BRUNS v. MAYHEW

Filing 34

ORDER denying 5 Motion for Preliminary Injunction. By JUDGE JOHN A. WOODCOCK, JR. (MFS)

UNITED STATES DISTRICT COURT
DISTRICT OF MAINE
HANS BRUNS, et al.,
Plaintiffs,
v.
MARY MAYHEW, Commissioner,
Maine Department of Health and
Human Services,
Defendant.

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1:12-cv-00131-JAW

ORDER ON THE PLAINTIFFS’ MOTION FOR
PRELIMINARY INJUNCTION
In 1997, the state of Maine elected to cover noncitizens under its state
Medicaid program and it continued to do so until June 2011, when the Maine
Legislature passed Public Law 2011, chapter 380, section KK-4, terminating
Medicaid-ineligible alien health benefit coverage.

Noncitizens Hans Bruns and

Kadra Hassan, on behalf of themselves and a proposed class of Maine residents,
request that the Court declare Public Law 2011, chapter 380, section KK-4
unconstitutional and grant a preliminary injunction enjoining Mary Mayhew, the
Commissioner of the Maine Department of Health and Human Services (DHHS),
from enforcing the law. They also petition the Court to order the restoration of
their MaineCare benefits. The Plaintiffs claim that the 2011 Maine law violates the
Equal Protection Clause of the Fourteenth Amendment of the United States
Constitution because it discriminates against noncitizens in favor of citizens in the

administration of MaineCare benefits. After an analysis of the four preliminary
injunction factors, the Court denies the Plaintiffs’ motion because they are unable to
establish a likelihood of success on the merits of their equal protection claim.
I.

BACKGROUND
A.

Procedural Background

On April 4, 2012, Hans Bruns filed a class action complaint against Mary
Mayhew in her official capacity as the Commissioner of Maine DHHS. Class Action
Compl. for Declaratory and Inj. Relief (ECF No. 1) (Compl.). The Complaint was
amended on December 7, 2012 to join an additional Plaintiff, Kadra Hassan, in the
action. First Am. Class Action Compl. for Declaratory and Inj. Relief (ECF No. 25)
(First Am. Compl.). On April 4, 2012, the Plaintiffs moved for class certification,
Pls.’ Mot. for Class Certification (ECF No. 4), and for a preliminary injunction, Pls.’
Mot. for Prelim. Inj. (ECF No. 5) (Pls.’ Mot.). The Commissioner moved to dismiss
the Plaintiffs’ initial Complaint pursuant to Rule 12(b)(6) on May 11, 2012, Def.’s
Mot. to Dismiss (ECF No. 12), and opposed the Plaintiffs’ motions for class
certification and preliminary injunction.

Def.’s Opp’n to Pls.’ Mot. for Class

Certification (ECF No. 14); Def.’s Opp’n to Pl.’s Mot. for Prelim. Inj. (ECF No. 13)
(Def.’s Opp’n).
On May 25, 2012, the Plaintiffs filed their opposition to the Commissioner’s
motion to dismiss. Pls.’ Opp’n to Def.’s Mot. to Dismiss (ECF No. 17) (Pls.’ Opp’n).
They also replied to the Commissioner’s opposition to the motions for class
certification and preliminary injunction.

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Pls.’ Reply Mem. in Supp. of Class

Certification (ECF No. 15); Pls.’ Reply Mem. in Supp. of Prelim. Inj. (ECF No. 16)
(Pls.’ Reply).

On November 20, 2012, the Court dismissed the Commissioner’s

motion to dismiss without prejudice.
(ECF. No. 19) (Order).

Order on Commissioner’s Mot. to Dismiss

On December 19, 2012, the Commissioner filed an Answer

to the First Amended Complaint. Def.’s Ans. to First Am. Compl. (ECF No. 27)
(Def.’s Ans.).
B.

The Allegations
1.

Federal Medicaid and MaineCare Frameworks

Medicaid is a jointly funded state and federal program that provides medical
assistance to low-income individuals. First Am. Compl. ¶ 26. In 1973, the Maine
Legislature enacted Aid to Needy Persons, Public Law 1973, chapter 790, codifying
its decision to provide Medicaid coverage to all qualified individuals regardless of
their immigration status and alienage. Id. The state of Maine’s Medicaid program
is called MaineCare and Maine DHHS is responsible for administering MaineCare
to Maine residents. Id.
In 1996, Congress changed the eligibility requirements for federal Medicaid
with its enactment of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (PRWORA), Public Law No. 104-193, 110 Stat. 2105
(1996).

Id. ¶ 27.

PRWORA divided noncitizens into two groups for Medicaid

eligibility: qualified and non-qualified aliens. Id. Qualified aliens include lawful
permanent residents and certain other specified groups of individuals, such as
asylees and refugees. Id.

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The Act further divided qualified aliens into two groups for Medicaid
eligibility based upon the length of an alien’s residency in the United States. Id.
The law generally made Medicaid benefits unavailable to qualified aliens residing
in the United States after August 22, 1996 until the aliens had resided in the
United States for at least five years with qualifying status. Id. Nevertheless, the
law provided that these Medicaid-ineligible noncitizens could receive medical
assistance required to treat emergency medical conditions. Id. ¶ 28.
PRWORA also authorized states to decide whether to provide health benefit
services to Medicaid-ineligible noncitizens residing within their borders. Id. ¶ 29.
In response, in 1997, the Maine Legislature voted unanimously to pass Temporary
Assistance to Needy Families (TANF), Public Law 1997, chapter 530, section A-16,
which provided state-funded health benefit coverage to all legal noncitizens “‘who
would be eligible for the TANF or Medicaid programs but for their status as aliens
under PRWORA.’” Id. ¶ 30. However, in June 2011, the Maine Legislature passed
Public Law 2011, chapter 380, section KK-4, which terminated Medicaid-ineligible
aliens’ health benefit coverage under the 1997 law.

Id. ¶ 31.

Maine DHHS

implemented this new law through emergency rulemaking on September 1, 2011
and adopted it permanently as of December 5, 2011. Id.
2.

Hans Bruns

Hans Bruns resides in Fort Fairfield, Maine. Id. ¶ 10. Mr. Bruns became a
United States lawful permanent resident on December 16, 2007. Id. ¶ 10, 32. He is
indigent and, because of his low income, cannot afford to pay for private health

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insurance. Id. ¶ 32. Sometime in December 2010, Mr. Bruns began to receive
health insurance benefits through the state of Maine. Id. On September 1, 2011,
DHHS sent form termination notices to approximately five hundred noncitizens
living in Maine, including Mr. Bruns, informing them that their state-funded
coverage was being reduced to emergency care only. Id. ¶ 4. The State terminated
Mr. Bruns’ benefits on October 1, 2011. Id. ¶ 34.
After experiencing pain on the right side of his face for more than a year and
seeking treatment for a mass on the right side of his neck, Mr. Bruns was diagnosed
in late 2011 or early 2012 with adenoid cystic carcinoma of the right parotid gland
and an apparent lesion in his lung. Id. ¶¶ 11, 33. Mr. Bruns has experienced
extreme pain and suffering, which has impacted his ability to sleep, hear, and
swallow because of the large cancerous tumor in his neck. Id. ¶ 1.
Without full MaineCare benefits, Mr. Bruns has been unable to afford
medical care required to cure his condition, which includes services such as MRI
imaging, resection of the lesion, radiation, and chemotherapy.

