Document: 432 U.S. 438 97 S.Ct. 2366 53 L.Ed.2d 464 Frank S. BEAL, etc., et al., Petitioners,v.Ann DOE al. No. 75-554. Argued Jan. 11, 1977. Decided June 20, Syllabus Title XIX of the Social Security Act establishes a Medical Assistance (Medicaid) program, under which participating States financially assist qualified individuals in five general categories medical treatment, state plans being required to establish "reasonable standards . for determining extent assistance plan are consistent with" XIX's objectives. Respondents, who eligible Pennsylvania's Medicaid and were denied financial desired nontherapeutic abortions pursuant regulations limiting such certified by physicians as medically necessary, brought this action seeking injunctive declaratory relief, contending that certification requirement contravened them equal protection laws. A three-judge District Court decided statutory issue against respondents but constitutional partially their favor. The Appeals, not reaching question, reversed on issue, holding prohibits from requiring medical-necessity certificate funding condition during first two trimesters pregnancy. Held: 1. does require participation program established Act. Pp. 443-447. (a) Nothing language requires State fund every procedure falling within delineated care. Each is given broad discretion determine "reasonable" "consistent with objectives" XIX. 443-444. (b) Although serious questions might be presented if did cover necessary it inconsistent Act's goals refuse unnecessary (though perhaps desirable) services. 444-445. (c) has strong interest encouraging normal childbirth exists throughout course woman's pregnancy, nothing suggests unreasonable further interest. It therefore will presumed Congress intended State's its willingness undercut subsidizing costs abortions. 445-446. (d) When passed unlawful most States, fact undermines contention rather than permit Moreover, Department Health, Education, Welfare, agency administers XIX, takes position allows, mandate, P. 447. 2. Whether or aspect provided unless addition attending physician have examined patient concurred writing necessity abortion interferes physician's judgment manner contemplated should considered remand. 448. 3 Cir., 523 F.2d 611, vacated remanded. Norman J. Watkins, Harrisburg, Pa., petitioners. Judd F. Crosby, Pittsburgh, respondents. Mr. Justice POWELL, delivered opinion Court. 1 case whether Act, added, 79 Stat. 343, amended, 42 U.S.C. § 1396 seq. (1970 ed. Supp. V), participate cost 2 * may provide federally funded needy persons.1 statute treatment.2 §§ 1396a(a)(13)(B) ed., 1396d(a)(1)-(5) V). all treatment categories, objectives (Title XIX)." 1396a(a)(17) approved plan, Pennsylvania those necessary.3 respondents' applications because failure furnish certificates, they filed United Western relief. Their complaint alleged relevant provisions laws violation Fourteenth Amendment. 4 (1) was convened 28 2281. After resolving respondents, held restriction Doe v. Wohlgemuth, 376 F.Supp. 173 (1974).4 Accordingly, court granted unconstitutional applied trimester. Appeals Third Circuit, sitting en banc, both second pregnancy.5 611 (1975). reach issue.6 5 We certiorari resolve conflict among federal courts requirements XIX.7 428 909, 96 3220, 49 1216 (1976). II 6 (2) only question before us one construction: permissible law. "The starting point involving construction itself." Blue Chip Stamps Manor Drug Stores, 421 723, 756, 95 1917, 1935, 44 539 (1975) (Powell, J., concurring). makes no reference abortions, or, matter, any other particular procedure. Instead, cast terms respect treatment. See n. 2, supra. But falls Indeed, expressly provides: 7 "A must include reasonable eligibility (Title) ." 8 This confers adopt assistance, Act.8 9 regulation comports fully broadly stated primary objective enable each State, far practicable, whose income resources insufficient meet 1396, 1396a(10)(C) excluded coverage, hardly though desirable 10 (3) thrust argument exclusion coverage economic health grounds.9 grounded view generally less expensive childbirth. Since pregnant woman normally either an carry her child full term, elects eventually confronted greater expenses associated corresponding based early poses risk Consequently, argue, considerations ordinarily support reasonableness limitations financing services applicable 11 Accepting assumptions accurate, we do agree As acknowledged Roe Wade, 410 113, 93 