Colon Health Centers v. Bill Hazel
Filing
PUBLISHED AUTHORED OPINION filed. Originating case number: 1:12-cv-00615-CMH-TCB. [999224261]. [12-2272]
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PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 12-2272
COLON HEALTH CENTERS OF AMERICA, LLC; WASHINGTON IMAGING
ASSOCIATES-MARYLAND, LLC, d/b/a Progressive Radiology,
Plaintiffs - Appellants,
v.
BILL HAZEL, in his official capacity as Secretary of Health
and Human Resources; BRUCE EDWARDS, in his official capacity
as Chairman of the Virginia State Board of Health; PAUL
CLEMENTS, in his official capacity as member of the Virginia
State Board of Health; KAY R. CURLING, in her official
capacity as member of the Virginia State Board of Health;
ERIC DEATON, in his official capacity as member of the
Virginia State Board of Health; JOHN DETRIQUET, in his
official capacity as member of the Virginia State Board of
Health; JAMES E. EDMONDSON, JR., in his official capacity as
member of the Virginia State Board of Health; STEVEN R.
ESCOBAR, in his official capacity as member of the Virginia
State Board of Health; H. ANNA JENG, in her official
capacity as member of the Virginia State Board of Health;
CHARLES K. JOHNSON, in his official capacity as member of
the Virginia State Board of Health; BENNIE MARSHALL, in his
official capacity as member of the Virginia State Board of
Health; MARY MCCLUSKEY, in her official capacity as member
of the Virginia State Board of Health; M. CATHERINE SLUSHER,
in her official capacity as member of the Virginia State
Board of Health; GAIL TAYLOR, in her official capacity as
member of the Virginia State Board of Health; AMY VEST, in
her official capacity as member of the Virginia State Board
of Health; ERIC O. BODIN, in his official capacity as Acting
Director of the Office of Licensure and Certification and
Director of the Division of Certificate of Public Need;
MAUREEN DEMPSEY, in her official capacity as State Health
Commissioner; JOHN W. SEEDS, in his official capacity as
member of the Virginia State Board of Health,
Defendants - Appellees.
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-----------------------------PACIFIC LEGAL FOUNDATION; CURVEBEAM, LLC,
Amici Supporting Appellants.
Appeal from the United States District Court for the Eastern
District of Virginia, at Alexandria.
Claude M. Hilton, Senior
District Judge. (1:12-cv-00615-CMH-TCB)
Argued:
September 19, 2013
Decided:
October 23, 2013
Before WILKINSON and KING, Circuit Judges, and Samuel G. WILSON,
United States District Judge for the Western District of
Virginia, sitting by designation.
Affirmed in part, reversed in part, and remanded by published
opinion. Judge Wilkinson wrote the opinion, in which Judge King
and Judge Wilson joined.
Judge Wilson wrote a concurring
opinion.
ARGUED: Robert McNamara, INSTITUTE FOR JUSTICE, Arlington,
Virginia, for Appellants. Earle Duncan Getchell, Jr., OFFICE OF
THE ATTORNEY GENERAL OF VIRGINIA, Richmond, Virginia, for
Appellees.
ON BRIEF: William H. Mellor, Lawrence Salzman,
Darpana M. Sheth, INSTITUTE FOR JUSTICE, Arlington, Virginia,
for Appellants. Kenneth T. Cuccinelli, II, Attorney General of
Virginia,
Michael
H.
Brady,
Assistant
Solicitor
General,
Patricia L. West, Chief Deputy Attorney General, Wesley G.
Russell, Jr., Deputy Attorney General, OFFICE OF THE ATTORNEY
GENERAL OF VIRGINIA, Richmond, Virginia, for Appellees. Timothy
Sandefur, PACIFIC LEGAL FOUNDATION, Sacramento, California, for
Amicus Pacific Legal Foundation.
Lewis S. Wiener, David W.
Arrojo, SUTHERLAND ASBILL & BRENNAN LLP, Washington, D.C., for
Amicus Curvebeam, LLC.
2
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WILKINSON, Circuit Judge:
Appellants are out-of-state medical providers who seek to
open facilities in Virginia similar to those they operate in
other states. They are hindered by Virginia’s certificate-ofneed requirement, which they challenged in the court below under
a variety of constitutional theories. That court dismissed the
suit for failure to state a claim upon which relief could be
granted. We reverse the dismissal of appellants’ Commerce Clause
claims,
affirm
the
dismissal
of
their
Fourteenth
Amendment
claims, and remand for further proceedings in accordance with
this decision.
I.
A.
In order to launch a medical enterprise in the state of
Virginia, a firm is required to obtain a “certificate of public
need.” Va. Code Ann. §§ 32.1-102.1 et. seq.; 12 Va. Admin. Code
§§
5-220-10
governs
state,
most
et
seq.
