See file
HHP4600
Module 2a PowerPoint Questions on Powers of State Government
1. Where are the constitutional roles of the state and federal governments described?
2. Explain the concept of “police powers.” In what amendment is it found?
3. Describe the 5th and 14th amendments. Which amendment limits the federal government? Which limits the state governments?
4. Was Jacobson v Massachusetts about state authority and individual privacy? What was the state’s compelling interest? What did the court decide?
5. List three specific activities regulated by the states that demonstrate the courts allow states to exercise Tenth Amendment power over individuals. Do courts allow broad authority of states to protect the health, safety, welfare, or morals of the public?
6. What three arguments defend compulsory helmet laws? Why do the courts allow states to regulate helmet wearing on motorcycles?
7. What are states allowed to do based on Buck vs. Bell? Has Buck vs. Bell been overruled?
8. How is guardianship applied to children and medical treatment? How is it applied to adults considered incompetent?
HHP 4600 Law and Public’s Health
Module 2b PowerPoint questions for Constitutional Discretion of State and Federal Governments to Limit Social Welfare Benefits
1. What two health programs were created in 1965?
2. What is the two-tier test? Explain in what situations it is applied and how it is applied.
3. What does the Hyde amendment prohibit? How is this not a violation of one’s right to an abortion?
4. Do U. S. citizens have a constitutional right to health care?
5. If a state now offering Medicaid decides to drop Medicaid from the services following due process, would that state be violating the constitutional rights of those receiving the services?
6. Does the current Supreme Court seem to believe the controversies surrounding matters like abortion funding and welfare should rest with the courts or be reflected for debate and resolution to the political arenas of the state legislatures and Congress?
Teitelbaum and Wilensky Chapter 4 and 5 Questions
T & W Chapter 4: Overview of the U.S. Healthcare System
1. How does the U.S. health care system compare to other countries in expenditures and outcomes?
2. What has been the trend in U.S. National health expenditures as a percentage of GDP since 1960? What country or countries spend more of their GDP for healthcare than the U.S?
3. How may have gained health care insurance coverage under the ACA since 2012? Does this mean the ACA was working as intended?
4. What was the projection of uninsured population for 2023 with the Affordable Care Act? (That projection has changed since the Trump Administration, after the text was written.)
5. What role does family planning services like Planned Parenthood have in health care delivery? Can Planned Parenthood perform abortions with federal tax dollars? What services do they provide and to whom?
6. What is the primary reason why some in the U.S. are not insured?
7. How did the Affordable Care Act change the age that insurance companies must allow for children to be on their parents’ policies?
8. Are undocumented immigrants eligible for public assistance to purchase health insurance under the Affordable Care Act of 2010?
9. How does having or not health insurance affect health status?
10. How does uncompensated care affect expenditures in other areas?
11. What is a deductible? What is a co-pay?
12. Briefly state what our health system is and what it is not.
13. Federal funds may be used for abortions in what three circumstances?
14. What role do safety net providers have in healthcare?
T & W Chapter 5 Health Institutions and Systems
1. What role do administrative agencies generally have in healthcare?
2. Explain how each of the following agencies can impact healthcare?
a. Department of Agriculture
b. Environmental Protection Agency (EPA)
c. Occupational Safety and Health Administration (OSHA)
3. What role do these private organizations have in healthcare?
a. Robert Wood Johnson Foundation
b. American Red Cross
c. Kaiser Family Foundation
Updated 7/9/20
State/Federal powers
U.S. Constitution enumerates powers of federal government
States retain powers not granted to federal government, but federal government is not limited only to only those explicit in the constitution & Interstate Commerce Clause
Interstate Commerce allows federal government to regulate commercial activity when it crosses state boundaries.
Interstate Commerce and Constitution
States have Tenth Amendment powers (health, education, policing, welfare)
Federal government has enumerated powers (defense, immigration)
Interstate Commerce Clause: When commerce crosses state lines, federal government can regulate that commerce. Results in seemingly dual state and federal regulation. Cannot force commerce (not make citizens eat broccoli) but can regulate existing commercial activity.
States’ rights or “police powers” as written in 10th Amendment of U.S. Constitution
Constitution grants any authority a state needs, but not obligates it, to legitimately preserve order and ensure the public health, safety, welfare, and morals
May not conflict with federal role as identified in the U. S. constitution.
May not abridge constitutional rights of individuals
Police Power and Individual Rights
May not abridge individual rights per 5th and 14th amendments
Rights in 14th and 5th amendments can be procedural (fair, reasonable, due process)
or
Substantive (freedom of speech, religion, and freedom from cruel and unusual punishment)
State Authority v Individual
When a state exercises its Tenth Amendment authority, an individual may contest that authority.
