Court Opinion

ID: 6933186
Source: CourtListenerOpinion
Date Created: 2022-07-24 00:15:41.640678+00
Date Added: 2024-06-11T16:07:18.585822
License: Public Domain

NIEMEYER, Circuit Judge, concurring in part and dissenting in part:
I concur with the rulings made in Part II of the majority opinion but with respect to the majority opinion’s interpretation of the Medicare and Medicaid statutes, I respectfully dissent. I find myself in full agreement with the opinion’s characterization of the statutes that:
There can be no doubt but that the statutes and provisions in question, involving the financing of Medicare and Medicaid, are among the most completely impenetrable texts within human experience. Indeed, one approaches them at the level of specificity herein demanded with dread, for not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of the matters addressed merely a passing phase.
Maj. op. at 1449-50. Yet, after engaging in that “dense reading of the most tortuous kind” and parsing these statutes for their meaning, I reach a different result.
While the majority opinion has courageously embarked on a survey of the amendments and legislative history of the Medicare and Medicaid statutes during the last 30 years and has striven to put forward a logical explanation for the various inconsistencies it identifies, it nevertheless admits in several places where two or more interpretations are possible that “[njeither interpretation is particularly satisfying.” Maj. op. at 1454. Moreover, the majority opinion fails, in my judgment, to address satisfactorily the plain language of the core provisions that we must construe, i.e. 42 U.S.C. §§ 1396a(a)(10)(VIII) & 1396a(n), and totally disregards legislative history developed during the 1988 and 1989 amendments.
The majority concludes erroneously, I submit, that because it can string together a reading of the text which supports its position, it has proven that “Congress has directly spoken to the precise question at issue,” and thus satisfied the first inquiry under Chevron U.S.A v. Natural Resources Defense Council, 467 U.S. 837, 842, 104 S.Ct. 2778, 2781, 81 L.Ed.2d 694 (1984). In fact, I have reached the conclusion that there is another interpretation of the statutes, a hybrid of the majority’s and the Secretary’s, which has the most textual support and is more consistent with the overall regulatory scheme. But even this more convincing reading of the statute does not, I acknowledge, leave one confident that every ambiguity is resolved. In the end, I find that the most appropriate judicial response is to conclude that Congress has not spoken directly and unambiguously to the issue before us and that therefore we must defer to the interpretation of the agency charged with interpretation and enforcement of the statutes. Indeed, the fact that well-intentioned and intelligent experts at legal exegesis have arrived at three or four seemingly plausible readings of a particular text may be the best *1463evidence that this interpretive puzzle has no definitive answer. Because the Secretary’s reading of the statute, though different from my own, is nonetheless a reasonable and therefore a permissible one, I would defer to the agency and reverse the judgment of the district court.
I
To begin with some background which may lend understanding to the more esoteric provisions at issue, I note that this ease involves the interplay of two separate federal health care programs originally enacted in 1965, the Medicare Act, 42 U.S.C. §§ 1395-1395ccc, and the Medicaid Act, 42 U.S.C. §§ 1396-1396v. Medicare is an insurance program, funded and operated by the federal government, for those over the age of 65 and for those with specified disabilities. Medicare’s coverage is divided into two parts. All eligible individuals who opt to participate in the program are entitled to benefits under Part A, which provides limited protection against the costs of certain hospital and related post-hospital care, home health service, and hospice care. 42 U.S.C. § 1395c. Under Part B, eligible individuals may purchase supplemental insurance for more extensive health care benefits, including coverage for physician and out-patient services. Once an individual who chooses to enroll in Part B pays the appropriate premium and annual deductible, the federal government then pays 80% of what it determines to be the reasonable costs of covered services, leaving the individual responsible for paying the remaining 20%, known as the “coinsurance” payment. 42 U.S.C. §§ 1395Z 1395cc(a).
The Medicaid program, in contrast, is funded and operated by both the federal and state governments and its availability is based upon financial need, irrespective of age. Each state sets its own criteria for financial need, and in most cases the state threshold is less than the federal poverty level. A state is not required to participate in the program, but once it decides to do so, it must comply with a wide range of federal statutes and regulations. 42 U.S.C. § 1396c. Each participating state must develop its own Medicaid plan, establishing a schedule of payment rates and methods for different types of medical services, 42 U.S.C. § 1396a(a), and the plan must be approved by the Secretary of the Department of Health and Human Services, 42 U.S.C. § 1396a(b). Those providing services to Medicaid patients must accept the established Medicaid rate as payment in full and may not demand additional payment from the patients themselves. 42 U.S.C. § 1320a-7b(d). In virtually all cases, the approved Medicaid rate is less than the reasonable charge permitted under the Medicare Act. Depending upon the circumstances of the medical services, the federal government will reimburse the state between 50% and 83% of the cost of the services. 42 U.S.C. § 1396d(b).
