Opinion ID: 423973
Heading Depth: 1
Heading Rank: 3

Heading: propriety of judicial review

Text: 32 HHS also argues that the matter is not ripe for judicial review. In Abbott Laboratories v. Gardner, 387 U.S. 136, 87 S.Ct. 1507, 18 L.Ed.2d 681 (1967), the Supreme Court enunciated the two factors relevant to a ripeness decision: first, the fitness of the issues for judicial resolution, and second, the hardship to the parties of withholding court consideration. Id. at 149, 87 S.Ct. at 1515. 33 The district court found that the issue presented in this case was ripe, rejecting HHS's argument that the court should await the more fully developed factual record emanating from the administrative agency charged with responsibility for interpreting and enforcing the statutory framework under review. 550 F.Supp. at 630. The court based its decision on a determination that it would be futile to pursue the matter through the administrative process, and on a finding that the case presented issues of sufficient immediacy and reality to justify the issuance of a declaratory judgment. Id. at 631. 34 HHS's contention regarding ripeness raises the issue of whether the district court was the appropriate forum in which to resolve the validity of HHS's classification of chemical dependency. See Craigg v. Russo, 667 F.2d 153, 160 (D.C.Cir.1981). The inquiry centers on whether, once the court's jurisdiction is established, it is proper for the court, under all of the circumstances, to reach the merits of the case before it. Although we agree with the district court that HHS's consideration of the matter to this point has been inadequate, we agree with HHS that the district court should not have acted on the basis of this record without the benefit of a final decision of the Grant Appeals Board (GAB). 35 There is no clear indication in the Medicaid statute, legislative history, or regulations as to what Congress meant by the term mental disease. The phrase institutions for mental disease was first inserted in the Social Security Act in 1950, as an exemption to old age assistance under Title I, apparently to avoid providing assistance to patients in state mental hospitals, which Congress considered a state responsibility. See H.R.Rep. 1300, 81st Cong., 1st Sess. 42 (1949), U.S.Code Cong. & Admin.News 1950, p. 3287; Schweiker v. Wilson, supra, 450 U.S. at 225 n. 5, 237 n. 19, 101 S.Ct. at 1078 n. 5, 1084 n. 19. See also S.Rep. No. 404, 89th Cong., 1st Sess. 146 (1965), reprinted in 1965 U.S.Code Cong. & Ad.News 1943, 2086. Although Congress used the term again in 1965 in Title XIX, and subsequently amended this statute in 1972 to lift the exemption as it applied to persons under age twenty-one who received inpatient psychiatric services, the record is simply silent as to whether Congress intended to include chemical dependency within the term mental disease. 36 There is also very little information in the record concerning the decision by the Health Care Financing Administration (HCFA) to use the ICD to define this term. Apparently the Bureau of Program Policy made this decision in 1975, without the benefit of a hearing or of comments from interested parties. At oral argument before this Court, counsel for the government stated that the ICD was widely used throughout HHS as a reference manual for disease classification purposes, but there is no indication that HHS has ever carefully considered whether chemical dependency should properly be viewed as a mental disease under the statutory framework of the Medicaid program. 37 Moreover, there has been no final decision by the Grant Appeals Board that the agency's use of the ICD's classification of chemical dependency is proper. We agree with the district court that resort to the administrative procedures culminating in a GAB decision may not persuade the agency to change its views, since the GAB has decided in a related matter that the use of the ICD is reasonable. See generally Grant Appeals Board Decision No. 231, JOINT CONSIDERATION: Institutions for Mental Diseases, Docket Nos. 79-52-MN-HC, 79-89-mn-hc, 80-44-il-hc, 80-150-ct-hc, 80-184-ca-hc, slip op. at 21-22 (November 30, 1981). 38 Nevertheless, given the lack of any hearings or formal consideration prior to the adoption of HHS's classification of chemical dependency, we believe that a final GAB decision would offer the agency an opportunity to articulate its rationale for its use of the ICD and for its rejection of the position argued by Granville in this case. HHS correctly argues that there is a factual dimension to the issue presented--a serious question concerning whether chemical dependency is properly viewed as a mental disease was raised by the evidence offered by Granville in the district court proceedings. 39 Granville presented testimony from eight highly qualified physicians, psychiatrists, and chemical dependency practitioners that chemical dependency is a primary disease that should not be viewed as a mental disease for purposes of the Medicaid program. 