Opinion ID: 3009856
Heading Depth: 2
Heading Rank: 2

Heading: reporting requirements for rape or incest

Text: The Secretary of HHS, who administers the Medicaid program, has interpret Medicaid statute as modified by the 1994 Hyde Amendment, to provide that, absent a 11 provision, reporting requirements for rape or incest abortions unduly impede or det woman's exercise of her right to the medically necessary procedure. Letter, (Dec. 1993), App. at 93; Letter, (Mar. 25, 1994), App. at 117. The Secretary does not re reporting requirements as per se invalid. Id. If this judgment is a reasonable ex of the Secretary's discretion, it is entitled to due deference. Our inquiry is the focused upon whether the Secretary's interpretation warrants our deference.
The Commonwealth disputes both the Secretary's and the district court's interpretations of the Hyde Amendment mandates regarding reporting requirements. T Commonwealth maintains that its requirements are valid and should be upheld in thei entirety. The Commonwealth acknowledges that under the Medicaid program, states are to participate or not as they see fit, but if a state does elect to participate, it comply with the conditions that Congress has set. The Commonwealth, however, citin Pennhurst State School and Hospital v. Halderman, 451 U.S. 1, 17, 101 S. Ct. 1531, (1981), argues that in setting those conditions, Congress [must] speak with a clea voice. It contends that a program like Medicaid: is much in the nature of a contract: in return for federal funds, the States agree to comply with federally imposed conditions . . . . There can, of course, be no knowing acceptance if a State is unaware of the conditions or is unable to ascertain what is expected of it. Accordingly, if Congress intends to impose a condition on the grant of federal moneys, it must do so unambiguously. [Pennhurst, 451 U.S. at 17, 101 S. Ct. 1540 (citation and footnote omitted).] The Commonwealth maintains that on its face, the 1994 Hyde Amendment is a prohibition on the use of federal money for certain specified purposes. It sets ne requirements nor prohibitions on the states; it says nothing explicit about reporti certification procedures. The Commonwealth concludes that the principles articulat Pennhurst, when applied to this case, require that the district court's holding be 12 reversed because it cannot reasonably be said that Congress has unambiguously for reporting and certification requirements such as those contained in the Pennsylvani The Commonwealth's reliance on Pennhurst is misplaced. Pennhurst involved obligations of states under the federal Developmentally Disabled Assistance and Bil Rights Act, 42 U.S.C. §§ 6000-6081 (DDABRA). In reversing our holding that the  rights provision of the DDABRA created enforceable rights and obligations, the Sup Court found no evidence that Congress intended to condition the grant of federal fu the states' assum[ing] the high cost of providing 'appropriate treatment' in the ' restrictive environment' to their mentally retarded citizens. 451 U.S. at 18, 101 at 1540. The Court reasoned that because Congress failed to speak clearly regarding state's obligations, it could not fairly say that the State could make an informed choice about participation in the joint program. Id. at 25, 101 S. Ct. at 1544. Here, the Medicaid Act by its terms requires state Medicaid plans to cove medically necessary services that fall within the mandatory areas of care. See 42 §1396a(a)(10)(A). Moreover, nearly fifteen years ago, we made clear in Roe v. Case states participating in the Medicaid program must provide the abortion services tha enumerated in the Hyde Amendment. 