (in addition to or in lieu of the conditions, limitations, and requirements otherwise applicable) as may be provided in regulations consistent with section 1395Í-5 of this title.
42 U.S.C. § 1395x(y)(l), as amended, reads:
Extended care in religious nonmedical health care institutions
The term 'skilled nursing facility' also includes a religious nonmedical health care institution (as defined in subsection (ss)(l) of this section), (except for purposes of subsection (a)(2) of this section) with respect to items and services ordinarily furnished by such an institution to inpatients, and payment may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements (in addition to or in lieu of the conditions, limitations, and requirements otherwise applicable) as may be provided in regulations consistent with section 1395Í-5 of this title.
The cross-referenced section x(ss)(l) reads in relevant part as follows:
Religious nonmedical health care institution
(1) The term "religious nonmedical health care institution" means an institution that—
(A) is described in subsection (c)(3) of section 501 of The Internal Revenue Code of 1986 and is exempt from taxes under subsection (a) of such section;
(B) is lawfully operated under all applicable Federal, State, and local laws and regulations;
(C) provides only nonmedical nursing items and services exclusively to patients who choose to rely solely upon a religious method of healing and for whom the acceptance of medical health services would be inconsistent with then-religious beliefs;
(D) provides such nonmedical items and services exclusively through non-medical nursing personnel who are experienced in caring for the physical needs of such patients;
(E) provides such nonmedical items and services to inpatients on a 24-hour basis;
(F) on the basis of its religious beliefs, does not provide through its personnel or otherwise medical items and services (including any medical screening, examination, diagnosis, prognosis, treatment, or the administration of drugs) for its patients;
(G)(i) is not owned by, under common ownership with, or has an ownership interest in, a provider of medical treatment or services;
(ii)is not affiliated with—
(I) a provider of medical treatment or services, or
(II) an individual who has an ownership interest in a provider of medical treatment or services;
(H) has in effect a utilization review plan which—
(i) provides for the review of admissions to the institution, of the duration of stays therein, of cases of continuous extended duration, and of the items and services furnished by the institution,
(ii) requires that such reviews be made by an appropriate committee of the institution that includes the individuals responsible for overall administration and for supervision of nursing personnel at the institution,
(iii) provides that records be maintained of the meetings, decisions, and actions of such committee, and
(iv) meets such other requirements as the Secretary finds necessary to establish an effective utilization review plan;
(I) provides the Secretary with such information as the Secretary may require to implement section 139H-5 of this title, including information relating to quality of care and coverage determinations; and
(J) meets such other requirements as the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the institution.
(2)To the extent that the Secretary finds that the accreditation of an institution by a State, regional, or national agency or association provides reasonable assurances that any or all of the requirements of paragraph (1) are met or exceeded, the Secretary may treat such institution as meeting the condition or conditions with respect to which the Secretary made such finding.
(3)(A)(i) In administering this subsection and section 1395Í-5 of this title, the Secretary shall not require any patient of a religious nonmedical health care institution to undergo medical screening, examination, diagnosis, prognosis, or treatment or to accept any other medical health care service, if such patient (or legal representative of the patient) objects thereto on religious grounds.
(ii) Clause (i) shall not be construed as preventing the Secretary from requiring under section 1395i-5(a)(2) of this title the provision of sufficient information regarding an individual's condition as a condition for receipt of benefits under part A of this subchapter for services provided in such an institution.
(B)(i) In administering this subsection and section 1395Í-5 of this title, the Secretary shall not subject a religious non-medical health care institution or its personnel to any medical supervision, regulation, or control, insofar as such supervision, regulation or control would be contrary to the religious beliefs observed by the institution or such personnel.
(ii) Clause (i) shall not be construed as preventing the Secretary from reviewing items and services billed by the institution to the extent the Secretary determines such review to be necessary to determine whether such items and services were not covered under part A of this subchapter, are excessive, or are fraudulent.
42 U.S.C. § 1395Í-5, Conditions for coverage of religious nonmedical health care institutional services, as amended, reads in relevant part:
(a) In general
Subject to subsections (c) and (d), payment under this part may be made for inpatient hospital services or post-hospital extended care services furnished an individual in a religious non-medical health care institution only if—
(1) the individual has an election in effect for such benefits under subsection (b) of this section; and
(2) the individual has a condition such that the individual would qualify for benefits under this part for inpatient hospital services or extended care services, respectively, if the individual were an inpatient or resident in a hospital or skilled nursing facility that was not such an institution.
