SSR 81-34c: SECTION 1611(e)(1)(A) and (B) (42 U.S.C. 1382(e)(1)(A) AND (B)) SUPPLEMENTAL SECURITY INCOME -- ELIGIBILITY DUE TO INSTITUTIONAL STATUS -- CONSTITUTIONALITY

20 CFR 416.231(a)

SSR 81-34c

Schweiker v. Wilson et al, 101 S.Ct. 1074 (1981)

BLACKMUN, Supreme Court justice:

The issue in this case is whether Congress constitutionally may decline

to grant Supplemental Security Income benefits to a class of otherwise

eligible individuals who are excluded because they are aged 21 through 64

and are institutionalized in public mental institutions that do not

receive Medicaid funds for their care. The United States District Court

for the Northern District of Illinois held unconstitutional, under the Due

Process Clause of the Fifth Amendment, that portion of the Social Security

Act, as amended, that excludes these otherwise eligible persons from the

supplemental benefits. The Secretary of Health and Human Services has

taken a direct appeal to this Court under 28 U.S.C. § 1252.

In October 1972, Congress amended the Social Security Act (Act) to create

the federal Supplemental Security Income program (SSI), effective January

1, 1974. 86 Stat. 1465, 42 U.S.C. § 1381 et seq . This program was

intended (t)o assist those who cannot work because of age, blindness or

disability," S. Rep. No. 92-1230, p. 4 (1972), by "set[ting] a Federal

guaranteed minimum income level for aged, blind, and disabled persons," id. , at 12. [1]

The SSI program provides a subsistence allowance, under federal

standards, to the Nation's needy aged, blind, and

disabled. [2] Included within the

category of "disabled" under the program are all those "unable to engage

in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result

in death or which has lasted or can be expected to last for a continuous

period of not less than twelve months." § 1614(a)(3)(A) of the Act, 42

U.S.C. § 1382c(a)(3)(A).

thin the

category of "disabled" under the program are all those "unable to engage

in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result

in death or which has lasted or can be expected to last for a continuous

period of not less than twelve months." § 1614(a)(3)(A) of the Act, 42

U.S.C. § 1382c(a)(3)(A).

Although the SSI program is broad in its reach, its coverage is not

complete. From its very inception, the program has excluded from

eligibility anyone who is an "inmate of a public institution." §

1611(e)(1)(A) of the Act, amended, 42 U.S.C. §

1382(e)(1)(A). [3] Also from the

program's inception, Congress has made a partial exception to this exclusion by providing a small amount of money (not exceeding $300

per year) to any otherwise eligible person in "a hospital, extended care

facility, nursing home, or intermediate care facility receiving payments

(with respect to such individual or spouse) under a State plan approved

under subchapter XIX [Medicaid]. . . ." § 1611(e)(1)(B), as amended, 42

U.S.C. § 1382(e)(1)(B). [4] Congress thus, while excluding generally any person residing in a public

institution, explicitly has tied eligibility for a reduced amount of SSI

benefits to residence in an institution receiving Medicaid benefits for

the care of the eligible individual.

Appellees brought this suit to challenge this resulting detail of

Congress' having conditioned the limited assistance grant on eligibility

for Medicaid: a person between the ages of 21 and 64 who resides in a

public mental institution is not eligible to receive this small stipend,

even though that person meets the other eligibility requirements for SSI

benefits, because treatment in a public mental institution for a person in

this age bracket is not funded under

Medicaid. [5]

ed the limited assistance grant on eligibility

for Medicaid: a person between the ages of 21 and 64 who resides in a

public mental institution is not eligible to receive this small stipend,

even though that person meets the other eligibility requirements for SSI

benefits, because treatment in a public mental institution for a person in

this age bracket is not funded under

Medicaid. [5]

Appellees attack this statutory classification as violative of the equal

protection component of the Fifth Amendment's Due Process

Clause. [6] Their challenge,

successful in the District Court, is two-fold. First, they argue that the

exclusion of their class of mentally ill (and therefore disabled) persons

bears no rational relationship to any legitimate objective of the SSI

program. They assert, in fact, that their class was excluded inadvertently

because of its political powerlessness. Brief for Appellees 6, 32. Second,

they insist that because the statute classifies on the basis of mental

illness, a factor that greatly resembles other characteristics that this

Court has found inherently "suspect" as a means of legislative

classification, special justification should be required for the

congressional decision to exclude appellees.

II

This case has had a somewhat complex procedural history. It initially was

instituted in December 1973 as a class action for injunctive and

declaratory relief to challenge the federal and Illinois assistance

schemes that prevailed prior to the effective date of the SSI program. See Wilson v. Edelman , 542 F.2d 1260, 1263-1266 (CA7 1976). The then

existing state assistance program, for which federal funds were received,

excluded from eligibility any person who was residing in a public mental

or tuberculosis institution or who was confined in a penal institution. Id. , at 1263, n. 2. The plaintiffs later amended their complaint to

include a challenge to the SSI exclusion, which by then had come into

effect. Id. , at 1266

. The then

existing state assistance program, for which federal funds were received,

excluded from eligibility any person who was residing in a public mental

or tuberculosis institution or who was confined in a penal institution. Id. , at 1263, n. 2. The plaintiffs later amended their complaint to

include a challenge to the SSI exclusion, which by then had come into

effect. Id. , at 1266. A three-judge court was convened under 28

U.S.C. §§ 2281 and 2282 (1970 ed.) (since repealed by Pub. L. 94-381, §§ 1

and 2, 90 (Stat. 1119). The case was consolidated with another that

challenged the exclusion from SSI benefits of any pretrial detainee.

