Court Opinion

ID: 9700844
Source: CourtListenerOpinion
Date Created: 2023-08-25 21:51:07.712522+00
Date Added: 2024-06-11T18:21:15.177055
License: Public Domain

Opinion by
Judge Wilkinson, Jr.,
The issue before us is the constitutionality of the mandatory insurance provisions of the Health Care Services Malpractice Act (Act)1 under the due process and equal protection clauses of the Fourteenth Amendment of the United States Constitution and Article III, Section 32, of the Pennsylvania Constitution. At issue is an order of the State Board of Medical Education and Licensure (Board) which suspended the license of petitioner, a practicing physician, pursuant to Section 701(a) of the Act, until such time as he has complied with the provisions of the Act. For the reasons set forth herein we find Section 701(a) constitutional and therefore affirm the action of the Board.
*534In 1974, jurisdictions throughout the United States were confronted with what was popularly referred to as a “medical malpractice crisis” evidenced by precipitous increases ,in malpractice claims and awards, concurrent and equally precipitous increases in the cost of malpractice insurance and the threatened unavailability of such insurance at any cost.2 The Pennsylvania General Assembly responded to this “crisis” by enacting the Act. Its stated purpose is “to make available professional liability insurance at a reason*535able cost and to establish a system through which a person who has sustained injury or death as a result of tort or breach of contract by a health care provider can obtain a prompt determination and adjudication of his claim and the determination of fair and reasonable compensation.”3 It implements this policy by establishing an arbitration system whereby claims against health care providers4 are initially heard5 and by limiting the dollar amount of liability of insurers on individual awards.6 This limitation on liability is achieved by the creation of a “Medical Professional Liability Catastrophe Loss Fund” [hereinafter referred to as the Fund], established by a' surcharge on insurance premiums or direct assessment by self-insurers.7 The Fund is guaranteed by requiring that all health care providers as defined by the Act either purchase insurance or develop a plan of self-insurance8 and by making insurance available ¡to high risk health care providers through a Joint Underwriting Association.9 The state licensure boards are required to suspend or revoke the license of a health care provider upon a failure to comply with the mandatory insurance provisions or to participate in the Fund.10
Petitioner, a practicing physician in Canton, Pennsylvania, licensed to practice medicine in this state since 1941, was cited by the Board on November 30, 1976 for failure to comply with the provisions of the *536Act in (1) failing to secure professional liability insurance or to submit an approved self-insurance plan and (2) failing to pay the 10 per cent surcharge into the Fund. At a hearing held on December 9, 1976, petitioner told the Board that he did not have and did not intend to acquire professional liability insurance and that he had not and did not intend to contribute to the Fund. His sole defense to the Board’s citation was the unconstitutionality of the Act.11 Accordingly, the Board on April 28, 1977 ordered petitioner’s license suspended. On May 4, 1977, the Board issued a stay pending a determination by this Court.12
Preliminarily, we must note the parameters of our review where a state statute is attacked on allegations of substantive constitutional infirmities.
‘It is the province of the legislature, not the judiciary ... to determine the means necessary to combat’ public problems, for with means as with ends, ‘the legislature, which is more responsive to the people and has more adequate facilities for gathering and assembling the requisite data, is in a better position to evaluate and determine’ alternative approaches. Basehore [v. Hampden Industrial Development Au*537thority, 433 Pa. 40,] at 49, 248 A.2d [212,] at 217 [(1968)]; see also Johnson v. Pennsylvania Housing Finance Agency, 453 Pa. 329, 337-38, 309 A.2d 528, 533 (1973). Our inquiry is limited to a determination of whether the means selected are so ‘demonstrably irrelevant to the policy the legislature is free to adopt’ as to bo arbitrary and irrational. (Footnote omitted.)'
Tosto v. Pennsylvania Nursing Home Loan Agency, 460 Pa. 1, 9, 331 A.2d 198, 202 (1975).
And, in distinguishing due process and equal protection standards under the United States Constitution, we begin with the general observation that in considering the due process clause we are concerned with the fundamental fairness of the State’s dealing with an individual while in considering the equal protection clause we evaluate the disparity of treatment by the state between classes of individuals whose situations are arguably indistinguishable. Ross v. Moffitt, 417 U.S. 600 (1974).
Due Process
