100 S.Ct. 2671

Supreme Court of the United States

Patricia R. HARRIS, Secretary of Health and Human Services, Appellant,

v.

Cora McRAE et al.

No. 79–1268.

|

Argued April 21, 1980.

|

Decided June 30, 1980.

|

Rehearing Denied Sept. 17, 1980.

|

See 448 U.S. 917, 101 S.Ct. 39.

Opinion

Mr. Justice STEWART delivered the opinion of the Court.

This case presents statutory and constitutional questions concerning the public funding of abortions under Title XIX of the Social Security Act, commonly known as the “Medicaid” Act, and recent annual Appropriations **2680 Acts containing *301 the…“Hyde Amendment.” The statutory question is whether Title XIX requires a State that participates in the Medicaid program to fund the cost of medically necessary abortions for which federal reimbursement is unavailable under the Hyde Amendment. The constitutional question, which arises only if Title XIX imposes no such requirement, is whether the Hyde Amendment, by denying public funding for certain medically necessary abortions, contravenes the liberty or equal protection guarantees of the Due Process Clause of the Fifth Amendment, or either of the Religion Clauses of the First Amendment.

I

The Medicaid program was created in 1965, when Congress added Title XIX to the Social Security Act, 79 Stat. 343, as amended, 42 U.S.C. § 1396 et seq. (1976 ed. and Supp. II), for the purpose of providing federal financial assistance to States that choose to reimburse certain costs of medical treatment for needy persons. Although participation in the Medicaid program is entirely optional, once a State elects to participate, it must comply with the requirements of Title XIX.

One such requirement is that a participating State agree to provide financial assistance to the “categorically needy”¹ with respect to five general areas of medical treatment: (1) inpatient hospital services, (2) outpatient hospital services, (3) other laboratory and X-ray services, (4) skilled nursing *302 facilities services, periodic screening and diagnosis of children, and family planning services, and (5) services of physicians. 42 U.S.C. §§ 1396a(a)(13)(B), 1396d(a)(1)–(5). Although a participating State need not “provide funding for all medical treatment falling within the five general categories, [Title XIX] does require that [a] state Medicaid pla[n] establish ‘reasonable standards . . . for determining . . . the extent of medical assistance under the plan which . . . are consistent with the objectives of [Title XIX].’ 42 U.S.C. § 1396a(a)(17).” Beal v. Doe, 432 U.S. 438, 441, 97 S.Ct. 2366, 2369, 53 L.Ed.2d 464.

Since September 1976, Congress has prohibited—either by an amendment to the annual appropriations bill for the Department of Health, Education, and Welfare² or by a joint resolution—the use of any federal funds to reimburse the cost of abortions under the Medicaid program except under certain specified circumstances. This funding restriction is commonly known as the “Hyde Amendment,” after its original congressional sponsor, Representative Hyde. The current version of the Hyde Amendment, applicable for fiscal year 1980, provides:

“[N]one of the funds provided by this joint resolution shall be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term; or except for such medical procedures necessary for the victims of rape or incest when such rape or incest has been reported promptly to a law enforcement agency or public health service.” (citations omitted)

On September 30, 1976, the day on which Congress enacted the initial version of the Hyde Amendment, these consolidated cases were filed in the District Court for the Eastern District of New York. The plaintiffs—Cora McRae, a New York Medicaid recipient then in the first trimester of a pregnancy that she wished to terminate, the New York City Health and Hospitals Corp., a public benefit corporation that operates 16 hospitals, 12 of which provide abortion services, and others—sought to enjoin the enforcement of the funding restriction on abortions. They alleged that the Hyde Amendment violated the First, Fourth, Fifth, and Ninth Amendments of the Constitution insofar as it limited the funding of abortions to those necessary to save the life of the mother, while permitting the funding of costs associated with childbirth. Although the sole named defendant was the Secretary of Health, Education, and Welfare, the District Court permitted Senators James L. Buckley and Jesse A. Helms and Representative Henry J. Hyde to intervene as defendants.⁵