Virginia’s
medical
including
the
capital
certificate-of-need
expenditures
construction
of
new
undertaken
facilities
program
in
the
and
the
addition of new equipment or services to an existing facility.
It
does
not,
however,
apply
to
the
replacement
of
existing
equipment. At its core, the program mandates that an applicant
demonstrate, within the relevant region, a public need for the
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service that it seeks to offer. Va. Code Ann. § 32.1-102.3(A).
The
primary
purposes
of
the
requirement
are
to
preclude
the
development of excess capacity, to ensure proper geographical
distribution
of
medical
facilities,
to
protect
the
economic
viability of existing providers, and to promote the provision of
cost-effective medical services. Appellees’ Br. at 2-3.
In
determining
whether
a
particular
applicant
has
demonstrated a sufficient public need for its proposed services,
the State Health Commissioner is required to consider a variety
of
factors.
factor
is
instance,
facility
Va.
Code
Ann.
dispositive.
“[t]he
The
extent
fosters
§
32.1-102.3(B)(1)-(8).
Commissioner
to
which
institutional
the
must
single
consider,
proposed
competition
No
that
for
service
benefits
or
the
area to be served,” in addition to “[t]he relationship of the
project to the existing health care system of the area to be
served,
including
the
utilization
and
efficiency
of
existing
services or facilities.” Id. § 32.1-102.3(B)(4)-(5).
Firms
required
that
to
unpredictable
desire
navigate
to
obtain
a
potentially
application
a
process.
certificate
The
lengthy,
cost
of
of
need
are
costly,
and
applying
is
pegged at one percent of the proposed expenditure, with a cap of
$20,000. In the review scheme, different types of submissions
are
grouped
into
subcategories
for
simultaneous
review
in
a
process referred to as “batching.” The statute facially requires
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the review process to be completed within 190 days of the start
of the relevant batching cycle.
Following the submission of an application, the appropriate
regional
health
planning
agency
must
complete
its
initial
investigation within 60 days. This stage of review includes a
public
hearing
in
proximity
to
the
site
of
the
proposed
expenditure. Affected persons are permitted to submit data to
assist the agency in its task. Subsequent to this preliminary
examination, the agency must provide the Department of Health
with
its
recommendation
regarding
the
disposition
of
the
application.
The Department is then required to determine whether an
informal fact-finding conference is warranted. Such a conference
will be held if the Department independently determines that it
is necessary or if an intervening party demonstrates that good
cause exists to hold such a hearing. Good cause exists if “(i)
there
is
presented
significant
at
and
not
relevant
available
information
at
the
time
not
of
previously
the
public
hearing, (ii) there have been significant changes in factors or
circumstances
relating
to
the
application
subsequent
to
the
public hearing, or (iii) there is a substantial material mistake
of
fact
or
law
in
the
Department
staff’s
report
on
the
application or in the report submitted by the health planning
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agency.” Id. § 32.1-102.6(G); see also 12 Va. Admin. Code § 5220-230(A).
The date on which the record closes varies depending on
whether
an
application
informal
is
fact-finding
deemed
approved
conference
if
the
is
conducted.
Commissioner
fails
An
to
issue a decision within 70 days of the closing of the record.
Appellants
allege
that
“[w]ithout
an
informal
fact-finding
conference, the entire application process and review can take
six to seven months to complete. If an informal fact-finding
conference is requested by any person, the certificate-of-need
process can take significantly longer.” Compl. ¶ 136. In their
brief before this court, appellants elaborate on this claim by
asserting
that
the
process
“can
take
literally
years.”
Appellants’ Br. at 11.
B.
Appellants, Colon Health Centers and Progressive Radiology,
are medical providers who seek to avoid the purportedly onerous
burdens
imposed
by
the
certificate
application
process.
Each
desires to offer potentially valuable services in the Virginia
market.
Colon
Health
“combines
the
advantages
of
the
two
prevailing colon-cancer screening methods in a ‘one-stop shop’
that screens, diagnoses, and treats colon cancer.” Compl. ¶ 47.
Traditional
colon-cancer
screening
involves
an
invasive
procedure referred to as optical colonoscopy. The alternative,
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virtual colonoscopy, relies on noninvasive computed tomography
(CT) scans but, unlike optical colonoscopy, does not permit the
treating physician to immediately remove any detected polyps.
Instead, a second visit is typically required.
Colon
images
Health
captured
circumvents
via
this
virtual
problem
colonoscopy
by
exporting
to
a
the
team
of
radiologists, who immediately scan the images for polyps. They
report
their
conclusions
within
an
hour
to
an
on-site
gastroenterologist, who is able to perform the necessary surgery
without
recalling
streamlined
the
approach
colonoscopy,
thus
patient
reduces
for
the
encouraging
a
a
cost
higher
second
and
visit.
This
inconvenience
percentage
of
of
at-risk
individuals to undergo screening.
