Court Opinion

ID: 8208479
Source: CourtListenerOpinion
Date Created: 2022-09-22 18:00:09.55786+00
Date Added: 2024-06-11T16:41:32.777544
License: Public Domain

(Slip Opinion)

       Intergovernmental Immunity for the Department of
       Veterans Affairs and Its Employees When Providing
                   Certain Abortion Services
The rule issued by the Department of Veterans Affairs on Reproductive Health Services is
  a lawful exercise of VA’s authority. States may not impose criminal or civil liability
  on VA employees—including doctors, nurses, and administrative staff—who provide
  or facilitate abortions or related services in a manner authorized by federal law, includ-
  ing VA’s rule. The Supremacy Clause bars state officials from penalizing VA employ-
  ees for performing their federal functions, whether through criminal prosecution, li-
  cense revocation proceedings, or civil litigation.

                                                                      September 21, 2022

     MEMORANDUM OPINION FOR THE ACTING GENERAL COUNSEL
             DEPARTMENT OF VETERANS AFFAIRS

   The Department of Veterans Affairs (“VA”) has issued an interim final
rule permitting VA to provide veterans and certain other VA beneficiaries
with access to abortion services when the life or health of the pregnant
individual would be endangered if the pregnancy were carried to term or
when the pregnancy is the result of rape or incest. Reproductive Health
Services, 87 Fed. Reg. 55,287, 55,287–88 (Sept. 9, 2022) (the “rule”).
VA’s rule also permits VA to provide abortion counseling. See id. Prior to
VA’s issuance of the rule, this Office advised VA that the rule represented
a reasonable exercise of the VA Secretary’s discretion to provide medical
services. We also advised that states may not impose criminal or civil
liability on VA employees—including doctors, nurses, and administrative
staff—who provide or facilitate abortions or related services in a manner
authorized by federal law, including VA’s rule. The Supremacy Clause of
the U.S. Constitution bars state officials from penalizing VA employees
for performing their federal functions, whether through criminal prosecu-
tion, license revocation proceedings, or civil litigation. See id. at 55,293–
94. This memorandum memorializes and expands upon our prior advice.

                                            I.

   “The Constitution’s Supremacy Clause generally immunizes the Feder-
al Government from state laws that directly regulate or discriminate
against it,” unless federal law authorizes such state regulation. United

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                       46 Op. O.L.C. __ (Sept. 21, 2022)

States v. Washington, 142 S. Ct. 1976, 1982 (2022); see U.S. Const. art.
VI, cl. 2. In McCulloch v. Maryland, 17 U.S. (4 Wheat.) 316 (1819),
“Chief Justice John Marshall explained that, under the Supremacy Clause,
‘the States have no power, by taxation or otherwise, to retard, impede,
burden, or in any manner control, the operations of the constitutional
laws enacted by Congress to carry into execution the powers vested in
the general government.’” Washington, 142 S. Ct. at 1983–84 (quoting
McCulloch, 17 U.S. (4 Wheat.) at 436). “The Court thus interpreted the
Constitution as prohibiting States from interfering with or controlling the
operations of the Federal Government.” Id. at 1984.
   This principle is often referred to as intergovernmental immunity.
The doctrine is “subject to nuances,” Disaster Assistance and the Su-
premacy Clause, 5 Op. O.L.C. 198, 199 (1981) (“Disaster Assistance”),
and “[o]ver time” it has “evolved,” Washington, 142 S. Ct. at 1984. As
relevant here, the doctrine “prohibit[s] state laws that . . . ‘regulate the
United States directly,’” absent any federal law consenting to the applica-
tion of state law. Id. (alterations omitted) (quoting North Dakota v. United
States, 495 U.S. 423, 435 (1990) (plurality opinion)).
   In determining whether a state law is invalid as a direct regulation of
the United States, courts look to whether the provision “seeks to regulate
the federal function itself.” Immunity of Smithsonian Institution from State
Insurance Laws, 21 Op. O.L.C. 81, 85 (1997) (citing North Dakota, 495
U.S. at 436–37 (plurality opinion)). For example, in North Dakota, the
Supreme Court held that state liquor laws, as applied to suppliers of U.S.
military facilities, did not violate the immunity doctrine, in part because
they operated against suppliers rather than directly against the federal
government and did not otherwise implicate “concerns about direct inter-
ference” with federal functions. 495 U.S. at 437 (plurality opinion) (citing
City of Detroit v. Murray Corp. of America, 355 U.S. 489, 504–05 (1958)
(opinion of Frankfurter, J.)).
   By contrast, state laws purporting to regulate the functions of federal
agencies themselves are direct regulations of the United States. See id. at
435 (plurality opinion). For example, in Mayo v. United States, 319 U.S.
441 (1943), the Supreme Court held that certain state inspection fees
could not be applied to the federal government’s distribution of fertilizer,
observing that the fees were “laid directly upon the United States” and
operated “like a tax upon the right to carry on the business of the post

