Court Opinion

ID: 9505379
Source: CourtListenerOpinion
Date Created: 2023-08-06 20:04:11.484655+00
Date Added: 2024-06-11T09:04:24.888143
License: Public Domain

SULLIVAN, Justice.
Indiana's Medicaid program will pay for a poor woman to have an abortion but only if necessary to preserve her life or if rape or incest caused her pregnancy. The plaintiffs in this case argue, and the trial court held, that Medicaid must pay for any abortion that is medically necessary, citing the Indiana Constitution's requirement that privileges or immunities cannot be granted to a citizen or class of citizens that do not equally belong to all citizens on the same terms.
For the reasons set forth in this opinion in part I under "Discussion," I believe that this provision of the Indiana Constitution does not require Medicaid to pay for all abortions that are medically necessary. *249Chief Justice Shepard and Justice Dickson join in this part of this opinion.
However, for the reasons set forth in this opinion in part II under "Discussion," I also conclude that, so long as the Indiana Medicaid program pays for abortions to preserve the lives of pregnant women and where rape or incest cause pregnancy, it must also pay for abortions in cases of pregnancies that create for pregnant women serious risk of substantial and irreversible impairment of a major bodily function. Justices Bochm and Rucker join in this part of this opinion.
Background
In 1965, Congress established the Medicaid program, a joint federal-state program that pays for some health care costs of low-income people, by amending Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396v. Under the Medicaid program, the federal government reimburses participating states for the health care services provided pursuant to the state's medical assistance or Medicaid plan. Id. at §§ 1396a(a)(10), 1896d(a). States are not required to participate in the Medicaid program but states that choose to participate must conform their Medicaid program to federal Medicaid law. Id. at § 1896a(a).
In 1978, the Supreme Court held that the Due Process Clause of the Fourteenth Amendment protected, to a certain extent, the freedom of a woman to terminate a pregnancy. Roe v. Wade, 410 U.S. 113, 93 S.Ct. 705, 35 L.Ed.2d 147 (1978).
In 1976, Congress first adopted legislation, referred to as the "Hyde Amendment" for its author, Representative Henry J. Hyde, that prohibits the federal government from reimbursing states under the Medicaid program for abortions except where a woman would be placed "in danger of death unless an abortion is performed" or where "the pregnancy is the result of an act of rape or incest." Pub.L. No. 106-113, §§ 508-509, 118 Stat. 1501, 1501A-274 (1999). Although the provisions of the Hyde Amendment have varied from time to time, this is the language of the prohibition and exception in effect today.1
*250In 1977, the Supreme Court held that the constitutional right to abortion recognized in Roe v. Wade did not include an entitlement to Medicaid payments that were not medically necessary. Maher v. Roe, 432 U.S. 464, 470, 97 S.Ct. 2376, 53 L.Ed.2d 484 (1977). In 1980, the Supreme Court was faced with a challenge to the constitutionality of the Hyde Amendment, i.e., whether Congress could prohibit the use of federal Medicaid funds to reimburse states for medically necessary abortions. The court held that the Hyde Amendment did not violate either the Due Process or the Equal Protection Clauses of the Fourteenth Amendment. Harris v. McRae, 448 U.S. 297, 100 S.Ct. 2671, 65 L.Ed.2d 784 (1980).
Any state that participates in the Medicaid program must cover those abortions for which federal funds are available. Zbaraz v. Quern, 596 F.2d 196, 201 (7th Cir.1979), cert. denied, 448 U.S. 907, 100 S.Ct. 3048, 65 L.Ed.2d 1136 (1980). Nevertheless, "[a] participating state is free, if it so chooses, to include in its Medicaid plan those medically necessary abortions for which federal reimbursement is unavailable ..." Harris, 448 U.S. at 309, 100 S.Ct. 2671.