Id. ¶¶ 1, 11 35.

Emergency care benefits under the State’s current MaineCare program could not
provide Mr. Bruns with the necessary medical services to treat his condition. Id. ¶
10. Because Mr. Bruns did not receive a timely diagnosis and treatment for his
cancer, he is now terminally ill and receiving hospice care. Id. ¶ 1.
3.

Kadra Hassan

Ms. Hassan was admitted to the United States as a non-immigrant on
December 25, 2010 and is awaiting a decision on her asylum application. Id. ¶ 36.

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She has lived in Maine for several years and currently resides in Lewiston. Id. ¶
12. Ms. Hassan suffers from Stage 5 Kidney Disease (End Stage Renal Disease)
and requires kidney dialysis several times per week, prescription medications, and
regular primary care physician visits, among other things.

Id. ¶¶ 13, 36.

Ms.

Hassan goes to kidney dialysis treatment several times a week. Id. ¶ 2. Like Mr.
Bruns, Ms. Hassan also requires medical care and treatment but cannot afford to
pay for that care without state subsidy. Id. ¶ 36.
In January of 2012, Ms. Hassan applied and was found eligible for
MaineCare benefits but was limited to emergency-only MaineCare benefits by
Maine DHHS due to her immigration status.

Id. ¶ 37.

Without treatment,

particularly dialysis and a kidney transplant, Ms. Hassan’s condition will
ultimately result in her death. Id. ¶ 36. Although she has been recommended for a
kidney transplant, Ms. Hassan was turned down for the operation because of her
lack of health insurance coverage. Id. ¶ 13.
II.

THE PARTIES’ POSITIONS
A.

The Plaintiffs’ Motion

The Plaintiffs claim they satisfy the first factor of the preliminary injunction
inquiry because the “State of Maine . . . plainly created a classification based upon
alienage that cannot survive strict scrutiny.” Pls.’ Mot. at 5. They contend that
Maine DHHS violated the Equal Protection Clause because the 2011 law created
“two classes of MaineCare recipients” based on the recipients’ immigration status
and because “citizens and noncitizens in Maine were always part of, and granted

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the same benefits by, one MaineCare program.”

Id. at 7, 9.

Given that the

Commissioner cannot proffer a compelling state interest to justify the 2011 law, the
Plaintiffs are confident they can demonstrate a likelihood of success on the merits.
Id. at 13.
With respect to the second factor, the potential for irreparable harm, the
Plaintiffs cite First Circuit caselaw supporting their argument that the
Commissioner’s wrongful denial of Medicaid benefits, which causes individuals like
the Plaintiffs to forgo necessary medical treatment, is irreparable injury. Id. at 14.
They point out that the Plaintiffs’ have “already suffered harm, and will continue to
do so until the Defendant is required to provide [them] with benefits.” Id. at 15.
Regarding the third factor, the Plaintiffs assert that the hardship they will
suffer absent health care support from the State outweighs the financial hardship
the Defendant will face if the Court grants their motion. Id. at 16. Specifically, the
Plaintiffs assert that the cost savings as a result of limiting coverage to some
qualified aliens saved the State only 0.1932% of the General Fund MaineCare
Budget for fiscal year 2012.

Id.

They argue that, “[t]his relatively small cost

savings cannot outweigh the significant and irreparable harm to the Plaintiffs.” Id.
Finally, regarding the fourth factor, the Plaintiffs insist that the public
interest favors granting the preliminary injunction because “[i]t is unimaginable
how seeking to prevent a State government’s infringement upon the right to equal
protection would disserve the public interest” especially considering the facts in this
case. Id. at 16. On a procedural note, the Plaintiffs ask the Court to waive the Rule

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56(c) security requirement because the Plaintiffs are indigent, this case involves an
important “public interest”, and they have demonstrated a strong likelihood of
success on the merits. Id. at 17.
B.

The Commissioner’s Opposition

First, the Commissioner maintains that “[a] showing of likelihood of success
on the merits stands as the sine qua non for obtaining preliminary injunctive relief .
. . a burden that the plaintiff[s] cannot carry.” Def.’s Opp’n at 1. She claims that
there was no Equal Protection Clause violation because the elimination of a state
program which serves only aliens does not constitute selective treatment. Id. at 1,
7. Regarding the second preliminary injunction factor, the Commissioner asserts
that the Plaintiffs do not necessarily face irreparable harm because they may be
eligible for MaineCare’s emergency care or medically necessary inpatient and
outpatient hospital care pursuant to Maine’s Free Care law. Id. at 8.
Next, the Commissioner argues that the balance of burdens weighs in the
State’s favor because if the Court grants the preliminary injunction it would shift
the Plaintiffs’ cost of care from hospitals to the State. Id. at 9. With respect to the
fourth factor, the Commissioner contends that the public interest in managing and
containing the current budgetary crisis controls the analysis.

Id.

Finally, the

Commissioner asserts that the goal of preliminary injunctions―to preserve the
status quo―is not furthered by granting a preliminary injunction in this case
because Maine’s termination of state-funded medical benefits to Medicaid-ineligible
qualified aliens in 2011 fundamentally changed the status quo. Id.

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C.

The Plaintiffs’ Reply

In response, the Plaintiffs argue that the 2011 Maine law violates the Equal
Protection Clause because there was never a “creation of a non-citizen-only program
or non-citizen-only benefit.” Pls.’ Reply at 1-2. Regarding the second factor, the
Plaintiffs argue that the Commissioner “overestimates the scope of the alternative
care options” because emergency care is extremely limited and explicitly excludes
care the Plaintiffs require in order to avoid irreparable injury such as “dialysis,
organ transplants, school based services, personal care services, waiver services,
nursing facility services and hospice services.” Id. at 4.