*304 After a hearing, the District Court entered a preliminary injunction prohibiting the Secretary from enforcing the Hyde Amendment and requiring him to continue to provide federal reimbursement for abortions under the standards applicable before the funding restriction had been enacted.  McRae v. Mathews, 421 F.Supp. 533. Although stating that it had not expressly held that the funding restriction was unconstitutional, since the preliminary injunction was not its final judgment, the District Court noted that such a holding was “implicit” in its decision granting the injunction. The District Court also certified the McRae case as a class action on behalf of all pregnant or potentially pregnant women in the State of New York eligible for Medicaid and who decide to have an abortion within the first 24 weeks of pregnancy, and of all authorized providers of abortion services to such women. Id., at 543.

The Secretary then brought an appeal to this Court. After deciding Beal v. Doe, 432 U.S. 438, 97 S.Ct. 2366, 53 L.Ed.2d 464, and Maher v. Roe, 432 U.S. 464, 97 S.Ct. 2474, 53 L.Ed.2d 534, we vacated the injunction of the District Court and remanded the case for reconsideration in light of those decisions. Califano v. McRae, 433 U.S. 916, 97 S.Ct. 2993, 53 L.Ed.2d 1103.

On remand, the District Court permitted the intervention of several additional plaintiffs, including (1) four individual Medicaid recipients who wished to have abortions that allegedly were medically necessary but did not qualify for federal funds under the versions of the Hyde Amendment applicable in fiscal years 1977 and 1978, (2) several physicians who perform abortions for Medicaid recipients, (3) the Women’s Division of the Board of Global Ministries of the United Methodist Church (Women’s Division), and (4) two individual officers of the Women’s Division.

**2682 An amended complaint was then filed, challenging the various versions of the Hyde Amendment on several grounds. At the outset, the plaintiffs asserted that the District Court need not address the constitutionality of the HydeAmendment *305 because, in their view, a participating State remains obligated under Title XIX to fund all medically necessary abortions, even if federal reimbursement is unavailable. With regard to the constitutionality of the Hyde Amendment, the plaintiffs asserted, among other things, that the funding restrictions violate the Religion Clauses of the First Amendment and the Due Process Clause of the Fifth Amendment.

After a lengthy trial, which inquired into the medical reasons for abortions and the diverse religious views on the subject,⁶ the District Court filed an opinion and entered a judgment invalidating all versions of the Hyde Amendment on constitutional grounds.⁷ The District Court rejected the plaintiffs’ statutory argument, concluding that even though Title XIX would otherwise have required a participating State to fund medically necessary abortions, the Hyde Amendment had substantively amended Title XIX to relieve a State of that funding obligation. Turning then to the constitutional issues, the District Court concluded that the Hyde Amendment, though valid under the Establishment Clause,⁸ violates the equal protection component of the Fifth Amendment’s Due Process Clause and the Free Exercise Clause of the First Amendment. With regard to the Fifth Amendment, the District Court noted that when an abortion is “medically necessary to safeguard the pregnant woman’s health, . . . the disentitlement to [M]edicaid assistance impinges directly on the woman’s right to decide, in consultation with her physician and in reliance on his judgment, to terminate  *306 her pregnancy in order to preserve her health.”⁹ McRae v. Califano, 491 F.Supp. 630, 737. The court concluded that the Hyde Amendment violates the equal protection guarantee because, in its view, the decision of Congress to fund medically necessary services generally but only certain medically necessary abortions serves no legitimate governmental interest. As to the Free Exercise Clause of the First Amendment, the court held that insofar as a woman’s decision to seek a medically necessary abortion may be a product of her religious beliefs under certain Protestant and Jewish tenets, the funding restrictions of the Hyde Amendment violate that constitutional guarantee as well.