6 All of Granville's witnesses had been actively involved in the chemical dependency field in Minnesota, in programs that are regarded as outstanding: two nationally and internationally renowned facilities, the Hazelden Foundation and the Johnson Institute, are located in Minnesota. Granville's witnesses testified that the basic assumption of the only successful chemical dependency treatment programs, which all utilize the Alcoholics Anonymous (A.A.) approach, is that chemical dependency is a disease, a primary diagnosis in its own right, and not a symptom of some underlying mental disorder. Dr. Daniel Anderson, a consulting clinical psychologist and President and Director of the Hazelden Foundation, described the history preceding the adoption of the disease concept in this way: 40 First of all, developmentally, alcoholism was simply considered to be a condition of willpower. 41 Most alcoholics were treated in the criminal justice system. 42 Then an attempt was made to explain alcoholism or chemical dependency as an illness. 43 And these early explanations were mainly psychiatric explanations where it was presumed that the excessive drinking or excessive drug use was symptomatic of some underlying psychiatric problem, and that the goal was to treat the underlying psychiatric problem and then the symptomatic behavior of alcoholism or drug addiction would go away. 44 Unfortunately that treatment never did prove to be successful, to my knowledge. 45 Dr. Robert Premer, Chief of Orthopedics at the Veterans Administration Hospital in Minneapolis, Minnesota, associate professor at the University of Minnesota Hospital, and Chairman of the Board of the Johnson Institute, testified that the disease concept of alcoholism is commonly accepted in the medical profession today. Premer criticized the classification of chemical dependency as a mental disorder, stating: 46 I think one of the things that has kept more chemically-dependent people ill than anything else is the idea that it is a mental illness; because they tend to attach to this, and If you could just treat my mental illness, then I could continue to take my drugs. 47 So I think this idea that it is a mental illness is not only fallacious, it is pernicious. 48 It is not supported by the facts. 49 The facts are that people who are chemically dependent, and particularly alcoholics, have lost control of the use of alcohol. 50 It is a primary condition caused by the misuse of alcohol. 51 Dr. Richard Heilman, a physician and psychiatrist who is the Director of the chemical dependency treatment program at the Veterans Hospital, as well as senior consulting psychiatrist at Hazelden, indicated that among his colleagues, chemical dependency is recognized and understood to be a disease that does not necessarily imply a mental disorder or mental disease. 7 Heilman rejected the terminology mental illness to describe chemical dependence, as did Dr. Randall Lakosky, another physician and psychiatrist who treats chemically dependent patients in his private practice. Lakosky stated that psychiatrists do not generally recognize alcoholism as a mental disorder. 52 Leonard Boche, a chemical dependency practitioner since 1959, past Director of Minnesota's alcohol and drug program and current Director of a private chemical dependency program, and Dr. Thomas Briggs, a physician who has specialized in alcoholism treatment for twenty-two years and who is currently the medical director of the Alcohol Treatment Center at St. John's Hospital, in St. Paul, Minnesota, shared the view that chemical dependency was a disease in its own right, and criticized the use of the ICD to define it as a mental disease. Both acknowledged that the ICD was used for reimbursement purposes by the HCFA for Medicaid and by insurance companies, but they did not consider such use reasonable because as Boche stated: 53 I believe it is somewhat of an artificial system that was designed for another purpose; and that purpose    was    for professional communication. 54 And to use a tool--essentially designed for professional communication--as a method of determining payment, in my judgment is inappropriate. 55 Boche stated that the concept of mental disorder is not applied to the treatment of chemical dependency in Minnesota, because the treatment is so very different in this State--between mental illness and chemical dependency--that they are literally two different systems. He noted that while there was a clearly established history of recovery in chemical dependency treatment, there is not the same optimism about the successful treatment of mental illness.Dr. Premer rejected the classification schemes of both the ICD and the Diagnostic and Statistical Manual of Mental Disorders (DSM-III); 8 Premer would classify alcoholism and other drug dependencies in a separate classification because [the diseases are] being caused by the drugs. Premer made the following comments concerning the ICD: 56 It's just a classification, putting a name on something. 57 And, you know, the classification could be accurate or inaccurate as far as the medical facts are concerned. 