623 F.2d at 836-37. The 1994 Hyde Amendment pla puts participating states on notice of their obligations to fund abortions where ne to save a woman's life or where the pregnancy is the result of rape or incest. Accordingly, the Commonwealth was given clear notice that, if it elected to continu participate in the Medicaid program, it was obligated to provide funding for such abortions. Furthermore, any participating state should have realized that reportin requirements could be so onerous as to defeat Congress' intent that Medicaid fundin provided for the categories of abortions in question. Unlike the claims of the def in Pennhurst, the Commonwealth cannot reasonably claim that it was unaware of its obligations under the Medicaid Act, as modified by the Hyde Amendment and its imple regulations. As such, the Secretary is reasonable in interpreting the Hyde Amendme 13 prohibit reporting requirements that operate as additional coverage requirements to or impede some women from receiving the mandated abortion services. The Commonwealth further maintains that other provisions of Title XIX aut the challenged provisions. Participating states are required to adopt reasonable standards . . . for determining eligibility for and the extent of medical assistanc U.S.C. § 1396a(a)(17). States are likewise required to adopt such safeguards as m necessary to assure that eligibility for care and services under the plan will be determined, and such care and services will be provided, in a manner consistent wit simplicity of administration and the best interests of the recipients. 42 U.S.C. 1396a(a)(19). Additionally, states must provide such methods and procedures relati the utilization of, and the payment for, care and services available under the plan as may be necessary to safeguard against unnecessary utilization. 42 U.S.C. §1396a(a)(30)(A). Moreover, the current version of the Hyde Amendment requires sta make known to the Secretary that the abortion for which funding is sought is one which the life of the mother is endangered or where the pregnancy resulted from rap incest. The Commonwealth argues that Pennsylvania's reporting and certification procedures further these statutory mandates. In her amicus brief, the Secretary acknowledges that Congress intended th states be allowed flexibility in developing procedures for administering their stat obligations under the Medicaid statute and their state plans. Amicus Brief at 20 (c Schweiker v. Hogan, 457 U.S. 569, 590-93, 102 S. Ct. 2597, 2610-11 (1982) (a state option to provide partial benefits to the medically needy); Mississippi Hospital As Inc. v. Heckler, 701 F.2d 511, 515 (5th Cir. 1983) (Congress intended states to be experiment with methods and standards of payment under their Medicaid plans)). The Secretary's regulations have long recognized that states have discretion to impose reasonable coverage limits, consistent with the objectives of the Act, on the amoun duration, and scope of services, particularly with respect to ensuring utilization 14 control. 42 C.F.R. § 440.230(b), (d). Indeed, the Secretary acknowledges that wh states are not required to adopt reporting requirements, properly tailored reportin requirements can serve the purposes of the Medicaid Act and the Hyde Amendment. However, in reconciling these eligibility requirements of the Medicaid st with the language and history of the Hyde Amendment, and with the other purposes of Medicaid program, the Secretary maintains that state-established reporting requirem may not serve as an additional coverage requirement to deny or impede payment for abortions where pregnancies result from rape or ince[s]t. Letter, (Mar. 25, 1994) at 117. The Secretary has thus concluded that reasonable reporting requirements are only if they contain a waiver provision.
The Providers argue that the district court correctly held that the Supre Clause requires the invalidation of Pennsylvania's reporting and second-physician certification requirements because they directly conflict with federal law. The Sup Clause requires invalidation of any state constitutional or statutory provision tha conflicts with federal law, see Reynolds v. Sims, 377 U.S. 533, 584, 84 S. Ct. 1362 (1964), and compels compliance by participants in Title XIX federal aid programs wi federal law and regulations. King v. Smith, 392 U.S. 309, 316-17, 88 S. Ct. 2128, (1968); Roe v. Casey, 623 F.2d at 837. The Providers maintain that the district court properly relied on Roe v. in holding that all state Medicaid programs must fund all abortions for which feder funds are available. In Roe v. Casey, we invalidated an earlier version of Pennsyl Medicaid funding restriction that proscribed coverage of abortions except when nece to save the life of the pregnant woman. The then-applicable Hyde Amendment, like t Hyde Amendment, permitted the expenditure of funds