Accordingly, the District Court ordered the Secretary to “[c]ease to give effect” to the various versions of the Hyde Amendment insofar as they forbid payments for medically necessary abortions. It further directed the Secretary to “[c]ontinue to authorize the expenditure of federal matching funds [for such abortions].” App. 87. In addition, the court recertified the McRae case as a nationwide class action on behalf of all pregnant and potentially pregnant women eligible for Medicaid who wish to have medically necessary abortions, and of all authorized providers of abortions for such women.¹⁰

**2683 The Secretary then applied to this Court for a stay of the judgment pending direct appeal of the District Court’s decision. We denied the stay, but noted probable jurisdiction of this appeal. 444 U.S. 1069, 100 S.Ct. 1010, 62 L.Ed.2d 750.

II

 It is well settled that if a case may be decided on either statutory or constitutional grounds, this Court, for sound *307 jurisprudential reasons, will inquire first into the statutory question…Accordingly, we turn first to the question whether Title XIX requires a State that participates in the Medicaid program to continue to fund those medically necessary abortions for which federal reimbursement is unavailable under the Hyde Amendment. If a participating State is under such an obligation, the constitutionality of the Hyde Amendment need not be drawn into question in the present case, for the availability of medically necessary abortions under Medicaid would continue, with the participating State shouldering the total cost of funding such abortions.

[The Court concludes that Title XIX does not require states to fund abortions the Hyde Amendment renders ineligible for reimbursement.]

II

 Having determined that Title XIX does not obligate a participating State to pay for those medically necessary abortions for which Congress has withheld federal funding, we must consider the constitutional validity of the Hyde Amendment. The appellees assert that the funding restrictions of the Hyde Amendment violate several rights secured by the Constitution—(1) the right of a woman, implicit in the Due Process Clause of the Fifth Amendment, to decide whether to terminate a pregnancy, (2) the prohibition under the Establishment Clause of the First Amendment against any “law respecting an establishment of religion,” and (3) the right to freedom of religion protected by the Free Exercise Clause of the First Amendment. The appellees also contend that, quite apart from substantive constitutional rights, the Hyde Amendment violates the equal protection component of the Fifth Amendment.¹⁷

*312  It is well settled that, quite apart from the guarantee of equal protection, if a law “impinges upon a fundamental right explicitly or implicitly secured by the Constitution [it] is presumptively unconstitutional.” (citations omitted) Accordingly, before turning to the equal protection issue in this case, we examine whether the Hyde Amendment violates any substantive rights secured by the Constitution.

(substantive due process, establishment and free exercise clause sections omitted)

C

It remains to be determined whether the Hyde Amendment violates the equal protection component of the Fifth Amendment. This challenge is premised on the fact that, although *322 federal reimbursement is available under Medicaid for medically necessary **2691 services generally, the Hyde Amendment does not permit federal reimbursement of all medically necessary abortions. The District Court held, and the appellees argue here, that this selective subsidization violates the constitutional guarantee of equal protection.

 The guarantee of equal protection under the Fifth Amendment is not a source of substantive rights or liberties,²⁵ but rather a right to be free from invidious discrimination in statutory classifications and other governmental activity. It is well settled that where a statutory classification does not itself impinge on a right or liberty protected by the Constitution, the validity of classification must be sustained unless “the classification rests on grounds wholly irrelevant to the achievement of [any legitimate governmental] objective.”(citation omitted) This presumption of constitutional validity, however, disappears if a statutory classification is predicated on criteria that are, in a constitutional sense, “suspect,” the principal example of which is a classification based on race, (citations omitted).

1

 …We now conclude…that [the claimed right to Medicaid funding for abortions] is not predicated on a constitutionally suspect classification. In reaching this conclusion, we again draw guidance from the Court’s decision in Maher v. Roe. As to whether the Connecticut *323 welfare regulation providing funds for childbirth but not for nontherapeutic abortions discriminated against a suspect class, the Court in Maher observed:

“An indigent woman desiring an abortion does not come within the limited category of disadvantaged classes so recognized by our cases. Nor does the fact that the impact of the regulation falls upon those who cannot pay lead to a different conclusion. In a sense, every denial of welfare to an indigent creates a wealth classification as compared to nonindigents who are able to pay for the desired goods or services. But this Court has never held that financial need alone identifies a suspect class for purposes of equal protection analysis.” [citations omitted].