(b) Election
(1) In general
An individual may make an election under this subsection in a form and manner specified by the Secretary consistent with this subsection. Unless otherwise provided, such an election shall take effect immediately upon its execution. Such an election, once made, shall continue in effect until revoked.
(2) Form
The election form under this subsection shall include the following:
(A) A written statement, signed by the individual (or such individual's legal representative), that—
(i) the individual is conscientiously opposed to acceptance of nonexcepted medical treatment; and
(ii) the individual's acceptance of nonexcepted medical treatment would be inconsistent with the individual's sincere religious beliefs.
(B) A statement that the receipt of nonexcepted medical services shall constitute a revocation of the election and may limit further receipt of services described in subsection (a) of this section.
(8) Revocation
An election under this subsection by an individual may be revoked by voluntarily notifying the Secretary in writing of such revocation and shall be deemed to be revoked if the individual receives nonexcepted medical treatment for which reimbursement is made under this subchapter.
(4) Limitation on subsequent elections
Once an individual's election under this subsection has been made and revoked twice — •
(A) the next election may not become effective until the date that is 1 year after the date of the most recent previous revocation, and
(B) any succeeding election may not become effective until the date that is 5 years after the date of the most recent previous revocation.
(5) Excepted medical treatment
For purposes of this subsection:
(A) Excepted medical treatment
The term "excepted medical treatment" means medical care or treatment (including medical and other health services)—
(i) received involuntarily, or
(ii) required under Federal or State law or law of a political subdivision of a State.
(B) Nonexcepted medical treatment
The term "nonexcepted medical treatment" means medical care or treatment (including medical and other health services) other than excepted medical treatment.
PROCEEDINGS
November 16, 2000, David Kong, identifying himself as a taxpayer of the United States and resident of the Northern District of California, filed the complaint initiating this case, challenging section 4454 of the Balanced Budget Act of 1997, as "a sect-specific establishment of religion" in its provisions for payment to Religious Nonmedical Healthcare Institutions (RNHCIs). Kong alleged that the only known institutions meeting the definitions of a RNHCI were Christian Science sana-toria promoting Christian Science spiritual healing and admitting for their services only Christian Scientists who had hired a Christian Science practitioner approved by The First Church of Christ, Scientist.
The United States defended the statute. The First Church of Christ, Scientist was permitted to intervene in its defense. After the submission of various declarations, motions for summary judgment were filed. The district court denied Kong's and granted those of the intervenor and of the United States. The district court took note of litigation in Minnesota that had challenged the 1965 version of Medicare and Medicaid because there was explicit exception for Christian Scientists objecting, according to their beliefs, to medical treatment and explicit authorization for the funding of physical services in Christian Science sanatoria. These sect-specific provisions were held to be unconstitutional as facially discriminating in favor of one religious body. Children's Healthcare Is A Legal Duty, Inc. v. Vladeck, 938 F.Supp. 1466, 1485 (D.Minn.1996) ("Child I "). The following year, Congress enacted the amendments challenged here, eliminating all explicit references to Christian Science. The same plaintiff which had been successful in Child I challenged the amendments and lost. Children's Healthcare Is A Legal Duty, Inc. v. Min De Parle, 212 F.3d 1084 (8th Cir.2000) ("Child II"), (affirming the judgment of the district court in 1998), cert. denied, 532 U.S. 957, 121 S.Ct. 1483, 149 L.Ed.2d 372 (2001).