for abortion where a pregnancy r from rape or incest, as well as in life-threatening circumstances. We reasoned: 15 Title XIX, as now modified [by the current Hyde Amendment], requires the states to fund abortions in two categories: where the mother is endangered and where the pregnancy was the result of rape or incest. Pennsylvania . . . would not fund the second category. Because Pennsylvania's statutes are not consistent with the modified Title XIX it is clear that, as written, they cannot stand. Id. at 836-37. The Providers argue that the district court correctly concluded that Pennsylvania's effort to restrict its Medicaid coverage of abortion to cases of rep rape and incest and dually-certified life endangerment runs directly contrary to Ro Casey's mandate that Pennsylvania must fund all abortions for which federal funds a available. According to the Providers, the Pennsylvania reporting requirements wou invalid under Roe v. Casey even if they contained a waiver provision. We agree that Roe v. Casey holds that the Hyde Amendment establishes a ma floor of required services, below which states may not fall. Under its ruling, all who are eligible must receive the benefits that have been made available to them by Congress. The question with which we are faced today focuses on the issue of eligi requirements that are utilized by states to determine whether a woman is entitled t services enumerated in the Hyde Amendment. Roe v. Casey indicates that these eligi requirements cannot be so onerous that they inhibit or deter women who are eligible receive the abortion services from receiving them. Roe v. Casey does not, however, invalidate all reporting requirements used for eligibility purposes. The Providers further argue that the legislative history provides a clear indication of congressional intent to prohibit the reporting and certification requirements contained in the Pennsylvania statute. The Providers note that in pas versions of the Hyde Amendment, Congress had specifically included reporting requir for rape and incest victims, and contained second-physician requirements for aborti cases of severe and long-lasting physical health damage. See Pub. L. No. 96-536, § 94 Stat. 3166, 3170 (1980) (1981 Hyde Amendment) (providing funding for rape or inc 16 victims when such rape has been reported within seventy-two hours to a law enforce agency or public health service); Pub. L. No. 96-123, § 109, 93 Stat. 923, 926 (19 (1980 Hyde Amendment) (providing Medicaid funded abortions for rape or incest victi when such rape or incest has been reported promptly to a law enforcement agency or health service); Pub. L. No. 95-480, § 210, 92 Stat. 1567, 1586 (1978) (1979 Hyde Amendment) (restricting Medicaid funding in cases of severe and long-lasting health to those cases so determined by two physicians); Pub. L. No. 95-205, § 101, 91 St 1460 (1977) (1978 Hyde Amendment) (same). Additionally, in 1993, Congress considere rejected a version of the 1994 Hyde Amendment that contained such a requirement. Se Cong. Rec. H4304 (daily ed. June 30, 1993) (showing previous version of amendment w included reporting requirement). The Providers contend that the district court pro inferred that, in repudiating previous versions of the Hyde Amendment, Congress cle intended to eliminate provisions such as those at issue here. The district court's reading of the legislative history goes too far. Wh Congress clearly no longer requires the states to implement reporting and certifica procedures, it does not follow that states are now forbidden to have them. At most rejection of the earlier versions of the Hyde Amendment is a sign that Congress did wish to mandate reporting requirements on the states. Cf. John Hancock Mutual Life Co. v. Harris Trust & Sav. Bank, U.S. , 114 S. Ct. 517, 526 (1993) (courts are by the statute's words, not by discarded draft legislation). Moreover, we note tha Congress' rejection of the reporting requirements for the 1994 Hyde Amendment was expressly based on procedural considerations. See 139 Cong. Rec. H4307-08. A reje on procedural grounds provides no basis for any inference regarding Congress' views the substantive provisions of the legislation. We are therefore left with no guida from the legislative history.