Indiana participates in the federal Medicaid program and is bound by all of its requirements. Ind.Code § 12-15-1-1. The Indiana Medicaid program provides low-income Hoosier citizens with virtually all non-experimental, medically necessary health care, including some services for which federal reimbursement is not available. See eg., Ind.Code § 12-15-5-1(18) (providing coverage for nonmedical nursing care given in accordance with tenants and practices of a recognized church); cf. 42 C.F.R. § 440.170(b) (restricting federal funding for such institutions to those organized pursuant to Section 501(c)(8) of the Internal Revenue Code). Indiana Medicaid covers inpatient hospital services, physicians' services, and outpatient hospital or clinic services for all recipients and provides a full range of reproductive health care for Medicaid-eligible men. Ind.Code § 12-15-5-1. Covered services must be "medically reasonable and necessary" and are required to be provided to Medicaid recipients in a uniformly equitable manner. Ind.Code § 12-15-1-10. Indiana Medicaid defines a "medically reasonable and necessary service" as one that "meets current professional standards commonly held to be applicable to the case." Ind. Admin. Code tit. 405, r. 5-2-17 (2001). However, in the case of abortion services, the program defines an abortion as necessary (and therefore covered under the program) only if "performed to preserve the life of the pregnant woman or in other cireum-stances if the abortion is required to be covered by Medicaid under federal law," e.g., where the pregnancy was caused by rape or incest. Ind.Code § 12-15-5-1(17);2 Ind.Code § 16-34-1-2;3 Ind. Admin. Code tit. 405, r. 5-28-7.4
*251The plaintiffs in this case, Clinic for Women, Inc., Women's Pavilion, Inc., rich G. Klopfer, D.0., and Martin Haskell, M.D., challenge the constitutionality of these two statutes and this regulation. The plaintiffs contend that the statutes' and regulation's collective prohibition on the use of state Medicaid funds to pay for abortions violates the Equal Privileges and Immunities Clause of Art. I, § 28, as well as Art I, §§ 1 and 12, of the Indiana Constitution.5
After hearing oral argument of the parties, the trial court granted the plaintiff's motion for summary judgment and denied the state's cross-motion for summary judgment, ruling that the challenged statutes and regulation violated Art. I, § 28. The trial court did not address plaintiffs' Art. I, § 1 and 12, claims and they are not before us here.
Article I, § 28, of the Indiana Constitution reads as follows:
The General Assembly shall not grant to any citizen, or class of citizens, privileges or immunities which, upon the same terms, shall not equally belong to all citizens.
From at least 1971 until about nine years ago, this court analyzed claims under the state Equal Privileges and Immunities Clause using the same techniques as those employed by the United States Supreme Court to analyze claims under the Equal Protection Clause of the Fourteenth Amendment. See Collins v. Day, 644 N.E.2d 72, 75 (Ind.1994). In Collins, this court jettisoned the use of federal equal protection analytical methodology to claims alleging violations of Art. I, § 28, and held that such claims should be analyzed using a different standard. Id. That standard was summarized as follows:
Article 1, Section 28 of the Indiana Constitution imposes two requirements upon statutes that grant unequal privileges or immunities to differing classes of persons. First, the disparate treatment accorded by the legislation must be reasonably related to inherent characteristics which distinguish the unequally treated classes. Second, the preferential treatment must be uniformly applicable and equally available to all persons similarly situated. Finally, in determining whether a statute complies with or violates Section 28, courts must exercise substantial deference to legislative discretion.
Id. at 80. Indiana courts have made frequent use of the Collins standard since its promulgation, including the trial court here.
The trial court found that the ban on funding abortions contained in the challenged statutes and regulation failed both prongs of the Collins standard summarized supra.
The first prong of the Collins test requires that "where the Legislature singles *252out one person or class of persons to receive a privilege or immunity not equally provided to others, such classification must be based upon distinctive, inherent characteristics which rationally distinguish the unequally treated class, and the disparate treatment accorded by the legislation must be reasonably related to such distinguishing characteristics." Id. at 78-79. The trial court started its analysis of this prong with the proposition that the "Medicaid program is a government program through which a benefit-government payment for medically necessary treatment-is provided to indigent Hoosiers." (Supp. R. 8.) "However," the trial court continued, "that benefit is not provided equally to all indigent Hoogiers-women who, for medical reasons, need to terminate their pregnancy in order to preserve and protect their health did not receive that funding benefit. Under the Indiana Medicaid program, indigent men and indigent pregnant women who need treatment (other than abortion) which is medically necessary to preserve their health are singled out for a benefit which is denied to indigent pregnant women needing to terminate their pregnancy to preserve and protect their health." (Supp. R. 8.)