Many individuals, who are both poor and either elderly or disabled, qualify for both Medicare and Medicaid and are therefore known as “dual-eligibles.” Because many of these individuals cannot afford to pay Medicare Part B premiums and because of the advantages of participation in the Part B program, the Medicaid Act has always permitted states to use Medicaid funds to enroll these “dual-eligibles” in Part B coverage. In 1986, Congress created a second class of persons eligible for Medicaid-financed participation in Part B of the Medicare Program, authorizing such coverage for those who, while not poor enough to qualify for Medicaid, nevertheless had incomes below a modest level set by the state, but not exceeding the federal poverty line. See 42 U.S.C. § 1396d(p)(l). Those made eligible to participate in 1986 were referred to as “qualified medicare beneficiaries” or “pure QMBs.”1 While the 1986 version of the Medicaid Act gave states the choice whether to enroll pure QMBs in Part B of the Medicare Program, a 1988 amendment to the Medicaid statute *1464made such enrollment mandatory by deleting the words “at the option of a State” from 42 U.S.C. § 1396a(a)(10)(E).
Thus, the question presented in this ease is not whether states are required to use Medicaid monies to enroll dual-eligibles and pure QMBs in Part B (because clearly they are required to do so), but whether they are required to pay all of the costs associated with Part B in fall; or, stated otherwise, whether it would be consistent with the Medicaid Act for the states to cap their coinsurance and annual deductible payments at the approved Medicaid rate (or some other amount less than 100 percent) for a given item or service. As of January 1, 1991, Virginia began paying coinsurance and deductibles only to the extent that the Medicaid rate would pay for the services. In response, plaintiff Rehabilitation Association of Virginia, an organization representing providers of rehabilitation services in Virginia, brought this action to compel full payment of coinsurance and deductibles under Part B of the Medicare Program for all qualified Medicare beneficiaries, including dual-eligibles and pure QMBs.
In support of its position, the Rehabilitation Association relies on 42 U.S.C. § 1396a(a)(10)(E), which requires that the state Medicaid plans provide “for making medical assistance available for medicare cost-sharing (as defined in Section 1396d(p)(3) of this title) for qualified medicare beneficiaries,” with certain exceptions. Section 1396d(p)(3), in turn, defines “medicare cost-sharing” to include Medicare premiums, deductibles and coinsurance. According to the Rehabilitation Association, 42 U.S.C. § 1396a(a)(10)(E), in combination with the definition of “medicare cost-sharing” in 42 U.S.C. § 1396d(p)(3), should be read to require payment in full for all of these medical costs, thus prohibiting states from capping their payments at any amount less than 100 percent. The Rehabilitation Association notes that two other circuits have adopted this position. See Pennsylvania Medical Soc’y v. Snider, 29 F.3d 886 (3d Cir.1994), and New York City Health & Hospitals Corp. v. Perales, 954 F.2d 854 (2d Cir.1992) (by divided vote, with dissenting opinion). But see Haynes Ambulance Service, Inc. v. Alabama, 820 F.Supp. 590 (M.DAla.1993) (reaching opposite result), rev’d and remanded, 36 F.3d 1074 (11th Cir.1994).2
The United States Secretary of Health and Human Services and the Commonwealth of Virginia argue that the requirement that the state Medicaid plans make available funds for Medicare Plan B premiums, deductibles and coinsurance should not be read to mandate that such funds provide 100 percent reimbursement at the Medicare rate, but rather that payment may be made for Medicare services at the generally lesser Medicaid rate of reimbursement. They contend that the statutory provisions cited by the Rehabilitation Association address only the requirement that Medicaid funds be available for Medicare coinsurance payments and deductibles but not the amount of payment. They argue that the amount of these medical payments is set forth in a separate provision, 42 U.S.C. § 1396a(n), entitled “Payment Amounts.” That section permits a state to pay beyond the Medicaid rates, but does not mandate it. Section 1396a(n) provides that state plans for QMBs
may provide payment in an amount with respect to the service or item that results in the sum of such payment and any amount of payment made under [Medicare] with respect to the service or item exceeding the amount that is otherwise payable under the State [Medicaid] plan for the item or service for eligible individuals who are not qualified medicare, beneficiaries.
(Emphasis added). According to the Secretary and Virginia, there would be no reason to use the permissive verb form “may provide” in § 1396a(n) if § 1396a(a)(10)(E) and § 1396d(p)(3) mandated payment in full at the Medicare rate. The Secretary argues further that, even if we disagree with her interpretation, the relationship of the various sections at least creates an ambiguity. Therefore, she argues we should uphold her *1465position for the independent reason that Congress has vested the responsible agency with the authority to interpret the two acts.
Relying largely upon the logic of the Second Circuit’s decision in Perales,3 the district court granted summary judgment to the Rehabilitation Association, and the Secretary and Virginia noticed this appeal.