17 We are thus faced with competing interests within the Medicaid statute as amended by the 1994 Hyde Amendment. On one hand, the Pennsylvania reporting requir that require a physician's averment setting forth that the woman signed a statement her pregnancy was the result of rape or incest can be defended on the ground that t further the state's interest under the Hyde Amendment in being able to make known Secretary that an abortion was performed upon a woman's representation that the pre was the result of rape or incest. The requirement under Pennsylvania law that a wo report the rape or incest to law enforcement agencies can be defended as an attempt ensure that the woman's representations are true as a part of the state's obligatio safeguard against unnecessary utilization. 42 U.S.C. § 1396a(a)(30)(A). On the other hand, however, the Supreme Court has held that a state law t establishes benefit eligibility criteria for a federal program that are more restri than the criteria established by Congress is invalid. King v. Smith, 392 U.S. 309, 88 S. Ct. 2128, 2141 (1968). Likewise, our decision in Roe v. Casey sets a mandato floor of services that must be provided by the states under the Medicaid Act, as mo by the Hyde Amendment, which cannot be undermined by onerous reporting requirements Furthermore, § 1369a(a)(19) requires that the state provide safeguards to assure th plan will be administered in a manner consistent with simplicity of administration the best interests of the recipients.0 0 The legislative history of this provision establishes that Congress added it to en that states would not impose bureaucratic and complicated mechanisms for determinin eligibility that would deter recipients from obtaining care. This provision was included in order to provide some assurance that the States will not use unduly complicated methods of determining eligibility which have the effect of delaying in an unwarranted fashion the decision on eligibility for medical assistance or that the States will not administer the provisions for services in a way which adversely affects the availability or the quality of the care to be provided. The committee expects that under this provision, the States will be eliminating unrewarding and unproductive policies and methods of investigation and that they will develop such procedures as will assure that the most effective working relationships with medical 18 It can reasonably be argued that the Pennsylvania reporting requirements inconsistent with this mandate because they create a formidable barrier for some wo would otherwise be eligible to obtain abortions in cases of rape and incest. The Pennsylvania statute creates numerous hurdles for rape and incest victims: (1) a wo must personally report the incident of rape or incest to state law enforcement authorities, together with the name of the offender; (2) physicians are required to that they have obtained a signed statement from the pregnant woman verifying that s pregnant as a result of rape or incest, that she complied with the reporting requir and that she is aware that false reporting is punishable by law; and (3) the Common must verify with a law enforcement agency or child protective service agency that t report was made. It can reasonably be argued that these requirements can be insurmountable for a victim of rape or incest who may be traumatized by the event. aware that rape is a vastly underreported crime, and it can be reasonably argued th reporting requirements such as Pennsylvania's can substantially deter some women fr receiving services intended to be available to them under the statute. The Secretary of HHS bears the responsibility of reconciling these compet interests in the statute. The Supreme Court has noted that [p]erhaps appreciating complexity of what it had wrought, Congress conferred on the Secretary exceptionall authority to prescribe standards for applying certain sections of the [Medicaid] Ac Schweiker v. Gray Panthers, 453 U.S. 34, 43, 101 S. Ct. 2633, 2640 (1981). The Secr has concluded that these competing interests are best reconciled if state reporting requirements contain a waiver provision allowing a treating physician to certify th facilities, practitioners, and suppliers of care and service in order to encourage their full cooperation and participation in the provision of services under the State plan. S. Rep. No. 404, 89th Cong., 1st Sess. 76, reprinted in 1965 U.S.C.C.A.N. 1943, 201 19 woman was unable to comply with reporting requirements for physical or psychologica reasons. The Director of HCFA explained this point in her December 1993 directive state Medicaid directors: As with all other mandatory medical services for which Federal funding is available, States are required to cover abortions that are medically necessary . . . . States may impose reasonable reporting or documentation requirements on recipients or providers, as may be necessary to assure themselves that an abortion was for the purpose of terminating a pregnancy caused by an act of rape or