Aliessa v. Novello

tions by denying State Medicaid benefits to plaintiffs based on their status as legal aliens. We conclude that it does.

L

Plaintiffs are 12 aliens who lawfully reside in New York State. They immigrated to the United States from various countries, including Bangladesh, Belorussia, Ecuador, Greece, Guyana, Haiti, Italy, Malaysia, the Philippines, Syria and Turkey. As legal aliens, they fall into two groups. Some are lawfully admitted permanent residents of the United States under the Immigration and Nationality Act (i.e., green card holders) (see, 8 USC § 1101 et seq.);^[1] the rest are permanently residing in the United States under color of law (PRUCOLs).^[2] All suffer from potentially life-threatening illnesses and, but for the exclusion under Social Services Law § 122, would allegedly qualify for Medicaid benefits funded solely by the State.

Plaintiffs brought a class action in Supreme Court seeking a declaration that Social Services Law § 122 violates article XVII, sections 1 and 3 of the New York State Constitution and the Equal Protection Clauses of the United States and New York State Constitutions. The putative class consists of “[a] 11 Lawful Permanent Residents who entered the United States on or after September 22, 1996 and all [PRUCOLs] who, but for the operation of New York Social Services Law § 122, would be eligible for Medicaid coverage in New York State.” The State moved to dismiss or, in the alternative, for summary judgment, for which plaintiffs cross-moved. Deferring its decision on class certification, Supreme Court denied the State’s motion and granted in part plaintiff’s motion for summary judgment, declaring that section 122 of the Social Services Law violates

certain categories of individuals, including residents between the ages of 21 and 65 whose income and resources fall below a statutory “standard of need” and who are not otherwise entitled to federally subsidized Medicaid (see, Social Services Law § 366 [1]; 18 NYCRR 360-3.3 [b]). Thus, New York State’s Medicaid system has two components: one that is federally subsidized and one that the State funds entirely on its own.^[3]

New York had long provided State Medicaid to needy recipients without distinguishing between legal aliens and citizens. It ceased to do so, however, after Congress enacted the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub L 104-193, 110 US Stat 2105 [codified in scattered sections of 8 and 42 USC]) (PRWORA). Asserting that they have been unlawfully deprived of State Medicaid for which they would otherwise qualify, plaintiffs have brought this challenge.

B.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996

After extensive debate, Congress enacted PRWORA as a comprehensive reform initiative designed to “end welfare as we know it.”^[4] PRWORA touches on virtually all aspects of welfare. In this case, however, we are concerned only with title IV of PRWORA, which deals with aliens.^[5]

In its preamble to title IV, Congress stressed that its goals were to promote self-sufficiency — an enduring principle of United States immigration law — and to discourage aliens from immigrating here just to avail themselves of welfare or other public resources (see, 8 USC § 1601 [l]-[2]). The lawmakers stated that meeting these goals was a “compelling government interest” (see, 8 USC § 1601 [5]-^[6]).

By enacting title IV, Congress restricted alien eligibility for federally funded public assistance benefits (including Medicaid) and authorized States to follow suit with their own programs. Its restrictions govern eligibility for Federal and State retirement, welfare, health, disability, public or assisted housing, post-secondary education, food assistance and unemployment benefits, among others (see, 8 USC § 1611 [c]; § 1621 [c]). For purposes of this decision, however, we address solely its effect on Medicaid eligibility.

Under title IV, aliens are divided into two categories: qualified aliens and non-qualified aliens (see, 8 USC § 1641 ). Broadly speaking, qualified aliens include aliens who are lawfully admitted for permanent residence (generally green card holders), granted asylum, designated refugees, paroled into the United States for at least one year, having their deportation withheld, granted conditional entry, Cuban and Haitian entrants or victims of battering or extreme cruelty by a spouse or other family member (see, 8 USC § 1641 [b]-[c]). All other aliens, including PRUCOLs, are non-qualified aliens.^[6] Plaintiffs in this case fall into both categories. The lawfully admitted permanent resident plaintiffs are qualified aliens and the PRU-COL plaintiffs non-qualified aliens. These classifications carry significant Medicaid consequences.

1.