Relying on Weinberger v. Salfi , 422 U.S. 749 (1975), the court

granted the Secretary's motion to dismiss both cases for lack of subject

matter jurisdiction on the ground that the plaintiffs had failed to

exhaust the administrative remedies provided for by § 1631(c)(3) of the

Act, as amended, 42 U.S.C. § 1383(c)(3). See 542 F.2d, at

1267-1268. [7]

On appeal, appellees abandoned their claims under the prior federal

statutes. Id. , at 1271. The United States Court of Appeals for the

Seventh Circuit reversed the dismissal, holding that the Secretary had

waived any requirement of exhaustion by her submission of the case to the

District Court for summary

disposition. [8] Id. , at

1272. Because the plaintiffs had dropped their request for injunctive

relief, the case was remanded to the single-judge District Court. Id. , at 1269. That court, on remand, certified the

class [9] and granted appellee's

motion for summary judgment, holding that § 1382 (e)'s exclusion of the

class members violated the equal protection guarantee of the Due Process

Clause of the Fifth Amendment. 478 F. Supp. 1046 (ND Ill.

1979). [10] The District Court

reasoned that the statute "creates three classifications: (1) age, and (2)

residence in a public, (3) mental health hospital." Id. , at 1050

ed appellee's

motion for summary judgment, holding that § 1382 (e)'s exclusion of the

class members violated the equal protection guarantee of the Due Process

Clause of the Fifth Amendment. 478 F. Supp. 1046 (ND Ill.

1979). [10] The District Court

reasoned that the statute "creates three classifications: (1) age, and (2)

residence in a public, (3) mental health hospital." Id. , at 1050.

It ruled that Congress' use of the first two factors need be justified

only by demonstration of their "rational relationship" to "a legitimate

state interest." Ibid. Under that standard, these classifications

withstood scrutiny. Congress' use, however, of a "mental health"

classification was deemed to require a closer examination because "mental

health classifications possess the significant indicia of the suspect

classifications recognized in other cases." Id. , at 1052. Although

recognizing that the mentally ill as a group do not demonstrate all the

characteristics this Court has considered as denoting inherently

suspicious classifications, such as race and national

origin, [11] the District court

believed that the mentally ill were "a politically impotent, insular

minority" that "have been subject to a 'history of unequal protection.'" Ibid. The court therefore concluded that Congress could

legislatively disfavor the mentally ill, as § 1611(e) did, only if the

statutory classification passes an "intermediate level of judicial

scrutiny," id. , at 1053, that is, only if the "classification bears

a substantial relation" to the object of the legislation evaluated "in

light of the primary purpose" of the scheme of which it is a part. Ibid. The court adjudged that the "primary purpose" of the small

monthly stipend as to enable the needy to purchase comfort items not

provided by the institution. Rejecting the Secretary's proposed

justifications for the

exclusion, [12] the District

court held that the classification could not withstand scrutiny

ted "in

light of the primary purpose" of the scheme of which it is a part. Ibid. The court adjudged that the "primary purpose" of the small

monthly stipend as to enable the needy to purchase comfort items not

provided by the institution. Rejecting the Secretary's proposed

justifications for the

exclusion, [12] the District

court held that the classification could not withstand scrutiny. The

legislative history, it said, revealed no intent to exclude appellees'

class; the court could conceive of no "possible unexpressed purpose for

the exclusion"; and the court reasoned that "aged, blind and disabled

inmates of all public institutions would have similar needs." Ibid. Upon the Secretary's direct appeal from this judgment, we noted probable

jurisdiction. _____ U.S. _____ (1980).

III

A

The equal protection obligation imposed by the Due Process Clause of the

Fifth Amendment is not an obligation to provide the best governance

possible. This is a necessary result of different institutional

competences, and its reasons are obvious. Unless a statute employes (sic)

a classification that is inherently invidious or that impinges on

fundamental rights, areas in which the judiciary then has a duty to

intervene in the democratic process, this Court properly exercises only a

limited review power over Congress, the appropriate representative body

through which the public makes democratic choices among alternative

solutions to social and economic problems. See San Antonio School

District v. Rodriguez , 411 U.S. 1 (1973). At the minimum level, this

Court consistently has required that legislation classify the persons it

affects in a manner rationally related to legitimate governmental

objectives. See e.g., Dandridge v. Williams , 397 U.S. 471 (1970); Mathews v. DeCastro , 429 U.S. 181 (1976)

native

solutions to social and economic problems. See San Antonio School

District v. Rodriguez , 411 U.S. 1 (1973). At the minimum level, this

Court consistently has required that legislation classify the persons it

affects in a manner rationally related to legitimate governmental

objectives. See e.g., Dandridge v. Williams , 397 U.S. 471 (1970); Mathews v. DeCastro , 429 U.S. 181 (1976). Appellees assert that the

particular grant of federal benefits under review here, however, should

"be subjected to a heightened standard of review." Brief for Appellees 39,

because the mentally ill "historically have been subjected to purposeful

unequal treatment; they have been relegated to a position of political

powerlessness; and prejudice against them curtails their participation in

the pluralist system and strips them of political protection against

discriminatory legislation." (Footnote omitted.) Id. , at 41.