incest. States may not impose reporting or documentation requirements that deny or impede coverage for abortions where pregnancies result from rape or incest. To insure that reporting requirements do not prevent or impede coverage for covered abortions, any such reporting requirement must be waived and the procedure considered to be reimbursable if the treating physician certifies that in his or her professional opinion, the patient was unable, for physical or psychological reasons, to comply with the requirement. Letter, (Dec. 28, 1993), App. at 93. See also Letter, (Mar. 25, 1994), App. at 117 (reiterating the need for waiver provision in state-established reporting requireme Under the Secretary's interpretation, physicians may take into account bo immediate and long-term psychological consequences of reporting rape or incest to authorities that could leave a woman unable to fulfill those reporting requirements waiver thus ensures that reporting requirements do not prevent or impede coverage f covered abortions. Without Pennsylvania's assurance that it will waive the reporti requirements if the woman is physically or psychologically unable to comply, the Pennsylvania Abortion Control Act requirements comprise impermissible eligibility criteria. The December 1993 HCFA directive constituted the Secretary's attempt to g interpretive guidance to the states in advance of their submission of state Medicai 0 plans. The HCFA directive is an interpretation of the Hyde Amendment mandates as 0 We are aware of the related action, Ridge v. Shalala, No. 94-7751, which is curren pending in this Court, in which the Commonwealth is challenging HHS's waiver requ 20 reconciled with the competing interests within the Medicaid statute. Since the dir clarifies and explains existing law, we deem it interpretive. See Bailey v. Sull 885 F.2d 52, 62 (3d Cir. 1989) (If the rule in question merely clarifies or explai existing law or regulations, it will be deemed interpretive.); American Min. Congr MSHA, 995 F.2d 1106, 1112 (D.C. Cir. 1993) (setting out factors to distinguish betw legislative and interpretive rules). As an interpretive rule, the Secretary's pronouncements are exempted from the APA notice-and-comment requirements. 5 U.S.C. 553(b)(A) (notice requirement does not apply to interpretive rules, general statem policy, or rules of agency organization, procedure, or practice). This Court and Supreme Court have upheld the validity of interpretive rules. Bailey, 885 F.2d at Shalala v. Guernsey Memorial Hospital, U.S. , 115 S. Ct. 1232, 1237 (1995). Courts have long recognized that considerable weight must be conferred executive department's construction of a statutory scheme which it is entrusted to administer. The Supreme Court has announced that the principle of deference to administrative interpretation: has been consistently followed by this Court whenever decision as to the meaning or reach of a statute has involved reconciling conflicting policies, and a full understanding of the force of the statutory policy in the given situation has depended upon more than ordinary knowledge respecting the matters subjected to agency regulations . . . . If this choice represents a reasonable accommodation of conflicting policies that were committed to the agency's care by the statute, we should not disturb it unless it appears from the statute or its legislative history that the accommodation is not one that Congress would have sanctioned. Chevron, U.S.A., Inc. v. Natural Resources Defense Council, 467 U.S. 837, 844-45, 1 Ct. 2778, 2782-83 (1984) (citations omitted). Such deference is appropriate here e though the Secretary's interpretation is not contained in a legislative rule. Se as violative of the Administrative Procedures Act. The district court dismissed th action on jurisdictional grounds because the Secretary has not yet called for a hea nor issued a decision about the conformity of Pennsylvania's plan with the Hyde Ame Casey v. Shalala, No. 94-390 (M.D. Pa. Nov. 28, 1994). 21 e.g., Health Insurance Ass'n of America v. Shalala, 23 F.3d 412, 424 (D.C. Cir. 199 Hicks v. Cantrell, 803 F.2d 789, 791-92 (4th Cir. 1986). Indeed, the Supreme Court recently reversed our decision in Reno v. Koray, 21 F.3d 558, 562-65 (3d Cir. 1994) we had declined to defer to the Bureau of Prisons' interpretation of 18 U.S.C. § 35 The Supreme Court explained: The Bureau, as the agency charged with administering the credit statute . . . has interpreted § 3585(b)'s official detention language to require credit for time spent by a defendant under a § 3142(e) detention order . . . . As we have explained, . . . the Bureau's interpretation is the most natural and reasonable reading of § 3585(b)'s official detention language. It is true that the Bureau's interpretation appears only in a Program Statement -- an internal agency guideline -- rather than in published regulations subject to the rigors of the Administrative Procedur[e] Act, including public notice and comment. 