705, 35 147 (1973), valid important recognized "important legitimate (of State) protecting potentiality human life." Id., at 162, S.Ct., 731. That alone not, least until approximately third trimester, become sufficiently compelling justify unduly burdensome interference constitutionally protected privacy significant existing Respondents legislative history unquestionably childbirth.10 Absent showing, presume abortions.11 12 Our interpretation reinforced considerations. First, when 1965, States.12 In then-prevailing law, more convincing proof offered. Second, charged administration complicated statute,13 allows mandate "(W)e mindful 'the execution followed there indications wrong .' " New York Services Dublino, 413 405, 421, 2507, 2516-2517, 37 688 quoting Red Lion Broadcasting Co. FCC, 395 367, 381, 89 1794, 1802, 23 371 (1969). Here, completely absent. 13 hold refusal extend XIX.14 made clear, however, leaves free so desires.15 III 14 (4) There feature addressed Under necessary. 3, On record, unable precise role played these additional physicians, consequently ascertain Congress. reversed, remanded consideration requirement. 15 ordered. 16 BRENNAN, whom MARSHALL BLACKMUN join, dissenting. 17 holds "necessary services" connected elective I dissent. 18 Though interpretation, difficult would raised where read Maher Roe, 464, 2376, 484 (1977); Bolton, 179, 739, 201 (1973); (1973). "first fairly possible (constitutional) avoided," Ashwander TVA, 297 288, 341, 348, 56 466, 480, 483, 80 L.Ed. (1936) (Brandeis, concurring); see Westby Doe, 420 968, 1385, 43 648 (1975), my view, light principle avoidance decisions, agreement our cases compel conclusion constitute find pay women participants program. 19 Pregnancy Norton, 380 726, 729 (D.C.Conn.1974); Klein Nassau County Center, 347 496, 500 (DC EDNY 1972), (in Wade Bolton), 412 925, 2747, 152 Treatment involve procedures termination, bring pregnancy resulting live birth. "(A)bortion childbirth, stripped sensitive moral arguments surrounding controversy, simply alternative methods dealing 408 660, 663 (Conn.1975). statutes leave decision choice exclusively doctor his patient, make provision whatever intervention decision. Section 1396a(a)(19) imposes obligation upon incorporate safeguards programs assure "care provided, best interests recipients." And, significantly, Senate Finance Committee Report bill "physician key figure utilization services." S.Rep. 404, 89th Cong., 1st Sess., 46 (1965). Thus very heart congressional scheme complete freedom choose suited needs patient. 20 Court's original decisions dovetail precisely purpose avoid physician. supra, U.S., 163, 732, "(t)he physician, consultation determine, without that, judgment, patient's terminated." And 192, 747, "the exercised factors physical, emotional, psychological, familial, age well-being All relate health. room he judgment. operates benefit, disadvantage, woman."* Once some sort dictate what be. face emphasis joint autonomy how treat beyond comprehension therapeutic births constitutes not. 21 If obligated rendered performing "necessary" meaning follow also violate refused "therapeutic" births. For availability "unnecessary," converse true. highlights violence done today's birth constituting responses must, command abortions; 22 1972 family-planning amendment 1396d(a)(4)(C) buttresses frustrates 1396(2) states explicit indigent recipients "attain retain capability independence self-care." furthered assisting "desire control family size order enhance capacity ability seek employment better needs." S.Rep.No. 92-1230, p. (1972). ideal mechanism, method avoiding emotional problems daily lot impoverished. Special Subcommittee Human Resources Labor Public 92d Secretary Welfare Submitting Five-Year Plan Family Planning Population Research Programs 319 (Comm. Print 1971). answer illegal 1965 enacted, adopted. deals services, specific procedures, even designed payment legally 1972. statement: 24 "It impossible believe enacting freeze available legal 1965. surely drugs marketable FDA's subsequently found marketable. can reason why same analysis apply Supreme legalization 1973." 622-623 25 Nor administrative mandatory dispositive according weight inapplicable departmental here, patently controlling statute. Townsend Swank, 404 282, 286, 92 502, 505, 30 448 (1971). 