For the reasons that follow, I believe that neither the Secretary nor the Rehabilitation Association has the better argument. In my view, each is only partially correct. While the language and history of the statute plainly supports the Secretary’s interpretation of the states’ payments obligation for pure QMBs, the Rehabilitation Association provides the better reading of the states’ obligation for dual-eligibles.
II
The analysis must begin with the text of the applicable provisions as they currently exist, and in particular with the core provision of the Medicaid Act which establishes and defines the contours of the state buy-in program, 42 U.S.C. § 1396a(a)(10)(E). That provision requires states that participate in the Medicaid program to make Medicaid monies available for “medicare cost-sharing” as defined in 42 U.S.C. § 1396d(p)(3). The definition of “medicare cost-sharing” in § 1396d(p)(3) lists four categories of costs, including premiums, deductibles and coinsurance payments, for which patients covered by Medicare Part B are normally held responsible. Reading § 1396a(a)(10)(E) and § 1396d(p)(3) in a vacuum, one might conclude, as the majority opinion does, that they combine to mandate that states use Medicaid funds to provide reimbursement for the full amount of all costs associated with Medicare Part B, including the full amounts of deductibles and coinsurance.
But the majority’s conclusion cannot be maintained in the presence of the exceptions clause to § 1396a(a)(10), which states:
except that ... (VIII) the medical assis-tanee made available to a qualified medicare beseSeiary described in section 1396d(p)(l) ... who is only entitled to medical assistance because the individual is such a beneficiary shall be limited to medical assistance for medicare cost-sharing ..., subject to the provisions of subsection (n) of this section....
42 U.S.C. § 1396a(a)(10)(VHI) (emphasis added). The exceptions clause directs attention to a separate provision in § 1396a entitled “Payment Amounts,” which specifies the amount of payments that a state must make under the Medicaid program for Medicare cost-sharing. See 42 U.S.C. § 1396a(n). That provision uses the permissive language “may” to allow states to make coinsurance payments for QMBs above the approved Medicaid rate, thus implying that state plans are equally free not to make payments above the Medicaid rate. The role of § 1396a(n) is simply to authorize, but not require, the states to pay an amount in excess of the Medicaid rates for that class of QMBs described in Exception VIII.
I find no difficulty in rejecting the Rehabilitation Association’s reading that the § 1396a(n)’s sole purpose is to clarify that states are indeed permitted to do what § 1396a(a)(10)(E) requires them to do. Even the majority opinion concedes that this reading is not “particularly satisfying,” since the Rehabilitation Association fails “to explain why the states needed permission to break the Medieaid fee cap for QMBs when Congress didn’t apparently think before this time that such permission was needed.” Maj. op. at 1454. One is hard pressed to explain why Congress would make an action mandatory for states in one section and still feel the need to clarify, in a separate section linked to the first by the words “except that,” that the states had permission to follow Congress’ mandate.
I agree with the Secretary that the plain language of § 1396a(n) requires a reading that states may provide payment in amounts *1466exceeding those otherwise mandated under the Medicaid statute. But what neither the parties nor the majority acknowledges is that the authorization given by § 1396a(n) applies only to pure QMBs and not to dual-eligibles. The plain language of Exception VIII, quoted above, demands this conclusion. That clause, which directs the reader to § 1396a(n), explicitly limits its own operation to cases where a state gives medical assistance to “a qualified medicare beneficiary ... who is only entitled to medical assistance because the individual is such a beneficiar ry.” 42 U.S.C. § 1396a(a)(10)(VIII) (emphasis added). Congress added the highlighted language in 1988, in the same bill in which it expanded the definition of “QMB” to cover both pure QMBs and dual-eligibles. See Technical and Miscellaneous Revenue Act of 1988, Pub.L. No. 100-647, §§ 8434(a), 8434(b)(1), 102 Stat. 3342, 3805. And pure QMBs, who are by definition ineligible for Medicaid, are only “entitled to medical assistance” (i.e. Medicaid monies) because they are considered “qualified medicare beneficiaries.” By contrast, dual-eligibles are otherwise entitled to medical assistance because they are otherwise eligible for the entire panoply of Medicaid benefits. By taking pains to add this language, Congress intended to continue treating the payment obligations of the two groups differently, despite combining them into a single definitional category for other purposes.4
Distinguishing the treatment of QMBs and the treatment of dual-eligibles is consistent with the approach Congress took before 1988. When enacted in 1986, § 1396a(n) applied only to pure QMBs. By adding to Exception VIII the qualifying clause highlighted above in 1988, Congress manifested its intent that § 1396a(n) remain applicable only to pure QMBs. That Congress wished to continue treating pure QMBs and dual-eligibles differently is not surprising given the fact that the two groups are not similarly situated. Indeed, dual-eligibles are by definition poorer than pure QMBs, and thus I think the scheme most in line with Congressional intent is the one in which the states may ask for a greater financial contribution from the group that is better able to contribute.