21 F.3d at 562. But BOP's internal agency guideline, which is akin to an interpretive rule that do[es] not require notice-and-comment, Shalala v. Guernsey Memorial Hospital, 514 U.S. , (1995) (slip op., at 11), is still entitled to some deference, cf., Martin v. Occupational Safety and Health Review Comm'n, 499 U.S. 144, 157 (1991), since it is a permissible construction of the statute. Chevron U.S.A. Inc. v. Natural Resources Defense Council, Inc., 467, U.S. 837, 843 (1984). Reno v. Koray, No. 94-790, 1995 WL 328305, at  (U.S. June 5, 1995) (footnote omit The Secretary's reconciliation of the competing interests in the Medicaid statute and Hyde Amendment is reasonable. Because the Secretary's consistent and contemporaneously expressed construction of the Medicaid statute as amended by the Amendment is a reasonable one, it is accorded considerable weight under principles announced in Chevron. Accordingly, we will defer to the Secretary's interpretation of the Hyde Amendment, and hold that because the Pennsylvania reporting requirements lack a wai procedure and therefore may deprive eligible women of the benefits which Congress h available to them, they are to this extent in conflict with federal law and are inv See Louisiana Public Service Comm'n. v. F.C.C., 476 U.S. 355, 368-69, 106 S. Ct. 18 1898-99 (1986) (under the Supremacy Clause, a federal agency acting within the scop 22 its congressionally delegated authority has the power to preempt state regulation a render unenforceable state laws). Thus, until Pennsylvania, pursuant to state law, a waiver provision in accordance with the Secretary's directive, the Commonwealth i enjoined from enforcing its rape and incest reporting requirements. III. SECOND PHYSICIAN CERTIFICATION REQUIREMENTS Like reporting requirements for abortions where pregnancies result from r incest, certification requirements for abortions necessary to save the life of the are not expressly addressed in the Hyde Amendment. However, pursuant to the broad authority to promulgate regulations in administering the Medicaid program, see, e.g Schweiker, 453 U.S. at 43, 101 S. Ct. at 2640, the Secretary, shortly after the pas the first Hyde Amendment in 1977, promulgated a regulation concerning abortions whe mother's life was endangered. The regulation provides: [Federal funding] is available in expenditures for an abortion when a physician has found, and certified in writing to the Medicaid agency, that on the basis of his professional judgment, the life of the mother would be endangered if the fetus were carried to term. 42 C.F.R. § 441.203 (emphasis added). This regulation has not been altered in subs since its initial promulgation. The Secretary construes this regulation to provide if any physician -- in a woman's attending physician --certifies that the life of the mother would be enda federal funding is available. Consistent with our holding in Roe v. Casey that s are required by the Medicaid Act to fund all abortion services that are allowed und Hyde Amendment, the Secretary concludes that a state regulation that attempts, in e to require a second physician's certification in addition to a certification given physician is inconsistent with the regulation. We must give substantial deference to an agency's construction of its own regulation. Martin v. Occupational Safety and Health Review Comm'n, 499 U.S. 144, 23 111 S. Ct. 1171, 1175-76 (1991); Lyng v. Payne, 476 U.S. 926, 939, 106 S. Ct. 2333, (1986). As the Supreme Court recently announced, courts must defer to the Secreta interpretation unless an 'alternative reading is compelled by the regulation's plai language or by other indications of the Secretary's intent at the time of the regul promulgation.' Thomas Jefferson University v. Shalala, U.S. , 114 S. Ct. 238 2386-87 (1994) (quoting Gardebring v. Jenkins, 458 U.S. 415, 430, 108 S. Ct. 1306, (1988)).0 We believe that the Secretary's construction comports with the plain lang the regulation. The phrase [Federal funding] is available . . . for an abortion w physician has found and certified [that the mother's life is endangered] does not the class of physicians who have the authority to certify. We believe that this re of the regulation gives the phrase a physician its ordinary and natural meaning. F.D.I.C. v. Meyer, U.S. , 114 S. Ct. 996, 1001 (1994) ([W]e construe a statut term in accordance with its ordinary or natural meaning.). Further, the history of the physician certification regulation indicates the Secretary intended this construction at the time of the regulation's promulgati The 1976 Hyde Amendment provided for federal funding where the life of the mother be endangered if the fetus were carried to term. Pub. L. No. 94-439, § 209, 90 St 1418, 1434 (1976). The 1976 Hyde Amendment did not require a physician's certificat The Secretary issued a notice of proposed rule-making which stated that: 0 In Gardebring, the Supreme Court, while recognizing that the Secretary had not take position until that litigation, held that: when it is the Secretary's regulation that we are construing, and when there is no claim in this Court that the regulation violates any constitutional or statutory mandate, we are properly hesitant to substitute an alternative reading for the Secretary's unless that alternative reading is compelled by the regulation's plain language or by other indications of the Secretary's intent at the time of the regulation's promulgation. 