They also argue that

medically necessary care under Maine’s Free Care law fails to remedy the Plaintiffs’
potential harm because it only provides care for inpatient and outpatient hospital
services and would disqualify a large number of individuals from receiving services
given the program’s income requirements. Id. at 5.
Here, because the indigent Plaintiffs would be responsible to either pay outof-pocket for their healthcare or forego treatment, they insist that the potential for
irreparable injury is undeniable. Id. at 6. Further, they note that “[i]t is not only
disappointing but appalling that the Defendant argues that a minuscule cost
savings . . . outweighs at least 500 Maine residents’ need to access necessary
medical care.” Id. at 6-7. Accordingly, the Plaintiffs contend that both the third
and fourth factors, the balance of hardships and public interest, weigh in their
favor. Id. Finally, the Plaintiffs urge the Court to disregard the Commissioner’s
“status quo” argument because motions for preliminary injunction “‘alter[] rather

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than preserve[] the status quo.’” Id. at 6 (quoting Braintree Labs., Inc. v. Citigroup
Global Mkts., 622 F.3d 36, 41 (1st Cir. 2010)).
III.

DISCUSSION
A.

Legal Standard

“‘A preliminary injunction is an extraordinary and drastic remedy that is
never awarded as of right.’” Peoples Fed. Sav. Bank v. People’s United Bank, 672
F.3d 1, 8-9 (1st Cir. 2012) (quoting Voice of the Arab World, Inc., v. MDTV Med.
Now, Inc., 645 F.3d 26, 32 (1st Cir. 2011)). When deciding whether to grant the
Plaintiffs’ motion for preliminary injunction, the Court must carefully weigh four
factors. Esso Std. Oil Co. v. Monroig-Zayas, 445 F.3d 13, 17-18 (1st Cir. 2006).
These factors include: “(1) the likelihood of success on the merits; (2) the potential
for irreparable harm [to the movant]; (3) the balance of the relevant impositions,
i.e., the hardship to the nonmovant if enjoined as contrasted with the hardship to
the movant if no injunction issues; and (4) the effect (if any) of the court’s ruling on
the public interest.” Id. (quoting Bl(a)ck Tea Soc’y v. City of Boston, 378 F.3d 8, 11
(1st Cir. 2004)).
“The party seeking the preliminary injunction bears the burden of
establishing that these four factors weigh in its favor.” Id. However, “[t]he sine qua
non of this four-part inquiry is likelihood of success on the merits: if the moving
party cannot demonstrate that he is likely to succeed in his quest, the remaining
factors become matters of idle curiosity.”

New Comm Wireless Servs., Inc.,

SprintCom, Inc., 287 F.3d 1, 9 (1st Cir. 2002); see Sindicato Puertorriqueno de

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Trabajadores v. Foruno, 699 F.3d 1, 7 (1st Cir. 2012) (confirming that “this factor is
the most important part of the preliminary injunction assessment”) (internal
citations omitted).

Ultimately, “trial courts have wide discretion in making

judgments regarding the appropriateness of [preliminary injunctive] relief.”
Sanchez v. Esso Std. Oil Co., 572 F.3d 1, 4 (1st Cir. 2009).
B.

The Plaintiffs’ Motion for Preliminary Injunction
1.

Likelihood of Success on the Merits

Here, because the Plaintiffs cannot satisfy the threshold requirements for
their Equal Protection Clause claim, they have not demonstrated the sine qua non
of the preliminary injunction test―a likelihood of success on the merits. See New
Comm Wireless Servs., Inc., 287 F.3d at 9; see Borinquen Biscuit Corp. v. M.V.
Trading Corp., 443 F.3d 112, 115 (1st Cir. 2006) (“the cynosure of this four-part test
is more often than not the movant's likelihood of success on the merits”). The Equal
Protection Clause of the Fourteenth Amendment of the United States Constitution
provides, “[n]o State shall . . . deny to any person within its jurisdiction the equal
protection of the laws.” U.S. CONST. amend. XIV, § 1. Because “person” denotes
lawfully admitted resident aliens and citizens of the United States, both noncitizens
and citizens are entitled to “equal protection of the laws of the State in which they
reside.” Graham v. Richardson, 403 U.S. 365, 371 (1971). Equal protection of the
laws necessarily requires that similarly situated individuals be treated alike by the
laws of a state. City of Cleburne v. Cleburne Living Ctr., 473 U.S. 432, 439 (1985);
Tapalian v. Tusino, 377 F.3d 1, 5 (1st Cir. 2004).

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To evaluate whether an equal protection claim is viable, the First Circuit has
explained that a court must “look for two elements: (1) whether the [ ] [plaintiffs]
[were] treated differently than others similarly situated, and (2) whether such a
difference was based on an impermissible consideration . . . .” Macone v. Town of
Wakefield, 277 F.3d 1, 10 (1st Cir. 2002); see Barrington Cove, LP, v. R.I. Hous. &
Mortg. Fin. Corp., 246 F.3d 1, 7 (1st Cir. 2001).

Once these two elements are

shown, the court must determine what level of scrutiny applies to the law at issue.
See City of Cleburne, 473 U.S. at 439-40.
“The formula for determining whether individuals or entities are ‘similarly
situated’ for equal protection purposes is not always susceptible to precise
demarcation.” Barrington Cove, LP, 246 F.3d at 8. In Dartmouth Review, the First
Circuit set out the prudent person test:
The test is whether a prudent person, looking objectively at the
incidents, would think them roughly equivalent and the protagonists
similarly situated . . . the ‘relevant aspects’ are those factual elements
which determine whether reasoned analogy supports, or demands a
like result. Exact correlation is neither likely nor necessary, but the
cases must be fair congeners. In other words, apples should be
compared to apples.
889 F.2d at 19.
Here, the parties fundamentally disagree about the statutory structure of the
state of Maine’s medical benefit program for Medicaid-ineligible qualified aliens
post-PRWORA.

The Plaintiffs insist that Medicaid-ineligible qualified aliens

received benefits through MaineCare―“a single program providing medical benefits
to both citizens and noncitizens alike.” Pls.’ Mot. at 8. They argue, “[the] creation

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of two classes of individuals within a medical benefits program like MaineCare is a
classification based upon alienage.”

Id.

The Commissioner disputes this

interpretation of MaineCare and claims that the State created two distinct medical
benefit programs: (1) MaineCare for citizens and Medicaid-eligible qualified aliens
and (2) a separate state-funded program for Medicaid-ineligible qualified aliens
subject to the five-year residency requirement.1 Def.’s Mot. to Dismiss at 12-16
(ECF No. 12). Because the Plaintiffs were not “as a matter of law, deprived of a
benefit to which citizens remain entitled”, the Commissioner urges the Court to
deny their motion. Def.’s Opp’n at 7. The First Circuit has not confronted this exact
legal issue; however, other federal and state courts have examined the validity of
state termination of state-funded benefits post-PRWORA in lawsuits concerning the
denial of medical and food stamp benefits.
a.