The court cases resolving those challenges have become established law.
States can require individuals to be vaccinated, wear masks or helmets, quarantine, hold licenses, attend school, have insurance, wear seat belts, etc.
Jacobson vs. Massachusetts (1905)
Compulsory small pox vaccination for adults upheld by Supreme Court citing
States may “enact health laws of every description” and “such reasonable regulations established directly by legislative enactment as will protect the public health and the public safety.” Only need a “common belief” to do so.
Massachusetts had not violated the sphere of privacy.
State Police Powers that have been upheld over individual rights challenges
Examine, quarantine, and treat people with contagious diseases
Confine civilly the mentally ill and mentally retarded (intellectually disabled)
Require medical exams & vaccinations for children before school admission
Compulsory exam before marriage
Exams of people in certain occupations
Comply with fire and safety regulations
Other Cases
Helmet and seat belt laws: Consistently and unanimously held that state has power to control and regulate the use of the highways.
Reasoning to uphold helmet, seat belt law
Protect the individual (paternalistic)
Affects third parties
Protect public from economic burden (usually cited)
Buck v. Bell (1927)
Compulsory Sterilization
Virginia law allowing state to sterilize mental patients was upheld because:
“…many defective persons who if now discharged would become a menace but if incapable of procreating might be discharged with safety and become self-supporting with benefit to themselves and to society and …heredity plays an important part in the transmission of insanity.”
Buck v. Bell (1927) con’d
“It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. (Jacobson) Three generations of imbeciles are enough.”
Buck v Bell
The cases may reflect out of date science and language from earlier time periods.
Current cases and enacted law are based upon the legal foundation of these historical cases.
Modern position on sterilization
Recent decisions never openly disagreed with Buck v. Bell
States theoretically have power to sterilize, but must justify a compelling reason
Some courts have stopped sterilization seeing it as punitive.
Some regard it as cruel and unusual.
Modern view of sterilization by courts
State must have a “compelling government interest” and show this remedy is the only one available and stand up to “close scrutiny” from the court since a right involved.
Court did not define what constitutes a state interest, and leaves door open for sterilization.
Compulsory Medical Treatment
Minors are “incompetent” to make legal decisions
Parents or guardians generally empowered to decide on behalf of child, respecting autonomy of family
When child’s health, well-being, or life threatened, every state allowed to assume custody or guardianship over objections of parents for some period.
Compulsory Medical Tx
Courts uphold states authority to provide medical treatment over objections of parents, even when based on religious grounds.
Parents can be criminally punished
Courts take active role in closely examining laws that limit parental role, especially on religious basis
Guardianship for adults who are legally incompetent
Guardianship is primary mechanism to provide involuntary medical treatment for adults with physical/mental disabilities unable to make informed decisions
Courts have unanimously upheld legitimacy of this procedure
Constitutional Discretion of the State and Federal Governments to Limit Social Welfare Benefits
M2b
Summary of Social Welfare in the U.S.
Labeled a complicated and fragmented patchwork of services understood by history of legal and political controversy.
Generally inadequate and inequitable
Categorically based, not need based
Federal Social Services
Social security and unemployment benefits created for financial security.
Medicaid and Medicare started in 1965
Universal healthcare laws never enacted in U.S. Even physicians in the American Medical Association (AMA), fought federal involvement in national health insurance, calling it “socialized medicine.”
State Level Social Services
Tenth Amendment of constitution grants states the authority but no obligation to offer education, police protection, health, or welfare services.
State discretion results in patchwork of fragmented services.
Citizens have no legal right to services.
History
Some states address wise allocation of limited resources, sometimes just cutting costs by cutting services
Decisions by states can be based not on how much is enough, but by politics and ideology
Eligibility is a political and legal privilege
And can be taken away
Two Tier Test
When a state enacts a law under its Tenth Amendment authority and an individual challenges it in court, how might the court approach resolving the dispute?
If there is a right involved determines how closely the court scrutinizes the law.
Shapiro v Thompson (1969)
Supreme Court: Decided making someone wait (residency) to get welfare was government discrimination prohibited by the Equal Protection Clause of the 14th Amendment.
Outcomes:
Cannot put burden on new residents as it prohibited right to travel freely
Cannot favor “old residents” over “new”
State can reduce costs if compelling interest and constitutional
Courts will have broad role in reviewing social welfare legislation
Two Tier Test established in Shapiro v.Thompson
Does legislation of state affect constitutionally protected right or‘fundamental interest’ or create suspect classifications?