458 U.S. at 430, 108 S. Ct. at 1314. Thus, we will defer to the Secretary's constr of her own regulation even if the interpretation is put forth in litigation. 24 the Department will provide Federal financial participation in the cost of abortions only where the attending physician, on the basis of his or her professional judgment, has certified that the abortion is necessary because the life of the mother would be endangered if the fetus were carried to term. 42 Fed. Reg. 40486 (1977) (emphasis added). The Secretary construed this notice as meaning that in the absence of fraud, the physician's judgment would be conclusive Fed. Reg. 4574 (1978). In enacting the 1977 Hyde Amendment, Congress retained the 1976 Hyde Amen language concerning funding for abortions when the mother's life is endangered. Pu No. 95-205, § 101, 91 Stat. 1460 (1977). The Secretary concluded that the failure Congress to question the manner in which the Secretary had previously implemented t exception, and its reenactment without change, should be understood as congressiona approval of the Secretary's interpretation. 43 Fed. Reg. 4574. Thus, notwithstand Congress' silence, the Secretary's 1977 implementing regulations construed the inte Congress to be that certification of life endangerment by a physician should be req 43 Fed. Reg. 4570 (§ 50.304). Accordingly, the Secretary's construction of her regulation, 42 C.F.R. § 441.203, as providing for federal funding when any physici including a woman's attending physician -- certifies that the life of the mother wo endangered, is consistent with the history of the regulation. The Secretary's construction is also consistent with other requirements o XIX and its implementing regulations. Section 1396a(a)(17) mandates that states est eligibility requirements that are consistent with the objectives of Title XIX. 4 U.S.C. § 1396a(a)(17). In Beal v. Doe, the Supreme Court explained that Title XIX broadly stated primary objective [is] to enable each state, as far as practicable, furnish medical assistance to individuals whose income and resources are insufficie meet the costs of necessary medical services. Beal v. Doe, 432 U.S. 438, 444, 97 2366, 2371 (1977) (citing 42 U.S.C. §§ 1396, 1396a(a)(10)). A further objective is 25 assure that state Medicaid plans are administered in a manner consistent with simp of administration and the best interest of the recipients. 42 U.S.C. § 1396a(a)(1 Hodgson, 614 F.2d at 607. The Secretary's construction of the implementing regulat the endangerment certification provision could be said to further these objectives. 1977, in promulgating 42 C.F.R. § 441.203, the Secretary noted: The purpose of the certification requirement is not to enable the Department to question physician judgment, but rather to ensure that physician judgment has in fact been exercised. This is the most efficient manner by which a State agency or a program or project -- or the Department in conducting audits or other enforcement reviews -- may ascertain that the statutory requirements for a claim for Federal financial participation in an abortion have been met. 43 Fed. Reg. 4574. Thus, we will defer to the Secretary's interpretation of her regulation that the sufficient condition triggering eligibility for a Medicaid fund abortion is certification by any physician that a woman's life would be endangered carrying the fetus to term. In contrast to the Secretary's construction of the federal certification regulation, Pennsylvania's certification requirements narrow the Secretary's criter The pertinent part of § 3215(c) of the Pennsylvania Abortion Control Act provides t state or federal funds will be expended for an abortion, except: When abortion is necessary to avert the death of the mother on certification by a physician. When such physician will perform the abortion or has a pecuniary or proprietary interest in the abortion there shall be a separate certification from a physician who has no such interest. 18 Pa. Cons. Stat. Ann. §3215(c)(1) (emphasis added). Under the Commonwealth's Med scheme, even if the attending physician who is to provide the abortion certifies th procedure is necessary because of life endangerment, there must be yet another certification. In effect, the Commonwealth's regulation renders the certification attending physician irrelevant. This reading is contrary to the Secretary's regula which provides that federal funding is available under such circumstances. 26 Accordingly, because the Pennsylvania second-physician certification requ for abortions necessary to save the life of the mother conflicts with a Medicaid implementing regulation as construed by the Secretary, this requirement is invalid.