The Elimination of a State’s Aliens-only Welfare
Program Does Not Violate the Equal Protection
Clause

Several federal and state courts have concluded that a state’s elimination of a
state-created and state-funded benefit program for noncitizens ineligible for federal
benefits does not violate the Equal Protection Clause. First, in Pimentel v. Dreyfus,
670 F.3d 1096 (9th Cir. 2012), the Ninth Circuit addressed a similar case. In 1997,
the state of Washington Legislature enacted the Food Assistance Program for Legal
Immigrants (“FAP”) in response to PRWORA, to provide food benefits to noncitizens
ineligible for the federal-state food benefit program (“SNAP”). Id. at 1101. When

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The Commissioner incorporates the arguments she made in her motion to dismiss into her
opposition to the Plaintiffs’ motion for preliminary injunction. See Def.’s Opp’n at 7.

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the state of Washington eliminated the FAP program in 2011, Monica Navarro
Pimentel, a noncitizen, faced termination from FAP and pursued a class action
lawsuit against the State alleging that by terminating food benefits for noncitizens,
the State violated the Equal Protection Clause. Id. at 1101-02. The Ninth Circuit
concluded that the district court improperly granted a preliminary injunction for
the plaintiff and her class because they failed to show that State treated the
ineligible noncitizens differently from similarly situated individuals. Id. at 1106.
In forming this conclusion, the Court stressed that citizens and the plaintiff class
members―qualified aliens ineligible for federal food benefits until they met
PRWORA’s residency requirement―were receiving benefits from two separate
programs: one sponsored and controlled by the federal and state governments; the
other exclusively state sponsored and controlled. Id. at 1107-08. Based on this
distinction, the Court held the plaintiffs were not “similarly situated” with citizens
receiving SNAP benefits. Id.
When determining whether the federal-state food benefit program, SNAP,
was distinct from the state food program, FAP, the Pimentel Court engaged in “[a]
careful consideration of the contours of the SNAP program, including the statutory
scheme, source of funding, extent of state involvement, and history, [which]
demonstrate[d] that SNAP is a federal program which the state merely assists in
administering, rather than a state program which receives federal assistance.” Id.
at 1107. Given this analysis, the Ninth Circuit concluded that SNAP’s beneficiaries
were not similarly situated with the plaintiffs. Id. The Court also rejected the

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district court’s finding that the programs were the same given that they offered food
benefits out of what appeared to be a unified program because “[t]he appearance of
a single program does not overcome this fact: the two programs are, in reality, two
separately administered programs funded by two distinct sovereigns.” Id.
Next, in Soskin v. Reinertson, 353 F.3d 1242 (10th Cir. 2004), the Tenth
Circuit reviewed the constitutionality of a Colorado statute that eliminated medical
coverage for Medicaid-ineligible qualified aliens after PRWORA. Id. at 1246-47.
The Soskin Court concluded that “[w]hat Congress has done in PRWORA is, in
essence, create two welfare programs, one for citizens and one for aliens. Within
the aliens-only program, states have the option of including more or fewer aliens.”
Id. at 1255. The Court also found that “[a] state’s exercise of the option to include
fewer aliens in its aliens-only program, then, should not be treated as
discrimination against aliens as compared to citizens.” Id. at 1255-56. Ultimately,
the Tenth Circuit affirmed the district court’s denial of the plaintiffs’ motion for a
preliminary injunction because the plaintiffs likely would not prevail on their equal
protection challenge. Id. at 1264-65.
In Hong Pham v. Strakowski, 16 A.3d 635 (Conn. 2011), the Supreme Court
of Connecticut reviewed a similar case where the Connecticut Legislature enacted a
post-PRWORA state-funded program to provide health benefits for Medicaidineligible qualified aliens. Id. at 641-42. The Hong Pham Court concluded that the
case involved two separate benefit programs and that “a state does not discriminate
against aliens when it treats aliens covered under an alien-only benefit program

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differently from the way in which citizens and other aliens are treated under
separate, federal-state benefit programs.”

Id. at 647, 654.

The Connecticut

Supreme Court reversed the trial court’s permanent injunction because it concluded
that there was no equal protection violation. Id. at 637, 664.
Finally, in Doe v. Commissioner of Transitional Assistance, 773 N.E.2d 404
(Mass. 2002), the Supreme Judicial Court of Massachusetts, addressing a similar
case, affirmed the Superior Court’s denial of the plaintiffs’ motion for preliminary
injunction because there was no equal protection violation.

Id. at 408.

The

plaintiffs claimed that the Commonwealth’s six-month residency requirement to
qualify for its supplemental health benefit program for Medicaid-ineligible aliens
violated their rights under the Equal Protection Clause because citizens were not
subject to the same residency requirement. Id. at 407-08. The Doe Court held that
because the benefit program for Medicaid-ineligible aliens was separate from the
federal-state funded program for citizens, the program was constitutional as it only
“discriminate[d] between groups of qualified aliens on the basis of the length of
their residency in Massachusetts.” Id. at 411.
b.

The Elimination of a State’s Welfare Program
Available to Both Citizens and Aliens Violates the
Equal Protection Clause

A few courts have found that states violate the Equal Protection Clause when
they eliminate state-sponsored health benefit coverage for Medicaid-ineligible aliens
while still allowing citizens to retain that coverage.

In Aliessa v. Novello, 754

N.E.2d 1085 (N.Y. 2001), the plaintiffs challenged the state of New York’s decision

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to change its state health benefit program to comport with federal Medicaid
standards and thereby impose a five-year waiting period for Medicaid-ineligible
qualified aliens. Id. at 1089-90, 1092. According to the New York Court of Appeals,
in 1966 New York created its own Medicaid system which has “two components: one
that is federally subsidized and one that the State funds entirely on its own . . . New
York had long provided State Medicaid to needy recipients without distinguishing
between legal aliens and citizens.” Id. at 1089-90. Yet, in light of PRWORA, where
Congress distinguished between qualified aliens and citizens for federal Medicaid
coverage, New York terminated all its previous Medicaid coverage for Medicaidineligible qualified aliens and imposed a five-year waiting period for those
noncitizens before they could receive benefits from the State’s own Medicaid
program.2 Id. at 1092.
Without addressing whether plaintiffs were “similarly situated” with citizens
for equal protection purposes, the Aliessa Court concluded that the State violated
the Equal Protection Clause when it “impermissibly imposed” a waiting period on
qualified aliens’ receipt of state Medicaid while still providing citizens with benefits
under the State’s uniform program. Id. at 1094-95, 1098-99. The New York Court
of Appeals analyzed the offending law under strict scrutiny because it determined
the law drew lines on the basis of alienage. Id. at 1097-98.
Notably in Khrapunskiy v. Doar, 909 N.E.2d 70 (N.Y. 2009), the New York
Court of Appeals distinguished its facts from Aliessa because it involved a
The law permitted Medicaid-ineligible aliens to continue their state Medicaid coverage only
if they previously received Medicaid and were either diagnosed with AIDS or residing in certain
licensed residential health care facilities as of August 4, 1997. Id. at 1092, 1098.
2