The intervenor challenged Kong's standing, but the district court, citing Flast v. Cohen, 392 U.S. 83, 88 S.Ct. 1942, 20 L.Ed.2d 947 (1968), held that Kong had standing to pursue all his claims. The district court found that there was no evidence that the statute was drafted to favor Christian Science; that the statute did have the secular purpose of lifting a burden from those who were obliged to pay taxes for the health services but whose religious beliefs precluded them from receiving medical services; that the statutes did not impose a substantial burden on nonbeneficiaries of RNHCIs, the amount paid to these institutions in 1999 amounting to approximately $8 million; that the primary effect of the statute was not to advance religion, neither conveying a message of endorsement of a religion nor encouraging non-believers in a favored religion to change their religious beliefs to the favored religion; that the statute did not entangle the government excessively with religion; that the statute did not delegate governmental power to a church without public standards or public review; and that, as applied, the statute did not fund activity that was pervasively sectarian, the activity, instead, being essentially secular health care. The court concluded by noting the presumption in favor of a federal statute's constitutionality, a presumption particularly appropriate "when, as here, Congress specifically considered the question of the Act's constitutionality." Rostker v. Goldberg, 453 U.S. 57, 64, 101 S.Ct. 2646, 69 L.Ed.2d 478 (1981). The court cited to statements by Senator Kennedy, 143 Cong. Rec. S6322 (daily ed. June 25, 1997) and Senator Hatch, 143 Cong. Rec. S8447 (daily ed. July 31,1997).
November 13, 2001, the district court entered judgment. This appeal timely followed.
ANALYSIS
Jurisdiction. The intervenor has not renewed its challenge, but we are un der obligation to satisfy ourselves that there is jurisdiction. Flast v. Cohen, 392 U.S. 83, 88 S.Ct. 1942, 20 L.Ed.2d 947 (1968) has been distinguished. Valley Forge Christian College v. Americans United for Separation of Church and State, Inc., 454 U.S. 464, 487, 102 S.Ct. 752, 70 L.Ed.2d 700 (1982), where it was observed: "The federal courts were simply not constituted as ombudsmen of the general welfare." The actual injury to Kong as a taxpayer is very small; the injury is to his principles, not his pocketbook. But assuming as we must the continued vitality of Flast, Kong has standing, and we have jurisdiction.
Establishment of religion: evolution. Establishment of a religion in the sense known to the Founders was well-expressed by Chief Justice Theophilus Parsons for the Supreme Judicial Court of Massachusetts describing the place of Protestant Christianity in the Commonwealth of Massachusetts:
And this religion, as understood by Protestants, tending by its effects to make every man submitting to its influence a better husband, parent, child, neighbor, citizen, and magistrate, was by the people established as a fundamental and essential part of their constitution.
Barnes v. First Parish in Falmouth, 6 Mass. 401 (1810). Establishment as essential part of the framework of government meant that "public Protestant teachers of piety" were required by the state constitution itself to be supported by tax laid on the population as a whole, Massachusetts Constitution of 1780, Part I, Art. Ill; that an oath be required of candidates for the legislature and principal executive officers disqualifying Catholics, Id., Part II, Ch. VI, Art. I; and that a college (Harvard) be publicly financed to educate, under supervision of Congregational clergy, students for service in "Church and State," Id. Part II, Ch. V, Art. I, Church and State not being separated but united.
The constitutional command at issue is the First Amendment: "Congress shall make no law respecting an establishment of religion." If we perform the elision and substitution effected by Justice Black in Everson v. Board of Education, 330 U.S. 1, 15, 67 S.Ct. 504, 91 L.Ed. 711 (1947), the phrase becomes a prohibition against Congress making an establishment of religion of the kind celebrated by Chief Justice Parsons. As the Constitution has been interpreted in the past fifty years, religion has been understood broadly so that the Selective Service Act of 1951's reference "to religious training and belief in a Supreme Being" was functionally satisfied by "[a] sincere and meaningful belief which occupies in the life of its possessor a place parallel to that followed by the God of those admittedly qualifying for the exemption." United States v. Seeger, 380 U.S. 163, 176, 85 S.Ct. 850, 13 L.Ed.2d 733 (1965). Establishment of religion has been found to exist, principally, in a state's aid to denominational pre-college schools, e.g. Committee for Public Educ. and Religious Liberty v. Nyquist, 413 U.S. 756, 93 S.Ct. 2955, 37 L.Ed.2d 948 (1973) and, occasionally, in a local government's promotion of a religious symbol, e.g. County of Allegheny v. American Civil Liberties Union Greater Pittsburgh Chapter, 492 U.S. 573, 109 S.Ct. 3086, 106 L.Ed.2d 472 (1989). No case is known, however, in which the Supreme Court discerned an establishment of religion in the federal funding of a federal program of assistance to the citizenry.