The second prong of the Collins analysis requires that the preferential treatment "be uniformly applicable and equally available to all persons similarly situated." Collins, 644 N.E.2d at 80. Here the trial court found that "[all Medicaid-eligible pregnant women are similarly situated in that all may require, from time to time, an array of medically necessary treatment to protect and preserve their health." But, under the challenged Medicaid statutes and regulations, "Medicaid coverage of needed medical services is not 'uniformly applicable and equally available' to those similarly situated. Pregnant women who require a medically necessary abortion to preserve their health will not receive state funding while pregnant women who require other types of medically necessary treatment will receive state funding." (Supp. R. 9.)
Under Collins, legislative discretion is accorded substantial deference. Collins, 644 N.E.2d at 80-81. The trial court identified the State's interests claimed to be served by the challenged statutes and regulation as potential life, administrative simplicity, and cost containment. But it found these justifications insufficient.
[Plursuing the goal of promoting fetal life at the expense of preserving the health of women who need to terminate their pregnancy for medical reasons contravenes the purpose of the Medicaid program, which is designed to enable indigent Hoosiers to obtain medically necessary treatment. The State's asserted interest in administrative simplicity and cost containment also do not justify the funding ban. First, the goal of achieving administrative simplicity in itself can never serve as a sufficient goal to justify depriving some citizens of privileges accorded others. Second, the goal of cost containment is also not reasonably related to the funding ban. Abortions are less expensive than the costs associated with childbirth. Moreover, preventing a Medicaid-eligible woman from terminating her pregnancy to protect and preserve her health will necessarily mean that she will have increased health problems that the Indiana Medicaid program must cover. Cost containment is not served by the funding ban and cannot be the basis to depriving some citizens of a privilege accorded others.
(Supp. R. 10.)
The State appealed the judgment directly to our Court pursuant to Ind. Appellate *253Rule 4(A)(1)(b).6
Our Court has been informed in this matter by a substantial number of decisions from sister courts on similar claims under their respective state constitutions, including some with constitutional provisions the same as our Equal Privileges and Immunities Clause. Many of these are identified and discussed in an excellent law journal article, Melanie D. Price, The Privacy Paradox: The Divergent Paths of the United States Supreme Court and State courts on the Issue of Sexuality, 33 Ind. L.Rev. 863, 875-879 (2000).
The Court also appreciates the assistance of amicus curiae Indiana Civil Liberties Union, Inc., Indiana Right to Life Committee, Inc., and twelve members of the Indiana General Assembly (Senators Frank Mrvan, Jr., Kent Adams, David C. Ford, Allie V. Craycraft, Jr., and R. Michael Young, and Representatives Gary L. Cook, Jeffrey A. Thompson, P. Eric Turner, James Russell Buck, Dennis K. Kruse, and Jerry L. Denbo), and their respective counsel.
Discussion
I
The Equal Privileges and Immunities Clause of Art. I, § 28, of the Indiana Constitution states, "The General Assembly shall not grant to any citizen, or class of citizens, privileges or immunities, which, upon the same terms, shall not equally belong to all citizens."
Article I, Section 28 of the Indiana Constitution imposes two requirements upon statutes that grant unequal privileges or immunities to differing classes of persons. First, the disparate treatment accorded by the legislation must be reasonably related to inherent characteristics which distinguish the unequally treated classes. Second, the preferential treatment must be uniformly applicable and equally available to all person similarly situated.
Collins, 644 N.E.2d at 80. In determining whether a statute complies with or violates this provision, the Court shows substantial deference to the discretion of the Legislature in attempting to "balance the competing interest involved," and the Legislature's basis in creating the distinction. Id. To resolve conflicts between the state constitution and a challenged statute, this Court has stated that "the better course is to construe or reconstrue the statute in such a way as to further the purpose of the legislature without offending the Indiana Constitution." Van Dusen v. Stotts, 712 N.E.2d 491, 496 (Ind.1999).
Under the first prong of the Collins test, any "disparate treatment accorded by the legislation must be reasonably related to inherent characteristics which distinguish the unequally treated classes." Collins, 644 N.E.2d at 80.
Where the legislature singles out one person or class of persons to receive a privilege or immunity not equally provided to others, such classification must be based upon distinctive, inherent characteristics which rationally distinguish the unequally treated class, and the disparate treatment accorded by the legislation must be reasonably related to such distinguishing characteristics.
Id. at 78-79.