We have no occasion to reach this issue because we conclude that the

statute does not classify directly on the basis of mental

health. [13] The SSI program

distinguishes among three groups of persons, all of whom meet the basic

eligibility requirements: persons not in a "public institution" may

receive full benefits; persons in a "public institution" of a certain

nature ("hospital, extended care facility, nursing home, or intermediate

care facility receiving payments (with respect to such individual) . .

. under [Medicaid]" (emphasis added). § 1611(e)(1)(B), may receive

reduced benefits; and person in any other "public institution" may not

receive any benefits. The statute does not isolate the mentally ill or

subject them, as a discrete group, to special or subordinate treatment

facility, nursing home, or intermediate

care facility receiving payments (with respect to such individual) . .

. under [Medicaid]" (emphasis added). § 1611(e)(1)(B), may receive

reduced benefits; and person in any other "public institution" may not

receive any benefits. The statute does not isolate the mentally ill or

subject them, as a discrete group, to special or subordinate treatment. At

the most, this legislation incidentally denies a small monthly comfort

benefit to a certain number of persons suffering from mental illness; but

is so doing it imposes equivalent deprivation on other groups who are not

mentally ill, while at the same time benefiting substantial numbers of the

mentally ill.

The group thus singled out for special treatment by § 1611(e) does not

entirely exclude the mentally ill. In fact, it includes, in a sizable

proportion to the total population receiving SSI benefits, large numbers

of mentally ill people. [14] Further, the group excluded is not congruent with appellees' class. Among

those excluded are the inmates of any other nonmedical "public

institution," such as a prison, other penal institution, and any other

publicly funded residential program the State may

operate; [15] persons residing

in a tuberculosis institution; and residents of a medical institution not

certified as a Medicaid

provider. [16] Although not by

the same subsection, Congress also chose to exclude from SSI eligibility

persons afflicted with alcoholism or drug addiction and not undergoing

treatment, § 1611(e)(3)(A), and persons who spend more than a specified

time outside the United States, § 1611(f). See Califano v.

Aznavorian , 439 U.S. 170 (1978) (upholding constitutionality of §

1611(f)); Califano v. Torres , 435 U.S. 1 (1978) (upholding

constitutionality of Congress' exclusion from SSI eligibility of residents

of Puerto Rico)

sm or drug addiction and not undergoing

treatment, § 1611(e)(3)(A), and persons who spend more than a specified

time outside the United States, § 1611(f). See Califano v.

Aznavorian , 439 U.S. 170 (1978) (upholding constitutionality of §

1611(f)); Califano v. Torres , 435 U.S. 1 (1978) (upholding

constitutionality of Congress' exclusion from SSI eligibility of residents

of Puerto Rico). Thus, in § 1611(e), Congress made a distinction not

between the mentally ill and a group composed of nonmentally ill, but

between residents in public institutions receiving Medicaid funds for

their care and residents in such institutions not receiving Medicaid

funds.

To the extent that the statute has an indirect impact upon the mentally

ill as a subset of publicly institutionalized persons, this record

certainly presents no statistical support for a contention that the

mentally ill as a class are burdened disproportionately to any other class

affected by the classification. The exclusion draws a line only between

groups composed (in part) of mentally ill individuals: those in public

mental hospitals, and those not in pubic mental hospitals. These groups

are shifting in population, and members of one group can, and often do,

pass to the other

group. [17]

We also note that appellees have failed to produce any evidence that the

intent of Congress was to classify on the basis of mental health.

Appellees admit that no such evidence exists; indeed, they rely on the

absence of explicit intent as proof of Congress' "inattention" to their

needs and therefore, its prejudice against them. Brief for Appellees 39.

As in Jefferson v. Hackney , 406 u.S. 535 (1972), the indirect

deprivation worked by this legislation upon appellees' class, whether or

not the class is considered "suspect," does not without more move us to

regard it with a heightened scrutiny. Cf. Personnel Administrator of

Massachusetts v. Feeney , 442 U.S. 256 (1979).

B

therefore, its prejudice against them. Brief for Appellees 39.

As in Jefferson v. Hackney , 406 u.S. 535 (1972), the indirect

deprivation worked by this legislation upon appellees' class, whether or

not the class is considered "suspect," does not without more move us to

regard it with a heightened scrutiny. Cf. Personnel Administrator of

Massachusetts v. Feeney , 442 U.S. 256 (1979).

B

Thus, the pertinent inquiry is whether the classification employed in §

1611(e)(1)(B) advances legitimate legislative goals in a rational fashion.

