Memorial Hospital v. Maricopa County

The appellants, Henry Evaro and Memorial Hospital, brought an action against Maricopa County challenging the constitutionality of a provision in an Arizona statute requiring 12 months residence in a county before medical care is provided to an indigent person in non-emergency situations.

Evaro, an indigent person, suffered from chronic asthma and bronchial illness. In June 1971 he moved from New Mexico to Maricopa County, Arizona. In July 1971, Evaro had a serious respiratory attack and was sent to Memorial Hospital, a non-profit private community hospital, to seek further treatment. Memorial wished to transfer Evaro to the County public hospital and to be reimbursed for the services that they had provided to him. This request was denied due to an Arizona statute that required counties to provide free, mandatory medical care for indigent people in non-emergency situations only if they were residents of the county for the twelve months preceding.

The trial court held the durational residence requirement to be unconstitutional, but on appeal to the Arizona Supreme Court this decision was reversed. The constitutionality of this requirement was then brought before the United States Supreme Court.

The Court held that it was unconstitutional to enforce a durational residence requirement in providing medical care to indigent people on the grounds that it violated the Equal Protection Clause of the U.S. Constitution. The durational residence requirement, through discrimination, impinged on the freedom of movement by denying the “basic necessities of life” to newcomers. Enforcing such a requirement could only be done on the showing of compelling state interest, which did not occur here. The Court held that a (non-durational) residential requirement was constitutional.

The Court’s analysis is strongly parallel to Shapiro v. Thompson, 394 U. S. 618 (1969). In Shapiro, the Supreme Court examined a similar durational residence requirement in the context of eligibility for welfare assistance programs. The Court in Shapiro established that penalizing someone for exercising the constitutional right of interstate travel is only justified if a competing state interest can be demonstrated. Excluding certain people from welfare programs was seen as denying them access to the basic necessities of life, and therefore seen as a penalty. The Court in the present case drew an analogy between welfare assistance and medical care for indigent people, in the sense that they both constitute basic necessities of life.

In finding no compelling state interest, the Court rejected the County’s arguments of trying to save money, serve only bona fide residents, and other administrative objectives. The Court rejected out of hand that saving money can justify discrimination between classes, and would push the burden of treating indigent people to private non-profit hospitals like Memorial Hospital. Regardless, the Court noted that the County would not likely save money as the denial of treatment for indigent people in non-emergency situations could lead to a serious deterioration of the individual’s health to the point where they would require emergency care, which does not have a durational residency requirement. The durational residency requirement was also over-inclusive because it assumed that all indigent migrants, in their first year of residence, came to the County purely for access to free medical care.

The concurrence noted that the critical issue in that the requirement “fences out” indigent persons by imposing a one-year barrier before they may utilize medical facilities when moving into a new county.

The dissent did not see the durational residency requirement as a real and purposeful barrier to Evaro's right to travel. It distinguished the present case from Shapiro on the basis that the case at hand does not involve an urgent need for the necessities of life or a benefit funded from revenues to which the claimant may have contributed. It also criticized the Majority’s rejection of the competing state interests advanced by the County and noted that Courts should respect the State's allocation of its limited financial resources.

“Whatever the ultimate parameters of the Shapiro penalty analysis, it is at least clear that medical care is as much "a basic necessity of life" to an indigent as welfare assistance. And, governmental privileges or benefits necessary to basic sustenance have often been viewed as being of greater constitutional significance than less essential forms of governmental entitlements.” (p. 259)

“Not unlike the admonition of the Bible that, "Ye shall have one manner of law, as well for the stranger, as for one of your own country," Leviticus 24:22 (King James Version), the right of interstate travel must be seen as insuring new residents the same right to vital government benefits and privileges in the States to which they migrate as are enjoyed by other residents. The State of Arizona's durational residence requirement for free medical care penalizes indigents for exercising their right to migrate to and settle in that State. Accordingly, the classification created by the residence requirement, "unless shown to be necessary to promote a compelling governmental interest, is unconstitutional."” (p. 261-262)

It is also useful to look at the other side of the coin—at who will bear the cost of indigents' illnesses if the County does not provide needed treatment. For those newly arrived residents who do receive at least hospital care, the cost is often borne by private nonprofit hospitals, like appellant Memorial—many of which are already in precarious financial straits. When absorbed by private hospitals, the costs of caring for indigents must be passed on to paying patients and "at a rather inconvenient time"—adding to the already astronomical costs of hospitalization which bear so heavily on the resources of most Americans. The financial pressures under which private nonprofit hospitals operate have already led many of them to turn away patients who cannot pay or to severely limit the number of indigents they will admit. And, for those indigents who receive no care, the cost is, of course, measured by their own suffering.” (p. 264-265)

“In addition, the County's claimed fiscal savings may well be illusory. The lack of timely medical care could cause a patient's condition to deteriorate to a point where more expensive emergency hospitalization (for which no durational residence requirement applies) is needed.” (p. 265)