Before we can determine whether the legislative classification under the first prong of Collins is permissible, we need to identify the legislative classification at issue. The parties here define the relevant *254clasgification differently. The plaintiffs contend (and the trial court agreed) that the legislative classification at issue places (1) "indigent men and indigent women who need treatment (other than abortion) which is medically necessary to preserve their health" into a class for which the necessary treatment is provided, and (2) "indigent pregnant women needing to terminate their pregnancy to preserve and protect their health" into a class for which the necessary treatment is not provided. (Supp. R. 8.) The State argues that the relevant classification is between (1) "medically necessary services and supplies" for which federal Medicaid reimbursement at some level is available (a class that includes abortions to save a woman's life and where pregnancy resulted from rape or incest) and (2) medically necessary services and supplies for which it is not (a class that includes all other medically nee-essary abortions). Br. of Appellants at 14.
In McIntosh v. Melroe Co., Justice Boehm examined the way in which the legislative classification at issue in the first prong of Collins is to be determined:
Although Collins itself uses the word "inherent" to describe the characteristic that defines the class, this cannot be equated with "innate" characteristics of members of the class. The worker's compensation scheme [the statute at issue in Collins], like the Product Liability Act [the statute at issue in McIntosh], turns on the characteristics of the employers, not the injured workers. Similarly, under the Product Liability Act, everyone may potentially recover for an injury from a product not yet ten years old, and everyone injured from an older product is barred. It is the claim, not any innate characteristic of the person, that defines the class.
729 N.E.2d 972, 981 (Ind.2000). We think the claim here, reduced to its essentials, is that some Medicaid-eligible pregnant women in Indiana are entitled to Medicaid-financed medically necessary abortions and others are not. We think this "claim ... defines the class:" (1) Medicaid-eligible pregnant women who seek to terminate their pregnancies in order to preserve their lives or where their pregnancies resulted from rape or incest are in a class where Medicaid pays for their abortions; and (2) Medicaid-eligible pregnant women who seek to terminate their pregnancies for any other medically necessary reason are in a class where Medicaid will not pay for their abortions. Although this formulation of the classification at issue differs somewhat from those advanced by the parties, we believe it sufficiently similar to each that their arguments against and in favor of the clasgifications retain their full force.
As already discussed, in analyzing the constitutional permissibility of the classification identified, we "accord considerable deference to the manner in which the legislature has balanced the competing interest involved." Collins, 644 N.E.2d at 80 (citing Johnson v. St. Vincent Hosp., 273 Ind. 374, 404-05, 404 N.E.2d 585, 604 (1980)). Indeed, we frequently recite that the challenger to the constitutionality of the legislative scheme bears the burden "to negative every conceivable basis which might have supported the classification." Johnson, 273 Ind. at 392, 404 N.E.2d at 597. In Collins, we quoted from an earlier opinion of this Court in this regard:
Legislative classification becomes a judicial question only where the lines drawn appear arbitrary or manifestly unreasonable. So long as the classification is based upon substantial distinctions with reference to the subject matter, we will not substitute our judgment for that of the legislature; nor will we inquire into *255the legislative motives prompting such classification.
Collins, 644 N.E.2d at 80 (quoting Chaffin v. Nicosia, 261 Ind. 698, 701, 310 N.E.2d 867, 869 (1974)).
The plaintiffs contend that even this deferential standard of review is violated by the statutory and regulatory scheme challenged here. Calling the classification "manifestly unreasonable," Br. of Appel-lees at 21, they argue that the
. classes of persons granted and denied the privilege are inherently the same in ways that relate directly to the subject matter of the Medicaid legislation: they are low-income, such that they meet the Medicaid eligibility requirements, and they seek medical care for which they have a medical need. What distinguishes between the two is that the members of the group denied the privilege have health conditions which cause them to need an abortion to preserve their health, while members of the class granted the privilege have health conditions which cause them to need medical care other than abortion to preserve their health. However, that difference does not relate to the subject matter of the Medicaid statutes. In fact, denying funding to a woman whose health will deteriorate if she does not have an abortion runs directly counter to the subject matter of the legislation.
Id. at 19.
The State offers four justifications for the classification.
First, the State argues that the unavailability of federal financial participation means that it would not be "fiscally prudent and rational" and that it would otherwise be "administrative[ly] inconvenien[t]" for the State to pay for abortions that are not eligible for federal reimbursement. Br. of Appellants at 14, 15.
