Court Opinion

ID: 9462113
Source: CourtListenerOpinion
Date Created: 2023-08-04 22:32:25.786639+00
Date Added: 2024-06-11T17:37:24.817401
License: Public Domain

MULLIGAN, Circuit Judge
(concurring in part and dissenting in part):
I concur in the result reached by the majority of the court that the judgment appealed from was erroneous and must be reversed and the matter be remanded for the convening of a three-judge court to determine the constitutionality of Section 275 of the Connecticut Welfare Department’s Regulations. I agree that there is nothing in Title XIX of the Social Security Act which requires a state to make Medicaid payments for elective abortions. My dissent here is prompted by my belief that Title XIX also precludes such payments so that Connecticut has not simply the option but the obligation to refuse Medicaid benefits for non-therapeutic abortions.
As the majority opinion emphasizes, when Title XIX was enacted elective abortions were illegal in a majority of the states. I therefore find it difficult to conclude that the Congress intended to provide public moneys to compensate those who engaged in what was then considered to be unlawful activity. In fact, I would think the presumption would be otherwise. The court below interpreted Title XIX to permit and in fact require payment for abortion on demand because to do otherwise in the opinion of the court would create constitutional issues. The majority here, while eschewing the constitutional question, has nonetheless adopted in part the strained interpretation of the court below.
There are two issues raised by the majority, both of which are decided erroneously in my view. The first question is whether or not Medicaid benefits are properly payable only for those medical services which are necessary. Phrased starkly but fairly, does Title XIX authorize public moneys for unnecessary medical services? The majority answers the question in the affirmative which I frankly find to be a startling proposition. I would assume without even examining the statute that the Congress had no such intention. In fact, 42 U.S.C. § 1396 of Title XIX states that its purpose is to furnish “medical assistance” for those whose income and resources are insufficient to meet the costs of “necessary medical services.” This would seem to be a clear expression of congressional intent. The majority here has embraced the argument that this section only defines the people who are eligible for medical assistance i. e., those who cannot afford “necessary medical services.” Once eligible they then are permitted to receive Medicaid payments for all medical services whether necessary or not, according to the majority view. This, I' submit, does not comport with either the language or spirit of the legislation. Medical assistance is referred to without limitation in other parts of Title XIX, as the majority points out, but the first use of the term in § 1396 would indicate to me that it means necessary medical services. The whole tenor of Title XIX indicates the intent to place some limit on medical assistance.1 The Congress was *940obviously aware of the possibility of abuse were Medicaid payments made available for unnecessary medical services. There has been such abuse which the press is now reporting2 and which can only be exacerbated if the majority view is accepted. We are not dealing here with the concept of medical assistance in vacuo but rather whether or not the plaintiff class is eligible for Medicaid. The plain language of § 1396 would indicate that only those whose resources are insufficient for necessary medical services are so entitled to the benefits of the taxpayers’ money. Suppose an indigent desires cosmetic surgery, e. g., to uplift the face, inflate the breasts, or remodel the nose. Medical indigency alone under the majority view would compel Medicaid assistance for such services. If this was the intent of Congress, it is the most unusual event since the bilocation of Saint Jerome.
At the same time and as part of the same bill, Public Law 89 — 97, entitled “Social Security Amendments of 1965,” the Congress adopted Title XVIII, Medicare, a program of health insurance for the aged. As the court below noted, the legislative history supports the state’s position that a common interpretation is to be given both titles.3 The Congress was explicit in the Medicare provision in denying benefits “which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”4 It would indeed be anomalous and highly unlikely that Congress intended to provide broader benefits to the indigent than to those who were purchasing Medicare protection.
This leads to the second and more prickly question — is a non-therapeutic abortion medically necessary? As I read the majority opinion, the court reasons that since a woman has the constitutional right to elect an abortion and since the abortion requires medical assistance, it is therefore medically necessary under Title XIX. I agree, of course, that an abortion requires the service of a physician but to argue that the abortion is therefore necessary, it seems to me, is a non sequitur. A woman may have a variety of reasons to terminate a pregnancy. They may be social or economic, selfish or altruistic, but they are only properly termed medical if her physician can attest that her pregnancy endangers her physical or mental health. If the test is that the service sought requires a physician, then the patient who seeks purely cosmetic surgery, which I would also assume is a constitutional right, could equally urge that Medicaid benefits are payable. Although the physician is the key factor under the statute,5 the majority eliminates his role since he has here refused to certify that the abortions are medically required.
*941I do not believe that we can equate abortion and child bearing as two comparable solutions to pregnancy under Title XIX. The pregnancy of the mother, absent miscarriage, inevitably and biologically terminates in the birth of the child, a process which today at least requires medical attention and assistance. Abortion, on the other hand, requires medical service only because the mother has made a voluntary decision which may or may not be dictated by medical necessity. If the motivation is not medical, I do not see how it becomes medically necessary under the statute. As the majority has pointed out, non-therapeutic abortions were generally illegal in 1965 and it would be indeed strange to imagine that Congress in enacting Title XIX intended that they be considered medically necessary. If any abortion at all is deemed medically necessary, then the distinction between non-therapeutic and therapeutic abortions must have been obliterated by the Congress in 1965 in the passage of Title XIX but we find nothing at all in the legislative history of the statute to support this proposition. As the majority indicates, the word abortion never appears in Title XIX and its absence, I think, is further evidence that Congress did not intend that drastic change which the majority finds.
I also believe that the determination as to whether Section 275 of the pertinent regulation should now be rescinded is a decision to be made by the appropriate agency and officials of the State of Connecticut. Even if the majority is correct in its view that Connecticut only has the option to make these payments and was in error in believing that its regulation was mandated by the Social Security Act, the regulation is appropriate. Abortions are still more controversial than appendectomies and the policy of the State of Connecticut with respect to the expenditure of public moneys should be determined by the state and not by a federal court.

. In addition to 42 U.S.C. § 1396, discussed above, see id. § 1396a(a)(10)(C)(i) (state plans under Medicaid must provide “for making medical assistance available to all individuals who have insufficient ... income and resources to meet the costs of necessary medical and remedial care and services . .”); § 1396a(a)(17) (such state plans *940must “include reasonable standards for determining eligibility for and the extent of medical assistance under the plan . . . .”); § 1396a(a)(30) (such state plans should “safeguard against unnecessary utilization of . care and services . . . .”); and § 1396b(g)(l) & (A) (to avoid certain decreases in federal aid for inpatient care, states must make a showing that they have in operation “an effective program of control over utilization of services;” these programs must include, inter alia, a certification by a physician “that such services are or were required to be given on an inpatient basis because the individual needs or needed such services . . . .”).

. See, e. g., N.Y. Times, July 18, 1975, at 35, cols. 7-8 (concerning the payment of padded Medicaid bills).

. 380 F.Supp. at 729, citing 1 U.S.C.Cong. & Admin.News (1965), at 1943, 1986, and 1989 (e. g., the “overall purpose” of the bill is “to provide a coordinated approach for health insurance and medical care for the aged under the Social Security Act by establishing three new health care programs: [(1) and (2), programs for the aged, and] (3) an expanded medical assistance program for the needy and medically needy aged, blind, disabled, and families with dependent children.” (1) and (2) constitute Title XVIII, and (3) is Title XIX).

. 42 U.S.C. § 1395y(a)(l).

. See note 3 supra.