The Court has said that, although this rational basis standard is "not a

toothless one," Mathews v. Lucas , 427 U.S. 495, 510, (1976), it

does not allow us to substitute our personal notions of good public policy

for those of Congress:

The Court also has said: "This inquiry employs a relatively relaxed

standard reflecting the court's awareness that the drawing of lines that

create distinctions is peculiarly a legislative task and an unavoidable

one. Perfection in making the necessary classifications is neither

possible nor necessary." Massachusetts Bd. of Retirement v. Murgia ,

427 U.S. 306, 314 (1976). See also United States Railroad Retirement

Bd. v. Fritz , _____ U.S. _____ (1980). As long as the classificatory

scheme chosen by Congress rationally advances a reasonable and

identifiable governmental objective, we must disregard the existence of

other methods of allocation that we, as individuals, perhaps would have

preferred.

We believe that the decision to incorporate the Medicaid eligibility

standards into the SSI scheme must be considered Congress' deliberate,

considered choice. The legislative record, although sparse, appears to be

unequivocal. Both House and Senate Reports on the initial SSI bill noted

the exclusion in no uncertain terms. The House Report stated:

dividuals, perhaps would have

preferred.

We believe that the decision to incorporate the Medicaid eligibility

standards into the SSI scheme must be considered Congress' deliberate,

considered choice. The legislative record, although sparse, appears to be

unequivocal. Both House and Senate Reports on the initial SSI bill noted

the exclusion in no uncertain terms. The House Report stated:

The Senate Report followed the House's language almost identically. See

S. Rep. No. 92-1230, p. 386 (1972). We find these passages, at the very

least, to be a clear expression of 'Congress' understanding that the

stipend grant was to be limited to a group smaller than the total

population of otherwise eligible, institutionalized people. That the

bill's section-by-section analysis contained in the House Report laid out

the terms of the exclusion precisely supports the conclusion that Congress

was aware of who was included in that limited group. See H.R. Rep. No.

92-231, at 334.

The limited nature of Medicaid eligibility did not pass unnoticed by the

enacting Congress. In the same bill that established the SSI program,

Congress considered, and passed, an amendment to Medicaid, providing

coverage of inpatient services to a large number of the juvenile needy in

public mental

institutions. [18] See §

1905(h) of the Act, 42 U.S.C. § 1396(h); S. Rep. No. 92-1230, pp. 280-281;

H.R. Conf. Rep. No. 92-1605, p. 65. Also, a Senate proposal for

demonstration projects on the feasibility of extending Medicaid to cover

all inpatient services provided in public mental institutions was

simultaneously defeated. See S. Rep. No. 92-1230, p. 281; H.R. Conf. Rep.

No. 92-1605, p. 65. Congress was in the process of considering the wisdom

of these limitations at the time it chose to incorporate them into the SSI

provisions. The decision to do so did not escape controversy

asibility of extending Medicaid to cover

all inpatient services provided in public mental institutions was

simultaneously defeated. See S. Rep. No. 92-1230, p. 281; H.R. Conf. Rep.

No. 92-1605, p. 65. Congress was in the process of considering the wisdom

of these limitations at the time it chose to incorporate them into the SSI

provisions. The decision to do so did not escape controversy. The

Committee hearings contained testimony advocating extension of both

Medicaid and SSI benefits to all needy residents in public mental

institutions. See Social Security Amendments of 1971, Hearings on H.R. 1

before the Senate Committee of Finance, 92d Cong., 1st and 2d Sess., 2180,

2408-2410, 2479-2485, 3257, 3319 (1972). This legislative history shows

that Congress was aware, when it added § 1611(e) to the Act, of the

limitations in the Medicaid program that would restrict eligibility for

the reduced SSI benefits; we decline to regard such deliberate action as

the result of inadvertence or ignorance. See Maine v. Thiboutot ,

_____ U.S. _____ (1980) (slip op. 6).

Having found the adoption of the Medicaid standards intentional, we deem

it logical to infer from Congress' deliberate action an intent to further

the same subsidiary purpose that lies behind the Medicaid exclusion,

which, as no party denies, was adopted because Congress believed the

States to have a "traditional" responsibility to care for those

institutionalized in public mental

institutions

ound the adoption of the Medicaid standards intentional, we deem

it logical to infer from Congress' deliberate action an intent to further

the same subsidiary purpose that lies behind the Medicaid exclusion,

which, as no party denies, was adopted because Congress believed the

States to have a "traditional" responsibility to care for those

institutionalized in public mental

institutions. [19] The

Secretary, emphasizing the then existing congressional desire to economize

in the disbursement of federal funds, argues that the decision to limit

distribution of the monthly stipend to inmates of public institutions who

are receiving Medicaid funds "is rationally related to the legitimate

legislative desire to avoid spending federal resources on behalf of

individuals whose care and treatment are being fully provided for by state

and local government units" and "may be said to implement a congressional

policy choice to provide supplemental financial assistance for only those

residents of public institutions who already receive significant federal

support in the form of Medicaid coverage." Brief for Appellant 27-28. We

cannot say that the belief that the States should continue to have the

primary responsibility for making this small "comfort money" allowance

available to those residing in state-run institutions in an irrational

basis for withholding from them federal general welfare

funds. [20]

lready receive significant federal

support in the form of Medicaid coverage." Brief for Appellant 27-28. We

cannot say that the belief that the States should continue to have the

primary responsibility for making this small "comfort money" allowance

available to those residing in state-run institutions in an irrational

basis for withholding from them federal general welfare

funds. [20]