Second, the State argues that it has a "valid and compelling" interest in protecting fetal life, quoting from this court's decision in Cheaney v. State, 259 Ind. 138, 147, 285 N.E.2d 265, 270 (1972), cert. denied, 410 U.S. 991, 98 S.Ct. 1516, 36 L.Ed.2d 189 (1973).7 The State quotes from Harris v. McRae for support in pressing its point that "limiting government funding for abortion is a rational means for indicating the government's interest in protecting fetal life." Br. of Appellants at 17 (quoting Harris, 448 U.S. at 325, 100 S.Ct. 2671).
Third, in addition to the fiscal and administrative efficiency dimensions of the federal funding argument made supra, the State advances additional fiscal and administrative justifications for the classification. It argues that a more liberal system of government payments for abortion "will result in more of that activity" and "may have a dramatic impact on the State's future tax base." Its broader point here is that the allocation of Medicaid spending is a fiscal policy determination for the legislative and executive branches. Br. of Appellants at 18-19.
The plaintiffs respond that the State should not be entitled to offer justifications for the classification extraneous to the purpose of the Medicaid program itself. "If the State's position is accepted, the Legislature could insulate any discriminatory statute from constitutional challenge by simply claiming that it serves multiple purposes. Thus, the State could withhold any and all government benefits from women who have had abortions, irrespective of the *256subject matter or goal of the statute at issue. For example, the State could grant free tuition to state universities to all its citizens except for those who have had an abortion, on the grounds that the statute furthers the State's interest in protecting fetal life." Br. of Appellees at 21.
We appreciate the point plaintiffs make but think it only has force if our determination is binary. To the contrary, Collins, its precursors, and its progeny all indicate that we look at the Legislature's "balancing of the competing interest involved." See American Legion Post No. 113 v. State, 656 N.E.2d 1190, 1192 (Ind.Ct.App.1995) (citing Collins, 644 N.E.2d at 80 (citing Johnson, 273 Ind. at 404-05, 404 N.E.2d at 604)), trans. denied.
In balancing the interests here, we have given careful attention to the evidence presented by the plaintiffs in the trial court demonstrating a number of different health risks faced by pregnant women with respect to which an abortion is medically necessary. In support of their motion for summary judgment, the plaintiffs submitted the affidavit of Dr. Jane Hodgson, a physician specializing in obstetrics and gynecology and an expert in the field. Dr. Hodgson testified that many women confront serious health risk when pregnant. Hypertension complicates about 8-10% of pregnancies. Hypertensive pregnant women are at a higher risk for cerebrovas-cular accidents (strokes), abruptio placen-tae (premature separation of the placenta from the uterus), and disseminated intra-vascular coagulation (a severe bleeding disorder). Dr. Hodgson further testified that pregnancey-induced diabetes occurs in approximately 1-3% of pregnancies. Women with preexisting diabetes have ten times the risk of pregnancy-related death than do non-diabetic women. Diabetes-associated retinopathy (eye disease) or ne-phropathy (kidney disease) often worsen significantly during pregnancy. Dr. Hodg-son added that pregnancy jeopardizes the health of a woman with advanced coronary artery disease or severe impairment of the heart valve, and all pregnant women with heart disease have a higher risk of congestive heart failure, cardiac infections, and arrhythmia (abnormal heart rhythms). The health of a pregnant woman is seriously impaired when she suffers from chronic renal failure, myasthenia gravis, or pulmonary embolism from a previous pregnancy. Pregnant women with lupus may experience aggravation of their disease.
Dr. Hodgson also testified that pregnant women with sickle cell anemia experience more frequent and more severe crises, especially in bones, infections such as pneumonia and urinary tract infections, increasingly severe anemia, congestive heart failure, and pulmonary complications such as embolus. Other conditions exacerbated by pregnancy include asthma, arthritis, inflammatory bowel disease, gall bladder disease, liver disease, and epilepsy. Dr. Hodgson added that when cancer threatens a pregnant woman's life, the pregnancy puts further strain on the woman's health, and may require a suspension of cancer treatment because of harm to the fetus from such treatments. Thus, if treatment of the disease requires radiation or chemotherapy, a choice must be made between the health of the patient and the fetus, since these forms of therapy are likely to result in fetal malformation or death,. Pregnancy may accelerate the condition of women with malignant breast tumors that are estrogen receptor positive. Dr. Hodgson's testimony was bolstered by the other affidavits submitted by the plaintiffs from Dr. Judith Belsky and Dr. William Mudd Haskell.