Strict separationists believe that any benefit bestowed by government on religion qualifies as "establishment." The metaphorical wall unmentioned by the First Amendment but celebrated by Everson, 330 U.S. at 16, 67 S.Ct. 504, cannot be porous. Abstractly speaking, their logic is impeccable. It is fortified by such sayings and aphorisms as "Don't let the camel's nose under the tent" and "Who says A must say B." But abstract logic and folk wisdom yield to historical experience. A variety of benefits have been bestowed by government on religious practices and either have been unchallenged or passed constitutional muster without fatal compromise of principle. A vital balance has been maintained rather than a syllogism parsed. Thus, for example, since the time of the First Congress, the government has paid for chaplains to pray for Congress. See Marsh v. Chambers, 463 U.S. 783, 787, 103 S.Ct. 3330, 77 L.Ed.2d 1019 (1983). Presidents have proclaimed days of prayer and of thanksgiving to God. E.g. Abraham Lincoln, Proclamation of Thanksgiving, July 15, 1863, in 6 The Collected Works of Abraham Lincoln 322 (Roy P. Basler ed., 1953). Hundreds of millions of dollars are spent annually to fund chaplains for the armed forces in war and in peace, abroad and in our own cities, paying not only for the religious services of the chaplains but also for the holy books and supplies used in acts of worship. See Katcoff v. Marsh, 755 F.2d 223, 229 (2d Cir.1985). The payment of chaplains by a state legislature has been upheld as constitutional by the Supreme Court. Marsh v. Chambers, 463 U.S. at 795, 103 S.Ct. 3330. Subsidy of buildings of worship by tax exemption, a universal practice of state and federal government, has been found not to be an establishment. Walz v. Tax Comm'n, 397 U.S. 664, 90 S.Ct. 1409, 25 L.Ed.2d 697 (1970). Provisions in the draft law exempting from service members of "the historic Pence Churches" has been found unobjectionable. Arver v. U.S., 245 U.S. 366, 389, 38 S.Ct. 159, 62 L.Ed. 349 (1918); and the discrimination in favor of total pacifists has been upheld even when it appeared as a religious discrimination disfavoring conscientious objection to unjust war. Gillette v. U.S., 401 U.S. 437, 462, 91 S.Ct. 828, 28 L.Ed.2d 168 (1971). History establishes that it is too late in the day to evoke an unbroken wall.
As history must play such a vital part in understanding what the Bill of Rights requires, it is also appropriate to note that at the time this charter of freedom was written, no massive programs of federal aid to the public existed. Just as the requirements of free speech have to be applied to a country in which television has become a form of speech, so the provision bearing on establishment must be understood in a country where federal aid is given to individuals in a broad range of categories and is as much taken for granted as a governmental function as the building of highways or the distribution of mail. As Everson itself holds, ordinary government services are not to be denied because they benefit a church or a church school. Everson, 330 U.S. at 18, 67 S.Ct. 504. Of the programs involved in this case, Medicare in 2001 disbursed $240 billion and Medicaid disbursed $129 billion. See Fiscal Year 2003 President's Budget for HHS, pgs. 64, 68, available at http://www.hhs.gov/budget/pdf/hhs 2003bib.pdf. In this cascade of money Congress has taken great pains to create a small island where persons who do not believe in medical help may have some governmental support comparable to that furnished by the government to those who do. We review its constitutionality under the familiar, oft-questioned prongs of Lemon v. Kurtzman, 411 U.S. 192, 93 S.Ct. 1463, 36 L.Ed.2d 151 (1973).
Passing the Prongs. The amendment does not advance religion. No one would become a Christian Scientist in order to obtain admission to an RNHCI when the cost of such a conversion would be renunciation of all medical treatment. The amendment indoctrinates no one in religion. The amendment does not symbolize government approval of faith healing. The amendment compels no belief. The amendment does not turn the mundane physical services that are provided into a "pervasively sectarian" activity. The extraordinary detail of the amended statutes evinces only a desire to accommodate a very small minority whose religious tenets put them in a position where they pay taxes, and, unless accommodated, would get no return from the taxes. Accommodation of a religious minority to let them practice their religion without penalty is a lawful secular purpose.