Thus, the Court in Maher found no basis for concluding that the Connecticut regulation was predicated on a suspect classification.

It is our view that the present case is indistinguishable from Maher in this respect. Here, as in Maher, the principal impact of the Hyde Amendment falls on the indigent. But that fact does not itself render the funding restriction constitutionally invalid, for this Court has held repeatedly that poverty, standing alone is not a suspect classification. [citations omitted] That Maher involved the refusal to fund nontherapeutic abortions, whereas the present case involves the refusal to fund medically necessary abortions, has no bearing on the factors that render a classification “suspect” within the meaning of the constitutional guarantee of equal protection.²⁶

*324 **2692 2

 The remaining question then is whether the Hyde Amendment is rationally related to a legitimate governmental objective. It is the Government’s position that the Hyde Amendment bears a rational relationship to its legitimate interest in protecting the potential life of the fetus. We agree.

[T]he Court [has] recognized that the State has an “important and legitimate interest in protecting the potentiality of human life.” [citations omitted] That interest was found to exist throughout a pregnancy, “grow[ing] in substantiality as the woman approaches term.” [citations omitted] Moreover, in Maher, the Court held that Connecticut’s decision to fund the costs associated with childbirth but not those associated with nontherapeutic abortions was a rational means of advancing the legitimate state interest in protecting potential life by *325 encouraging childbirth. [citations omitted]

 It follows that the Hyde Amendment, by encouraging childbirth except in the most urgent circumstances, is rationally related to the legitimate governmental objective of protecting potential life. By subsidizing the medical expenses of indigent women who carry their pregnancies to term while not subsidizing the comparable expenses of women who undergo abortions (except those whose lives are threatened),²⁷ Congress has established incentives that make childbirth a more attractive alternative than abortion for persons eligible for Medicaid. These incentives bear a direct relationship to the legitimate congressional interest in protecting potential life. Nor is it irrational that Congress has authorized federal reimbursement for medically necessary services generally, but not for certain medically necessary abortions.²⁸ Abortion is inherently different from other medical procedures, because no other procedure involves the purposeful termination of a potential life.

 After conducting an extensive evidentiary hearing into issues surrounding the public funding of abortions, the District Court concluded that “[t]he interests of **2693 . . . the federal government . . . in the fetus and in preserving it are not sufficient, weighed in the balance with the woman’s threatened health, to justify withdrawing medical assistance unless the *326 woman consents . . . to carry the fetus to term.” 491 F.Supp., at 737. In making an independent appraisal of the competing interests involved here, the District Court went beyond the judicial function. Such decisions are entrusted under the Constitution to Congress, not the courts. It is the role of the courts only to ensure that congressional decisions comport with the Constitution.

 Where, as here, the Congress has neither invaded a substantive constitutional right or freedom, nor enacted legislation that purposefully operates to the detriment of a suspect class, the only requirement of equal protection is that congressional action be rationally related to a legitimate governmental interest. The Hyde Amendment satisfies that standard. It is not the mission of this Court or any other to decide whether the balance of competing interests reflected in the Hyde Amendment is wise social policy. If that were our mission, not every Justice who has subscribed to the judgment of the Court today could have done so. But we cannot, in the name of the Constitution, overturn duly enacted statutes simply “because they may be unwise, improvident, or out of harmony with a particular school of thought.” [citations omitted] Rather, “when an issue involves policy choices as sensitive as those implicated [here] . . . , the appropriate forum for their resolution in a democracy is the legislature.”  [citations omitted]

IV

For the reasons stated in this opinion, we hold that a State that participates in the Medicaid program is not obligated under Title XIX to continue to fund those medically necessary abortions for which federal reimbursement is unavailable under the Hyde Amendment. We further hold that the funding restrictions of the Hyde Amendment violate neither the Fifth Amendment nor the Establishment Clause of the First Amendment. It is also our view that the appellees *327 lack standing to raise a challenge to the Hyde Amendment under the Free Exercise Clause of the First Amendment. Accordingly, the judgment of the District Court is reversed, and the case is remanded to that court for further proceedings consistent with this opinion.