The question for this Court is whether the Legislature may prohibit the State from paying for an abortion for a *257Medicaid-eligible pregnant woman facing any of these health risks while at the same time it authorizes the State to pay for an abortion to preserve the life of a Medicaid-eligible pregnant woman or where the pregnancy was caused by rape or incest. We find the State's justifications of unavailability of federal financial participation, interest in protecting fetal life, fiscal policy, and administrative efficiency sufficient to sustain the constitutionality of the classification under the first prong of the Collins test. We are in no position to deny plaintiffs argument that the statutes and regulation at issue impose significant financial, physical, and emotional hardship on many low-income Hoosier women. But we hold that the State's justifications for the classification do not rise to the level of being "arbitrary or manifestly unreasonable." Collins, 644 N.E.2d at 80 (quoting Chaffin, 261 Ind. at 701, 310 N.E.2d at 869).
The second prong of the Collins test requires that the "privileged" legislative classification "be open to any and all persons who share the inherent characteristics which distinguish and justify the classification, with the special treatment accorded to any particular classification extended equally to all such persons." Collins, 644 N.E.2d at 79.
The trial court found this aspect of Collins violated because "[plregnant women who require a medically necessary abortion to preserve their health will not receive state funding while those who require other types of medically necessary treatment will receive state funding." (Supp. R. 9.) We believe the State is correct when it responds that, because the plaintiffs "challenge not the provision of Medicaid benefits to indigent people generally, but rather the deprivation of Medicaid benefits to some who seek abortions, it is clearer to frame the issue as whether that deprivation is uniformly applicable to all who share the inherent characteristics that justify the classification." Brief of Appellants at 23. We find the requirement of the second prong of Collins met because Medicaid will pay for abortions for all persons in the classification of Medicaid eligible pregnant women seeking to terminate their pregnancies to preserve their life or where the pregnancy resulted from rape or incest.
II
A statute that is constitutional on its face may be unconstitutional as applied to a particular plaintiff. See Martin v. Richey, 711 N.E.2d 1273, 1284-85 (Ind.1999) (holding Indiana Medical Malpractice Act statute of limitations constitutional on its face but unconstitutional as applied to plaintiffs whose medical condition and the nature of the asserted malpractice make it unreasonable to expect that they could discover the asserted malpractice and resulting injury within the limitations period); City of Fort Wayne v. Cameron, 267 Ind. 329, 334, 370 N.E.2d 338, 341 (1977) (holding Indiana Tort Claims Act notice requirement constitutional on its face but unconstitutional as applied to plaintiffs whose mental and physical incapacity render them unable to comply with the notice requirement). For the reasons set forth below, we believe that the statute and regulations challenged here are unconstitutional as applied to Medicaid-eligible pregnant women whose pregnancies "create serious risk of substantial and irreversible impairment of a major bodily function." 8
*258Article I, § 28, of our Constitution prohibits a statute from providing disparate treatment to different classes of persons if the disparate treatment is not reasonably related to inherent characteristics that distinguish the unequally treated classes. McIntosh, 729 N.E.2d at 981; Martin, 711 N.E.2d at 1280; Collins, 644 N.E.2d at 80. We believe that the characteristics that distinguish Medicaid-eligible pregnant women whose pregnancies create serious risk of substantial and irreversible impairment of a major bodily function to be virtually indistinguishable from the characteristics of women for whose abortions the State does pay. To the extent there is a distinction, it is too insubstantial to be sustained by the State's justifications.
The challenged statutory and regulatory scheme here provides disparate treatment to different classes of persons: Medicaid (1) will pay for abortions where necessary to preserve the life of the pregnant woman or where the pregnancy was caused by rape or incest but (2) will not pay for any other abortions. Thus the Constitution requires that the disparate treatment be reasonably related to inherent characteristics that distinguish the "preserve the life, rape, or incest" classification from the "any other abortions" classification. Within this "any other abortions" classification is a subset consisting of abortions where the pregnancies create for Medicaid-eligible women a serious risk of substantial and irreversible impairment of a major bodily function.
The State's argument is that there are "inherent characteristics ... reasonably related to permissible legislative goals" that justify Medicaid-funded abortions where necessary to preserve the life of the pregnant woman or where the pregnancy was caused by rape or incest. Br. of Appellants at 17. This is because "[albor-tions in those cireumstances raise problems and concerns that abortions in other circumstances do not." Id. Although it does not elaborate, the State says that these problems are the result of certain "medical, moral, social, and ethical concerns" that "do not arise in other abortion cases." Id. at 18.