PRWORA’s Treatment of Aliens’ Entitlement to Medicaid

Title IV renders non-qualified aliens ineligible for Federal Medicaid ( 8 USC § 1611 [a]). Qualified aliens are divided into two subcategories. The first subcategory includes those who were lawfully residing in the United States before August 22, 1996. Section 1612 (b) (2) requires States to provide Federal Medicaid to some, but not all, of this group.^[7] The second subcategory includes those who entered the country on or after August 22, 1996. This latter group is largely ineligible for Federal Medicaid for five years (see, 8 USC § 1613 [a]).^[8] Moreover, title IV authorizes States to extend the ineligibility period beyond the initial five years (see, 8 USC § 1612 [b] [1]).

In addition to rendering PRUCOLs ineligible for Federal Medicaid, title IV renders them ineligible for State Medicaid as well (see, 8 USC § 1621 [a], [c] [1] [B]). Section 1621 (d), however, authorizes States to provide State Medicaid to PRUCOLs — and indeed even to illegal aliens — by enacting a new law (after August 22, 1996) “which affirmatively provides for such eligibility” (see, 8 USC § 1621 [d]).^[9] As for qualified aliens, title IV does not require, but instead allows States to grant or deny them State Medicaid, subject to certain exceptions (see, 8 USC § 1622 [a]).^[10]

Finally, notwithstanding all of these restrictions, both non-qualified aliens and qualified aliens (during their periods of ineligibility) may receive State and federally funded emergency

medical treatment (see, 8 USC § 1611 [b] [1] [A]; § 1613 [c] [2] [A]; § 1621 [b] [1]).

2.

New York’s Response to PRWORA

In response to PRWORA, New York enacted Social Services Law § 122, terminating Medicaid for non-qualified aliens— including PRUCOL plaintiffs (see, Social Services Law § 122 [1] [c]). New York did, however, maintain Medicaid for otherwise eligible PRUCOLs who, as of August 4, 1997, were receiving Medicaid and were diagnosed with AIDS or residing in certain licensed residential health care facilities (see, Social Services Law § 122 [1] [c]).

As for qualified aliens, section 122 provides Medicaid to all otherwise eligible qualified aliens who entered the United States before August 22, 1996 and continuously resided in the United States until attaining qualified status (Social Services Law § 122 [1] [b] [i]). Those entering on or after August 22, 1996, however, are no longer immediately eligible for State Medicaid, but must now wait five years for coverage (see, Social Services Law § 122 [1] [b] [ii]).^[11] This group includes the lawfully admitted permanent resident plaintiffs. Finally, all plaintiffs (both PRUCOLs and qualified aliens) may receive safety net assistance and emergency medical treatment (see, Social Services Law § 122 [c] [i]-[ii]).

Plaintiffs argue that section 122 violates article XVII of the New York State Constitution and denies them equal protection under the United States and New York State Constitutions.

A.

New York State Constitution, Article XVII

Plaintiffs contend that section 122 violates article XVII, § 1 of the State Constitution, which provides:

“The aid, care and support of the needy are public concerns and shall be provided by the state and by such of its subdivisions, and in such manner and

whereas emergency medical treatment becomes necessary when their medical conditions reach crisis or catastrophic levels. Plaintiffs and amici point out that diabetics, for example, often require daily insulin doses and blood glucose monitoring in order to stay alive, and that with such care they can lead healthy, productive lives. They are, however, denied this coverage. Treatment is unavailable until the condition reaches emergency proportions, involving insulin shock, renal failure and possibly amputation. Similarly, asthmatics receive no coverage for inhalers and medications to control their conditions. They receive no medical care until they experience severe attacks that can lead to suffocation and death. Contrasting it with emergency treatment, the Supreme Court has characterized ongoing medical care as a “basic necessity of life” (see, Memorial Hosp. v Maricopa County, 415 US 250 , 259-261). “To allow a serious illness to go untreated until it requires emergency hospitalization is to subject the sufferer to the danger of a substantial and irrevocable deterioration in his health” (id. at 261).

In this context, plaintiffs and amici argue that when such patients are treated in emergency settings, the hospitals are not permitted to release them without a discharge plan for necessary continuing health care services, citing Public Health Law § 2803 (1) (g). Because they cannot be readily discharged, many remain in hospital facilities. Those who are discharged experience a cycle of emergency, recovery, stabilization, deterioration and the onset of another emergency. All of this, plaintiffs and amici contend, could be avoided through ongoing medical treatment.