It is so ordered.

Mr. Justice WHITE, concurring. [omitted]

Justices Brennan and Stevens, dissenting [omitted]

Mr. Justice MARSHALL, dissenting.

***

*341 II

The Court resolves the equal protection issue in this case through a relentlessly **2708 formalistic catechism. Adhering to its “two-tiered” approach to equal protection, the Court first decides that so-called strict scrutiny is not required because the Hyde Amendment does not violate the Due Process Clause and is not predicated on a constitutionally suspect classification. Therefore, “the validity of classification must be sustained unless ‘the classification rests on grounds wholly irrelevant to the achievement of [any legitimate governmental] objective.’ ” [citations omitted]. Observing that previous cases have recognized “the legitimate governmental objective of protecting potential life,” [citations omitted], the Court concludes that the Hyde Amendment “establishe[s] incentives that make childbirth a more attractive alternative than abortion for persons eligible for Medicaid,” ibid., and is therefore rationally related to that governmental interest.

I continue to believe that the rigid “two-tiered” approach is inappropriate and that the Constitution requires a more exacting standard of review than mere rationality in cases such as this one. Further, in my judgment the Hyde Amendment cannot pass constitutional muster even under the rational-basis standard of review.

A

This case is perhaps the most dramatic illustration to date of the deficiencies in the Court's obsolete “two-tiered” approach to the Equal Protection Clause. [citations omitted] With all deference, I am unable to understand how the Court can afford the same level of scrutiny to the legislation involved here-whose cruel impact falls exclusively on indigent pregnant women-that it has given to legislation distinguishing opticians from ophthalmologists, or to other legislation that makes distinctions between economic interests more than able to protect themselves in the political process. [citations omitted]. Heightened scrutiny of legislative classifications has always been designed to protect groups “saddled with such disabilities, or subjected to such a history of purposeful unequal treatment, or relegated to such a position of political powerlessness as to command extraordinary protection from the majoritarian political process.” [citations omitted] And while it is now clear that traditional “strict scrutiny” **2709 is unavailable to protect the poor against classifications that disfavor them, [citations omitted], I do not believe that legislation that imposes a crushing burden on indigent women can be treated with the same deference given to legislation distinguishing among business interests.

*343 B

The Hyde Amendment, of course, distinguishes between medically necessary abortions and other medically necessary expenses.⁵ As I explained in [an earlier case], such classifications must be assessed by weighing “ ‘the importance of the governmental benefits denied, the character of the class, and the asserted state interests,’ ” [citations omitted] Under that approach, the Hyde Amendment is clearly invalid.

[T]he governmental benefits at issue here are “of absolutely vital importance in the lives of the recipients.” (citations omitted) An indigent woman denied governmental funding for a medically necessary abortion is confronted with two grotesque choices. First, she may seek to obtain “an illegal abortion that poses a serious threat to her health and even her life.” Ibid. Alternatively, she may attempt to bear the child, a course that may both significantly threaten her health and eliminate any chance she might have had “to control the direction of her own life,” id., at 459, 97 S.Ct., at 2397.

The class burdened by the Hyde Amendment consists of indigent women, a substantial proportion of whom are members of minority races. As I observed in Maher, nonwhite women obtain abortions at nearly double the rate of whites, ibid.. In my view, the fact that the burden of the Hyde Amendment falls exclusively on financially destitute women *344 suggests “a special condition, which tends seriously to curtail the operation of those political processes ordinarily to be relied upon to protect minorities, and which may call for a correspondingly more searching judicial inquiry.” United States v. Carolene Products Co., 304 U.S. 144, 153, n. 4, 58 S.Ct. 778, 784, n. 4, 82 L.Ed. 1234 (1938). For this reason, I continue to believe that “a showing that state action has a devastating impact on the lives of minority racial groups must be relevant” for purposes of equal protection analysis. [citation omitted]