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   Intergovernmental Immunity for VA When Providing Certain Abortion Services

office or upon the privilege of selling United States bonds through federal
officials,” id. at 447. The Court stated that the federal government’s
freedom from state regulation “is inherent in sovereignty.” Id. Where “the
governmental action is carried on by the United States itself and Congress
does not affirmatively declare its instrumentalities or property subject to
regulation or taxation, the inherent freedom continues.” Id. at 448.
   Similarly, in Johnson v. Maryland, 254 U.S. 51 (1920), the Court held
that a state lacks the power to require a federal postal employee to obtain
a license and pay a fee “before performing his official duty in obedience
to superior command,” id. at 55; see also id. at 57. The Court character-
ized the question as whether a state “can interrupt the acts of the general
government itself.” Id. at 55. The Court acknowledged that federal em-
ployees do not have “a general immunity from state law while acting in
the course of [their] employment,” and might be subject to state laws
“affect[ing] incidentally the mode of carrying out the employment,” such
as “a statute or ordinance regulating the mode of turning at the corners
of streets.” Id. at 56. The Court observed, however, that “even the most
unquestionable and most universally applicable of state laws, such as
those concerning murder, will not be allowed to control the conduct of a
marshal of the United States acting under and in pursuance of the laws of
the United States.” Id. at 56–57 (citing In re Neagle, 135 U.S. 1 (1890)).
The Court held that the state law at issue in Johnson could not be applied
to the postal employee, describing the statute as not “merely touch[ing]”
federal employees “remotely by a general rule of conduct,” but rather as
“lay[ing] hold of them in their specific attempt to obey orders” and as
“requir[ing] qualifications in addition to those that” the federal govern-
ment had “pronounced sufficient.” Id. at 57.
   Consistent with these cases, in Disaster Assistance, our Office conclud-
ed that the Federal Emergency Management Agency (“FEMA”) would not
be subject to state prohibitions while administering disaster relief under
the Disaster Relief Act of 1974, 42 U.S.C. §§ 5121–5202. Disaster Assis-
tance, 5 Op. O.L.C. at 198. We observed that when Congress “place[s]
responsibility for the execution of [federal] law in a federal official or
instrumentality,” that “execution of the law by the responsible official or
agency is no less a federal activity than was the delivery of the mail in
Johnson . . . , the operation of a bank in McCulloch . . . , or the sale of
fertilizer in Mayo.” Id. at 199–200. In other words, when a federal agency
“perform[s] a federal function pursuant to a law validly enacted by Con-