Colon Health currently provides joint virtual colonoscopy
and treatment services at offices in Delaware and New Jersey.
Its attempts to enter the Virginia market, however, were stymied
after
potential
competitors
intervened
to
oppose
its
certificate-of-need application. Id. ¶ 140. It alleges that, in
the
absence
of
the
certificate
requirement
(which
covers
CT
scanners), it would open Virginia facilities offering its unique
package of services.
Progressive
Radiology
specializes
in
using
magnetic
resonance imaging (MRI) to diagnose neurological and orthopedic
injuries.
Id.
¶¶
75-76.
Progressive
7
currently
maintains
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radiology facilities in Maryland and the District of Columbia.
It
formerly
operated
a
radiology
business
in
Virginia,
but
ceased to do so when the facility which had contracted for its
services was purchased and the contract subsequently terminated.
Like
Colon
Health,
Progressive
alleges
that
the
certificate
requirement, which covers MRI machines, deters it from providing
its
specialized
services
in
the
Commonwealth.
Progressive
estimates that it would serve approximately 400 patients per
month if it were permitted to reenter the market.
Notably, Virginia does not contend that either Colon Health
or Progressive is unqualified to render the services that each
seeks to offer in the state, nor does it deny that the firms’
respective
sources
of
facilities
funding.
would
It
be
also
financed
makes
entirely
private
attempt
no
by
to
contest
appellants’ assertion that the proffered services are medically
uncontroversial
and
would
be
performed
by
state-licensed
physicians. Id. ¶ 41.
Appellants
challenged
the
certificate
program
in
the
district court, alleging that it violates the dormant Commerce
Clause
in
addition
to
the
Fourteenth
Amendment’s
Equal
Protection, Due Process, and Privileges or Immunities Clauses.
The
court
Clause,
concluded,
that
the
with
respect
to
the
certificate-of-need
dormant
Commerce
program
was
nondiscriminatory, served legitimate local purposes, and imposed
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negligible
respect
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burdens
to
on
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interstate
appellants’
commerce.
Fourteenth
J.A.
Amendment
142-47.
challenges,
With
the
district court held that the statute was supported by a rational
basis. Id.
at
131-42.
In
an
opinion
that
reproduced,
almost
verbatim, appellees’ memorandum in support of their motion to
dismiss, the court dismissed the entire suit under Federal Rule
of Civil Procedure 12(b)(6) for failure to state a claim. Id. at
147. This appeal followed.
II.
Appellants’ most serious challenge to the certificate-ofneed
requirement
is
predicated
on
the
dormant
aspect
of
the
Constitution’s Commerce Clause. The Commerce Clause authorizes
Congress
“[t]o
regulate
Commerce
.
.
.
among
the
several
States.” U.S. Const. art. I, § 8, cl. 3. By its terms, the
clause does not explicitly restrain the conduct of the states.
It is “well-established,” however, “that this affirmative grant
of authority implies a ‘negative’ or ‘dormant’ constraint on the
power of the States to enact legislation that interferes with or
burdens interstate commerce.” Brown v. Hovatter, 561 F.3d 357,
362 (4th Cir. 2009) (citing Dennis v. Higgins, 498 U.S. 439, 447
(1991)). As relevant here, “[t]he dormant Commerce Clause is
implicated by burdens placed on the flow of interstate commerce
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-- the flow of goods, materials, and other articles of commerce
across state lines.” Id. at 364.
Modern dormant Commerce Clause jurisprudence is motivated
primarily by a desire to limit “economic protectionism -- that
is, regulatory measures designed to benefit in-state economic
interests
by
burdening
out-of-state
competitors.”
Dep’t
of
Revenue of Ky. v. Davis, 553 U.S. 328, 337-38 (2008) (internal
quotation
marks
omitted).
By
invalidating
unlawfully
impede
interstate
commerce,
courts
statutes
that
effectuate
the
Framers’ desire to prevent the “economic Balkanization” “‘that
had plagued relations among the Colonies and later among the
States
under
the
Articles
of
Confederation.’”
Id.
at
338
(quoting Hughes v. Oklahoma, 441 U.S. 322, 325-26 (1979)).
A.
As
the
Court’s
concern
with
economic
protectionism
suggests, “[t]he principal objects of dormant Commerce Clause
scrutiny
are
statutes
that
discriminate
against
interstate
commerce.” CTS Corp. v. Dynamics Corp. of Am., 481 U.S. 69, 87
(1987)
(emphasis
differential
interests
added).
treatment
that
benefits
of
“‘[D]iscrimination’
in-state
the
former
simply
means
and
out-of-state
economic
and
burdens
latter.”
the
Oregon Waste Sys., Inc. v. Dep’t of Envtl. Quality, 511 U.S. 93,
99
(1994).