Additional textual support for this interpretation is provided by two provisions which the majority puzzlingly overlooks. The first is the “part or all” language in Exception II, also to § 1396a(a)(10). See 42 U.S.C. § 1396a(a)(10)(II). This clause states that “provision for meeting part or all of the cost of deductibles, cost sharing, or similar charges under [Medicare Part B] ... for individuals eligible for benefits under such part, shall not ... require the making available of any such benefits, or the making available of services of the same amount, duration, and scope, to any other individuals.” 42 U.S.C. § 1396a(a)(10)(II) (emphasis added). This language shows that Congress contemplated that states might provide only a portion of the costs associated with enrolling individuals in Medicare Part B. This militates against the majority’s and the Rehabilitation Association’s insistence that the Medicaid Act mandates that states provide all costs, in full.
Second and even more convincing is the existence of a provision which limits the imposition of cost-sharing charges on qualified Medicare beneficiaries to certain “nominal” amounts, as defined by the Secretary’s regulations. See 42 U.S.C. § 1396a(a)(14) (requiring that enrollment fees, premiums, deductions, cost sharing, or similar charges, may be imposed under state Medicaid plans only as provided in section 1396o); 42 U.S.C. § 1396o(a) (with some exceptions, requiring that “any deduction, cost sharing, or similar charge” imposed on qualified Medicare beneficiaries be limited to a “nominal” amount as defined by regulation, or “twice the nominal amount” for non-emergency services received in a hospital emergency room). Without determining the definition of “nominal,” it is sufficient to identify these sections as further *1467and convincing proof of Congress’ expectation that states would not always provide 100 percent reimbursement for the patients they enrolled in Medicare Part B insurance. These provisions, requiring that any such costs imposed on QMBs be “nominal,” would be rendered mere surplusage if the majority’s opinion were correct because the majority believes that QMBs should never have to pay such nominal costs. I hasten to add, however, that if my interpretation were to be adopted by the Secretary and imposed on the states, states such as Virginia would no longer be able to cap their contributions at the Medicaid rate, where the difference, between the state Medicaid rate and 100 percent of the federal Medicare fee was more than “nominal.”
To summarize, then, the Medicaid Act’s core buy-in provision, § 1396a(a)(10)(E), together with the definition of cost-sharing in § 1396d(p)(3), if read in a vacuum, might be interpreted to mandate that the states cover the full amount of all the costs associated with Medicare Part B. But, as I have already pointed out this is a faulty interpretation in light of Exception VIII, which applies only to pure QMBs. As for dual-eligibles, I can find no provision which qualifies or otherwise creates an exception to full payment of all their costs. Thus, I conclude that as to dual-eligibles, the majority and the Rehabilitation Association are correct; the states may not, given the text of the Medicaid Act in its current form, ask dual-eligibles to share the costs of Medicare Part B, including coinsurance payments. But as to pure QMBs, the states may ask them to shoulder the responsibility for costs exceeding what the state would normally pay for a service under its Medicaid plan, at least up to a “nominal” amount.
Confining myself solely to the statutory language, I therefore must conclude that Medicaid’s core buy-in provision, § 1396a(a)(10)(E), cannot be read in a vacuum and that Exception VIII explicitly exempts one group of qualified Medicare beneficiaries, what we refer to as “pure QMBs,” from the 100 percent reimbursement mandate. While participating states are authorized under the Medicaid Act to provide payment beyond Medicaid rates to pure QMBs in assisting them to participate in. Medicare Part B, they are not required to do so. See 42 U.S.C. § 1396a(n). In certain circuirn-stances, states may cap their levels of reimbursement at the Medicaid rates, but only if doing so leaves the patient with no more than a “nominal” cost. See 42 U.S.C. § 1396o (a)(3). As for dual-eligibles, the statute does not seem to exempt them from the 100 percent ' reimbursement mandate of § 1396a(a)(10)(E), and thus I agree that adequate textual support exists for this aspect of the majority’s interpretation of the Act.
Ill
I believe that-the historical treatment of the states’ payment obligations for dual-eligi-bles and QMBs, within the framework of an evolving statutory scheme, provides further corroborative evidence of the congressional intent that I have derived from the statutory language itself. This historical treatment, which in many instances is ambiguous, is nevertheless relevant because earlier versions of the two‘acts explicitly address the issues presented to us in this case.