Although we understand and are inclined to be sympathetic with appellees'

and their supporting amici's assertions as to the beneficial

effects of a patient's receiving the reduced stipend, we find this a

legislative, and not a legal, argument. Congress rationally may elect to

shoulder only part of the burden of supplying this allowance, and may

rationally limit the grant to Medicaid recipients, for whose care the

Federal Government already has assumed the major portion of the

expense. [21] The limited

gratuity represents a partial solution to a far more general

problem, [22] and Congress

legitimately may assume that the States would, or should, provide an

equivalent, either in funds or in basic care. See Baur v. Mathews ,

578 F.2d 228, 233 (CA9 1978). This Court has granted a "strong presumption

of constitutionality" to legislation conferring monetary benefits, Mathews v. DeCastro , 429 U.S., at 185, because it believes that

Congress should have discretion in deciding how to expend necessarily

limited resources. Awarding this type of benefits inevitably involves the

kind of line-drawing that will leave some comparably needy person outside

the favored circle. [23] We

cannot say that it was irrational of Congress, in view of budgetary

constraints, [24] to decide

that it is the Medicaid recipients in public institutions that are the

most needy and the most deserving of the small monthly supplement. See,

e.g., Califano v. Boles , 443 U.S. 282, 296 (1979); Califano v.

Jobst , 434 U.S. 47, 53 (1977); Weinberger v. Salfi , 422 U.S.

749, 768-770 (1975); Richard v

ay that it was irrational of Congress, in view of budgetary

constraints, [24] to decide

that it is the Medicaid recipients in public institutions that are the

most needy and the most deserving of the small monthly supplement. See,

e.g., Califano v. Boles , 443 U.S. 282, 296 (1979); Califano v.

Jobst , 434 U.S. 47, 53 (1977); Weinberger v. Salfi , 422 U.S.

749, 768-770 (1975); Richard v. Belcher , 404 U.S. 78, 83-84

(1971).

We conclude that congress did not violate appellees' rights to equal

protection by denying them the supplementary benefit. The judgment of the

District Court is reversed.

It is so ordered.

JUSTICE POWELL, with whom JUSTICE BRENNAN, JUSTICE MARSHALL, and JUSTICE

SEVENS join, dissenting.

[1] The Supplemental Security

Income program, Title XVI of the Social Security Act, largely replaced the

prior system of federal grants to state-run assistance programs for the

aged, blind, and disabled contained in Titles I, X, XIV, and XVI of the

act, that is, Old Age Assistance, 49 Stat. 620, as amended, 42 U.S.C. §

301 et seq .; Aid to the Blind, 49 Stat. 645, as amended, 42 U.S.C.

§ 1201 et seq .; Aid to Permanently and Totally Disabled, 64 Stat.

555, as amended, 42 U.S.C. § 1351 et seq ,; and Aid to the Aged,

Blind, or Disabled, 76 Stat. 197, 42 U.S.C. § 1381 et seq .; (1970

ed). See Califano v. Aznavorian , 439 U.S. 170, 171 (1978); Califano v. Torres , 435 U.S. 1, 2, (1978).

[2] To be eligible for SSI

benefits, a person must be "aged," that is, 65 or older, or "blind," or

"disabled," as those terms are defined in § 1614 of the At, as amended, 42

U.S.C. § 1382c, and his income and resources must be below the levels

specified in § 1611(a), as amended, 42 U.S.C. § 1382(a).

[3] Section 1611(e)(1)(A), as

amended, provides:

"(e) Limitation on eligibility of certain individuals

ble for SSI

benefits, a person must be "aged," that is, 65 or older, or "blind," or

"disabled," as those terms are defined in § 1614 of the At, as amended, 42

U.S.C. § 1382c, and his income and resources must be below the levels

specified in § 1611(a), as amended, 42 U.S.C. § 1382(a).

[3] Section 1611(e)(1)(A), as

amended, provides:

"(e) Limitation on eligibility of certain individuals

"(1)(A) Except as provided in subparagraph (B) and (C), no person shall

be an eligible individual or eligible spouse for purposes of this

subchapter with respect to any month if throughout such month he is an

inmate of a public institution."

[4] Section 1611(e)(1)(B), as

amended, modifying § 1611(e)(1)(A), as amended, stated:

"(B) In any case where an eligible individual or his eligible spouse (if

any) is, throughout any month, in a hospital, extended care facility,

nursing home, or intermediate care facility receiving payments (with

respect to such individual or spouse) under a States plan approved under

title XIX, the benefit under this title for such individual for such month

shall be payable --

"(i) at a rate not in excess of $300 per year (reduced by the amount of

any income not excluded pursuant to section 1612(b)) in the case of an

individual who does not have an eligible spouse;

"(ii) in the case of an individual who has eligible spouse, if only one

of them is in such a hospital, home or facility throughout such month, at

a rate not in excess of the sum of --

"(l) the rate of $300 per year (reduced by the amount of any income, not

excluded pursuant to section 1612(b), of the one who is in such hospital,

home, or facility), and

"(ii) the applicable rate specified in subsection (b)(1) (reduced by the

amount of any income, not excluded pursuant to section 1612(b), of the

other); and

roughout such month, at

a rate not in excess of the sum of --

"(l) the rate of $300 per year (reduced by the amount of any income, not

excluded pursuant to section 1612(b), of the one who is in such hospital,

home, or facility), and

"(ii) the applicable rate specified in subsection (b)(1) (reduced by the

amount of any income, not excluded pursuant to section 1612(b), of the

other); and

"(iii) at a rate not in excess of $600 per year (reduced by the amount of

any income not excluded pursuant to section 1612(b)) in the case of an

individual who has an eligible spouse, if both of them are in such a

hospital, home, or facility throughout such month."