A
statute
may
discriminate
“facially,
in
its
practical effect, or in its purpose.” Envtl. Tech. Council v.
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Sierra Club, 98 F.3d 774, 785 (4th Cir. 1996) (citing Wyoming v.
Oklahoma, 502 U.S. 437, 454-55 (1992)).
The discrimination test thus has an empirical as well as a
formal dimension: merely noting a law’s facial neutrality is
insufficient
under
this
analysis.
“The
principal
focus
of
inquiry must be the practical operation of the statute, since
the validity of state laws must be judged chiefly in terms of
their probable effects.” Lewis v. BT Inv. Managers, Inc., 447
U.S.
27,
37
(1980);
see
also
Yamaha
Motor
Corp.
v.
Jim’s
Motorcycle, Inc., 401 F.3d 560, 568 (4th Cir. 2005). In order to
prove
discriminatory
demonstrate
that
the
effect,
for
challenged
instance,
statute,
“if
plaintiffs
must
enforced,
would
negatively impact interstate commerce to a greater degree than
intrastate commerce.” Waste Mgmt. Holdings, Inc. v. Gilmore, 252
F.3d 316, 335 (4th Cir. 2001).
In conducting the discrimination inquiry, a court should
focus
on
discrimination
against
interstate
commerce
--
not
merely discrimination against the specific parties before it.
See Exxon Corp. v. Governor of Md., 437 U.S. 117, 127 (1978)
(noting
that
the
Commerce
Clause
“protects
the
interstate
market, not particular interstate firms”). The district court
opinion here appeared to contravene this principle at various
points. See J.A. 145-46 (declining to find a substantial burden
on
interstate
commerce
in
part
11
because
appellants
are
“two
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small
discrimination
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businesses”).
against
individual
Focusing
firms,
exclusively
however,
on
improperly
narrows the scope of the judicial inquiry and has the baneful
effect of precluding certain meritorious claims. For while the
burden on a single firm may have but a negligible impact on
interstate commerce, the effect of the law as a whole and in the
aggregate may be substantial.
B.
State laws that discriminate against interstate commerce in
any of the three ways identified by this court -- facially, in
practical effect, or in purpose -- are subject to “a virtually
per
se
rule
(internal
of
invalidity.”
quotation
marks
Wyoming,
omitted).
502
Under
U.S.
this
at
454-55
variant
of
“strict scrutiny analysis,” Waste Mgmt. Holdings, 252 F.3d at
334,
a
court
must
invalidate
the
challenged
law
“unless
the
state demonstrates ‘both that the statute serves a legitimate
local purpose, and that this purpose could not be served as well
by available nondiscriminatory means.’” Yamaha, 401 F.3d at 567
(quoting Maine v. Taylor, 477 U.S. 131, 138 (1986) (internal
quotation marks omitted)).
Here,
appellants
concede
that
Virginia’s
certificate-of-
need law is not facially discriminatory. Appellants’ Br. at 21
n.3. The statute applies to all firms that seek to engage in the
covered activities (e.g., expansion of an existing facility or
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construction of a new one), regardless of their geographical
location.
Appellants
do,
however,
allege
discrimination
in
both
purpose and effect. Compl. ¶¶ 200-07. With respect to purpose,
they declare that “[t]he primary goal of Virginia’s certificateof-need program is to provide current healthcare providers with
a government-backed shield from competition.” Id. ¶ 103. More
concretely,
they
point
to
an
implementing
regulation
which
states that the certificate requirement is intended, at least in
part, to “‘discourage[] the proliferation of services that would
undermine
the
ability
of
essential
community
providers
to
maintain their financial viability.’” Id. ¶ 104 (quoting 12 Va.
Admin.
Code
§
5-230-30).
Under
this
theory,
since
current
medical providers are by definition in-state entities, a major
purpose of the certificate requirement is to protect them at the
expense of new out-of-state entrants, such as Colon Health and
Progressive. Id. ¶¶ 43, 103, 200.
Appellants’ allegations of discriminatory effect are rooted
in the administrative process prescribed by the statutory text.
As
noted,
authorizing
the
relevant
individuals
to
code
sections
request
an
include
informal
a
proviso
fact-finding
conference to further examine the implications of a particular
application. Va. Code Ann. § 32.1-102.6; see also 12 Va. Admin.
Code § 5-220-230(A). Appellants assert that the default process
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requires between six and seven months to complete, but that the
addition of an informal fact-finding conference can result in
the process taking “significantly longer.” Compl. ¶ 136. Such a
prolonged
delay
may
occur
in
part
because,
“[d]espite
the
‘informal’ label, [fact-finding conferences] can resemble fullblown litigation, involving attorneys, adversarial parties, and
expert witnesses.” Id. ¶ 134. Appellants further allege that,
“[u]pon
almost
information
exclusively
and
belief,
requested
by
fact-finding
entities
conferences
that
would
be
are
in
economic competition with” the applicant. Id. ¶ 137.