As originally enacted in 1965, the Medicaid Act permitted states to pay on behalf of certain dual-eligibles the entire costs associated with Medicare Part B. If states chose not to make such payment in full, the Medicaid Act required that payment be made “on a basis reasonably related ... to such individual’s income or his income and resources.” Social Security Amendments of 1965, Pub.L. No. 89-97, § 1902(a)(15), 1965 U.S.C.C.A.N. 305, 373 (codified prior to repeal at 42 U.S.C. § 1396a(a)(15)). Thus, a state which chose not to pay the entire Medicare Part B insurance for dual-eligibles was nonetheless responsible for a portion of the payment, but the portion for which it was responsible bore no relation to the Medicaid rate.
In 1986, Congress decided to create a second class of persons eligible for Medicaid-financed enrollment in the Medicare Part B insurance program. Specifically, it gave the states the option of enrolling in Medicare Part B certain individuals — pure QMBs— who were not poor enough to be eligible for Medicaid but still had income and resources *1468below a defined level. Omnibus Budget Reconciliation Act of 1986 (“OBRA”), Pub.L. No. 99-509, § 9403(b), 100 Stat. 1874, 2053-54 (codified as amended at 42 U.S.C. §§ 1396a(a)(10)(E) & 1396d(p)(l)): Significantly, Congress treated the states’ payment obligations to each of the two groups who were eligible for the buy-in program separately and distinctly. Instead of simply extending the means test of old § 1396a(a)(15) to pure QMBs, Congress explicitly excluded pure QMBs from application of that subsection, leaving the means test to apply only to dual-eligibles. See OBRA § 9403(g)(4)(A), 100 Stat.2056 (amending § 1396a(a)(15) prior to its repeal).5
What Congress intended in 1986 as a substitute for the means test for pure QMBs is the key to this case. For in 1986 Congress enacted essentially the same network of provisions governing the payment obligations for states which opted to buy-in pure QMBs as exists today, with two caveats: today, (1) states are required to buy-in pure QMBs, and (2) the definition of “qualified medicare beneficiary” has been expanded. But as for the amount of a state’s payment obligation, the exact same textual analysis I applied to the current statutory scheme also applies to the statutory language as it existed in 1986. To summarize that analysis, while the definition of Medicare cost-sharing included a list of all of the costs associated with Medicare Plan B, the definition was immediately followed by an exceptions clause which stated that the states may provide costs in an amount exceeding the Medicaid rate, implying clearly that states were not required to provide the full amount of all the costs.6
The majority opinion is hard pressed, to come up with an alternative reading of these provisions as they were passed in 1986. The majority, as I noted above, is highly skeptical, and justifiably so, of the Rehabilitation Association’s position that Exception VIII merely clarifies that the states have permission to do what the Act requires them to do. Recognizing the weakness of the Rehabilitation Association’s position, the majority attempts to derive a third interpretation, consistent with its position, by closely analyzing the wording of § 1396a(n). In that section, states are told that they “may provide” payments for services for QMBs through the buy-in program in excess of what is “otherwise payable under [Medicaid] for the item or service for eligible individuals who are not qualified medicare beneficiaries” (emphasis added). The natural reading of the quoted phrase is that it compares the amount paid for pure QMBs under Medicare Part B with the amount paid normally for Medicaid patients under the state Medicaid plan, indicating that the former may exceed the latter. The majority chooses instead to read it as comparing the amount paid for pure QMBs under Medicare Part B with the amount paid for dual-eligibles under Medicare Part B.7 “This understanding of the statute suggests simply that the State may pay more for [pure] QMB payments under Plan B than it pays for dual eligibles under Plan B.” Maj. op. at 1454.
The majority’s position is unconvincing for several reasons. First and foremost, the reading suggested by the majority, like that of the Rehabilitation Association, would re-*1469suit in a system where the states would be required to make larger payments for pure QMBs than for dual-eligibles, while, by definition, dual-eligibles are poorer than pure QMBs. I would agree with the majority (though with less understatement) that this notion seems “somewhat incongruous.” Maj. op. at 1454. For it is wholly unclear to me why Congress would create a system forcing dual-eligibles to contribute to their coinsurance payments, while the states would be required to pick up the entire cost of coinsurance for pure QMBs. One cannot simply state that this was an unintended anomaly of the new statutory regime, because, as noted above, the 1986 amendments specifically excluded pure QMBs from application of old § 1396a(a)(15). If Congress intended that the states have a different payment obligation for pure QMBs than for dual-eligibles, as it clearly did, the rational inference is that Congress intended that states have a lesser obligation for pure QMBs.
Second, it makes little sense to read the requirement that states “mak[e] medical assistance available for medicare cost sharing,” 42 U.S.C. § 1396a(a)(10)(E), to require full payment of coinsurance for pure QMBs when that subsection, when it was drafted in 1986, allowed such payments “at the option of a State.” See OBRA § 9403(a)(3), 100 Stat. 2053. If a state had the option of deciding whether or not it would even pay Medicare Part B premiums for pure QMBs at that time, one must assume that it also had discretion as to the amount of coinsurance that it would pay.