As I explained in Maher, the asserted state interest in protecting potential life is insufficient to “outweigh the deprivation or serious discouragement of a vital constitutional right of especial importance to poor and minority women.” In Maher, the Court found a permissible state interest in encouraging normal childbirth. The governmental interest in the present case is substantially weaker than in Maher, for under the Hyde Amendment funding is refused even in cases in which normal childbirth will not result: one can scarcely speak of “normal childbirth” in cases where the fetus will die shortly after birth, or in which the mother's life will be shortened or her health otherwise gravely impaired by the birth. Nevertheless, the Hyde Amendment denies funding even in such cases. In these circumstances, I am unable to see how even a minimally rational **2710 legislature could conclude that the interest in fetal life outweighs the brutal effect of the Hyde Amendment on indigent women. Moreover, both the legislation in Maher, and the Hyde Amendment were designed to deprive poor and minority women of the constitutional right to choose abortion. That purpose is not constitutionally permitted under Roe v. Wade.

C

Although I would abandon the strict-scrutiny/rational-basis dichotomy in equal protection analysis, it is by no *345 means necessary to reject that traditional approach to conclude, as I do, that the Hyde Amendment is a denial of equal protection. My Brother BRENNAN has demonstrated that the Amendment is unconstitutional because it impermissibly infringes upon the individual's constitutional right to decide whether to terminate a pregnancy. See ante, at 2703 (dissenting opinion). And as my Brother STEVENS demonstrates, see post, at 2712-2713 (dissenting opinion), the Government's interest in protecting fetal life is not a legitimate one when it is in conflict with “the preservation of the life or health of the mother,” and when the Government's effort to make serious health damage to the mother “a more attractive alternative than abortion,” does not rationally promote the governmental interest in encouraging normal childbirth.

The Court treats this case as though it were controlled by Maher. To the contrary, this case is the mirror image of Maher. The result in Maher turned on the fact that the legislation there under consideration discouraged only nontherapeutic, or medically unnecessary, abortions. In the Court's view, denial of Medicaid funding for nontherapeutic abortions was not a denial of equal protection because Medicaid funds were available only for medically necessary procedures. Thus the plaintiffs were seeking benefits which were not available to others similarly situated. I continue to believe that Maher was wrongly decided. But it is apparent that while the plaintiffs in Maher were seeking a benefit not available to others similarly situated, appellees are protesting their exclusion from a benefit that is available to all others similarly situated. This, it need hardly be said, is a crucial difference for equal protection purposes.

Under Title XIX and the Hyde Amendment, funding is available for essentially all necessary medical treatment for the poor. Appellees have met the statutory requirements for eligibility, but they are excluded because the treatment that is medically necessary involves the exercise of a fundamental *346 right, the right to choose an abortion. In short, these have been deprived appellees a governmental benefit for which they are otherwise eligible, solely because they have attempted to exercise a constitutional right. The interest asserted by the Government, the protection of fetal life, has been declared constitutionally subordinate to appellees' interest in preserving their lives and health by obtaining medically necessary treatment. Roe v. Wade, supra. And finally, the purpose of the legislation was to discourage the exercise of the fundamental right. In such circumstances the Hyde Amendment must be invalidated because it does not meet even the rational-basis standard of review.

III

The consequences of today's opinion-consequences to which the Court seems oblivious-are not difficult to predict. Pregnant women denied the funding necessary to procure abortions will be restricted to two alternatives. First, they can carry the fetus to term-even though that route may result in severe injury or death to the mother, the fetus, or both. If that course appears intolerable, they can resort to self-induced abortions or attempt to obtain illegal abortions-not because bearing a child **2711 would be inconvenient, but because it is necessary in order to protect their health.⁷ The result will not be to protect what the Court describes as “the legitimate governmental objective of protecting potential life,” (citation omitted) but to ensure the destruction of both fetal and maternal life. “There is another world ‘out there,’ the existence of which the Court . . . either chooses to ignore or fears *347 to recognize.”(citation omitted) In my view, it is only by blinding itself to that other world that the Court can reach the result it announces today.