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comparison between the treatment of aliens under a state-funded and statecontrolled health benefit program and the treatment of citizens under a similar
federal-state program. Id. at 76-77. For the same reasons discussed in Pimentel,
Soskin, Hong Pham, and Doe, the Khrapunskiy Court found that there was no equal
protection violation when the State eliminated the aliens-only program. Id. at 7677; see also Doe, 773 N.E.2d at 411 (distinguishing Aliessa because that case
presented the Court of Appeals with “the very paradigm so definitively addressed in
Graham, [ ] a State-funded benefit program available to citizens but not available to
aliens on the same terms”); Hong Pham, 16 A.3d at 656 (“Aliessa involved a claim of
discrimination within a [ ] state funded and state controlled public assistance
program and did not involve a comparison of the treatment of aliens under one
program to the treatment of citizens under a separate federal-state program”).
In Korab v. Koller, No. 10-00483 JMS/KSC, 2010 U.S. Dist. LEXIS 119855 (D.
Haw. Nov. 10, 2010) (Korab I), the plaintiffs challenged a Hawaii law passed in
response to PRWORA, which ended the plaintiffs’ eligibility for certain state health
benefit programs (“old programs”).

Id. at *36, 40.

The old programs provided

medical assistance to both noncitizens and citizens. Id. In 2010, Hawaii carved out
a new state-funded program for Medicaid-ineligible aliens that provided them with
less medical coverage than other aliens and citizens. Id. at *7-8. The Korab I court
observed:
For the last fourteen years, Defendants have treated COFA Residents
[aliens from Compacts of Free Association countries with the United
States] the same as citizens and other qualified aliens by allowing
them access to the same programs, with the only difference being that
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COFA Residents participation was funded through State dollars only.
It is only now that Defendants have decided to single out COFA
Residents for lesser benefits than are provided to citizens and other
classes of aliens.
Id. at *21.

Applying strict scrutiny to the Hawaii law, the Court denied the

defendant’s motion to dismiss because the plaintiffs were able to state a viable
equal protection claim. Id. at *5-9.
Later in Korab v. Mcmanaman, 805 F. Supp. 2d 1027 (D. Haw. 2011) (Korab
II), the district court, addressing a new set of motions on the same facts but for a
separate group of plaintiffs, denied the defendant’s motion for summary judgment.
Id. at 1030, 1038.

The Korab II court considered Hong Pham in evaluating

defendant’s argument against plaintiffs’ equal protection claim but rejected its
premise because “by limiting the inquiry to a particular program on its own as
opposed to a state’s provision of medical benefits to its residents through various
programs generally, Hong Pham . . . stands the Equal Protection clause on its
head.”3 Id. at 1036. Notably, the Korab II court distinguished the facts in its case
from Hong Pham: “Hong Pham addressed Connecticut’s termination of a state
program that was available to aliens only. In comparison, the State allowed both
Medicaid-eligible residents as well as COFA Residents to participate in the Old
Programs - - there was no separate program for COFA Residents.” Id. at 1037 n.7.
Finally, in Fitch v. Commonwealth Health Insurance Connector Authority,
959 N.E.2d 970 (Mass. 2012), the Supreme Judicial Court of Massachusetts

In Pimentel, decided after Korab I and II, the Ninth Circuit engaged in the exact analysis the
Korab II district court advised against when it compared two distinct medical benefit programs
against one another. 670 F.3d at 1106-08.
3

19

concluded that the Commonwealth violated noncitizens’ rights under the Equal
Protection Clause when it maintained a uniform program granting medical benefits
to both citizens and Medicaid-ineligible qualified aliens until 2009 and then
eliminated those benefits exclusively for Medicaid-ineligible aliens. Id. at 974-75;
cf. Pimentel, 670 F.3d at 1108 n.13 (“[T]he Finch court carefully tethered its
analysis to the particular statutory design of Commonwealth Care - - a single
program distributing a single benefit to eligible individuals . . . [h]ere, we have not a
single unified program but two distinct ones”).
Only one case suggests that where a state creates two separate programs for
Medcaid-eligible and ineligible aliens and citizen populations, the state violates the
Equal Protection Clause by eliminating the separate aliens-only program.

In

Ehrlich v. Perez, 908 A.2d 1220 (Md. 2006), the Maryland Court of Appeals affirmed
the trial court’s grant of a preliminary injunction to plaintiffs who challenged
Maryland’s elimination of an alien-only health benefit program. Id. at 1223, 1247.
Similar to Pimentel, Pham, and Doe, the state of Maryland maintained two health
benefit programs: a federal-state funded program for citizens and Medicaid-eligible
aliens and a post-PRWORA state funded program for Medicaid-ineligible aliens. Id.
at 1226-27.

The Ehrlich Court did not discuss a “similarly situated” equal

protection finding or the significance of Maryland’s separate programs for citizens
and Medicaid-ineligible aliens presumably because the defendant did not raise that
issue on appeal. See id. at 1230-32. Like the Courts in Pimentel and Pham, this

20

Court does not find Ehrlich persuasive. Pimentel, 670 F.3d at 1107 n.12; Hong
Pham, 16 A.3d at 652-53.
c.

Medicaid in Maine

To assess whether the programs in this case were separate or part of the
same statutory scheme, the Court examines their history. Created by Congress in
1965, Medicaid enables the federal government, through cooperative agreements
with the states, to assist elderly, poor, and disabled individuals to obtain medical
care.

42 U.S.C. § 1396 (2000); 42 C.F.R. § 430.0 (2002).

The federal program

provides financial assistance to states that establish Medicaid programs consistent
with federal law and according to state plans approved by the United States
Department of Health and Human Services. 42 U.S.C. § 1396 (2000); 42 C.F.R. §§
430.0, 430.10-.20 (2002); see Long Term Care Pharm. Alliance v. Ferguson, 362 F.3d
50, 51 (1st Cir. 2004). Thus, federal-state Medicaid programs are subject to federal
approval and control. See Frew ex rel. Frew v. Hawkins, 540 U.S. 431, 433 (2004)
(“State participation is voluntary; but once a State elects to join the program, it
must administer a state plan that meets federal requirements”).
In April 1974, the state of Maine began providing medical assistance to the
needy in conjunction with federal Medicaid. See An Act Relating to Supplemental
Security Income, 1973 Me. Laws 790 § 2 (stating that “[t]he department is
authorized to administer programs of aid, medical or remedial care and services for
medically indigent persons”).

In 1996, Congress passed PRWORA which

significantly changed the United States welfare system and eliminated Medicaid

21

coverage for some aliens to ensure that “the availability of public benefits [does] not
constitute an incentive for immigration to the United States.” Pub. L. No. 104-193,
110 Stat 2105 (1996); 8 U.S.C. § 1601(2)(B). The law divided aliens into two classes
for Medicaid eligibility: qualified and non-qualified aliens.