According to this characterization, Virginia’s certificateof-need program grants established, in-state economic interests
the power to obstruct the market entrance of new, primarily outof-state competitors in two ways. First, by requesting factfinding
conferences,
established
interests
can
dramatically
lengthen the application process, thus increasing the costs and
uncertainty borne by the applicant. Second, objecting firms may
influence
the
substantive
outcome
of
the
process
through
an
effective adversarial presentation at the conference. Apart from
these practical advantages, the intervention proviso also grants
a structural edge to local firms: if an established, in-state
facility desires to expand its operations, it will necessarily
face one fewer objector than would an out-of-state firm that
seeks to enter the market de novo -- itself.
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All these allegations raise practical questions of fact. It
is
entirely
possible
that
in-state
interests
frequently
commandeer the process to derail the applications of out-ofstate firms, but whether this outcome actually obtains cannot be
resolved without examining the functioning of the statute in
practice. Similarly, it may be that the Commissioner, although
charged
with
considering
a
variety
of
factors,
focuses
exclusively on protecting existing businesses. See Walgreen Co.
v.
Rullan,
405
discriminates
F.3d
against
50,
55
(1st
interstate
Cir.
commerce
2005)
by
(“[T]he
Act
permitting
the
Secretary to block a new pharmacy from locating in its desired
location simply because of the adverse competitive effects that
the new pharmacy will have on existing pharmacies.”). Whether
this
actually
occurs,
however,
cannot
be
ascertained
in
the
absence of proper fact-finding.
Thus,
law
determining
discriminates
requires
looking
in
whether
either
behind
the
Virginia’s
purpose
statutory
or
certificate-of-need
effect
text
to
necessarily
the
actual
operation of the law. This conclusion is confirmed by a host of
precedents which have repeatedly emphasized the factual nature
of the dormant Commerce Clause inquiry. The Supreme Court has
observed, for instance, that “when considering the purpose of a
challenged
statute,
[courts
are]
not
bound
by
[t]he
name,
description or characterization given it by the legislature or
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the courts of the State, but will determine for [themselves] the
practical impact of the law.” Hughes, 441 U.S. at 336 (internal
quotation
marks
consciously
omitted).
“eschewed
In
this
formalism
for
respect,
a
the
sensitive,
Court
has
case-by-case
analysis of purposes and effects.” West Lynn Creamery, Inc. v.
Healy, 512 U.S. 186, 201 (1994).
The
fact-intensive
quality
of
the
substantive
inquiry
assumes heightened importance when considered in light of the
procedural posture of the instant dispute. “To survive a motion
to dismiss, a complaint must [merely] contain sufficient factual
matter, accepted as true, to ‘state a claim to relief that is
plausible on its face.’” Ashcroft v. Iqbal, 556 U.S. 662, 678
(2009) (quoting Bell Atlantic Corp. v. Twombly, 550 U.S. 544,
570
(2007)).
Rule
12(b)(6)
“does
not
countenance
.
.
.
dismissals based on a judge’s disbelief of a complaint’s factual
allegations.” Neitzke v. Williams, 490 U.S. 319, 327 (1989).
Here, appellants’ claims of discrimination are sufficient “to
raise
[their]
right
to
relief
above
the
speculative
level.”
Twombly, 550 U.S. at 555. They therefore satisfy the standard
articulated in the above precedents. The district court gave a
serious claim the back of its hand. This was error.
C.
Even
if
Virginia’s
certificate-of-need
requirement
discriminates neither in purpose nor in effect, it may still be
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unconstitutional under Pike v. Bruce Church, Inc., 397 U.S. 137
(1970), if it places an “undue burden” on interstate commerce.
Yamaha,
401
F.3d
at
567.
“Where
[a]
statute
regulates
even-
handedly to effectuate a legitimate local public interest, and
its effects on interstate commerce are only incidental, it will
be upheld unless the burden imposed on such commerce is clearly
excessive in relation to the putative local benefits.” Pike, 397
U.S. at 142.
Unlike the more exacting standard of review employed in the
context of discriminatory statutes, “[a] ‘less strict scrutiny’
applies under the undue burden tier.” Yamaha, 401 F.3d at 567
(quoting Wyoming, 502 U.S. at 455 n.12). The putative benefits
of a challenged law are evaluated under the rational basis test,
id. at 569, though “speculative” benefits will not pass muster,
Medigen of Ky., Inc. v. Pub. Serv. Comm’n, 985 F.2d 164, 167
(4th Cir. 1993). “The Pike test requires closer examination,
however, when a court assesses a statute’s burdens, especially
when the burdens fall predominantly on out-of-state interests.”
Yamaha, 401 F.3d at 569. The test is therefore deferential but
not toothless. See Davis, 553 U.S. at 339.