Petitioner contends that the statutory requirement of mandatory insurance is unreasonable and unrelated to the objectives sought to be achieved by the Act and therefore violates his right to substantive due process guaranteed by the Fourteenth Amendment. Further, he argues, assuming the validity of the mandatory insurance provision, that enforcement by suspension or revocation of his license to practice medicine is likewise violative of due process as unreasonable and unrelated to the object of the legislation.
It is well established that a state may regulate professions, consistent with the substantive due process right of an individual to pursue the occupation of his choosing, so long as the matters regulated affect the public interest. Pirillo v. Takiff, 462 Pa. 511, 341 A.2d 896 (1975), cert. denied, 423 U.S. 1083 *538(1976); Adler v. Montefiore Hospital Association, 453 Pa. 60, 311 A.2d 634 (1973), cert. denied, 414 U.S. 1131 (1974); State Board of Podiatry Examiners v. Lerner, 213 Pa. Superior Ct. 63, 245 A.2d 669 (1968). Where such regulations are attacked, substantive due process requires:
[A] law which purports to be an exercise of the police power must not be unreasonable, unduly oppressive or patently beyond the necessities of the case, and the means which it employs must have a real and substantial relation to the objects sought to be attained. Under the guise of protecting the public interests the legislature may not arbitrarily interfere with private business or impose unusual and unnecessary restrictions upon lawful occupations.
Gambone v. Commonwealth, 375 Pa. 547, 551, 101 A.2d 634, 637 (1954).
Certainly it cannot be gainsaid that health care providers, in particular the medical profession, stand in the forefront of guardians of the public health and welfare.
Thus, we do not doubt the authority of the state to recognize the problem of malpractice insurance availability and to deal with it. It is no answer to say the petitioner had no claims made against him during the course of his career. In framing its policy the legislature was not bound to provide for determinations of the relative proficiency of particular health care providers. The legislature was entitled to consider the general effects of the unavailability of malpractice insurance and, if these effects were injurious, to counteract them by a general rule, even though as applied to particular practitioners there might be no evidence of need for the legislative regulation. See Semler v. Oregon State Board of Dental Examiners, 294 U.S. 608 (1935).
*539Testing Section 701(a) of the Act against these principles of substantive due process, we cannot conclude that requiring professional liability insurance is wholly unreasonable and arbitrary and bears no rational relation to the public’s interest in assuring the compensability of malpractice claims. Petitioner’s holistic approach to the statute as aimed simply at making malpractice insurance available, glosses over the myriad and complex factors that gave rise to the malpractice crisis that confronted the legislature and which petitioner candidly admits was the reason for the legislation. This view also ignores the interrelated nature of the entire statute, a full reading of which discloses that mandatory insurance is inextricably tied to the creation and maintenance of the Catastrophe Loss Fund, the legislative quid pro quo to insurance companies’ continuing to provide malpractice insurance coverage in Pennsylvania. Moreover, the 10 per cent surcharge on insurance premiums by which the health care provider’s contribution is determined roughly relates to the degree of risk (and thus the health care provider’s direct interest in the maintenance of the Fund). If health care providers could elect not to participate in contributing to tbe Fund, it takes no special knowledge of logic or human nature to conclude that “low risk” health care providers would withdraw, leaving the Fund to be financed by “high risk’’ insureds and almost inevitably assuring its depletion. Without the Fund which allows insurers to establish an actuarial basis for anticipation of needed reserves, insurers might again find malpractice an uninsurable risk and either drastically curtail or withdraw totally from participating in the market, in short, creating conditions for precisely the same “crisis” the legislation was designed to obviate. Therefore, we find, within the words of the statute itself, a real and demonstrable relation between the *540requirement of insurance, or proof of financial responsibility, and the object of the legislation to make malpractice insurance available to all health care providers. Similarly, we find the public has an interest in providing that malpractice insurance be available not only to assure compensability for claims but also to protect those who provide medical services in the state from the threat of financial ruin.
We do not understand petitioner’s due process argument-that the penalty of suspension of his license to practice medicine is too harsh. If it is proper to require him to obtain insurance, then what other penalty would be appropriate?
Equal Protection
