Beal v. Doe

Title XIX of the Social Security Act establishes the Medicaid program under which participating States may provide federally funded medical assistance to needy persons. Title XIX requires that state Medicaid plans establish “reasonable standards . . . for determining . . . the extent of medical assistance under the plan which . . . are consistent with the objectives” of Title XIX.

Pennsylvania’s Medicaid plan prohibited assistance for abortions unless certified as medically necessary by the attending physician and two additional physicians.  Doe et al. were eligible for Pennsylvania’s Medicaid plan but they were denied financial assistance for medically unnecessary abortions after failing to present the requisite certificates.

Doe et al. sought declaratory and injunctive relief in the District Court alleging that the certificate requirement contradicted Title XIX and denied them equal protection as guaranteed by the Fourteenth Amendment to the Constitution.  The District Court resolved the statutory issue against Respondents, but granted a declaratory judgment that the certification requirement denied them equal protection of the law as applied during the first trimester.  The Court of Appeals did not address the constitutionality of the provision; it reversed the District Court on the statutory issue and held that Title XIX did not allow states to require a physician’s certificate of medical necessity during the first and second trimesters.

The Court first examined whether Title XIX of the Social Security Act required States that participate in the Medical Assistance (Medicaid) program to fund the cost of non-therapeutic abortions.  The Court held that Title XIX leaves states free to determine, within reason and consistent with Title XIX’s objectives, whether or not to cover medically unnecessary abortions. States have a legitimate interest in encouraging childbirth (as established in Roe v. Wade 410 U.S. 113 (1973)) and nothing in either the language or the legislative history of Title XIX suggests that it is unreasonable for a participating state to attempt to further this interest. Two other considerations support this interpretation: first, medically unnecessary abortions were illegal in many states when Medicaid was established; and secondly, the Department of Health, Education, and Welfare, the agency charged with the administration of Title XIX, takes the position that the statute allows—but does not mandate—funding for such abortions.

The Court then examined whether the certification provision which required certificates of medical necessity from the attending physician as well as two other physicians valid under Title XIX. The Court remanded the question of whether requiring certification from two physicians (in addition to the attending physician) interferes with the attending physician’s medical judgment.

“Pennsylvania's regulation comports fully with Title XIX's broadly stated primary objective to enable each State, as far as practicable, to furnish medical assistance to individuals whose income and resources are insufficient to meet he costs of necessary medical services. See 42 U. S. C. §§ 1396, 1396a (10) (C) (1970 ed., Supp. V). Although serious statutory questions might be presented if a state Medicaid plan excluded necessary medical treatment from its coverage, it is hardly inconsistent with the objectives of the Act for a State to refuse to fund unnecessary—though perhaps desirable— medical services.” 432 U.S., pp. 444 – 445.

“Our interpretation of the statute is reinforced by two other relevant considerations. First, when Congress passed Title XIX in 1965, nontherapeutic abortions were unlawful in most States. In view of the then-prevailing state law, the contention that Congress intended to require—rather than permit —participating States to fund nontherapeutic abortions requires far more convincing proof than respondents have offered. Second, the Department of Health, Education, and Welfare, the agency charged with the administration of this complicated statute, takes the position that Title XIX allows —but does not mandate—funding for such abortions. ‘[W]e must be mindful that ‘the construction of a statute by those charged with its execution should be followed unless there are compelling indications that it is wrong . . . .’’ New York Dept. of Soc. Services v. Dublino, 413 U. S. 405, 421 (1973), quoting Red Lion Broadcasting Co. v. FCC, 395 U. S. 367, 381 (1969). Here, such indications are completely absent.” 432 U.S., pp. 447.