Subsection (C) of § 1382(e)(1), not implicated in this case, further

modifies § 1611(e)(1)(A), as amended, by providing:

"(C) As used in subparagraph (A), the term public institution' does not

include a publicly operated community residence which serves no more than

16 residents."

Added in 1976 by Pub. L. 94-566, § 505(a), 90 Stat. 2686, this subsection

met objections that § 1611(e) impeded reform efforts to

de-institutionalize certain groups of handicapped individuals, such as the

mentally retarded. Congress determined to encourage the establishment of

state-run group homes for such people by making residents in these

institutions eligible for SSI benefits. See S. Rep. No. 94-1265, p. 29

(1976); H.R. Conf. Rep. No. 92-1745, pp. 27-28 (1976).

jections that § 1611(e) impeded reform efforts to

de-institutionalize certain groups of handicapped individuals, such as the

mentally retarded. Congress determined to encourage the establishment of

state-run group homes for such people by making residents in these

institutions eligible for SSI benefits. See S. Rep. No. 94-1265, p. 29

(1976); H.R. Conf. Rep. No. 92-1745, pp. 27-28 (1976).

[5] Federal funds are available

under the Medicaid program to pay for the following "residential"

services; "inpatient hospital services (other than services in an

institution for tuberculosis or mental diseases)," § 1905(a)(1), 42 U.S.C.

§ 1396d(a)(1); "skilled nursing facility services (other than services in

an institution for tuberculosis or mental diseases) for individuals 21

years of age or older," § 1905(a)(4)(A); "inpatient hospital services,

skilled nursing facility services, and intermediate care facility services

for individuals 65 years of age or over in an institution for tuberculosis

or mental diseases," § 1905(a)(14); "intermediate care facility services

(other than such services in an institution for tuberculosis or mental

diseases) for individuals . . . in need of such care," § 1905(a)(15);

certain "inpatient psychiatric hospital services for individuals under age

21," §§ 1905(a)(16) and (h). Subsection (17)(B) of § 1905(a), which

provides for funding of any other medical or remedial care recognized

under state law, specifically excludes "payments with respect to care or

services for any individual who has not attained 65 years of age and who

is a patient in an institution for tuberculosis or mental diseases."

al services for individuals under age

21," §§ 1905(a)(16) and (h). Subsection (17)(B) of § 1905(a), which

provides for funding of any other medical or remedial care recognized

under state law, specifically excludes "payments with respect to care or

services for any individual who has not attained 65 years of age and who

is a patient in an institution for tuberculosis or mental diseases."

In 1950, when it first enacted federal grants for medical assistance,

Congress excluded "any individual who is a patient in an "institution for

. . . mental diseases" from eligibility. 64 Stat 558. This exclusion was

incorporated into the Medicaid statute in 1965, 79 Stat. 352, but

exceptions were made for the needed aged in mental institutions, and for

the care of mentally ill persons in general medical facilities. Ibid . In 1972, in the bill enacting the SSI program, Congress

further broadened Medicaid benefits for the mentally ill to include most

children in mental institutions, 86 Stat. 1461. A Senate proposal for

demonstration projects to investigate the possibility of extending

Medicaid benefits to the mentally ill between the ages of 21 through 64 in

mental hospitals was defeated at that time. See S. Rep. No. 92-1230, p.

281 (1972); H.R. Conf. Rep. No. 92-1605, p. 65 (1972).

[6] "This court repeatedly has

held that the Fifth Amendment imposes on the Federal Government the same

standard required of state legislation by the Equal Protection Clause of

the Fourteenth Amendment. See, e.g., Weinberger v. Salfi , 422 U.S.

749, 768-770 (1975); Richardson v. Belcher , 404 U.S. 78, 81

ee S. Rep. No. 92-1230, p.

281 (1972); H.R. Conf. Rep. No. 92-1605, p. 65 (1972).

[6] "This court repeatedly has

held that the Fifth Amendment imposes on the Federal Government the same

standard required of state legislation by the Equal Protection Clause of

the Fourteenth Amendment. See, e.g., Weinberger v. Salfi , 422 U.S.

749, 768-770 (1975); Richardson v. Belcher , 404 U.S. 78, 81

(1971).

[7] The three-judge court also

found that the state statute classified on the basis of age, not mental

health, and that it was rational and constitutional. The Court of Appeals

declined to review that constitutional holding on the ground that review

from the three-judge court could be had only in this Court. Wilson v.