Appellants
program
“does
contend
not
that
actually
Virginia’s
achieve
any
certificate-of-need
legitimate
local
benefits.” Compl. ¶ 208. To substantiate this claim, appellants
cite a joint report issued by the Department of Justice and the
17
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Federal Trade Commission concluding that certificate “programs
are not successful in containing health care costs, and . . .
pose serious anticompetitive risks that usually outweigh their
purported economic benefits.” Id. ¶ 99. Appellants also allege
that the Virginia program substantially burdens the interstate
market for both medical devices and services. Id. ¶¶ 194-99,
202.
Appellants’ contentions find some support in the case law.
For example, with regard to putative local benefits, the Medigen
court
invalidated
a
certificate-of-need
program
because
“[r]estricting market entry” not only fails to expand service
availability, but also “does nothing to [e]nsure that services
are
provided
Furthermore,
at
with
reasonable
respect
to
prices.”
burdens
985
on
F.2d
interstate
at
167.
commerce,
Virginia’s certificate program may be “uniquely anti-competitive
even as [certificate-of-need] laws go.” Yamaha, 401 F.3d at 571.
Apart from Virginia, only Connecticut and Michigan are said to
have
similarly
onerous
certificate
requirements
for
low-value
devices like CT and MRI scanners. Br. for Curvebeam, LLC as
Amicus Curiae at 23. Finally, this court has recognized that
when the burdens of a challenged law fall primarily on out-ofstate economic interests -- as appellants allege is the case
with
respect
to
Virginia’s
statute
18
--
the
state’s
political
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process
Filed: 10/23/2013
cannot
be
relied
Pg: 19 of 28
upon
to
rectify
legislative
abuse.
Yamaha, 401 F.3d at 573.
The Pike inquiry, like the discrimination test, is factbound.
“If
a
legitimate
local
purpose
is
found,
then
the
question becomes one of degree. And the extent of the burden
that will be tolerated will of course depend on the nature of
the local interest involved, and on whether it could be promoted
as well with a lesser impact on interstate activities.” Pike,
397 U.S. at 142. We shall not attempt to forecast what further
investigation may demonstrate. The fact-intensive character of
this inquiry, however, counsels against a premature dismissal.
As
noted
above,
in
order
to
survive
a
motion
to
dismiss,
plaintiffs’ “[f]actual allegations must be enough to raise a
right
to
relief
above
the
speculative
level,
.
.
.
on
the
assumption that all the allegations in the complaint are true
(even if doubtful in fact).” Twombly, 550 U.S. at 555. In the
instant
case,
appellants
have
succeeded
in
“nudg[ing]
their
claims across the line from conceivable to plausible.” Id. at
570. This particular challenge too presents issues of fact that
cannot be properly resolved on a motion to dismiss. The district
court therefore erred in dismissing appellants’ Pike claim.
D.
On remand, the factual development of the dormant Commerce
Clause
claims
should
focus
primarily
19
on
the
discriminatory
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Pg: 20 of 28
effects test. In particular, the proceedings must investigate
the differential burdens imposed on out-of-state and in-state
firms subject to the certificate-of-need process. The fulcrum of
this inquiry will be whether the certificate requirement erects
a special barrier to market entry by non-domestic entities. As
noted, the district court should not confine its focus to the
effect on appellants alone, but should instead survey the burden
imposed on interstate commerce generally.
The
discriminatory
effects
test
represents
the
superior
framework of analysis for two reasons. First, this standard,
although fact-intensive, has the virtue of providing a clearer
measure by which to gauge the challenged statute’s validity. The
Pike test is often too soggy to properly cabin the judicial
inquiry or effectively prevent the district court from assuming
a
super-legislative
role.
See,
e.g.,
Davis,
553
U.S.
at
353
(declining to apply Pike because “the Judicial Branch is not
institutionally suited to draw reliable conclusions of the kind
that
would
be
necessary
for
[plaintiffs]
to
satisfy
a
Pike
burden in this particular case”). Second, the factual material
relevant to the Pike standard largely overlaps with evidence
germane
to
the
effect
of
the
constitutes
the
discrimination
challenged
principal
test.
statute
focus.
20
In
on
both
inquiries,
out-of-state
Discovery
on
the
the
firms
issue
of
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Filed: 10/23/2013
discrimination
should
Pg: 21 of 28
therefore
substantially
suffice
with
respect to Pike, as well.
Although the precise effects of the certificate program can
only be uncovered via fact-finding, further inquiry is likely to
confirm
that
outcomes.
the
requirement
First,
the
certificate
program
interstate
commerce.
produces
district
has
court
significant,
The
one
may
of
three
discover
deleterious
bureaucratic
red
tape
possible
that
effects
foisted
the
on
upon
businesses by the program may well be so cumbersome that, as a
functional
commerce
matter,
and
it
imposes
discourages
a
major
out-of-state
burden
on
firms
from
interstate
offering
important medical services in Virginia.