In Barie the work incentive requirement was an appropriate mechanism for identifying need. Here, however, the concept of need plays no part in the operation of section 122. Indeed, the statute suffers from an infirmity comparable to the one in Tucker and cannot be justified on the basis of a distinction between qualified aliens and PRUCOLs on the one hand, and citizens on the other. We conclude that section 122 violates the letter and spirit of article XVII, § 1 by imposing on plaintiffs an overly burdensome eligibility condition having nothing to do with need, depriving them of an entire category of otherwise available basic necessity benefits.^[12]

licenses to citizens but denied them to aliens who were ineligible for citizenship]; see generally, 3 Rotunda & Nowak, Constitutional Law: Substance and Procedure § 18.12, at 469 [3d ed 1999]). Under strict scrutiny, a State statute will withstand an equal protection challenge only when the State can show that the law “furthers a compelling state interest by the least restrictive means practically available” (see, Bernal v Fainter, 467 US, at 227 , supra).^[13]

Heightened scrutiny is premised on the Supreme Court’s view of the political process. The Court generally accords States broad discretion to create classifications in implementing economic and social welfare policy (see, Dandridge v Williams, 397 US 471 , 485). In these instances, the Court leaves it to the political process to “bring about repeal of undesirable legislation” (see, United States v Carolene Prods. Co., 304 US 144 , 152-153 n 4). If a statute has “some 'reasonable basis,’ ” the Court will sustain it even if the classification “ 'is not made with mathematical nicety [or] results in some inequality’ ” (Dandridge v Williams, 397 US, at 485 , supra [quoting Lindsley v Natural Carbonic Gas Co., 220 US 61 , 78]). Recognizing, however, that “discrete and insular minorities” can be shut out of the political process,” the Court has applied a more searching inquiry to statutes that draw classifications aimed at these groups (see, United States v Carolene Prods. Co., 304 US, at 152-153 n 4, supra).

In Graham v Richardson ( 403 US 365 , 372, supra), the Supreme Court held that as a class, aliens are a “prime example of a ‘discrete and insular’ minority * * * for whom such heightened judicial solicitude is appropriate.” Lawful resident aliens benefit our country in a great many ways. Like citizens, they contribute to our economy, serve in the Armed Forces and pay taxes (see, Hampton v Mow Sun Wong, 426 US 88 , 107 n 30; In re Griffiths, 413 US, at 722 , supra; see generally, Notes, Constitutional Limitations on the Naturalization

Power, 80 Yale L Journal 769, 803 [1971]) including, of course, taxes that fund State Medicaid. Nevertheless, aliens may not vote, which has historically inhibited their ability to protect their interests (see, Nyquist v Mauclet, 432 US 1 , 12; Hampton v Mow Sun Wong, 426 US, at 107 , supra; see generally, Chemerinsky, Constitutional Law: Principles and Policies § 9.5.2, at 618-619 [1997]; Notes and Legislation, 17 NYU LQ Rev 242, 242-243 [1940]).

The State does not attempt to justify section 122 under a strict scrutiny standard.^[14] Nor has it identified any “compelling governmental interest” that section 122 promotes. Instead, the State argues that strict scrutiny does not apply here. It contends that section 122 implements title IV’s Federal immigration policy and should therefore be evaluated under the less stringent “rational basis” standard. To address this argument, we must compare State and Congressional legislative authority in the context of immigration and naturalization.

The Constitution empowers Congress to “establish [a] uniform Rule of Naturalization” (US Const, art I, § 8, cl [4]), “regulate Commerce with foreign Nations” (US Const, art I, § 8, cl [3]), “declare War” (US Const, art I, § 8, cl [11]) approve treaties (US Const, art II, § 2, cl [2]), and legislate over foreign affairs (see, Toll v Moreno, 458 US 1 , 10, supra; Mathews v Diaz, 426 US, at 81 n 17, supra). In entertaining challenges to Federal immigration and naturalization statutes, the Supreme Court has interpreted these sources of authority to accord Congress — as distinguished from the States — considerable latitude (see, Fiallo v Bell, 430 US 787 , 792-797; Hampton v Mow Sun Wong, 426 US, at 100-105 , supra; Kleindienst v Mandel, 408 US 753 , 765-770; see generally, Chemerinsky, Constitutional Law: Principles and Policies § 3.5.1, at 204-208, supra). The Court has explained that “over no conceivable subject is

the legislative power of Congress more complete” (Oceanic Steam Nav. Co. v Stranahan, 214 US 320 , 339).^[15]

