Opinion ID: 2525321
Heading Depth: 3
Heading Rank: 1

Heading: The Challenged Regulation Violates Equal Protection.

Text: By providing health care to all poor Alaskans except women who need abortions, the challenged regulation violates the state constitutional guarantee of equal rights, opportunities, and protection under the law. [15] The State, having established a health care program for the poor, may not selectively deny necessary care to eligible women merely because the threat to their health arises from pregnancy. Because we decide this case on state constitutional equal protection grounds, we do not review the superior court's privacy-based ruling. We do note, however, that our analysis today closely parallels that applied by many of the fifteen courts that have rejected similar restrictions. [16] Although other courts' decisions have rested on a variety of state constitutional provisions, including equal protection, [17] constitutional equal-rights-for-women clauses, [18] due process, [19] and privacy, [20] the underlying logic has been the same in decision after decision: [W]hen state government seeks to act for the common benefit, protection, and arid security of the people in providing medical care for the poor, it has an obligation to do so in a neutral manner so as not to infringe upon the constitutional rights of our citizens. [21] As the Massachusetts Supreme Judicial Court observed, the constitutional principle at issue is straightforward: It is elementary that `when a State decides to alleviate some of the hardships of poverty by providing medical care, the manner in which it dispenses benefits is subject to constitutional limitations.' [22] The State's spending discretion is limited by the constitution[w]hile the State retains wide latitude to decide the manner in which it will allocate benefits, it may not use criteria which discriminatorily burden the exercise of a fundamental right. [23] Alaska's constitutional equal protection clause mandates equal treatment of those similarly situated; [24] it protects Alaskans' right to non-discriminatory treatment more robustly than does the federal equal protection clause. [25] In analyzing a challenged law under Alaska's equal protection provision, we first determine what level of scrutiny to apply, using Alaska's sliding scale standard. [26] The weight [that] should be afforded the constitutional interest impaired by the challenged enactment is the most important variable in fixing the appropriate level of review. [27] Second, we examine the State's interests served by the challenged regulation. [28] If the burden placed on constitutional rights by the regulation is minimal, then the State need only show that its objectives were legitimate for the regulation to survive an equal protection challenge. [29] But if the objective degree to which the challenged legislation tends to deter [exercise of constitutional rights] [30] is significant, the regulation cannot survive constitutional challenge unless it serves a compelling state interest. [31] Finally, if the State shows that its interests justify burdening the rights of citizens, for the regulation to survive constitutional challenge the State must demonstrate that the means it has chosen to advance those goals are well-fitted to the ends, and that its goals could not be accomplished by less restrictive means. [32] The regulation at issue in this case affects the exercise of a constitutional right, the right to reproductive freedom. [33] Therefore, the regulation is subject to the most searching judicial scrutiny, often called strict scrutiny. [34] We have explained in the past that such scrutiny is appropriate where a challenged enactment affects fundamental rights, including the exercise of intimate personal choices. [35] This court has specified that the right to reproductive freedom may be legally constrained only when the constraints are justified by a compelling state interest, and no less restrictive means could advance that interest. [36] Judicial scrutiny of state action is equally strict where the government, by selectively denying a benefit to those who exercise a constitutional right, effectively deters the exercise of that right. In Alaska Pacific Assurance Co. v. Brown , we held the State to a very high burden to justify a statute that reduced workers' compensation benefits paid to workers who exercised their constitutional right to leave the state. [37] We concluded that the challenged regulation did not meet this high standard and thus violated equal protection. [38] Like the regulation at issue today, the challenged statute in Alaska Pacific Assurance Co. did not forbid individual exercise of constitutional rights; rather, it limited the government benefits distributed to the class of individuals who exercised that right. [39] As we explained in that case, we look to the real-world effects of government action to determine the appropriate level of equal protection scrutiny: The suspicion with which this court will view infringements upon [constitutional rights] depends upon ... the objective degree to which the challenged legislation tends to deter [the exercise of those rights]. [40] We reached a similar conclusion in Alaska Gay Coalition v. Sullivan, holding that the Municipality of Anchorage could not constitutionally withhold a public benefit based on a potential recipient's beliefs and public expression. [41] The municipality had undertaken to publish a guidebook to public and private organizations in Anchorage, but excluded the Alaska Gay Coalition from the book. [42] We held that this exclusion violated the Coalition's constitutional rights to equal protection under the law. [43] We explained: When the Municipality decided to publish a limited informational guide to public and private local resources, it did not thereby assume the obligation of providing space to every possible group.... Had the Municipality deleted groups at random or used criteria not related to the nature of the particular organizations, constitutional violations may not have resulted. In deleting the Alaska Gay Coalition ... however, appellees denied that group access to a public forum based solely on the nature of its beliefs. In so doing, they violated appellant's constitutional rights to ... equal protection under the law. [44] Similarly, in the instant case, the State's obligations do not depend on whether the State has undertaken to provide limitless health care services to all poor Alaskans. Rather, DHSS is constitutionally bound to apply neutral criteria in allocating health care benefits, even if considerations of expense, medical feasibility, or the necessity of particular services otherwise limit the health care it provides to poor Alaskans. The State argues in this case that it does not provide all necessary medical care to indigent Alaskans. For support, it cites 7 AAC 43.385, a regulation that excludes from Medicaid coverage such services as medically unnecessary inpatient treatment, [45] beautifying cosmetic surgery, [46] and transplants of organs other than kidney, cornea, skin, and bone marrow. [47] This regulation has not been challenged, and the issue has not been thoroughly briefed by the parties, but the restrictions appear to relate to medical necessity, cost, and feasibilityall politically neutral criteria. Such spending limits are