Second, it seems less likely, though conceivable, that the
requirement produces the opposite effect and actually stimulates
interstate commerce. In this scenario, firms are encouraged to
enter the market because the certificate program ensures that
they will have time to build patient goodwill, establish the
necessary
business
and
referral
relationships,
and
generally
acquire a market foothold before being economically submerged.
In
essence,
the
certificate
requirement
theoretically
grants
out-of-state firms a limited safe harbor to recoup the sizeable
capital investment that the establishment of a medical facility
requires.
21
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Finally,
commerce
may
Filed: 10/23/2013
the
certificate
be
entirely
Pg: 22 of 28
program’s
neutral,
or
effect
at
on
least
interstate
sufficiently
insubstantial to avoid implicating the dormant Commerce Clause.
The point is: we do not know. It is impossible to ascertain
which
of
these
potential
outcomes
actually
obtains
without
examining the practical operation of the statute and the actual,
concrete effects it has on out-of-state firms seeking to enter
the Virginia market.
III.
Appellants
also
assert
a
battery
of
claims
under
the
Fourteenth Amendment. Specifically, they allege that Virginia’s
certificate-of-need requirement violates the Equal Protection,
Due Process, and Privileges or Immunities Clauses. Unlike the
Commerce
Clause,
the
Fourteenth
Amendment
is
not
primarily
focused on commerce and economic discrimination against out-ofstate
interests,
and
its
general
provisions
provide
correspondingly less warrant for close judicial supervision. For
the
reasons
that
follow,
we
affirm
the
district
court’s
dismissal of each of these claims.
A.
First,
violates
Amendment.
appellants
the
This
Equal
argue
that
Protection
particular
claim
22
the
certificate
Clause
centers
of
on
the
the
requirement
Fourteenth
statute’s
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Pg: 23 of 28
treatment of nuclear cardiac imaging, which is exempted from the
certificate-of-need
requirement.
Compl.
¶
110.
Appellants
contend that nuclear cardiac imaging is “similarly situated to
other types . . . of medical imaging,” id. ¶ 111, and that the
differential treatment of the two is irrational and therefore
unconstitutional. See City of Cleburne v. Cleburne Living Ctr.,
473 U.S. 432, 439 (1985).
Non-suspect classifications -- such as the one at issue
here -- are “accorded a strong presumption of validity,” Heller
v. Doe, 509 U.S. 312, 319 (1993), and must be upheld “if there
is any reasonably conceivable state of facts that could provide
a rational basis” for the distinction, FCC v. Beach Commc’ns,
Inc., 508 U.S. 307, 313 (1993). This deferential standard is
informed
by
the
principle
that
“equal
protection
is
not
a
license for courts to judge the wisdom, fairness, or logic of
legislative choices.” Id.
Here,
Virginia
has
articulated
sufficient
justifications
for the nuclear cardiac imaging exemption to survive rational
basis
scrutiny.
State
legislators
could
reasonably
have
concluded, for instance, that nuclear cardiac imaging services
are provided in a different market than other imaging services,
and thus less susceptible to the dangers of excess capacity or
geographical misallocation. Appellees’ Br. at 54; see also 12
Va. Admin. Code § 5-230-30. Moreover, appellants have provided
23
Appeal: 12-2272
no
Doc: 66
general
Filed: 10/23/2013
context
or
Pg: 24 of 28
perspective
to
support
their
equal
protection challenge, and we are disinclined to pick apart the
Virginia statute specialty by specialty or to unravel a complex
medical regulatory scheme strand by strand. We thus affirm the
district
court’s
dismissal
of
appellants’
equal
protection
claim.
B.
Second, appellants argue that the certificate requirement
violates
the
Fourteenth
Appellants’
specific
substantive
rights
rests
the
on
irrationally
fails
to
Amendment’s
claim,
into
a
which
advance
whose
that
the
appellants’
any
seeks
clause
contention
burdens
Due
state
right
Process
to
focus
import
is
further
procedural,
certificate
to
earn
a
other
purpose
Clause.
than
bald
does
not
program
living
and
economic
protectionism. Compl. ¶¶ 221-25.
The
certificate-of-need
fundamental
rational
or
basis
enumerated
review
program
right
under
and
the
is
Due
infringe
therefore
Process
subject
Clause.
any
to
See
Washington v. Glucksberg, 521 U.S. 702, 719-20 (1997). Rational
basis scrutiny in the due process context -- as in the equal
protection context -- is quite deferential. See Star Scientific
Inc. v. Beales, 278 F.3d 339, 348-49 (4th Cir. 2002).