In considering whether Section 701(a) of the Act denies the petitioner equal protection of the laws13 in violation of the Fourteenth Amendment, we are initially confronted with choosing the appropriate standard, that is, the rational basis test where the constitutionality of the statute is presumed or the strict scrutiny test where the state’s creation -of a classification places special burdens on a suspect class or impinges on a fundamental liberty so that the state must come forward with compelling reasons for its classification. See San Antonio School District v. Rodriguez, 411 U.S. 1 (1973). Petitioner invites this Court to examine the demands of the equal protection clause under the standards of strict scrutiny alleging infringement of a fundamental right to practice medi*541cine.14 This we cannot do. The Supreme Court of the United States has made it clear that in order for the strict scrutiny standard to apply, the fundamental right must be explicitly or implicitly guaranteed by the Constitution. San Antonio School District, supra. In equal protection challenges to state limitations on employment opportunities and state licensing, the Court has consistently applied the rational basis test in determining the constitutionality of the state’s classification. See, e.g., Massachusetts Board of Retirement v. Murgia, 427 U.S. 307 (1976); New Orleans v. Dukes, 427 U.S. 297 (1976); Williamson v. Lee Optical of Oklahoma, Inc., 348 U.S. 483 (1955). These cases recognize that there is no fundamental right to employment in general or the practice of medicine in particular. Shaw v. Hospital Authority of Cobb County, 507 F.2d 625 (5th Cir. 1975); Liggett, supra note 2. Thus, we deem the proper standard to be applied is whether the classification bears some rational relationship to a permissible state objective. Dandridge v. Williams, 397 U.S. 471 (1970).
In this context, petitioner argues that Section 701 (a) fails to meet the standard because the health care providers who are subject to the mandatory provisions of the Act are a legislatively created class whose *542definition has no rational relationship to the avowed purposes of the Act. Section 103 of the Act defines the health care provider subject to Section 701(a) as “a physician, an osteopathic physician or surgeon, a podiatrist,, hospital [or] nursing home.” The classification thus excludes other state licensees who provide health care services, such as nurses, chiropractors and dentists, who are also subject to malpractice claims, but áre not subject to the provisions of the Act. This statutory scheme of exclusion and inclusion, petitioner argues, evidences a classification that is wholly arbitrary with no obvious rational relationship to thé Act’s stated objective.
Where a statutory classification is attacked for its uhder-inclusiveness, the Supreme Court has observed,
[T]his Court' consistently defers to legislative determinations as to the desirability of particular statutory discriminations. . . . Legislatures may implement their program step by step . . . adopting regulations that only partially ameliorate a perceived evil and deferring complete elimination of the evil to future regulations. (Citations omitted.)
New Orleans v. Dukes, supra at 303; see also Williamson, supra.
The equal protection clause does not require that the state must choose between attacking every aspect of the problem or not attacking the problem at all. Dandridge, supra. The constitutional safeguard is offended only if the classification rests on grounds wholly unrelated to the state’s objective. McGowan v. Maryland, 366 U.S. 420 (1961); Adler, supra. Finally, the fact that a state might have achieved its underlying purpose more artfully or more completely does not warrant the conclusion that the method it chose was unconstitutional. Singer v. Sheppard, 33 Pa. Commonwealth Ct. 276, 381 A.2d 1007 (1978).
*543Within this constitutional framework, we turn to an examination of the statute and its stated objectives, to make professional liability insurance available at a reasonable cost and to establish a system to assure compensation for justified claims. The studies of malpractice legislation nationwide indicates the availability of insurance and increasing costs for insurance was most critical for physicians, hospitals and nursing homes; moreover, studies, indicated other health care providers were able to acquire insurance at acceptable rates. See generally Forum, supra. Therefore, there is a basis to support the legislature’s conclusion that the exclusion of other health care professionals did in fact rest upon a ground of difference that bore a fair and substantial relationship to the object of the legislation. Moyer v. Phillips, 462 Pa. 395, 341 A.2d 441 (1975).
Absent a factual showing by petitioner, who had the burden of showing unconstitutionality under the rational relationship test, that physicians, hospitals and nursing homes bore the cost of professional liability insurance when in fact the risk involved, as shown by actual claims, involved health care providers other than this class, we fail to see how petitioner could have been treated unfairly by the classification.
Accordingly, we will enter the following
Order
And Now, September 14, 1978, the order of the State Board of Medical Education and Licensure dated April 28, 1977, suspending the license of Orlo C. McCoy, M.D., until he has complied with the provisions of the Health Care Services Act, is hereby affirmed.