irrelevant to the constitutional issue raised by the State's denial of coverage for medically necessary abortions. As the United States Supreme Court noted in Shapiro v. Thompson : We recognize that the State has a valid interest in preserving the fiscal integrity of its programs. It may legitimately attempt to limit its expenditures, whether for public assistance, public education, or any other program. But a State may not accomplish such a purpose by invidious distinctions between classes of its citizens. [48] Like Alaska Pacific Assurance Co., Alaska Gay Coalition establishes that under Alaska's equal protection provision the government may not allocate state benefits so as to deter citizens' exercise of constitutional rights. In this case, it is undisputed that 7 AAC 43.140 deters women from obtaining abortions. The State itself stated that eliminating public assistance for medically necessary abortions would cause about thirty-five percent of women who would otherwise have obtained abortions to instead carry their pregnancies to term, despite the associated threat to their health. Under Alaska Pacific Assurance Co., such a restriction warrants the highest degree of judicial scrutiny. In the seminal Shapiro v. Thompson decision, the United States Supreme Court also strictly scrutinizedand ultimately held unconstitutionalstate programs that denied benefits to citizens based on their exercise of constitutional rights. [49] Shapiro invalidated state laws that denied welfare benefits to persons who had moved into the jurisdiction within the past year. [50] The Court found that the prohibition of benefits ... creates a classification which constitutes an invidious discrimination denying [new residents] equal protection of the laws. [51] The Court held that states could not constitutionally tailor their benefits programs to deter immigration from other states: If a law has no other purpose ... than to chill the assertion of constitutional rights by penalizing those who choose to exercise them, then it [is] patently unconstitutional. [52] Although Shapiro and Alaska Pacific Assurance Co. applied strict scrutiny to reject restrictions like the one at issue in this case, 7 AAC 43.140 would fail equal protection analysis under any standard. Under the regulation, the State grants needed health care to some Medicaid-eligible Alaskans, but denies it to others, based on criteria entirely unrelated to the Medicaid program's purpose of granting uniform and high quality medical care to all needy persons of this state. [53] Thus, even if 7 AAC 43.140 did not affect constitutional privacy rights and we applied our most deferential standard of review, the regulation still could not withstand equal protection challenge. Under Alaska's rational basis standard, [54] differential treatment of similarly situated people is permissible only if the distinction between the persons rest[s] upon some ground of difference having a fair and substantial relation to the object of the legislation. [55] DHSS provides necessary medical care to all Medicaid-eligible Alaskans except women who medically require abortions. This differential treatment lacks a fair and substantial relation to the object of the Medicaid program, and therefore violates equal protection. [56] The United States Supreme Court reached a similar conclusion in Shapiro: although the Court invalidated states' differential treatment of similarly situated welfare recipients under strict scrutiny, it also noted that the differentiation would be deemed irrational and unconstitutional even under federal rational basis review. [57] In United States Department of Agriculture v. Moreno , the United States Supreme Court invalidated a similar restriction under rational basis scrutiny alone. [58] The Court found no rational basis for a statute denying food stamps to unrelated persons who shared a household; it therefore concluded that the statute violated equal protection. [59] Lower court decisions have applied this principle to states' allocation of health care benefits, and concluded that classification [among recipients] must be based upon some difference between the classes which is pertinent to the purpose for which the legislation is designed. [60] A California court found that the state violated equal protection by paying for attendant services by spouses of elderly and blind aid recipients, but denying payment for the same services by the spouses of otherwise disabled aid recipients. [61] And New York's highest court held that equal protection was violated by a statute that effectively provide[d] ... that the aged, disabled, and blind are entitled to less public assistance than other needy persons. [62] DHSS's differential treatment of Medicaideligible Alaskans violates equal protection under rational basis review as surely as it does under strict scrutiny. Under any standard of review, the State may not jeopardize the health and privacy of poor women by excluding medically necessary abortions from a system providing all other medically necessary care for the indigent. [63] Because 7 AAC 43.140 infringes on a constitutionally protected interest, the State bears a high burden to justify the regulation. [64] Unless the State asserts a compelling state interest, the statute will necessarily fail constitutional scrutiny. [65] The State has failed to demonstrate such an interest in this case. It primarily defends 7 AAC 43.140 on the grounds that medical and public welfare interests ... are served by the legislature's decision to fund childbirth. But the regulation does not relate to funding for childbirth, and the State's decision to fund prenatal care and other pregnancy-related services has not been challenged. Indeed, a woman who carries her pregnancy to term and a woman who terminates her pregnancy exercise the same fundamental right to reproductive choice. Alaska's equal protection clause does not permit governmental discrimination against either woman; both must be granted access to state health care under the same terms as any similarly situated person. The State's undisputed interest in providing health care to women who carry pregnancies to term has no effect on the State's interest in providing medical care to Medicaid-eligible women who, for health reasons, require abortions. The State also asserts an interest in minimizing health risks to mother and child, and submits that these interests are often closely aligned. But those interests are not aligned in precisely the situation contemplated by 7 AAC 43.140's Medicaid exclusion: when pregnancy threatens a woman's health. Under the U.S. Supreme Court's analysis in Roe v. Wade, the State's interest in the life and health of the mother is paramount at every stage of pregnancy. [66] And in Alaska, [t]he scope of the fundamental right to an abortion... is similar to that expressed in Roe v. Wade. [67] Thus, although the State has a legitimate interest in protecting a fetus, at no point does that interest outweigh the State's interest in the life and health of the pregnant woman. [68] Because the State has not asserted an interest sufficiently compelling to justify denying medically necessary care to women who need abortions, we need not consider the means-ends fit of the challenged regulation. We conclude that 7 AAC 43.140 violates equal protection under the Alaska Constitution.