Here, appellants have failed to plausibly rebut the state’s
asserted justifications for the certificate-of-need program. The
24
Appeal: 12-2272
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state,
both
articulates
Filed: 10/23/2013
in
a
its
brief
variety
Pg: 25 of 28
and
of
its
implementing
legitimate
purposes
regulations,
served
by
the
statute, including ensuring geographically convenient access to
healthcare
for
Appellees’
Br.
Virginia
at
49-50.
residents
at
Appellants’
a
reasonable
cursory,
cost.
unsubstantiated
assertion that the statute fails to advance this purpose or any
other is insufficient to merit further factual inquiry. As is
the
case
with
their
equal
protection
claim,
appellants
have
failed to state a plausible due process entitlement to relief.
Iqbal, 556 U.S. at 678. The district court’s dismissal of this
count is therefore affirmed.
C.
Finally,
program
appellants
contravenes
the
contend
“right
that
to
the
earn
certificate-of-need
an
honest
living”
embodied in the Fourteenth Amendment’s Privileges or Immunities
Clause, which provides that “No State shall make or enforce any
law which shall abridge the privileges or immunities of citizens
of
the
United
States.”
They
concede,
however,
that
this
particular claim is foreclosed by the Supreme Court’s decision
in the Slaughter-House Cases, 83 U.S. 36, 79-80 (1872), which
confined the reach of that clause to a set of national rights
that
does
occupation.
not
This
include
court
the
right
lacks
the
to
pursue
authority
a
to
particular
disturb
an
unimpeached precedent issued by a superior tribunal. State Oil
25
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Pg: 26 of 28
Co. v. Khan, 522 U.S. 3, 20 (1997). This is especially the case
where
recognition
of
an
unenumerated
substantive
right
would
open the door to a host of textually dubious challenges to state
economic
regulation
dismissal
of
of
appellants’
every
sort.
privileges
The
or
district
immunities
court’s
claim
is
therefore affirmed.
IV.
In
sum,
appellants’
closer
scrutiny
court,
but
the
and
Commerce
further
Fourteenth
Clause
proceedings
Amendment
challenges
before
claims
require
the
district
were
properly
dismissed. We thus affirm in part, reverse in part, and remand
this
case
for
further
proceedings
in
accordance
with
this
decision.
AFFIRMED IN PART,
REVERSED IN PART,
AND REMANDED
26
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WILSON, District Judge, concurring:
Plaintiffs
Virginia
with
would
like
equipment
to
they
render
cannot
medical
utilize
services
without
in
first
proving to the Commonwealth that the competition they bring with
them will not harm established local health care providers.
In
my opinion, little distinguishes such a regulatory system from
one that offends the dormant commerce clause by isolating local
interests from the national economy.
A handful of states initially developed certificate of need
regulations in the 1960s.
Congress injected the certificate of
need regimen more broadly into national health care planning
when
it
enacted
the
National
Health
Planning
and
Resource
Development Act of 1974 (the “NHPRDA”), Pub. L. 93-641, 88 Stat.
2225, §§ 1-3, to control escalating health care costs and the
widely
diverging
NHPRDA
had
the
incidental
of
certificate
scrutiny.
availability
need
of
effect
regimens
health
of
from
care
services.
protecting
dormant
the
The
states’
commerce
clause
But twelve years later, Congress repealed the NHPRDA,
Pub. L. 99-60, 100 Stat. 3743 (1986), after its failures had
become
well
past
certificate
of
scrutiny.
Yet,
throughout
much
obvious.
need’s
shield
twenty-seven
of
the
The
NHPRDA’s
from
years
country,
repeal
dormant
later,
state
removed
commerce
in
clause
Virginia,
certificate
the
of
and
need
regimens continue to grow and now regulate an enormous segment
27
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of
Doc: 66
the
Filed: 10/23/2013
national
economy.
Pg: 28 of 28
The
Virginia
regimen
explicitly
regulates its share of that economy by using the certificate of
need to “discourage[] the proliferation of services that would
undermine
the
ability
of
essential
community
providers
to
maintain their financial viability.” 12 Va. Admin. Code § 5-23030
(2013).
Stripped
Commonwealth’s
providers”
purpose
(i.e.,
of
is
to
its
protect
established
effects of competition.
linguistic
pretense,
established
in-state
interests)
the
“community
from
the
Though this purpose or goal may be
legitimate, I find little difference in the means it employs to
accomplish that goal -- the limitation of competition -- from
illegitimate efforts to isolate local economic interests from
the national economy. Wyoming v. Oklahoma, 502 U.S. 437, 456-57
(1992)
(noting
legitimate
the
goal,’
court
only
to
has
“often
find
that
examined
the
State
a
‘presumably
attempted
to
achieve it by ‘the illegitimate means of isolating the State
from the national economy’”).
But even apart from its stated
purpose, in my view, a state regulatory system that chooses to
limit competition as its means to promote the delivery of health
care will still likely, if not inevitably, entangle itself with
the dormant commerce clause.
28
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