That is, the State says that providing Medicaid-financed abortions is reasonably related to the "inherent characteristics" that distinguish the "preserve the life, rape, or incest" classification from the "any other abortions" classification (and, therefore, makes the distinction constitutionally permissible). Those inherent characteristics are the "medical, moral, social, and ethical concerns" raised by the "preserve the life, rape, or incest" classification that are not raised by the "any other abortions" classification.
It is clear that the inherent characteristics of the "preserve the life, rape, or incest" classification do not require that the life of the pregnant woman be at stake. This classification includes abortions where the pregnancy was caused by rape or incest where there is no inherent threat to life. But if the "medical, moral, social, and ethical concerns" that justify Medicaid-funded abortions do not require that the life of the pregnant woman be at stake, what are the inherent characteristics that distinguish the abortions permitted by the "preserve the life, rape, or incest" classification from cases where the pregnant woman faces substantial and irreversible impairment of a major bodily function? The medical, moral, social, and ethical concerns are the same or at least the differences too insubstantial to be sustained by the State's justifications.
The application of the challenged statute and regulations to pregnant women who face substantial and irreversible impairment of a major bodily function is significant because the Legislature itself has identified it for special treatment in the State abortion control statute. For that *259purpose, the Legislature has treated in exactly the same way cases where the life of the pregnant woman is at stake and cases where the woman faces substantial and irreversible impairment of a major bodily function. Indiana law forbids an abortion to be performed in Indiana unless the pregnant woman consents following specified disclosures provided to her at least 18 hours before the abortion is performed. Ind.Code § 16-34-2-1.1. However, the Legislature has exempted from these disclosure and waiting period cases where "the medical condition of a pregnant woman ... necessitates the immediate termination of her pregnancy to avert her death or for which a delay would create serious risk of substantial and irreversible impairment of a major bodily function." Ind.Code §§ 16-18-2-228.5 (emphasis supplied) & 16-34-2-1.1; A Woman's Choice, East Side Women's Clinic v. Newman, 671 N.E.2d 104, 111 (Ind.1996) ("severe-but-temporary conditions in which an abortion is not the medically necessary treatment are not covered by the exception").
The fact that the Legislature has treated as a single classification in the abortion control statute "abortions for which a delay would create serious risk of substantial and irreversible impairment of a major bodily function" and abortions necessary to preserve the pregnant woman's life reinforces our conclusion that the inherent characteristics of these cases (when combined with abortions where the pregnancy was caused by rape or incest) are so similar that disparate treatment is not justified under Medicaid. McIntosh, 729 N.E.2d at 981; Martin, 729 N.E.2d at 1280; Collins, 644 N.E.2d at 80. We find the challenged statute and regulations unconstitutional as applied to Medicaid-eligible women whose pregnancies create serious risk of substantial and irreversible impairment of a major bodily function. So long as the Indiana Medic aid program pays for abortions for Medicaid-eligible women where necessary to preserve the life of the pregnant woman or where the pregnancy was caused by rape or incest, we hold that it must pay for abortions for Medicaid-eligible women whose pregnancies create serious risk of substantial and irreversible impairment of a major bodily function.9
Conclusion
It is the judgment of the Court that the challenged Medicaid statutes and regula*260tion do not violate the Equal Privileges and Immunities Clause of the Indiana Constitution and are, therefore, constitutional except that, so long as the Indiana Medicaid program pays for abortions to preserve the lives of pregnant women and where pregnancies are caused by rape or incest, it must also pay for abortions for Medicaid-eligible women whose pregnancies create serious risk of substantial and irreversible impairment of a major bodily function. The trial court is reversed in part and affirmed in part.
SHEPARD, C.J., and DICKSON, J., concur in Part I and dissent from Part II.
BOEHM and RUCKER, JJ., dissent from Part I and concur in Part IL.
SHEPARD, C.J., concurs and dissents with separate opinion.
DICKSON, J., concurs and dissents with separate opinion.
BOEHM, J., concurs and dissents with separate opinion in which RUCKER, J., concurs.

. The Hyde Amendment has never had the status of permanent law but instead has been attached annually to legislation appropriating funds for certain departments of the federal government for a given fiscal year or has been adopted as a stand-alone joint resolution. The full version of the Hyde Amendment in effect on the date this lawsuit was filed states:
"Sec. 508. (a) None of the funds appropriated under this Act, and none of the funds in any trust funds are appropriated under this Act shall be expended for any abortion.