Ultimately, the result reached today may be traced to the Court's unwillingness to apply the constraints of the Constitution to decisions involving the expenditure of governmental funds. In today's decision,…the Court suggests that a withholding of funding imposes no real obstacle to a woman deciding whether to exercise her constitutionally protected procreative choice, even though the Government is prepared to fund all other medically necessary expenses, including the expenses of childbirth. The Court perceives this result as simply a distinction between an “limitation on governmental power” and “an affirmative funding obligation.” (citation omitted) For a poor person attempting to exercise her “right” to freedom of choice, the difference is imperceptible. As my Brother BRENNAN has shown,…the differential distribution of incentives-which the Court concedes is present here, [citation omitted] can have precisely the same effect as an outright prohibition. It is no more sufficient an answer here than it was in Roe v. Wade to say that “the appropriate forum' ” for the resolution of sensitive policy choices is the legislature. [citation omitted]

.

More than 35 years ago, Mr. Justice Jackson observed that the “task of translating the majestic generalities of the Bill of Rights . . . into concrete restraints on officials dealing with the problems of the twentieth century, is one to disturb self-confidence.” [citation omitted] These constitutional principles, he observed for the Court, “grew in soil which also produced a philosophy that the individual['s] . . . liberty was attainable through mere absence of governmental restraints.” Ibid. Those principles must be “transplant[ed] . . . to a soil in which the laissez-faire concept or principle of *348 has withered at least as to economic affairs, and social advancements are increasingly sought through closer integration of society and through expanded and strengthened governmental controls.” (citation omitted).

In this case, the Federal Government has taken upon itself the burden of financing practically all medically necessary expenditures. One category of medically necessary expenditure has been singled out for exclusion, and the sole basis for the exclusion is a premise repudiated for purposes of constitutional law in Roe v. Wade. The consequence is a devastating impact on the lives and health of poor women. I do not believe that a Constitution committed to the equal protection of the laws can tolerate this result. I dissent.

142 S.Ct. 1539

Supreme Court of the United States.

UNITED STATES, Petitioner

v.

Jose Luis VAELLO MADERO

No. 20-303

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Argued November 9, 2021

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Decided April 21, 2022

Justice KAVANAUGH delivered the opinion of the Court.

*1541 The United States includes five Territories: American Samoa, Guam, the Northern Mariana Islands, the U. S. Virgin Islands, and Puerto Rico. This case involves Puerto Rico, which became a U. S. Territory in 1898 in the wake of the Spanish-American War.

For various historical and policy reasons, including local autonomy, Congress has not required residents of Puerto Rico to pay most federal income, gift, estate, and excise taxes. Congress has likewise not extended certain federal benefits programs to residents of Puerto Rico.

The question presented is whether the equal-protection component of the Fifth Amendment’s Due Process Clause requires Congress to make Supplemental Security Income benefits available to residents of Puerto Rico to the same extent that Congress makes those benefits available to residents of the States. In light of the text of the Constitution, longstanding historical practice, and this Court’s precedents, the answer is no.

* * *

The Territory Clause of the Constitution states that Congress may “make all needful Rules and Regulations respecting the Territory ... belonging to the United States.” Art. IV, § 3, cl. 2. The text of the Clause affords Congress broad authority to legislate with respect to the U. S. Territories.

Exercising that authority, Congress sometimes legislates differently with respect to the Territories, including Puerto Rico, than it does with respect to the States. That longstanding congressional practice reflects both national and local considerations. In tackling the many facets of territorial governance, Congress must make numerous policy judgments that account not only for the needs of the United States as a whole but also for (among other things) the unique histories, economic conditions, social circumstances, independent policy views, and relative autonomy of the individual Territories.

Of relevance here, Congress must decide how to structure federal taxes and benefits for residents of the Territories. In doing *1542 so, Congress has long maintained federal tax and benefits programs for residents of Puerto Rico and the other Territories that differ in some respects from the federal tax and benefits programs for residents of the 50 States.