Non-qualified aliens

include illegal aliens who are ineligible for Medicaid benefits.
1611(a).

See 8 U.S.C. §

Qualified aliens include lawful permanent residents, asylees, certain

refugees, and a few other specific categories of legal noncitizens. Id. § 1641(b). The
law further broke down eligibility for Medicaid benefits so that qualified aliens are
only eligible to receive federal benefits if they have lived in the United States for at
least five years.4 Id. § 1613(a) (“[A]n alien who is a qualified alien [ ] and who
enters the United States on or after [August 22, 1996] is not eligible for any Federal
means-tested public benefit for a period of 5 years beginning on the date of the
alien’s entry into the United States”).
In compliance with federal law, states are required to deny federal Medicaid
coverage to qualified aliens who are subject to the five-year benefit bar. See 42
U.S.C. § 1396; 10-144 C.M.R. ch. 332, pt. 2 § 3.4 (2012) (stating that for MaineCare
“[l]egal permanent residents are not eligible for full benefits if they have been in the
U.S. less than five years”). Qualified aliens unable to receive Medicaid may still
receive benefits necessary for the treatment of emergency medical conditions. 8
U.S.C. § 1611(b). Nevertheless, PRWORA explicitly authorizes states to provide

Section 1613(b) carves out some exceptions to this rule and deems certain refugees and
asylees as well as veterans and members of the Armed Forces on active duty as qualified immigrants
eligible for federal benefits despite the five-year residency requirement. 8 U.S.C. § 1613(b).
4

22

state-funded health benefit programs to qualified aliens subject to the five-year
Medicaid residency requirement. Id. § 1622(a).
In response to PRWORA, the state of Maine enacted a state statute in 1997
which granted state-funded medical care to Medicaid-ineligible qualified aliens. See
Temporary Assistance for Needy Families, 1997 Me. Laws 530, ch. 1053-B §
3762(3)(B).

The Maine Legislature provided that “recipients under this

subparagraph are limited to categories of noncitizens who would be eligible for
TANF or Medicaid programs but for their status as aliens under PRWORA.” Id. §
3762(3)(B)(2).

As a result, in Maine, qualified aliens subject to the five-year

Medicaid residency requirement received state-funded health benefits until 2011
when the Maine Legislature eliminated the program. 2011 Me. Laws 380, § KK4(B)(2).
d.

The Contours of the Disputed Programs

After considering the “contours” of the programs in dispute, the Court
concludes that there were two separate benefit programs: an aliens-only program
and a program for citizens and qualified aliens who satisfied PRWORA’s residency
requirement.5 See Pimentel, 670 F.3d at 1107 (reversing the Plaintiffs’ preliminary
injunction because “[a] careful consideration of the contours” of each benefit
program “including the statutory scheme, source of funding, extent of state
involvement, and history” aided the court in finding there were two separate benefit
programs). The statutorily mandated separate funding structures for MaineCare,
The Court refers the parties to and incorporates by reference its discussion regarding the
independence of the programs at issue in its Order on the Commissioner’s motion to dismiss. See
Order at 21-25.
5

23

which receives federal and state funds, and the aliens-only program, which received
only state funds post-PRWORA, is the first indicator of their independence.6
Compare 2001 Me. Laws 450 § C-2; with 8 U.S.C. § 1613(a), 1622(a), and 2011 Me.
Laws 380, § KK-4(B)(2); see Order at 22-24. The laws’ separate funding structures
also signify that the programs were separately controlled by the governments that
funded them. Compare 42 U.S.C. § 1396a (2000), and 42 C.F.R. §§ 430.0, 430.10-.20
(2002), with 8 U.S.C. § 1613(a), 1622(a), and 1997 Me. Laws 530, ch. 1053-B §
3762(3)(B).
Moreover, the history of the benefit programs, specifically the federal
government’s express relinquishment of its former obligation to provide benefits for
qualified aliens subject to the residency requirement and the State’s decision to
assume that obligation only underscores their autonomy. 1997 Me. Laws 530, ch.
1053-B § 3762(3)(B). The resulting Maine law’s statutory language, which limited
state-funded benefits to “categories of noncitizens who would be eligible . . . for
Medicaid programs but for their status as aliens under PRWORA”, further confirms
the separate nature of the programs. 1997 Me. Laws 530, ch. 1053-B § 3762(3)(B).
Admittedly, the two programs were often inaccurately referred to as MaineCare,
but the Court does not find that this mistake overcomes the substantive differences
between the two programs. See Order at 24; Def.’s Mot. to Dismiss at 13; Pimentel,

Ms. Mayhew admits that “[a] Department administrative error led to some amount of federal
money being applied to Maine’s state medical assistance benefits for Medicaid-ineligible aliens. Such
errors are subject to a financial reconciliation process between the Department and the U.S.
Department of Health and Human Services.” Def.’s Mot. to Dismiss at 7 n.4. The Court does not find
that this error changes the program’s funding structure because by statute it was not supposed to be
funded with federal dollars.
6

24

670 F.3d at 1007 (“The appearance of a single program does not overcome this fact:
the two programs are, in reality, two separately administered programs funded by
two distinct sovereigns”).
e.

Two Separate Benefit Programs

Without the guidance of clear First Circuit precedent, the Court follows the
well-reasoned legal analysis of courts in other jurisdictions, such as Pimentel and
Pham. The Court concludes that it cannot award preliminary injunctive relief to
the Plaintiffs because there were two separate programs distributing medical
benefits to Medicaid-ineligible qualified aliens and citizens. Because citizens were
statutorily unable to receive health benefits under the same state-sponsored
program, the Plaintiffs are unable show they were similarly situated with citizens
for equal protection purposes. Barrington Cove, LP, 246 F.3d at 10. In other words,
the Plaintiffs cannot show that the State engaged in selective treatment because
Maine’s 1997 law never included the Plaintiffs in a benefit group with citizens.
The Court’s conclusion is supported by a comparison of the facts in this case
to those in Pimentel, Pham, and Doe. In addition, the Court views the Aliessa,
Korab I, and Korab II decisions as factually-distinguishable and unpersuasive.
Moreover, under the First Circuit’s “prudent person” test, looking objectively at the
incidents here, the factual comparison of the Plaintiffs’ aliens-only benefit program
with MaineCare shows that these “cases [ ] [are not] fair cogeners” as “apples [ ] [are
not being] compared to apples.” Dartmouth Review, 889 F.2d at 19. Because the
Plaintiffs are unable to show a likelihood of success on the merits, “the remaining

25

factors become matters of idle curiosity.” New Comm Wireless Servs., Inc., 287 F.3d
at 9. Nevertheless, for the sake of completeness, the Court addresses the remaining
three injunction factors.
2.