58 And it is my view that that classification is inaccurate as far as alcoholism is concerned. 59 And in the future I would suspect--when they come to their senses--they will reclassify it. 60 As the thing is set up right now, it's inaccurately classified. 61 And, you know, that classification doesn't really have any relationship to the facts--as we know them today--about alcoholism and chemical dependency. 62 It was apparently made by a group of psychiatrists who consider it a mental illness [and who have] little experience with alcoholism. 9 63 Dr. Heilman agreed that chemical dependency should be reclassified outside of the mental disorder category, even though he agreed that in general a primary disease could also be a mental disorder. The following dialogue between Heilman and counsel for HHS reveals his views more fully: 64 Q: Does the fact that a disorder could be considered a primary disease, does that necessarily exclude the idea that it is also a mental disorder? 65 A: Well, I think that is important, to make a distinction, I think this is where we may be having differences. 66 Years back with Freud, the field of psychiatry was dealing primarily with consequences of physical problems--Freud was a neurologist--and there was a lot of mental illness caused by syphilis; and until they found out that that was its cause, they thought it was a mental illness. 67 And when they found out that syphilis was underlying it, they reclassified it. 68 And the same way with thyroid diseases that manifested themselves as psychiatric problems--when they found out it was thyroid disease, they reclassified it. 69 And the same way with brain tumors.    70 And I think that is kind of the issue here, that [chemical dependency] is addiction. 71 In Minnesota we've kind of honed in on what [chemical dependency] is, underneath, as primary. 72 It is an addictive problem--which is not made reference to in the [DSM-III]. 73 They talk about only the consequences in [DSM-III]--not about what the problem is. 74 They don't define what addiction is. 75 HHS defends its use of the ICD and DSM-III classifications despite this substantial criticism by chemical dependency physicians, psychiatrists, and practitioners in effect suggesting that while the ICD and DSM-III are not perfect, they are the best classification systems available, and their use, as many of Granville's witnesses acknowledged, is thus a necessary evil. See Appellant's Br. at 17. The agency also presented the testimony of Dr. Robert Spitzer, a physician and psychiatrist who is Chief of Psychiatric Research with the Biometrics Research Department, New York State Psychiatric Institute, and Professor of Psychiatry at Columbia University, in support of its classification of chemical dependency as a mental disease. Spitzer is a generally recognized expert in disease classification, and he was a consultant to the last revision of the ICD, as well as chairperson of the task force that developed the American Psychiatric Association's DSM-III. 76 Spitzer testified that the primary reason he believed it was reasonable to classify alcoholism and chemical dependency as mental disorders in these references was because that classification identifies correctly the nature of the symptoms, which are primarily psychological and behavioral. He also noted that this classification correctly identifies that we don't yet know the entire etiology [or] cause of alcoholism, and    we generally classify as mental disorders those behavioral or psychological conditions for which the ultimate etiology is still unknown. Finally, he indicated that classifying chemical dependency as a mental disorder suggests that treatment at the present time is probably going to be non-physical    that is, drugs are not very effective, and the treatment generally consists of programs and approaches which are essentially psychological. Spitzer's view is that the A.A. model of treatment is behavioral or psychological rather than physical. 77 While Spitzer suggested that one reason to classify chemical dependency as a mental disorder would be to indicate that psychiatrists ought to be able to study--in a helpful way--this disease, he agreed that psychiatrists generally recognize that they don't have an awful lot to offer--as psychiatrists--in the treatment of alcoholism. Spitzer also conceded that the A.A. model is an effective, non-psychiatric treatment for chemical dependency, and he acknowledged that although there was not much controversy about the classification of alcoholism as a mental disorder among members of the substance abuse classification committee, neither this classification nor the DSM-III were designed with a reimbursement purpose in mind. In fact, he stated that there were no considerations given to the use of this classification for reimbursement. 