Facts
- Congress enacted Medicaid in 1965 under Title XIX of the Social Security Act to provide joint federal-state funding for medical care for eligible low-income individuals.
- Beginning in 1976, Congress adopted annual appropriations riders known as the Hyde Amendment restricting federal reimbursement for abortions under Medicaid.
- The 1980 Hyde Amendment generally barred federal funds for abortions except when the pregnancy endangered the woman’s life, and in limited circumstances involving rape or incest reported promptly to authorities.
- Medicaid recipients, related organizations, a municipal hospital corporation, and other plaintiffs sued to block enforcement of the Hyde Amendment and related funding limits.
- Plaintiffs argued Title XIX still required participating states to fund all medically necessary abortions even when federal reimbursement was unavailable, and that the Hyde Amendment violated the Fifth Amendment (due process and equal protection component) and the First Amendment (establishment and free exercise).
- A three-judge federal district court concluded the Hyde Amendment effectively relieved states of any Title XIX obligation to fund abortions lacking federal reimbursement but held the Amendment unconstitutional under the Fifth Amendment’s equal protection component and the Free Exercise Clause.
- The Secretary of Health and Human Services appealed directly to the Supreme Court.
Issues
- Whether Title XIX requires a participating state to fund medically necessary abortions for which federal reimbursement is unavailable because of the Hyde Amendment.
- Whether the Hyde Amendment’s Medicaid funding restrictions violate the Fifth Amendment Due Process Clause, including any protected liberty interest in choosing abortion, or its equal protection component.
- Whether the Hyde Amendment violates the Establishment Clause or the Free Exercise Clause of the First Amendment.
Decision
- The Supreme Court reversed the district court and upheld the Hyde Amendment.
- Title XIX does not require participating states to pay for medically necessary abortions for which federal reimbursement is barred by the Hyde Amendment.
- The Hyde Amendment does not violate the Fifth Amendment Due Process Clause or its equal protection component.
- The Hyde Amendment does not violate the Establishment Clause or the Free Exercise Clause.
Legal Principles
- Medicaid’s structure contemplates joint federal-state financing; absent clear congressional direction, Title XIX does not require states to assume the full cost of a service when Congress has withdrawn federal reimbursement for that service.
- Constitutional protection for the abortion decision does not create an entitlement to government funding to exercise that choice; due process generally restrains governmental interference rather than imposing affirmative funding duties.
- Government may favor childbirth over abortion through public spending choices so long as it does not create a direct legal obstacle to the abortion decision.
- Poverty is not a suspect classification for equal protection purposes; funding restrictions that do not target a suspect class and do not impose a direct governmental barrier are reviewed under rational basis and may be justified by legitimate governmental interests.
- A statute does not violate the Establishment Clause merely because it aligns with certain religious beliefs; a coincidence with religious tenets, without more, is insufficient.
- The Free Exercise Clause does not require the government to remove financial burdens attributable to private indigency by subsidizing conduct that the government declines to fund.
Conclusion
The Court held that Title XIX does not obligate states to fund abortions for which federal reimbursement is barred and that Congress may restrict Medicaid abortion funding without violating the Fifth Amendment or the First Amendment, because the Constitution does not require the government to subsidize the exercise of a protected choice.