On the tax side, for example, residents of Puerto Rico are typically exempt from most federal income, gift, estate, and excise taxes. [citations omitted] At the same time, residents of Puerto Rico generally pay Social Security, Medicare, and unemployment taxes.[citations omitted]

On the benefits side, residents of Puerto Rico are eligible for Social Security and Medicare. [citations omitted]. Residents of Puerto Rico are also eligible for federal unemployment benefits.[citations omitted]

But just as not every federal tax extends to residents of Puerto Rico, so too not every federal benefits program extends to residents of Puerto Rico. One example is the Supplemental Security Income program…[citations omitted] The Supplemental Security Income program provides benefits for, among others, those who are age 65 or older and cannot financially support themselves.

To be eligible for Supplemental Security Income, an individual must be a “resident of the United States,” which the statute defines as the 50 States and the District of Columbia. A later statute included residents of the Northern Mariana Islands in the program. [citations omitted]But residents of Puerto Rico are not eligible for Supplemental Security Income. Instead, the Federal Government provides supplemental income assistance to covered residents of Puerto Rico through a different benefits program—one that is funded in part by the Federal Government and in part by Puerto Rico. [citations omitted]

The dispute in this case concerns a claim for Supplemental Security Income benefits by a resident of Puerto Rico named Jose Luis Vaello Madero. In 2013, Vaello Madero moved from New York to Puerto Rico. While he lived in New York, Vaello Madero received Supplemental Security Income benefits. After moving to Puerto Rico, Vaello Madero no longer was eligible for Supplemental Security Income benefits. Yet for several years, the U. S. Government remained unaware of Vaello Madero’s new residence and continued to pay him benefits. The overpayment totaled more than $28,000.

Seeking to recover those errant payments, the U. S. Government sued Vaello Madero for restitution. In response, Vaello Madero invoked the U. S. Constitution. Vaello Madero argued that Congress’s exclusion of residents of Puerto Rico from the Supplemental Security Income program violated the equal-protection component of the Fifth Amendment’s Due Process Clause.

Vaello Madero’s constitutional argument prevailed in the District Court and the Court of Appeals, [citations omitted] and we granted certiorari [citations omitted]. We respectfully disagree with those Courts. In our view, this Court’s precedents, in addition to the constitutional text and historical practice discussed above, establish that Congress may distinguish the  *1543 Territories from the States in tax and benefits programs such as Supplemental Security Income, so long as Congress has a rational basis for doing so.

***

Puerto Rico’s tax status—in particular, the fact that residents of Puerto Rico are typically exempt from most federal income, gift, estate, and excise taxes—supplies a rational basis for likewise distinguishing residents of Puerto Rico from residents of the States for purposes of the Supplemental Security Income benefits program. [citations omitted]  In devising tax and benefits programs, it is reasonable for Congress to take account of the general balance of benefits to and burdens on the residents of Puerto Rico. In doing so, Congress need not conduct a dollar-to-dollar comparison of how its tax and benefits programs apply in the States as compared to the Territories, either at the individual or collective level. [citations omitted] Congress need only have a rational basis for its tax and benefits programs. Congress has satisfied that requirement here.

Moreover, Vaello Madero’s position would usher in potentially far-reaching consequences. For one, Congress would presumably need to extend not just Supplemental Security Income but also many other federal benefits programs to residents of the Territories in the same way that those programs cover residents of the States. And if this Court were to require identical treatment on the benefits side, residents of the States could presumably insist that federal taxes be imposed on residents of Puerto Rico and other Territories in the same way that those taxes are imposed on residents of the States. Doing that, however, would inflict significant new financial burdens on residents of Puerto Rico, with serious implications for the Puerto Rican people and the Puerto Rican economy. The Constitution does not require that extreme outcome.¹

*1544

* * *

The Constitution affords Congress substantial discretion over how to structure federal tax and benefits programs for residents of the Territories. Exercising that discretion, Congress may extend Supplemental Security Income benefits to residents of Puerto Rico. Indeed, the Solicitor General has informed the Court that the President supports such legislation as a matter of policy. But the limited question before this Court is whether, under the Constitution, Congress must extend Supplemental Security Income to residents of Puerto Rico to the same extent as to residents of the States. The answer is no. We therefore reverse the judgment of the U. S. Court of Appeals for the First Circuit.

It is so ordered.