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                       46 Op. O.L.C. __ (Sept. 21, 2022)

gress[,] . . . under the Supremacy Clause, the states may not prohibit or,
by regulation, significantly burden the manner of its execution without the
consent of the United States.” Id. at 200. We cautioned that this “does not
mean that [agencies] may totally ignore state law in all cases and on all
subjects.” Id. We cited Johnson, where the Supreme Court remarked that
a state law “‘regulating the mode of turning at the corners of streets’”
could still apply to federal employees undertaking their federal functions.
Id. (quoting Johnson, 254 U.S. at 56). We also cited lower court decisions
“refus[ing] to excuse, on Supremacy Clause grounds, federal employees
who violated routine state (or local) traffic laws from prosecution when
the violations were not necessary to the accomplishment of their federal
functions.” Id. (collecting cases). “In light of this case law, caution dic-
tates that federal employees . . . should, to the extent possible, obey . . .
state or local laws, the violation of which is not necessary to the accom-
plishment of the federal function.” Id. Nonetheless, we concluded that “in
exigent circumstances in which violations of such laws are necessary
to permit FEMA to perform essential disaster relief activities under
the [Disaster Relief Act], the federal interest would . . . prevail.” Id. at
200–01.
   As noted above, Congress (or an agency acting pursuant to statutory
authorization) can authorize state regulation of federal functions that
would otherwise violate the federal government’s intergovernmental
immunity, but such an authorization must be “‘clear and unambiguous.’”
Washington, 142 S. Ct. at 1984 (quoting Goodyear Atomic Corp. v. Mil-
ler, 486 U.S. 174, 180 (1988)); see also Hancock v. Train, 426 U.S. 167,
179 (1976) (“Because of the fundamental importance of the principles
shielding federal installations and activities from regulation by the States,
an authorization of state regulation is found only when and to the extent
there is a clear congressional mandate, specific congressional action that
makes this authorization of state regulation clear and unambiguous.”
(footnotes and internal quotation marks omitted)).

                                      II.

  Applying these general principles to potential state interference with
VA’s provision of abortion services as authorized by VA’s rule, 87 Fed.
Reg. 55,287, raises two questions: First, does federal law authorize VA
and its employees to provide the specified abortion services? We conclude

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   Intergovernmental Immunity for VA When Providing Certain Abortion Services

that it does and that state attempts to interfere would thus constitute direct
regulation of an authorized federal function. Second, does federal law
clearly and unambiguously authorize states to restrict VA and its employ-
ees from providing the specified abortion services? We conclude that it
does not.

                                      A.

   VA’s rule lawfully eliminated earlier regulatory exclusions that had
prevented VA from providing abortion services and abortion counseling
to veterans whom VA serves pursuant to VA’s general treatment authori-
ty, 38 U.S.C. § 1710. VA’s rule also lawfully eliminated regulatory exclu-
sions that had prevented VA from providing certain abortion services and
abortion counseling to beneficiaries of the Civilian Health and Medical
Program of the Department of Veterans Affairs (“CHAMPVA”) whom
VA serves pursuant to 38 U.S.C. § 1781.

                                      1.

   “The primary function” of the Veterans Health Administration within
VA “is to provide a complete medical and hospital service for the medical
care and treatment of veterans, as provided in” title 38 of the U.S. Code
“and in regulations prescribed by the Secretary pursuant to” title 38. 38
U.S.C. § 7301(b); see also id. § 501(a) (authorizing the Secretary “to
prescribe all rules and regulations which are necessary or appropriate
to carry out the laws administered by the Department and are consistent
with those laws”). Pursuant to VA’s general treatment authority, VA
“shall furnish” specified veterans with “hospital care and medical ser-
vices” that “the Secretary determines to be needed.” Id. § 1710(a)(1)–
(2). For veterans not described in paragraphs (1) and (2), the Secretary
“may,” subject to certain limitations, similarly “furnish hospital care” and
“medical services . . . which the Secretary determines to be needed.” Id.
§ 1710(a)(3). As relevant here, such “medical services” include “medical
examination, treatment,” “[s]urgical services,” and “[p]reventive health
services.” Id. § 1701(6). “Except where the [statute] requires specific
services or care for [a] designated medical condition, the Secretary has
broad discretion to determine the precise hospital or medical services to
be supplied.” E. Paralyzed Veterans Ass’n, Inc. v. Sec’y of Veterans Affs.,
257 F.3d 1352, 1362 (Fed. Cir. 2001).