26 Finally, certainly affirmative policy justification aids including cannot contend protects fiscal incurs expense paying costly performed carrying pregnancies and, after birth, increased welfare incurred mother child. mother's discouraging abortion, force use measures dangerous life but, 149, 725, concluded, competent licensed now "relatively safe" risks undergoing means "appear low lower childbirth." 27 result practical matter forcing penniless children borne had weighted scales substantially onerous. said last Term: "For afford work nothing, him, effective 'interdiction' ever necessary." Singleton Wulff, 106, 118-119, 7, 2868, 2876, 826 thus mockery construing chosen patients appropriate pregnancies. address concurrence conflicts invalid clearly paramount decision, event 198-200, 750-751. 29 affirm Appeals. groups persons: "categorically" needy, includes persons dependent aged, blind, disabled, 1396a(a)(10)(A) V); "medically" persons, 1396a(a)(10)(C) Participating so. enumerated are: "(1) inpatient hospital (other institution tuberculosis mental diseases); "(2) outpatient services; "(3) laboratory X-ray "(4)(A) skilled nursing facility diseases) years older (B) July 1, 1969, periodic screening diagnosis physical defects, care, correct ameliorate defects chronic conditions discovered thereby, Secretary; (C) planning supplies furnished (directly arrangements others) child-bearing (including minors sexually active) desire supplies; "(5) physicians' (as defined section 1395x(r)(1) title), office, home, hospital, facility, elsewhere." 1396d(a) elect option providing somewhat different individuals. 1396a(a)(13)(C)(ii) An deemed if: documented evidence continuance threaten mother; infant born incapacitating deformity deficiency; forcible rape incest, threat patient; "(4) Two professional competency writing; accredited Joint Commission Accreditation Hospitals." Brief Petitioners 4, citing Bulletin 2207, 2209 (Sept. 29, 1973). indicated "(w)hether 'an necessary' judgment." informed oral definition enough encompass specified Bolton. Tr. Oral Arg. 7-8. dissent BRENNAN emphasizes "key" noting Post, 449-450. done. Its necessity, determination authorized basis factors. creates "an distinction between terminate abortion." F.Supp., 191. 484, today conclude Equal Protection Clause Amendment prevent making incident similar appealed cross-appealed denial relief review jurisdiction over appeals. Gerstein Coe, 417 279, 94 2246, 41 68 (1974). petitioners issued Temporary Revised Policy September 25, 1975. interim regard necessity. 3. Courts concluded 522 928 (CA2 1975); Ferguson, 515 279 (CA6 1975). also, e. g., Westby, 402 140 (WDSD 1975) (three-judge court) abortions), appeal docketed, 75-813; Stewart, Civ. 74-3197 (ED La., 26, 1976) 75-6721. concede "indicates wide provided." 9. concerning With exception Part III, infra, interfere needs. certifies covered If, concludes indicates perform request, covered. depends solely initial determination. rely heavily amending "family exclude service. prior legislation, 300a-6, amendments "strongly indicates" intention line reasoning flawed. allow violated equality individual's "shall amount, duration, scope individual." 1396a(a)(10)(B) According "force(s) voluntary while imposing qualify aid." 619 entirely excluding At time 1973 eight enactment prohibitions 118 709, Federal funds been HEW. prohibited year 1977 except endangered fetus carried term. Departments Appropriation 1977, 209, Pub.L. 94-439, 90 1434. dissenting Brothers, 482, 2386, express vivid anguish perceived impact prefer think Brothers misconceive issues us, well judiciary. merely (i) participation, program; (ii) Government through processes democracy, funding. present widest concern. They resolved representatives people, states, ante, 442 left prescribed indeed "on factors," 442, concept relevance doctors freely certificates argument, counsel carefully follows: "(L)et me perfectly clear concession. is, examining take familial into mind considerations, affect deem "I Bolton language, Vuitch (United Vuitch, 62, 91 1294, 601 (1971)) using facts probably psychological jeopardized "That say, obviously, Plaintiffs asserting, going increase 8. Petitioners' "concession" goes consider relates "may health," paragraph directed "well-being" woman. 747 (emphasis added). While right implicate "right individual, married single, unwarranted governmental intrusion matters fundamentally affecting person bear beget child." Eisenstadt Baird, 405 438, 453, 1029, 1038, 31 349

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