Opinion ID: 818004
Heading Depth: 4
Heading Rank: 2

Heading: Freedom of expressive association

Text: The right of expressive association is the First Amendment right to associate for the purpose of speaking. Rumsfeld v. Forum for Academic and Inst. Rights, Inc., 547 U.S. 47, 68 (2006); Miller v. City of Cincinnati, 622 F.3d 524, 537 (6th Cir. 2010). The right protects a group’s membership decisions and shields against laws that make group membership less attractive without directly interfering in an organization’s composition. Miller, 622 F.3d at 537. The freedom to speak “could not be vigorously protected from interference by the State unless a correlative freedom to engage in group effort toward those ends were not also guaranteed.” Roberts, 468 U.S. at 622. “Freedom of association . . . plainly presupposes a freedom not to associate.” Id. at 623. But the Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 14 “right to associate for expressive purposes is not . . . absolute.” Id. Infringements on the right “may be justified by regulations adopted to serve compelling state interests, unrelated to suppression of ideas, that cannot be achieved through means significantly less restrictive of associational freedoms.” Id. To evaluate an expressive association claim, the court uses a three-step process. Miller, 622 F.3d at 538. The first element asks whether a group is entitled to protection; the second asks whether the government action in question significantly burdens the group’s expression (affording deference to the group’s view of what would impair its expression); and the third requires weighing the government’s interest in the restriction against plaintiff’s right of expressive association. Id. While USCA appears to be a group entitled to protection, plaintiffs do not satisfy step two. Plaintiffs have failed to show how the individual mandate significantly burdens the group’s expression. The individual mandate does not impair plaintiffs’ ability to engage in expressive conduct—they are free to voice their disapproval of PPACA or health insurance in general, and “nothing about the statute affects the composition of the group by making group membership less desirable.” See Rumsfeld, 547 U.S. at 69–70. Nor does PPACA force USCA to admit insurance companies as members. See Boy Scouts of Am. v. Dale, 530 U.S. 640, 648 (2000); Roberts, 468 U.S. at 623. Plaintiffs are not required to obtain health insurance and associate with health insurers at all; they may choose to pay the shared responsibility payment instead. See Nat’l Fed’n of Indep. Bus., 132 S. Ct. at 2597 (“[I]f someone chooses to pay rather than obtain health insurance, they have fully complied with the law”). While Congress passed PPACA “to increase the number of Americans covered by health insurance and decrease the cost of health care,” id. at 2580, failure to obtain health insurance does not, as alleged, turn Thompson and Grapek into outlaws. Rather, payment of “the shared responsibility payment merely imposes a tax citizens may lawfully choose to pay in lieu of buying health insurance.” Id. Because plaintiffs’ right of expressive association is not impaired by the individual mandate, this claim is without merit and the district court properly dismissed it. Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 15 C. Right to liberty Plaintiffs next allege that PPACA violates certain fundamental rights encompassed within the term “liberty” in the Due Process Clause of the Fifth Amendment. They alleged the following rights: to be let alone, including the right to make choices not to receive medical treatment of a particular kind or at all; not to pay for unwanted treatments or pay for insurance that covers unwanted treatments; and not to divulge medical confidences to a private insurer or its agents in order to obtain health insurance. Plaintiffs aver that competent adults possess a fundamental right to refuse unwanted medical care, see Cruzan v. Director, Mo. Dep’t of Health, 497 U.S. 261, 278 (1990), as well as a fundamental right to medical autonomy, see Planned Parenthood v. Casey, 505 U.S. 833 (1992). They argue that the constitutionally protected liberty right to reject unwanted medical care encompasses their decision not to pay for unwanted medical care. The individual mandate places a coercive burden on the exercise of the right to refuse unwanted medical care, plaintiffs contend, because they must either (1) pay for unwanted health insurance that covers unwanted medical services, or (2) pay the tax. They claim that the financial penalty burdens the exercise of a fundamental right and is therefore coercive and presumptively unconstitutional. The individual mandate does not implicate the fundamental liberty right of Thompson or Grapek to refuse unwanted medical care. As we previously stated, the individual mandate requires either the purchase of health insurance or the payment of a shared responsibility payment. See Nat’l Fed’n of Indep. Bus., 132 S. Ct. at 2597. Plaintiffs remain free to choose their medical providers and the medical treatments they will or will not accept. Further, “no court has invalidated these kinds of mandates under the Due Process Clause or any other liberty-based guarantee of the Constitution.” Thomas More Law Ctr., 651 F.3d at 565 (Sutton, J., concurring in part), abrogated on other grounds in Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566. The Supreme Court long ago abandoned the protection of economic rights through substantive due process. Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 16 See Ferguson v. Skrupa, 372 U.S. 726, 730 (1963) (“The doctrine that prevailed in Lochner . . .–that due process authorizes courts to hold laws unconstitutional when they believe the legislature has acted unwisely–has long since been discarded.”) An alleged fundamental right must be carefully formulated, and it must be “objectively, deeply rooted in this Nation’s history and tradition, and implicit in the concept of ordered liberty, such that neither liberty nor justice would exist if they were sacrificed.” Washington v. Glucksberg, 521 U.S. 702, 720–22 (1997). Regardless of whether plaintiffs’ claim is cast as a freedom to remain uninsured or a freedom to refuse to pay for unwanted medical care, the right asserted cannot be characterized as “fundamental” so as to receive heightened protection under the Due Process Clause. See Fla. ex rel. Atty. Gen. v. U.S. Dep’t of Health and Human Servs., 648 F.3d 1235, 1362–63 (11th Cir. 2011) (Marcus, J., concurring in part and dissenting in part), aff’d in part and rev’d in part on other grounds, Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566 (2012). USCA has not attempted to make a showing, nor could it, that it possesses a fundamental liberty right to refuse unwanted medical care. Plaintiffs’ right to liberty claim is also without merit, and the district court properly dismissed it. D. Right to privacy Finally, in the last count of the Second Amended Complaint, plaintiffs alleged that they enjoy a constitutionally protected interest in the confidentiality of their medical information. They claimed that the federal government cannot constitutionally compel disclosure of USCA members’ private medical information to a private insurer because the government’s interest in disclosure fails to outweigh plaintiffs’ constitutionally protected interest in privacy. They also alleged that PPACA compels them to enter contracts against their will and forces them to disclose confidential medical information to insurance companies and, by virtue of the government’s right of access to that information, to the government itself. Plaintiffs alleged that this right arises from the First, Third, Fourth, Fifth and Ninth Amendments. Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 17 Substantive due process protects an individual’s interest in avoiding the disclosure of personal matters, such as private health information. Whalen v. Roe, 429 U.S. 589, 599 (1977); Bailey v. City of Port Huron, 507 F.3d 364, 367 (6th Cir. 2007). But not all statutes that require the disclosure of personal information are unconstitutional. In Whalen, the Supreme Court rejected a constitutional challenge to a state statute that required physicians and pharmacists to use a triplicate form to document each prescription written and filled for Schedule II drugs and then to supply a copy of each form to the State. Id. at 593. Upon receipt of the forms, state employees entered the data into computers for the purpose of investigating any cases of overdispensing of the drugs. Id. at 594–95. The statute expressly prohibited public disclosure of patient identities, but this did not allay the patients’ fears that their private health information would be disclosed and they would be stigmatized as “drug addicts.” Id. at 595. The Supreme Court upheld the constitutionality of the statute as “the product of an orderly and rational legislative decision” to exercise the State’s broad police power. Id. at 597–98. The Court characterized the possibility of unwarranted disclosure of patient information as “remote” and insufficient to invalidate the entire program. Id. at 601–02. Importantly, the Court stated that public disclosures of private health information are not meaningfully distinguishable from a host of other unpleasant invasions of privacy that are associated with many facets of health care. Unquestionably, some individuals’ concern for their own privacy may lead them to avoid or to postpone needed medical attention. Nevertheless, disclosures of private medical information to doctors, to hospital personnel, to insurance companies, and to public health agencies are often an essential part of modern medical practice even when the disclosure may reflect unfavorably on the character of the patient. Requiring such disclosures to representatives of the State having responsibility for the health of the community, does not automatically amount to an impermissible invasion of privacy. Id. at 602 (footnote omitted). Nos. 11-3327/3798 U.S. Citizens Ass’n, et al. v. Sebelius, et al. Page 18 The individual mandate does not actually compel plaintiffs to disclose personal medical information to insurance companies. But even if it did, the Supreme Court’s reasoning in Whalen dispenses with plaintiffs’ position that the individual mandate is unconstitutional because it may require the disclosure of private health information to insurance companies. Plaintiffs can avoid any privacy concern altogether by simply foregoing insurance and complying with the individual mandate by making the shared responsibility payment. See Nat’l Fed’n of Indep. Bus., 132 S. Ct. at 2597. Finally, any injury plaintiffs may suffer by disclosing their private health information to insurance companies is highly speculative at this point, see Wilson v. Collins, 517 F.3d 421, 430 (6th Cir. 2008), and plaintiffs did not allege any specific facts to support such injury. Plaintiffs’ right to privacy claim is without merit and was properly dismissed.