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                       46 Op. O.L.C. __ (Sept. 21, 2022)

   VA implements its general treatment authority, and the Secretary de-
termines what care is “needed,” 38 U.S.C. § 1710(a)(1)–(3), by regulation
establishing the scope of VA’s “medical benefits package,” 38 C.F.R.
§ 17.38. VA’s medical benefits package consists of a wide range of basic
and preventive care. See id. “Care included in the medical benefits pack-
age is ‘provided to individuals only if it is determined by appropriate
health care professionals that the care is needed to promote, preserve, or
restore the health of the individual and is in accord with generally accept-
ed standards of medical practice.’” 87 Fed. Reg. at 55,288 (quoting 38
C.F.R. § 17.38(b)).
   Before VA issued its recent rule, the medical benefits package had ex-
pressly excluded abortions and abortion counseling. Id. Such exclusions
are not compelled by statute, and “VA did not explain the rationale be-
hind” them when VA introduced them as part of the establishment of the
medical benefits package in 1999. Id.; see also Enrollment—Provision of
Hospital and Outpatient Care to Veterans, 64 Fed. Reg. 54,207, 54,217
(Oct. 6, 1999).
   In its new rule, VA’s Secretary has determined that access to abortion
“is ‘needed’ within the meaning of VA’s general treatment authority”
when “the life or health of the pregnant veteran would be endangered if
the pregnancy were carried to term” or when “the pregnancy is the result
of an act of rape or incest.” 87 Fed. Reg. at 55,288 (quoting 38 U.S.C.
§ 1710(a)). VA explained that pregnancy and childbirth can result in
physical harm for certain pregnant individuals, and that individuals with
pregnancy complications who lack access to abortion may risk loss of
future fertility, significant morbidity, or death. Id. at 55,291. VA also
explained the “severe health consequences associated with being forced to
carry a pregnancy that is the result of rape or incest to term.” Id. at
55,292. VA therefore concluded that access to abortion in such circum-
stances is “needed” medical care. 38 U.S.C. § 1710(a). Similarly, VA’s
Secretary determined that access to abortion counseling “is needed to
ensure that [veterans] can make informed decisions about their health
care.” 87 Fed. Reg. at 55,288 (“Abortion counseling is a part of pregnancy
options counseling and is a component of comprehensive, patient-
centered, high quality reproductive health care both as a responsibility of
the provider and a right of the pregnant veteran.”).

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   Intergovernmental Immunity for VA When Providing Certain Abortion Services

   Accordingly, VA eliminated the medical benefits package’s exclusions
for abortions and abortion counseling. See id. at 55,296; 38 C.F.R.
§ 17.38(c). This means that VA must now provide veterans access to
abortions in the circumstances the rule specifies “if an appropriate health
care professional determines that such care is needed to promote, pre-
serve, or restore the health of the individual and is in accord with general-
ly accepted standards of medical practice.” 87 Fed. Reg. at 55,288 (citing
38 C.F.R. § 17.38(b)(1)–(3)). It also means that “abortion counseling will
be provided as part of conversations a veteran has with their provider
related to pregnancy options care, when appropriate.” Id. at 55,292.
   As VA explained in its rule, section 106 of the Veterans Health Care
Act of 1992, Pub. L. No. 102-585, 106 Stat. 4943 (“VHCA”), does not
prohibit VA from providing abortion care under its general treatment
authority, 38 U.S.C. § 1710. See 87 Fed. Reg. at 55,288–89. As relevant
here, section 106 of the VHCA states:
     In furnishing hospital care and medical services under chapter 17 of
     title 38, United States Code, the Secretary of Veterans Affairs may
     provide to women the following health care services: . . . [g]eneral
     reproductive health care, including the management of menopause,
     but not including under this section infertility services, abortions, or
     pregnancy care (including prenatal and delivery care), except for
     such care relating to a pregnancy that is complicated or in which the
     risks of complication are increased by a service-connected condition.
106 Stat. at 4947. The text of section 106 specifies that its exclusions for
“infertility services, abortions,” and certain “pregnancy care” only limit
VA’s authority “under [that] section.” Id. Those exclusions do “not limit
VA’s authority to provide care under any other provision of law.” 87 Fed.
Reg. at 55,289. Since 1993—shortly after the VHCA’s enactment—VA
has consistently interpreted section 106 in this fashion. Id. at 55,289 &
n.5. VA’s interpretation is therefore entitled to “considerable weight.”
Davis v. United States, 495 U.S. 472, 484 (1990) (courts “give an agen-
cy’s interpretations and practices considerable weight where they involve
the contemporaneous construction of a statute and where they have been
in long use” (citing Norwegian Nitrogen Products Co. v. United States,
288 U.S. 294, 315 (1933))). Consistent with VA’s longstanding interpre-
tation, VA has “for decades . . . offered general pregnancy care and cer-
tain infertility services under” its general treatment authority, 38 U.S.C.