It was contended by Judge Lay dissenting in Child II that if this kind of accommodation is constitutional, it would be permissible for a state to pay for parochial schools on the theory that the pupils' parents had paid taxes to support public schools but were getting nothing in return. Child II, 212 F.3d at 1106 (Lay, J. dissenting). The analogy fails. The parochial schools are not permitted direct governmental support because they are engaged in promoting a religion and indoctrinating pupils in it. That is not how the physical care of the RNHCIs can be described.
The Delegated Government Power. An individual obtains admission to an RNHCI only if the individual "has a condition such that the individual would qualify for benefits . for inpatient hospital services. ." 42 U.S.C. § 1395i-5(a)(2). An RNHCI cannot use a medical examination or diagnosis to determine this condition or to admit or to discharge Medicare and Medicaid beneficiaries. 42 U.S.C. § 1395x(ss)(l)(F). As there is no medical examination, there are no apparent standards for admission except a belief that one needs admission and does not believe in medical help; and there are no apparent standards for discharge. Kong contends that consequently a governmental power is delegated to a religious institution, the RNHCI, in violation of the principle laid down in Larkin v. Grendel's Den, 459 U.S. 116, 103 S.Ct. 505, 74 L.Ed.2d 297 (1982). It is true that the power held unconstitutional in that case was an absolute power to deny a liquor license to a church's neighbors. In distinction, here the delegated power is to benefit persons seeking to be benefited. In both Grendel's Den and here, government has delegated a governmental power without standards to guide its exercise.
The government argues that the RNHCI merely submits bills for reimbursement. The bills are not paid until approved by "a fiscal intermediary," which has no religious character. 42 U.S.C. § 1395h; 42 U.S.C. § 1395x(ss)(l)(H)-(J); § 1395x(ss)(3)(B)(ii); 42 C.F.R. § 405.1803; see Regions Hosp. v. Shalala, 522 U.S. 448, 452-53, 118 S.Ct. 909, 139 L.Ed.2d 895 (1998). There is, however, nothing for the financial intermediary to review as to the physical condition of the beneficiary who has been billed by the RNHCI. The fiscal intermediary can review whether the services that have been billed were provided. The fiscal intermediary has no means of determining whether the condition of the beneficiary justified admission or discharge.
The question presented, therefore, is whether delegation of governmental power without standards to institutions identified by their religious rejection of medicine is an unconstitutional establishment of religion. Exercise of the delegated power facilitates the payment of funds for physical services that are in themselves neither religious nor teaching a religion. If the power were not delegated and a medical examination or diagnosis were required to qualify for the benefits, the very purpose of the statutory accommodation would be defeated. Nonmedical help to persons re ligiously rejecting medical help can only be given by exempting them from proving any medical condition. Congress, aware of the constitutional difficulty, has attempted to achieve this objective.
The resulting legislation is not an establishment of religion as originally understood by the Framers. Even a penny of tax in aid of such an establishment is objectionable, as James Madison maintained in his famous Memorial and Remonstrance of 1785. See Everson v. Board of Education, 380 U.S. 1, 65-66, 67 S.Ct. 504, 91 L.Ed. 711 (1947) (reprinting Madison's Memorial and Remonstrance). Here an arguably unconstitutional delegation of power to religious institutions has occurred; but it has occurred as the only way of unburdening an exercise of religious belief. Logic leads us to condemn the establishment. The history of this country, with its willingness to let new religions be founded and flourish, counsels against extending Grendel's Den further. It is more in tune with the Bill of Rights to give relief to a religious minority than to find a constitutional evil in congressional response to a constituency. When the government is in the business of taxing for health care and providing it to its citizens, an incidental expenditure, less than 1/10 of 1% of the amount annually expended, in order to accommodate, to a degree, the religious beliefs of a minority is not reasonably read as an establishment of religion. In this case, as in many cases involving government relationship to religion, Holmes's dictum holds: "A page of history is worth a volume of logic." NY Trust Co. v. Eisner, 256 U.S. 345, 349, 41 S.Ct. 506, 65 L.Ed. 963 (19821). Accordingly, the judgment of the district court is AFFIRMED.