When allocating Federal welfare benefits, the Constitution does not prohibit Congress from distinguishing between aliens and citizens. In Mathews v Diaz ( 426 US 67 , 69, 77-81, supra) a group of aliens challenged a Federal statute that denied aliens Medicare eligibility unless they had been admitted for permanent residence and resided in the United States for at least five years. The Court held that the “decision to share [our] bounty with our guests may take into account the character of the relationship between the alien and this country: Congress may decide that as the alien’s tie grows stronger, so does the strength of his claim to an equal share of that munificence” (id. at 80). Moreover, when Federal welfare programs are jointly administered with the States, Congress may direct the States to implement national immigration objectives as long as the “Federal Government has by uniform rule prescribed what it believes to be appropriate standards for the treatment of an alien subclass” (see, Plyler v Doe, 457 US, at 219 n 19, supra [emphasis added]).^[16]

Relying on these cases, the State argues that section 122 does what title IV has authorized it to do with regard to Federal immigration policy. Plaintiffs contend, however, that the issue is not whether the State has followed the authorization. Rather, it is whether title IV can constitutionally authorize New York to determine for itself the extent to which it will discriminate against legal aliens for State Medicaid eligibility. Plaintiffs argue that it cannot, and we agree.

Graham v Richardson ( 403 US 365 , supra) is at the center of our analysis. There, the State of Arizona administered a Federal disability program under Federal guidelines much the same as New York administers Medicaid. Arizona argued that because its 15-year residency period for aliens was impliedly authorized by Federal law, it did not violate the Fourteenth

Amendment (see, Graham v Richardson, 403 US, at 382 , supra). The Supreme Court rejected this contention, holding that a Federal statute authorizing “discriminatory treatment of aliens at the option of States” would present “serious constitutional questions” ( 403 US, at 382 [emphasis added]). The Court recognized that although the Federal government has broad constitutional power to distinguish among aliens in setting the rules for their admission and naturalization, “Congress does not have the power to authorize the individual States to violate the Equal Protection Clause” (see, 403 US, at 382 , supra). Indeed, the Court went on to state that a “congressional enactment construed so as to permit state legislatures to adopt divergent laws on the subject of citizenship requirements for federally supported welfare programs would appear to contravene this explicit constitutional requirement of uniformity” (see, 403 US, at 382 , supra).^[17]

Additional Supreme Court decisions reinforce Graham’s requirement for uniformity in immigration policy (see, Plyler v Doe, 457 US, at 219 n 19, supra [“(I)f the Federal Government has by uniform rule prescribed what it believes to be appropriate standards for the treatment of an alien subclass, the States may, of course, follow the federal direction”] [emphasis added]). Moreover, in Mathews v Diaz, the Court recognized that when it comes to State welfare policy, “there is little, if any, basis for treating persons who are citizens of another State differently from persons who are citizens of another country” (see, id., 426 US, at 85, supra). In distinguishing between Federal and State powers, the Court held that a “division by a State of the category of persons who are not citizens of that State into subcategories of United States citizens and aliens has no apparent justification, whereas, a comparable classification by the Federal Government is a routine and normally legitimate part of its business” (see, Mathews v Diaz, 426 US, at 85 , supra).

Finally, in Hampton v Mow Sun Wong ( 426 US 88 , 104, supra), the Supreme Court drew limits on the power of entities

Because title IV authorizes each State to extend the ineligibility period for Federal Medicaid beyond the mandatory five years (see, 8 USC § 1612 )^[18] and terminate Federal Medicaid eligibility for certain refugees and asylees after seven years (see, 8 USC § 1612 [b] [1], [2] [A] [i]), it is directly in the teeth of Graham insofar as it allows the States to “adopt divergent laws on the subject of citizenship requirements for federally supported welfare programs” (see, 403 US, at 382 , supra [emphasis added]). Moreover, title TV goes significantly beyond what the Graham Court declared constitutionally questionable. In the name of national immigration policy, it impermissibly áuthorizes each State to decide whether to disqualify many otherwise eligible aliens from State Medicaid.^[19] Section 122 is a product of this authorization. In light of Graham and its progeny, title IV can give section 122 no special insulation from strict scrutiny review. Thus, section 122 must be evaluated as any other State statute that classifies based on alien-age. We hold that section 122 violates the Equal Protection Clauses of the United States and New York State Constitutions insofar as it denies State Medicaid to otherwise eligible PRUCOLs and lawfully admitted permanent residents based on their status as aliens.

Accordingly, the order of the Appellate Division should be reversed, with costs, and the case remitted to Supreme Court for further proceedings in accordance with this Opinion.

Chief Judge Kaye and Judges Smith, Levine, Ciparick, Wesley and Graffeo concur.

Order reversed, etc.