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                      46 Op. O.L.C. __ (Sept. 21, 2022)

§ 1710, notwithstanding the exclusions that apply to services provided
under section 106. 87 Fed. Reg. at 55,289. In its recent rule, VA also
explained that Congress has legislated consistent with VA’s interpreta-
tion, that section 106 has effectively been overtaken by subsequent legis-
lation, and that VA no longer relies on section 106 to provide any ser-
vices. See id. at 55,289–90. We agree that section 106 does not prohibit
VA from providing abortion services to veterans pursuant to its general
treatment authority, 38 U.S.C. § 1710.

                                     2.

   Pursuant to VA’s statutory CHAMPVA authority, VA’s “Secretary
is authorized to provide” specified “medical care” to certain spouses,
children, survivors, and caregivers of veterans who meet specific eligibil-
ity criteria. 38 U.S.C. § 1781(a). VA provides medical services to
CHAMPVA beneficiaries that VA determines by regulation to be “medi-
cally necessary and appropriate for the treatment of a condition and that”
VA has not “specifically excluded.” 87 Fed. Reg. at 55,290 (citing 38
C.F.R. § 17.270(b)). VA also “must provide ‘for medical care’ under
CHAMPVA ‘in the same or similar manner and subject to the same or
similar limitations as medical care is’ provided by the Department of
Defense to active-duty family members, retired service members and their
families, and others under” a health benefits program known as TRICARE
(Select). Id. (quoting 38 U.S.C. § 1781(b); citing 32 C.F.R. §§ 199.1(r),
199.17(a)(6)(ii)(D)).
   Prior to VA’s issuance of its rule, VA’s CHAMPVA regulations ex-
cluded abortions except when a physician certified that the life of the
woman would be endangered if the fetus were carried to term. 87 Fed.
Reg. at 55,291. VA’s CHAMPVA regulations also excluded abortion
counseling. Id. at 55,292. Neither exclusion was compelled by statute. In
its recent rule, VA’s Secretary “determined that when the health of the
pregnant CHAMPVA beneficiary would be endangered if the pregnancy
were carried to term, access to abortions is . . . medically necessary and
appropriate,” id. at 55,291, for reasons similar to those summarized
above, see id. at 55,291–92. VA’s Secretary likewise “determined that
access to abortion when the pregnancy is the result of an act of rape or
incest is medically necessary and appropriate,” id. at 55,292, again for
reasons similar to those summarized above, see id. VA’s Secretary also

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   Intergovernmental Immunity for VA When Providing Certain Abortion Services

determined that providing CHAMPVA beneficiaries with abortion coun-
seling “is medically necessary to ensure that they can make informed
decisions about their health.” Id. at 55,293. Finally, VA explained how
each category of newly authorized care is “the same or similar” as that
provided by the Department of Defense under TRICARE (Select). 38
U.S.C. § 1781(b); see 87 Fed. Reg. at 55,290–93. VA therefore revised
its CHAMPVA regulations to authorize such care. See 87 Fed. Reg. at
55,296; 38 C.F.R. § 17.272(a)(64).