Edelman , 542 F.2d, at 1276-1282.

[8] The Court of Appeals also

held that only two of the named plaintiffs, Maudie Simmons and John

Kiernan Turney; had satisfied the minimum, nonwaivable requirement of 42

U.S.C. § 405(g) that a party may seek review only of a "final decision of

the Secretary" denying, terminating, or suspending benefits under the SSI

program. The other named plaintiffs, including Charles Wilson, were

eligible for, or had sought and been denied, benefits only under the prior

cooperative state-federal programs, and therefore they were dismissed as

parties. We have retained Wilson as a named party in the caption of this

case, however, as did the District Court on remand, for the sake of

uniformity.

[9] The class was defined as

:

"all persons residing in HEW Region V who have been terminated from

benefits under Title XVI, or who have applied for Supplemental Security

income benefits under Title XVI and have been denied such benefits, on or

after January 1, 1974, solely because they are between the ages of 21 and

65 and hospitalized in a public mental institution." App. to Juris.

Statement 21a.

was defined as

:

"all persons residing in HEW Region V who have been terminated from

benefits under Title XVI, or who have applied for Supplemental Security

income benefits under Title XVI and have been denied such benefits, on or

after January 1, 1974, solely because they are between the ages of 21 and

65 and hospitalized in a public mental institution." App. to Juris.

Statement 21a.

[10] The District Court

denied, however, the claim of the pretrial detainees to the monthly

stipend, applying a "rational relation" standard and finding the exclusion

rational because "[t]he detainee status is necessarily temporary in

nature, and the [Secretary] could legitimately wish to withhold these

extra-subsistence payments while the detainee is housed in a public

institution and until his future status is determined." 478 F. Supp., at

1055.

[11] The District Court noted

that a person's mental health problem, especially one that has led to

institutionalization, is likely to "bear" [a] relation to ability to

perform or contribute to society." Id. , at 1051-1052, quoting Frontiero v. Richardson , 411 U.S. 677, 686 (1973). The court also

acknowledged that "[i]t is debatable whether and to what extent the mental

illness is an 'immutable characteristic determined solely by the accident

of birth." 478 F. Supp. at 1052, again quoting Frontiero , 411 U.S.,

at 686.

[12] The Secretary argued that

the statutory exclusion has three purposes: "1) the conversation (sic) of

federal resources; 2) the concern that federal funds be received on behalf

of residents of qualified institutions; and 3) the fact that plaintiffs

are not 'similarly situated' with Medicaid patients in terms of federal

interest and control." 478 F. Supp., at 105

[13] We therefore intimate no

views as to what standard of review applies to legislation expressly

classifying the mentally ill as a discrete group.

the concern that federal funds be received on behalf

of residents of qualified institutions; and 3) the fact that plaintiffs

are not 'similarly situated' with Medicaid patients in terms of federal

interest and control." 478 F. Supp., at 105

[13] We therefore intimate no

views as to what standard of review applies to legislation expressly

classifying the mentally ill as a discrete group.

[14] Social Security

Administration statistics show that 30.7% of all blind and disabled adult

persons awarded SSI benefits in 1975 (109,509 persons) were deemed

disabled by mental disorders, and the Administration has concluded that

"[m]ental illness was the most common cause of disability in 1975."

Kochhar, Blind and Disabled Persons Awarded Federally administered SSI

Payments, 1975, Social Security Bulletin 13, 15 (June 1979). Half of this

number suffered from mental illness rather than mental retardation and

these statistics did not include any persons with prior entitlement to

benefits. Ibid.

Further, as a recent study also indicates, a substantial number of

mentally ill people in institutions actually receive SSI benefits.

Representative Payments under the SSI Program, August, 1977, Social

Security Administration, Research and Statistics Note No. 9, September 16,

1980. This study established that 15% of the total population receiving

SSI benefits (for all reasons, including age, blindness, and disability)

had "representative payees" (a person "appointed to manage the benefits of

an adult beneficiary" because of "the adult beneficiary's inability to

manage his own funds"). Id. , at 1. Out of a total of 184,133

institutionalized persons who were receiving SSI benefits in August 1977

through such "representative payees," 76,494, or approximately 41%, were

institutionalized because of mental disorders. Id. , at 7 (Table 6)

and 2 (Table 1). Thus, even on this incomplete data, a sizable number of

SSI recipients were persons institutionalized for mental illness.

Id. , at 1. Out of a total of 184,133

institutionalized persons who were receiving SSI benefits in August 1977

through such "representative payees," 76,494, or approximately 41%, were

institutionalized because of mental disorders. Id. , at 7 (Table 6)

and 2 (Table 1). Thus, even on this incomplete data, a sizable number of

SSI recipients were persons institutionalized for mental illness.

[15] Appellees appear to

concede the rationality of Congress' general exclusion of publicly

institutionalized persons from full SSI benefits.

[16] An otherwise eligible

person does not receive SSI benefits if he is receiving long-term

treatment in a medical facility that is not certified under Medicaid

standards as a provider. See § 1861 of the Act, 42 U.S.C. § 1395x. These

strict standards exclude many facilities but work to the ultimate benefit

of those receiving Medicaid Cf. O'Bannon v. Town Court Nursing

Center , _____ U.S. _____ (1980).