(b) None of the funds appropriated under this Act, and none of the funds in any trust fund to which funds are appropriated under this Act, shall be expended for health benefits coverage that includes coverage of abortion.
(c) The term "health benefits coverage" means the package of services covered by a managed care provider or organization pursuant to a contract or other arrangement.
Sec. 509 (a) The limitations established in the preceding section shall not apply to an abortion
(1) if the pregnancy is the result of an act of rape or incest; or
(2) in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.
(b) Nothing in the preceding section shall be construed as prohibiting the expenditure by a State, locality, entity, or private person of State, local, or private funds (other than a State's or locality's contribution of Medicaid matching funds).
(c) Nothing in the preceding section shall be construed as restricting the ability of any managed care provider from offering abortion coverage or the ability of a State or locality to contract separately with such a provider for such coverage with State funds (other than a State's or locality's contribution of Medicaid matching funds)." Consolidated Appropriations Act of 2000, Pub.L. No. 106-113, *250§§ 508-509, (1999). 113 Stat,. 1501, 1501A-274

. "Except as provided in IC 12-15-2-12, IC 12-15-6, and IC 12-15-21, the following services and supplies are provided under Medicaid: (17) Family planning services except the performance of abortions." Ind.Code § 12-15-5-1..

. 'Neither the state nor any political subdivision of the state may make a payment from any fund under its control for the performance of an abortion unless the abortion is necessary to preserve the life of the pregnant woman." Ind.Code § 16-34-1-2.

. "Medicaid reimbursement is available for abortions only if performed to preserve the life of the pregnant woman or in other circumstances if the abortion is required to be covered by Medicaid under federal law. Termination of an ectopic pregnancy is not considered an abortion. All appropriate docu*251mentation must be attached to the claim and to claims for directly related services before reimbursement shall be made." Ind. Admin. Code tit. 405, r. 5-28-7 (2001).

. "We declare, that all people are created equal; that they are endowed by their creator with certain inalienable rights; that among these are life, liberty, and the pursuit of happiness; that all free governments are, and of right ought to be, founded on their authority, and instituted for their peace, safety, and well-being. For the advancement of these ends, the people have, at all times, an indefeasible right to alter and reform their government." Art. IL § 1.
"All courts shall be open; and every person, for injury done to him in his person, property, or reputation, shall have remedy by due course of law. Justice shall be administered freely, and without purchase; completely, and without denial; speedily, and without delay." Art. I, § 12.

. "The Supreme Court shall have mandatory and exclusive jurisdiction over the following cases: ... Appeals of Final Judgments declaring a state or federal statute unconstitutional in whole or in part." Ind. Appellate Rule 4(A)(1)(b).

. Cheaney v. State, decided about six months prior to Roe v. Wade, rejected (over the dissent of Justice DeBruler) a federal constitutional challenge to Indiana's criminal abortion statute.

. The quoted language is from Ind.Code § 16-18-2-223.5 (1998), the State abortion control statute, discussed infra.

. The State, in addition to its arguments on Art I, § 23, sought summary judgment on two additional grounds.
First, it argued that the plaintiffs were barred from the relief they sought by Ind. Code § 12-15-5-2, which prohibits Indiana Medicaid from funding any service for which the federal government does not provide reimbursement. The trial court found, first, that one statute cannot save another found to be unconstitutional, and second, that the State does not strictly abide by the statute because the Indiana Medicaid program covers services for which federal financial participation is unavailable.
The State also argued that the Separation of Functions clause of Art. III, § 1, of the Indiana Constitution barred the court from granting the relief that the plaintiffs requested. The trial court found that if the challenged enactments violate the state Constitution, the Court could grant relief even if doing so means that state funds will be spent in a manner not explicitly approved of by the Legislature. "The Court has the power to shape appropriate remedies and the Legislature has a duty to appropriate funds to meet its constitutional obligations." (Supp. R. 12 (quoting State v. Monfort, 723 N.E.2d 407, 413 (Ind. 2000).))
While we do not necessarily agree with the trial court's reasoning, we affirm as to these issues. We believe the course of these proceedings effectively placed Ind.Code § 12-15-5-2 at issue. And as to the separation of powers issue, we believe that the general and open-ended nature of the Medicaid appropriation, combined with the limited relief provided, does not tread impermissibly upon the Legislature's appropriation prerogatives.