                                      3.

   VA has “broad discretion,” E. Paralyzed Veterans Ass’n, 257 F.3d at
1362, to determine what care is “needed” for veterans, 38 U.S.C.
§ 1710(a)(1)–(3), and has similarly broad discretion to determine what
care is medically necessary and appropriate for CHAMPVA beneficiaries,
see 38 U.S.C. § 1781(a); 38 C.F.R. § 17.270(b). VA has reasonably exer-
cised its discretion in the rule, explaining why abortion counseling must
be provided and access to abortion services must be provided when the
life or health of the pregnant individual is endangered or in cases of rape
or incest. Accordingly, federal law authorizes VA and its employees to
provide the abortion and abortion counseling services specified in the
rule. Moreover, states’ attempts to restrict VA or its employees from
providing such services would “‘regulate the United States directly,’” and
therefore would be invalid absent any federal law consenting to the appli-
cation of state law. Washington, 142 S. Ct. at 1984 (alterations omitted)
(quoting North Dakota, 495 U.S. at 435). In other words, because in
providing these services VA is “performing a federal function pursuant to
a law validly enacted by Congress,” the Supremacy Clause precludes
states from “prohibit[ing] or, by regulation, significantly burden[ing] the
manner of” VA’s “execution” of that function “without the consent of the
United States.” Disaster Assistance, 5 Op. O.L.C. at 200.

                                      B.

   Consistent with VA’s representation to us, we are not aware of any fed-
eral law that authorizes states to restrict VA and its employees from
providing access to abortion services, let alone any law that does so
“clear[ly] and unambiguous[ly].” Washington, 142 S. Ct. at 1984 (internal
quotation marks omitted). To the contrary, VA’s regulations provide

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                        46 Op. O.L.C. __ (Sept. 21, 2022)

that state laws that “unduly interfere[]” with VA health care profession-
als’ federal duties are preempted. 38 C.F.R. § 17.419(b)(1); see id.
§ 17.419(c). As a general matter, VA determines whether a state law
“unduly interferes on a case-by-case basis.” Authority of VA Profession-
als to Practice Health Care, 85 Fed. Reg. 71,838, 71,842 (Nov. 12, 2020).
In its recent rule, VA determined that, consistent with 38 C.F.R. § 17.419,
“State and local laws, rules, regulations, or requirements that restrict,
limit, otherwise impede access to, or regulate the provision of health care
provided by VA pursuant to Federal law, would unduly interfere with VA
health care professionals’ practice within the scope of VA employment.”
87 Fed. Reg. at 55,294 (brackets and internal quotation marks omitted).
“Accordingly, consistent with [38 C.F.R.] § 17.419,” VA’s rule “con-
firm[ed] that a State or local civil or criminal law that restricts, limits, or
otherwise impedes a VA professional’s provision of care permitted by”
the rule—i.e., certain abortion and abortion counseling services—“would
be preempted.” Id. VA did bring to our attention its regulation governing
“[s]ecurity and law enforcement at VA facilities,” 38 C.F.R. § 1.218,
which disclaims abrogation of “State or local laws and regulations appli-
cable to the area in which the property is situated,” id. § 1.218(c)(3). But
that regulation is limited to matters involving security and law enforce-
ment, not medical practice. It therefore does not subject VA and its em-
ployees to state restrictions on any forms of medical care.

                                * * * * *

   In conclusion, and as we previously advised, the rule is a lawful exer-
cise of VA’s authority. Moreover, states may not restrict VA and its
employees acting within the scope of their federal authority from provid-
ing abortion services as authorized by federal law, including VA’s rule.
States may not penalize VA employees for providing such services,
whether through criminal prosecution, civil litigation, or license revoca-
tion proceedings.

                                 CHRISTOPHER H. SCHROEDER
                                   Assistant Attorney General
                                     Office of Legal Counsel

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