Potential for Irreparable Harm

“Irreparable harm can consist of ‘a substantial injury that is not accurately
measurable or adequately compensable by money damages.’”

Ross-Simons of

Warwick, Inc. v. Baccarat, Inc., 217 F.3d 8, 13 (1st Cir. 2000) (quoting Ross-Simons
of Warwick, Inc., v. Baccarat, Inc., 102 F.3d 12, 19 (1st Cir. 1996)). To satisfy this
factor, the Plaintiffs must “demonstrate that irreparable injury is likely in the
absence of an injunction”, i.e., before a decision on the merits can be rendered.
Wilson v. NRDC, 555 U.S. 7, 22 (2008). “A preliminary injunction usually will be
denied if it appears that the applicant has an adequate alternate remedy in the
form of money damages or other relief.” 11A CHARLES ALAN WRIGHT, ARTHUR R.
MILLER, & MARY KAY KANE, FEDERAL PRACTICE AND PROCEDURE § 2948.1, at 149-50
(2d ed. 1995).
In their motion, the Plaintiffs claim a preliminary injunction is the only
available relief because they are indigent and require immediate medical attention
to fight ongoing life-threatening illnesses.7

Pls.’ Mot. at 14-15.

Further, the

Plaintiffs cite Massachusetts Association of Older Americans v. Sharp, 700 F.2d 749
(1st Cir. 1985), a Medicaid case, for the proposition that “[t]ermination of benefits

“Although monetary relief may compensate some class members for out-of-pocket
expenditures and other injuries resulting from the wrongful denial of MaineCare, monetary damages
will provide no relief against the ongoing and future violations of the Plaintiffs’ and class members’
constitutional rights.” First Am. Compl. ¶ 38.
7

26

that causes individuals to forego such necessary medical care is clearly irreparable
injury.”8 Id. at 753. The Commissioner rejects this argument by pointing out that
the Plaintiffs have other state-funded options for medical care; namely MainCare’s
emergency care and medically necessary inpatient and outpatient hospital care
under Maine’s Free Care law. Def.’s Opp’n at 8.
It may be that money damages or the current state-funded medical care
options would be unable to thwart the potential for irreparable injury to the
Plaintiffs pending trial. However, as later discussed, the record on this issue is
undeveloped and unsatisfactory. Not all members of the Plaintiffs’ class may suffer
from the same tragic illnesses as Mr. Bruns and Ms. Hassan or require the same
intensity of care. At the same time, for some of the Plaintiffs’ class members, the
threat of becoming sick and requiring treatment that is unavailable through the
State’s limited medical care options still looms. First, MaineCare’s emergency care
provision is limited given it only covers an individual’s health care costs if “the
absence of immediate medical attention could reasonably be expected to result in - (A) placing the patient’s health in serious jeopardy, (B) serious impairment to bodily
functions, or (C) serious dysfunction of any bodily organ or part.”

42 U.S.C. §

1396b(v)(3). Emergency services may be limited further to exclude “any services
after stabilization of the emergency condition for non-citizens” such as “dialysis,
organ transplants, school based services, personal care services, waiver services,
The Plaintiffs cite Maine Association of Interdependent Neighborhoods v. Petit to support
their irreparable injury argument because “[t]he wrongful denial of governmental benefits may
constitute irreparable injury . . . .” 647 F. Supp. 1312, 1315 (D. Me. 1986). The key word is
“wrongful”, and because the Court ultimately does not find that the termination of benefits in the
State’s aliens-only program was wrongful, Petit is distinguishable.
8

27

nursing facility services and hospice services.”9 10-144-101 ME. CODE R. §§ 1.024(C), 1.06. The State’s Free Care law also has limited health care offerings as it
simply requires hospitals to provide free inpatient and outpatient care if the
individual meets the relevant income guidelines, is not covered by insurance, and
the “services received were medically necessary.” 10-144-105 ME. CODE R. §§ 1.01,
1.05(B).
The First Amended Complaint and relevant affidavits suggest that both Mr.
Bruns and Ms. Hassan are receiving some medical treatment from the State, and
that this treatment is not enough to cure their illnesses. See First Am. Compl. ¶¶
10-13; Pls.’ Mot. Attach 2, Aff. of Danielle N. Margalit, M.D. (ECF No. 5-2) (Dr.
Margalit Aff.), Attach 3, Aff. of Mary Allen, FNP (ECF No. 5-3) (Allen Aff.). Thus,
according to the allegations in the First Amended Complaint, there is a significant
possibility that their health will deteriorate dramatically or that they may die from
their illnesses while waiting to fulfill PRWORA’s residency requirement and reach
trial.10 The fact that Mr. Bruns is now terminally ill and Ms. Hassan may die

The Plaintiffs assert that “[a]lthough the rule for Emergency MaineCare pertains expressly
to undocumented non-citizens, Defendant appears to also be applying the rule to all legal noncitizens who are not eligible for full MaineCare.” Pls.’ Mot. at 4, n.4; see 10-144-101 ME. CODE R. §
1.02-4(C). The State’s failure to include “undocumented” in Section 1.06’s description of the
Emergency Services exclusion combined with the denial of Ms. Hassan’s kidney transplant and Mr.
Brun’s appointment at the Dana Farber Cancer Institute suggests that the limitation in Rule 1.024(C) may be applied to all non-citizens receiving emergency care. 10-144-101 ME. CODE R. § 1.06;
First Am. Compl. ¶¶ 12-13; Pls.’ Reply Attach 1, MaineCare Denial Notice (ECF No. 16-1).
10
Tragically, Mr. Bruns is now terminally ill and receives hospice care. First Am. Compl. ¶ 1.
Also, because Mr. Bruns became a lawful permanent resident on December 16, 2007, PRWORA
should not bar him from accessing full MaineCare benefits as long as he maintained “qualifying
status” for the past five years. Id. ¶ 10; see 8 U.S.C. § 1613(a). As of the date of this Order, the
parties have not provided any further update on Mr. Bruns’ status.
It may be that, based on these new developments, Mr. Bruns’ quest for a preliminary
injunction is moot. However, despite questions about Mr. Bruns’ continuing standing, the Plaintiffs’
motion for a preliminary injunction (brought on behalf of himself and his fellow class members)
9