Third, the majority’s textual analysis of § 1396a(n) raises more questions than it answers and is subject to the same criticism that the majority applies to the Rehabilitation Association’s reading of that provision. If, as the majority believes, the 1986 version of the Act contained one section which clearly allowed states to provide less than 100 percent reimbursement for dual-eligibles according to a needs-based standard, and another section which clearly mandated 100 percent reimbursement for pure QMBs (i.e., the all-or-nothing option), § 1396a(n) would be rendered mere surplusage. It is utterly implausible, I submit, to believe that Congress would create a new section in the Act solely to acknowledge that it is permissible for states to do what Congress requires them to do in other sections.8
Thus, I cannot conclude that the operative sections cited by the majority and the Rehabilitation Association, as enacted in 1986, required full payment of coinsurance for pure QMBs. The difficulties with the majority’s and the Rehabilitation Association’s reading of the 1988 amendments are apparent. If Congress did not intend for § 1396a(a)(10)(E) to require full payment for pure QMBs in 1986, how can we assume that it intended for such payment in 1988 with no statement in the statute to that effect? This would be a substantial change in the law. To assume that those new state obligations are created by implication, without some expressed indication to that effect in the statute, is a greater leap than I am prepared to make. Moreover, my interpretation of the 1986 version of the statute is fully consistent with the changes Congress adopted in 1988. Though alluded to above, it is worthwhile to once again review what the 1988 amendments actually did.9
*1470In 1988, Congress made a number of significant changes in the treatment of dual-eligibles and pure QMBs. First, it removed the phrase “at the option of a State” from 42 U.S.C. § 1396a(a)(10)(E), thus obligating states to emolí their pure QMBs in Part B of the Medicare program. See Medicare Catastrophic Coverage Act of 1988, Pub.L. No. 100-360, § 301(a)(1), 102 Stat. 683, 748. Also in 1988, Congress eliminated the distinction between dual-eligibles and pure QMBs by changing the definition of “qualified medicare beneficiary” to include dual-eligibles. See Technical and Miscellaneous Revenue Act of 1988, Pub.L. No. 100-647, § 8434(a), 102 Stat. 3342, 3805. As a consequence, Congress repealed 42 U.S.C. § 1396a(a)(15) which had been applicable only to dual-eligi-bles.
It would be misleading to conclude from the new singular definition of “qualified medicare beneficiary,” however, that Congress intended the coinsurance payment obligation of the states to be identical for dual-eligibles and pure QMBs. In fact, in the 1988 amendments Congress explicitly added language to the exceptions clause attached to § 1396a(a)(10)(E) indicating that § 1396a(n) continued to apply solely to pure QMBs, as it did in 1986. The combination of the congressional repeal of the needs-based test for dual-eligibles in old § 1396a(a)(15) and the restriction of the “may provide” language in § 1396a(n) to apply only to pure QMBs is sufficient evidence that Congress intended to require full reimbursement for dual-eligi-bles — but for them only.
Thus, the history of the 1986 and 1988 amendments leads to the following condu-sions. The statutory scheme prior to the 1988 amendments required coinsurance payments for dual-eligibles to the extent that the beneficiary could not pay, according to some “reasonable” scale of need as determined by the state. 42 U.S.C. § 1396a(a)(15) (repealed in 1988). If my reading of the 1986 amendments is correct, they did not require any such payments for pure QMBs. Thus, the 1988 amendments effectively changed the states’ payments obligation for only one of the two groups. The payment obligation for pure QMBs remained flexible,10 while the payment obligation for dual-eligibles went from a needs-based standard to a requirement of 100 percent reimbursement.
IV
I remain with the firm belief that mine is the most accurate interpretation of the statutes. Notwithstanding that conviction, I am also prepared to acknowledge that the statutory language may not give rise to a single conclusive interpretation and that one cannot derive a definitive interpretation from the nature of the multitudinous amendments made over the years. While the proper limit of our judicial function is coterminous with our power to interpret, I am willing to concede there are circumstances that fall beyond the limits of reason. In this instance, therefore, I am not prepared to order a construction in conflict with the view of the agency happily charged with these statutes’ interpretation. Accordingly I conclude it best, in light of all the circumstances, that we defer to the agency.
*1471Congress has given the Secretary the power to administer both the Medicare and Medicaid Acts, see 42 U.S.C. §§ 1395ff(a), 1396a(b), and deference is due to the Secretary’s interpretations of them under the principles announced in Chevron U.S.A. v. Natural Resources Defense Council, 467 U.S. 837, 104 S.Ct. 2778, 81 L.Ed.2d 694 (1984). Those principles, which are well known but merit repeating here, are stated quite simply:
When a court reviews an agency’s construction of the statute which it administers, it is confronted with two questions. First, always, is the question whether Congress has directly’ spoken to the precise question at issue. If the intent of Congress is clear, that is the end of the matter; for the court, as well 'as the agency, must give effect to the unambiguously expressed intent of Congress. If, however, the court determines Congress has not directly addressed the precise question at issue, the court does not simply impose its own construction on the statute, as would be necessary in the absence of an administrative interpretation. Rather, if the statute is silent or ambiguous with respect to the specific issue, the question for the court is whether the agency’s answer is based on a permissible construction of the statute.