If so, court will closely scrutinize the purpose of the state and the means for achieving those purposes and hold constitutional only those where state has a‘compelling interest.’
2. Where no ‘fundamental interest’ is involved, court must find only that the state legislation is rationally related to a legitimate purpose.
Two tier (short version)
Two Tier Test
Tier One:
Court first asks, “Is there a fundamental right involved?”
Tier Two:
If so, courts apply close scrutiny and state must show a compelling interest.
If not, state only needs to be rational or reaonable.
.
Dandridge v Williams (1970)
Since 1970’s court has found few fundamental rights involved in state authority, so the rational, not the close scrutiny, has been typically applied. Court has not subjected states to much close scrutiny.
Other cases applying two tier test
Fullington v Shea (1971)
Colorado allowed to use Medicaid only to categorically needy, not medically needy.
San Antonio Schools v Rodriquez (1973)
Texas schools allowed to fund districts resulting in ‘poor’ districts. Education is not a fundamental right, so state law only had to be rational, the Supreme Court held.
Other cases applying two tier test
Memorial Hospital v Maricopa (1974)
Residency requirement for state medical care unconstitutional (like Shapiro)
Saenz v California (1999)
Not allowed to limit new residents to a benefit amount equal to that they received in the state they came. Required state to show compelling interest and meet close scrutiny.
Two tier test of equal protection & government funding for abortions
Right to life lobby resulted in states amending Medicaid to limit funding for abortions to medically necessary
Beal v Doe & Maher v Roe
Upheld state laws restricting Medicaid funding of abortions
Does this lack of funding by Medicaid disadvantage impede a fundamental right? If not, state law only has to be rational.
Hyde amendment & Harris v McRae (1980)
Restricted use of any federal dollars for abortion unless life of mother threatened or rape or incest.
Was argued this violated right to privacy, but restriction held constitutional
Can have abortion, but not constitutionally entitled to funding for it, i.e. no fundamental interest recognized
Used 2 tier basis—no fundamental right to dollars for abortion, therefore only required to be rational
Two Tier Test & Gov’t Discretion to limit/condition spending programs
Webster case upheld state limiting public employees in abortion activity and limiting use of public facilities in abortion. Right of privacy not limited if public people or buildings are not available. Can still get abortion.
Rust v Sullivan (1971) a regulation from DHHS forbid Title X employees or money from supporting abortion.
Was upheld as not affecting privacy interest or decision to have abortion.
Rust v. Sullivan (1991)(Con’d)
Plaintiffs argued that ‘gag rules’ on Title X funded employees prohibited speech concerning abortion.
Chief Justice Rehnquist’s response for majority of court was employees free speech is not violated by government as employees can advocate and promote abortion on their own time, but not under auspices of Title X funding or employment.
DeShaney v. Winnebago County Department of Social Services (1989)
Victim of child abuse cannot sue state for the state failing to take action against his abusive parent.
Constitution confers no affirmative right to an individual to get government aid even where such aid may be necessary to secure life, liberty or property interests
Constitutional right to health care?
Constitutionally government can omit Medicaid or other government programs or not provide medical assistance, whether funding it or providing it directly.
No constitutional right to health care, at least under the federal Constitution? Did Affordable Care Act give Americans right to healthcare?
Qualifiers to government funding limitations
If government decision can be characterized as a penalty or obstacle to right, it can be unconstitutional
-Denying eligibility to someone who exercises a constitutional right would be viewed as imposing a penalty on that person.
Government can choose to not fund the exercise of a fundamental interest, but cannot use funding to penalize those who do so with their own resources.
Government can use the powers of the purse to penalize other activities that to do not involve constitutionally protected rights or fundamental interests.
Legal bases to challenge government decisions in social welfare situations
States must comply with federal statutory requirements such as those that come with voluntary participation in Medicaid
States must comply with own statutes and constitutions. Some states held referendum votes resulting in denial of same sex marriage. That vote was then in some states overturned by courts as contradicted by that state’s constitution.
Applications
Does testing Medicaid recipients for illegal drug use violate individual right to privacy?
Can we deny Medicaid from those (and the family) who are found using illegal drugs?
Can we deny their right to vote if Medicaid recipient found using illegal drugs?
Future
Court seems to respect its role in balance of powers, even if it sees the individual merits of a case, deflecting controversies over abortion funding and welfare limits from the courts to the political arenas of the state and federal legislatures, where some Court members thinks it belongs
Slides developed in part using Wing’s The Law and the Public’s Health, 7th ed. 2007