28

prematurely if she does not receive a necessary kidney transplant only underscores
the potential for irreparable harm to the Plaintiffs. First. Am. Compl. ¶¶ 13, 36; see
Wilson, 555 U.S. at 22.
At the same time, the Plaintiffs have presented the Court with a truncated
record for purposes of the motion for preliminary injunction. They are relying on a
motion filed on April 19, 2012, when the only Plaintiff was Mr. Bruns. Pls.’ Mot. To
that motion, they attached three affidavits concerning Mr. Bruns and his medical
condition. These affidavits establish that his medical condition is potentially dire;
however, there is no information about the cost of his treatment and his affidavit
merely says that he has “very little money”, nothing more. Aff. of Hans Bruns ¶ 7
(ECF No. 5-1); Dr. Margalit Aff.; Allen Aff.
The Plaintiffs included Ms. Hassan as a co-plaintiff in their First Amended
Complaint, which was filed well after their motion for preliminary injunction. For
whatever reason, they never filed any affidavits in support of her allegations,
leaving the Court only with the unsworn allegations in the First Amended
Complaint, many of which the Commissioner has denied. See First Am. Compl.;
Def.’s Ans. ¶¶ 12-13. On December 18, 2012, the Court discussed with counsel the
possibility of developing a more complete record for purposes of the motion for
preliminary injunction; however, the Plaintiffs were determined to proceed forward
on the record then before the Court. Unfortunately, the record is extremely thin.
As regards Ms. Hassan, it contains unsworn, unverified and largely denied factual
survives as the Plaintiffs timely amended their original complaint and added Ms. Hassan before Mr.
Bruns became eligible for full MaineCare benefits. See First Am. Compl. Given Ms. Hassan’s
immigration status and medical condition, she can properly pursue this motion for the class.

29

allegations.

It contains no reliable information about the availability of other

private, charitable, or governmental sources of funding. In short, there is very little
concrete information in this record to sustain the Plaintiffs’ claims of irreparable
harm.
Using Mr. Bruns and Ms. Hassan as examples, although a potential for
irreparable harm may exist with respect to their fellow class members, the
Plaintiffs have not made out an adequate case on this record for irreparable injury
to justify the issuance of injunctive relief.
3.

Balance of the Relevant Impositions

The Court must also balance each party’s potential hardships. The Plaintiffs
argue that without “charity care” from Maine hospitals, they will be forced either to
pay for treatment or to forego treatment altogether. Pls.’ Mot. at 16. They argue
that the State’s relatively minor savings do not justify cutting off health care
benefits that could prevent human suffering. Pls.’ Reply at 6-7; Pls.’ Mot. at 16
(arguing that a savings of $1,279,555 for fiscal year 2012, which is only 0.1932% of
the $662,057,680 MaineCare budget for 2012 was insignificant). In opposition, the
Commissioner asserts that state-funded programs for free care and emergency care
adequately address the Plaintiffs’ health care needs.

Def.’s Opp’n at 8-9.

If

hospitals are allowed to transfer health care costs to the State, she argues that it
would impose severe hardship on the State and contribute to its current budgetary
crisis. Id.

30

Neither argument tips the balance. On one hand, if the Court denies the
preliminary injunction, the Plaintiffs appear to be receiving some medical care and
could receive care from the State in the event of an emergency, even though they
require more services to fully treat their illnesses.11 On the other hand, if the
Plaintiffs’ motion is granted, it is unclear, based on the record before the Court,
exactly how much the preliminary injunction will cost the state of Maine. As both
these hardships are substantial and do not obviously outweigh each another, this
factor is neutral.
4.

Effect of the Court’s Ruling on the Public Interest

The final factor the Court must assess is the likely effect of the preliminary
injunction on the public interest. The Plaintiffs argue that the public interest would
be furthered by a preliminary injunction because it would stop the Commissioner’s
violation of their constitutional rights and would uphold the public’s interest in
preserving those rights. Pls.’ Mot. at 16-17. Citing the current budgetary crisis, the
Commissioner argues that a preliminary injunction would harm the public interest
because it would burden the State with more costs.

Def.’s Opp’n at 8-9.

The

Plaintiffs balk at the Commissioner’s argument because it is “appalling that the
Defendant argues that a miniscule cost savings of only .19% of the MaineCare

The Plaintiffs cite Lopez v. Heckler, 713 F.2d 1432 (9th Cir. 1983) to support their argument
that the balance of equities weighs in their favor. Pls.’ Reply at 7. Although at first glance Lopez is
compelling, it is factually distinguishable from this case because it dealt with the Secretary of Health
and Human Services’ denial of disability benefits to certain individuals based upon the Secretary’s
determination that they were no longer be disabled. Lopez, 713 F.2d at 1433-34, 1437. Further, the
cases are grounded in distinct federal law contexts, involve different populations, and have different
remedies available to address hardship.
11

31

General Fund Budget outweighs at least 500 Maine residents’ need to access
necessary medical care.”12 Pls.’ Reply at 6-7.
First, the Court concludes that the Plaintiffs have not established that the
Commissioner violated their equal protection rights. Therefore, the public’s interest
in preserving constitutional protections is not an issue. Next, although the public
has an interest in ensuring the health and welfare of the people living in its
community, “preserving the Plaintiffs’ health and well-being comes at a cost and
must be balanced against other public interests, one of which is solvency.” Bourgoin
v. Sebelius, No. 2:13-cv-00055-JAW, 2013 Dist. LEXIS 27680 at *36 (D. Me. Feb. 28,
2013).

Accordingly, the Court does not find the Commissioner’s cost argument

“appalling” especially since a preliminary injunction would affect both the interests
of the taxpayers’ within the State and the State’s own economic interests.
Fundamentally, where, as here, the public interest is inherently tied to the
government’s policy decisions, the appropriate balance of the public interest “must
be struck through the political process, not by an order of this Court.” Id. The
Court therefore concludes that this factor is neutral and does not favor either party.
5.

Summary

As the Court concludes that the Plaintiffs have failed to demonstrate a
likelihood of success on the merits, the “sine qua non” of the four-part preliminary

The Plaintiffs cite the Commissioner’s memorandum to the State Legislature’s
Appropriations and Financial Affairs Committee, which reports cost savings of $1,279,555 (0.1932%
of the overall MaineCare Budget for fiscal year 2012) due to its limitation of medical assistance
benefits.
Mary
C.
Mayhew,
Shortfall-Analysis
6,
8
(Dec.
9,
2011)
http://www.maine.gov/dhhs/budget/2012-2013/documents/MaineCare-Shortfall-Analysis.pdf.
Although this chart gives information on savings to the State, it is still unclear how much a
preliminary injunction would actually cost the state of Maine.
12

32

injunction test, the Court must deny their requested relief. See New Comm Wireless
Servs., Inc., 287 F.3d at 9 (“[T]he sine qua non of this four-part inquiry is likelihood
of success on the merits”). Moreover, because of the inadequate state of the record,
the Plaintiffs have failed to demonstrate that the remaining three factors are in
their favor.
IV.

CONCLUSION

The Court DENIES the Plaintiffs’ Motion for Preliminary Injunction (ECF
No. 5).
SO ORDERED.
/s/ John A. Woodcock, Jr.
JOHN A. WOODCOCK, JR.
CHIEF UNITED STATES DISTRICT JUDGE
Dated this 14th day of March, 2013

33