 Act of October 15, 1975, P.L. 390, as amended, 40 P.S. §1301.101 et seq.
The challenged section provides:
(a) Every health care provider as defined in this act, practicing medicine or podiatry or otherwise providing health care services in the Commonwealth shall insure his professional liability or provide proof of self insurance in accordance with this section.
Section 701(a) of the Act, 40 P.S. §1301.701 (a).

 See, Note, Medical Malpractice — A Question of Insurability, 80 Dick. L. Rev. 594 (1976).
As evidence of the national scope of the problem, all states with the exception of Montana have within the past two years adopted medical malpractice legislation. The statutes may be divided into four general legislative schemas: (1) those such as Pennsylvania’s which limit the liability of insurers by the creation of a fund from which excess payments for damages over a specified ceiling are to be paid; (2) those limiting-the damages recoverable in malpractice actions and providing for compulsory arbitration of claims; (3) those revising the statute of limitations in malpractice actions; and (4) those requiring insurers to pro,vide professional liability insurance as a condition of doing business in the state. See generally White & McKenna, Constitutionality of Recent Malpractice Legislation, 13 Forum 312 (1977). Compulsory insurance provisions have been enacted in statutes of the first category which, in addition to Pennsylvania, include Alaska, Idaho, Kansas, Kentucky and North Dakota. See Alaska Stat. §08.64.215; Idaho Code §§39-4206, 3904208, 3904209; Kan. Stat. §40-3402; Ky. Rev. Stat. Ann. §304.40-330; N.D. Cent. Code §26-40.01. The compulsory insurance provisions have been upheld in constitutional challenges in two states. See Kansas ex rel. Schneider v. Liggett, Kan. , 576 P.2d 221 (1978) ; Jones v. State Board of Medicine, 97 Idaho 859, 555 P.2d 399 (1976), cert. denied, 431 U.S. 914 (1977). In Kentucky, the statutory mandate was declared in violation of the equal protection clause of the Kentucky Constitution. McGuffey v. Hall, 557 S.W. 2d 401 (Ky. 1977). In North Dakota, a district court found that state’s statute denied equal protection to a physician who was required but unable to obtain insurance. Arneson v. Olson, Civil No. 26309 (4th Dist. — Burleigh County, Filed December 15, 1977).

 Section 102 of the Act, 40 P.S. §1301.102.

 Section 103 of the Act, 40 P.S. §1301.103, defines a “health care provider” as “physician, an osteopathic physician or surgeon, a podiatrist, hospital [or] nursing home. ...”

 See Sections 301 to 514 of the Act, 40 P.S. §§1301.301-1301.514.

 Section 701(b) of the Act, 40 P.S. §1301.701(b).

 Section 701(d) of the Act, 40 P.S. §1301.701 (d).

 Section 701(a) of the Act, 40 P.S. §1301.701(a).

 See Sections 801 to 810 of the Act, 40 P.S. §§1301.801-1301.810.

 Section 701(f) of the Act, 40 P.S. §1301.701 (f).

 Ronald Bachman, director of financial affairs for the Pennsylvania Medical Society also testified in behalf of petitioner. Bach-man testified that current costs for insurance by Pennsylvania physicians ranged from $736 to $13,580 annually with Argonaut Insurance Company and $988 to $18,180 annually through the Joint Underwriting Association. Petitioner appears to raise some argument by the mere recitation of these statistics that the statutory requirement is unreasonable. However, absent some showing in the record, or facts not apparent to us at this time, we are unable to say that requiring health care providers to bear the cost of such insurance is per se unreasonable.

 In addition to the detailed briefs of petitioner and respondent, this Court also had the benefit of an amicus brief submitted by the Keystone Podiatry Society of Pennsylvania.

 The issues raised under equal protection were also alleged violative of Article III, §32 of the Pennsylvania Constitution. Since the content of these two provisions are not significantly different, these issues will he considered together. Baltimore & Ohio Railroad Co. v. Department of Labor and Industry, 461 Pa. 68, 334 A.2d 636 (1975).

 At oral argument petitioner also asserted that the right of his patients to be treated by the physician of their own choosing was also being infringed. Petitioner asserts that this “right” is one of the personal rights reserved to the people under the Ninth Amendment of the United States Constitution and that therefore this Court must apply the strict scrutiny test. Griswold v. Connecticut, 381 U.S. 479 (1965). Apart from the substantial question of standing this issue raises, there has been no allegation the statute impairs or infringes upon the physician-patient relationship. See Adler, supra. To require insurance coverage and participation in the Fund is not to deny the physician the right to treat hi's patient or the corresponding right of a patient to choose his own physician.