‡ ‡ & sfc ‡
If Congress has explicitly left a gap for the agency to fill, there is an express delegation of authority to the agency to elucidate a specific provision of the statute by regulation. Such legislative regulations are given controlling weight unless they are arbitrary, capricious, or manifestly contrary to the statute. Sometimes the legislative delegation to an agency on a particular question is implicit rather than explicit. In such a case, a court may not substitute its own construction of a statutory provision for a reasonable interpretation made by the administrator of an agency.
Id. at 842-44, 104 S.Ct. at 2781-82 (emphasis added) (footnotes omitted). See also, Pauley v. BethEnergy Mines, Inc., 501 U.S. 680, 702, 111 S.Ct. 2524, 2537, 115 L.Ed.2d 604 (1991) (“[I]t is axiomatic that the Secretary’s interpretation need not be the best or most natural one by grammatical or other standards .... Rafter, the Secretary’s view need be only reasonable to warrant deference.”).
The deference mandated by Chevron has a number of justifications. It insures that agencies — which are more politically accountable than federal courts — have final say on matters of policy not resolved by Congress.
While agencies are not directly accountable to the people, the Chief Executive is, and it is entirely appropriate for this political branch of the Government to make such policy choices — resolving the competing interests which Congress itself either inadvertently did not resolve, or intentionally left to be resolved by the agency charged with the administration of the statute in light of everyday realities.
Chevron, 467 U.S. at 865-66, 104 S.Ct. at 2793. In addition, the judicial deference to agency interpretations mandated by Chevron “increases the prospect of uniform federal regulatory law and reduces the burden on the Supreme Court of insuring that uniformity.” Laurence A. Silberman, Chevron — The Intersection of Law & Policy, 58 Geo. Wash. L.Rev. 821, 824 (1990). Finally, Congress may be better equipped to draft legislation with knowledge of how an agency, with a track record of interpretation and hard-earned expertise in the field, is likely to read its language. See Antonin Scalia, Judicial Deference to Administrative Interpretations of Law, 1989 Duke L.J. 511, 517 (1989). Thus, where we.are not convinced that Congress has spoken to a matter, we should grant discretion to an agency because of its special competence to fill , the statutory gap.
Where an agency is given discretion to administer a “complex and highly technical regulatory program,” it is entitled to an even greater degree of deference from the courts. BethEnergy Mines, 501 U.S. at 697, 111 S.Ct. at 2534. The provisions of the Medicaid and Medicare Acts at issue here are just the sort of complicated statutes that are entitled to this special deference. See Mowbray v. Ko-zlowski, 914 F.2d 593, 598 (4th Cir.1990) (“Judicial deference is especially appropriate in the area of welfare administration.”). I believe that the courts must acknowledge *1472their lack of expertise in such complicated fields and, in the face of an unresolvable ambiguity, accord extra deference to the appropriate agency which has the greater familiarity with the statutory scheme at issue.
In this ease, I would also grant extra deference to the position of the Secretary because of the major financial ramifications of our decision. Affidavits submitted by the Director of the Virginia Department of Medical Assistance Services state that the reading urged by the Rehabilitation Association would cost an additional $10 million annually. Assuming that federal matching funds are available for half of that total, Virginia would be forced to budget an extra $5 million annually just to cover the costs inherent in the Rehabilitation Association’s interpretation, at a time when Virginia already projects significant budget shortfalls. According to representations from counsel at oral argument, almost half of the states in the country have similar limitations upon coinsurance payments, so that a ruling that full payment is mandatory could have an even greater fiscal impact. With so great a budgetary change at stake, I am convinced that we should be especially sure of the result Congress intended before acting, and failing that confidence, we should defer to the federal and state agencies which regularly and continuously operate under the statutes’ terms.
In short, while I continue to believe that my statutory interpretation is more persuasive than that urged by the majority, the fact that the majority opinion and my opinion— both of which are purportedly grounded on a rational interpretation of the statutes — arrive at significantly different results surely manifests an actual ambiguity and an almost self-evident lack of clarity in the statutes. In these circumstances, I believe that the court has no other alternative but to defer to the agency charged with interpretation and enforcement of the statutes, particularly in light of the major budgetary implications. Accordingly, I would reverse the judgment of the district court, and therefore I respectfully dissent.