78 The Grant Appeals Board has not had the opportunity to consider this very important factual information. Moreover, as the agency charged with administering the Medicaid Act, HHS legitimately claims that the district court has prematurely interfered with its processes in ruling on the merits of Granville's case. The Grant Appeals Board does have at least two cases pending before it which present the precise issue litigated here. See Appeal of Colorado, Department of Social Services, Docket Nos. 82-125-CO-HC, 83-22-CO-HC (filed July 22, 1982 & January 28, 1983). A hearing has been held before the Board on these cases, but counsel for the government informed this Court that the Board has stayed its consideration of the issue, pending our decision in this case. 79 Clearly, an adequate factual record has been developed to permit a decision to be made concerning the validity of the use of the ICD to classify alcoholism and chemical dependency as mental diseases under Medicaid, but we are concerned that the agency's Grant Appeals Board has not had the opportunity to evaluate this evidence nor to offer its considered analysis of the issue before us. HHS argues that if we agree that it should be given the opportunity to make a final decision, we should reverse the district court with directions to it to dismiss the case. We are reluctant to dismiss the case outright, however, because of the hardship to the parties that such action would create. 80 This is not a case such as was presented in Abbott Laboratories v. Gardner, supra, 387 U.S. at 152-154, 87 S.Ct. at 1517-1518, where the party challenging the agency action was faced with compliance at a very high cost or the risk of serious civil and criminal penalties, id. at 153, 87 S.Ct. at 1517, but the impact on Granville is certainly sufficiently direct and immediate. Id. at 152, 87 S.Ct. at 1517. One of Granville's three facilities, Team House, has received certification by the State Department of Health, the first step in the Medicaid eligibility process. Granville voluntarily delayed pursuing certification of all its facilities pending some indication that its clients would be eligible for Medicaid funds because of the costs of the requirements for certification; costs which Granville did not believe would improve the quality of its programs. 81 Granville has made other substantial expenditures in bringing its facilities into compliance with Title XIX requirements, and has likely incurred costs in advancing the present litigation, all in its attempt to advance its legitimate corporate purpose and to have declared invalid an interpretation of mental diseases that it views as wholly unsupported by the current state of knowledge concerning the nature of the diseases of alcoholism and other chemical dependencies. HHS would offer Granville no recourse but to state administrative procedures, which culminate in a state court review of whether the Department of Public Welfare acted properly. We deem this remedy inadequate under the present circumstances. 82 Alternatively, since the State has now aligned itself against HHS in this matter, presumably the agency would require the State to exhaust its administrative remedies. Under this scenario, Granville would have to admit a Medicaid-eligible patient to Team House, treat the patient with its own funds, submit a request to the State for reimbursement, convince the State to agree to reimburse, even though the State has little hope of receiving any federal financial participation for some time, and then convince the State to press its argument before the Grant Appeals Board and the federal courts. This expenditure of time, effort, and additional money would do nothing to sharpen the issue for decision, however, and would add nothing to the present record save the Grant Appeals Board's official decision in the matter. 83 For the above reasons, we believe the best course in this case is to reverse and remand to the district court, with directions to it to remand to the Grant Appeals Board to make an initial determination on the issue of whether otherwise-eligible residents of Granville's facilities (which have been certified as intermediate care facilities) are eligible for Medicaid under 42 U.S.C. §§ 1396 et seq. The district court shall certify the record made in the present case to the Board, which may consolidate this record with the two Colorado cases now pending before it. The Board may conduct such further evidentiary hearings as it deems appropriate, see 45 C.F.R. § 16.13 (1982), and the district court shall retain jurisdiction pending the outcome of the Grant Appeals Board decision. Cf. Craigg v. Russo, supra, 667 F.2d at 160; Hayes v. Secretary of Defense, 515 F.2d 668, 675 (D.C.Cir.1975) (district courts ordered to retain jurisdiction pending remand to administrative agencies). Any party may resubmit the case to the district court after the Grant Appeals Board renders a decision. The district court shall, after reviewing the decision of the Grant Appeals Board, make such further rulings as it deems necessary, and any party dissatisfied with the district court's decision may again appeal to this Court. 84 Accordingly, the decision of the district court is reversed in part and the case is remanded for further proceedings consistent with this opinion. Each party to this appeal shall bear its own costs.