. In keeping with the terminology of the majority opinion, I will refer to those who met the 1986 definition of "qualified medicare beneficiary” as "pure QMBs.” As noted, infra, in 1988 Congress changed the official definition of “qualified medicare beneficiaiy” to encompass both pure QMBs and dual-eligibles. To avoid confusion, I keep the terminology of the two mutually exclusive classifications — dual-eligibles and pure QMBs— distinct throughout.

. Subsequent to the argument of this case, the Eleventh Circuit issued an opinion essentially adopting the position of the Second and Third Circuits in Perales and Snider, reversing the Alabama district court.

. The majority opinion, in affirming the district court’s judgment, does not rely, quite properly I believe, upon the argument raised by the Rehabilitation Association and relied on by Perales that the Secretary's policy violates the Medicare Act by denying to health care providers the full reasonable value of their services.

. Interestingly, the recent Eleventh Circuit opinion is the only other opinion which has acknowl- , edged this crucial piece of language which Congress inserted into the exceptions clause in 1988. See Haynes, 36 F.3d 1074, at 1076-77. The Haynes court agrees that this language is intended to distinguish pure QMBs from dual-eligibles, but then fails, without explanation, to follow through on its observation and recognize the implication that the exception clause’s reference to "subsection (n)” is meant only to apply to pure QMBs.

.In 1986, Congress amended § 1396a(a)(15) by inserting “are not qualified medicare beneficiaries" after "older who.” Thus, prior to its repeal in 1988, § 1396a(a)(15) required a state Medicaid plan to—
In the case of eligible individuals 65 years of age or older who are not qualified medicare beneficiaries (as defined in § 1396d(p)(l) of this title) but are covered by either or both of the insurance programs established by [Medicare], provide where, under the plan, all of any deductible, cost sharing, or similar charge imposed with respect to such individual under the insurance program established by [Medicare] is not met, the portion thereof which is met shall be determined on a basis reasonably related ... to such individual's income or his income and resources.
(Emphasis added).

. The same additional textual supports outlined above also existed in 1986. See 42 U.S.C. §§ 1396a(a)(10)(II), 1396a(a)(14), and 1396o (a).

. The majority achieves this interpretation by reading "eligible individuals” to mean (i) individuals eligible for the buy-in program, rather than (ii) individuals eligible for Medicaid. Thus, “eligible individuals who are not qualified medicare beneficiaries” would refer logically to the other category of patients who are eligible for the buy-in program, namely dual-eligibles. See slip op. at 1454.

. The Majority’s textual analysis is also technically flawed because it would create a glitch in the current version of § 1396a(n). Section 1396a(n) reads today exactly as it did in 1986. Congress has made no changes to its wording, although in 1988 it did expand the definition of "qualified medicare beneficiary.” The Majority therefore presumably remains firm in its position that the phrase "eligible individuals” in section 1396a(n) refers to (i) individuals eligible for the buy-in program, rather than (ii) individuals eligible for Medicaid. See n. 7, supra. Unfortunately, this renders the rest of the section meaningless, as the clause "eligible individuals who are not qualified medicare beneficiaries” would refer to an empty set. As of 1988, when Congress expanded the definition of "qualified medicare beneficiaty” to include pure QMBs and dual-eligibles, all individuals eligible for the buy-in program are considered qualified Medicare beneficiaries.
Thus, I am confident that the natural reading of § 1396a(n) was correct in 1986 and is correct today.

. In addressing the meaning of the 1988 amendments, the Secretary urges that we consider the House Report which appears to approve limiting the coinsurance payment for QMBs to the Medicaid rate. See H.R.Rep. No. 100-105(11), 100th Cong., 2d Sess. 61, reprinted in 1988 U.S.C.C.A.N. 857, 884. That report provides:
*1470it is the understanding of the Committee that, with respect to dual Medicaid-Medicare eligi-bles, some states pay the coinsurance even if the amount Medicare pays for the service is higher than the State Medicaid payment rate, while others do not. Under the Committee hill, States would not be required to pay the Medicare coinsurance in the case of a hill where the amount reimbursed by Medicare — i.e., 80 percent of the reasonable charge — exceeds the amount Medicaid would pay for the same item or service. However, if a State chooses to pay some or all of the coinsurance in this circumstance, Federal matching funds would, as under current law, be available for this cost.
(Emphasis added). Even though that aspect of the report appears to be commenting on the practice under the 1986 amendments and does not explain the particular changes accomplished by the 1988 amendments, I would not entirely reject the import of this expressed congressional understanding, as does the majority opinion, because that commentary implicates a budgetary concern of some magnitude which had to be taken into account in adopting the 1988 amendments. I agree with the majority, however, that such legislative history must be reviewed cautiously.

. Subject to the caveat that any cost sharing charged imposed could only be "nominal in amount.” See 42 U.S.C. § 1396o (a)(3).