[17] The average inpatient

stay in public mental hospitals is short. Recently collected data for 1975

reveals an average stay in state and county mental hospitals of only 25.5

days. Witkin, Characteristics of Admissions to Selected Mental Health

Facilities, 1975; An Annotated Book of Charts and Tables, National

Institute of Mental Health _____, DHHA Publication No. (ADM) 80-1005

(1981). This study also showed that young and elderly patients had longer

periods of stay than patients in the middle-age group. Id. , at

_____ . The rapidity with which inpatients are released from public

institutions has increased since the 1950's. In 1971, 75% of all patients

admitted to state mental hospitals were released within the first three

months, while 87% were released within the first six months. Ozarin,

Redick, & Taube, A Quarter Century of Psychiatric Care, 1950-1974: A

Statistical Review, 27 Hospital & Community Psychiatry 516 (1976)

hich inpatients are released from public

institutions has increased since the 1950's. In 1971, 75% of all patients

admitted to state mental hospitals were released within the first three

months, while 87% were released within the first six months. Ozarin,

Redick, & Taube, A Quarter Century of Psychiatric Care, 1950-1974: A

Statistical Review, 27 Hospital & Community Psychiatry 516 (1976).

Data from the National Institute of Mental Health show that the proportion

of "patient care episodes" (admissions during a year plus residents at the

beginning of the year) attributable to inpatient treatment at state and

county hospitals declined from 49% in 1955 to 9% in 1977. This dramatic

decrease in the percentage of persons admitted to these hospitals was

paralleled by a growth in treatment through outpatient and community

mental health facilities; that percentage grew from 23% in 1955 to 76% in

1977. Witkin, Trends in Patient Care Episodes in Mental Health Facilities,

1955-1977, National Institute of Mental Health, Mental Health Statistical

Note No. 154, p. 3 (September 1980). At the same time, the total number of

"patient care episodes" increased fourfold, from approximately 1.7 million

in 1955 to 6.9 million in 1977. Id. , at 1.

[18] To be eligible for

Medicaid reimbursement for inpatient services, mentally ill persons under

the age of 21 being treated in mental institutions must be receiving

"active treatment" that meets standards prescribed by the Secretary and

that "can reasonably be expected to improve the condition by reason of

which such services are necessary to the extent that eventually such

services will no longer be necessary." § 1905(h)(10(B) of the Act, 42

U.S.C. § 139d(h)(1)(B).

persons under

the age of 21 being treated in mental institutions must be receiving

"active treatment" that meets standards prescribed by the Secretary and

that "can reasonably be expected to improve the condition by reason of

which such services are necessary to the extent that eventually such

services will no longer be necessary." § 1905(h)(10(B) of the Act, 42

U.S.C. § 139d(h)(1)(B).

[19] The Medicaid limitation

was based on Congress' assumption that the care of persons in public

mental institutions was properly a responsibility of the States. See H.R.

Rep. No. 1300, 81st Cong., 1st Sess., 42 (1949) (enacting federal funding

for services to the needy aged, blind, and disabled provided in public

medical institutions, but excluding assistance to those in "public or

private institutions for mental illness and tuberculosis, since the States

have generally provided for medical care of such cases"); S. Rep. No. 404,

89th Cong., 1st Sess., pt. 1, 144-147 (1965) (enactment of Medicaid

providing coverage only to the aged needy in mental or tuberculosis

institutions; noting that "(t)he reason for this exclusion was that

long-term care in such hospitals had traditionally been accepted as a

responsibility of the States," id. , at 144). This exclusion was

upheld in Legion v. Richardson , 354 F. Supp. 456 (SDNY), aff'd sub nom. Legion v. Weinberger , 414 U.S. 1058 (1973), and Kantrowitz v. Weinberger , 388 F. Supp. 1127 (DC 1974), aff'd, 174

U.S. App. D.C. 182, 530 F.2d 1034, cert. denied, 429 U.S. 819 (1976), and

appellees disavow any intention to dispute that holding. Brief for

Appellees 26-27; Tr. of oral Arg. 19.

[20] Whether a State chooses

to elect or not to elect to provide an equivalent monthly stipend to

institutionalized mental patients does not alter the rationality of

Congress' decision.

(DC 1974), aff'd, 174

U.S. App. D.C. 182, 530 F.2d 1034, cert. denied, 429 U.S. 819 (1976), and

appellees disavow any intention to dispute that holding. Brief for

Appellees 26-27; Tr. of oral Arg. 19.

[20] Whether a State chooses

to elect or not to elect to provide an equivalent monthly stipend to

institutionalized mental patients does not alter the rationality of

Congress' decision.

[21] The Secretary has

interpreted § 1611(e)(1)(B) to require that at least 50% of the cost of

services be reimbursed by Medicaid before the reduction of benefits

becomes effective. 20 CFR § 416.231(b)(5) (1980).

[22] Congress continues to

investigate other more general solutions and to propose alternations in §

1611)(e). See H.R. Rep. No. 96-451, pt. 1, p. 153 (1979); 125 Cong Rec.

H10301, H10306, E5526 (daily eds. Nov. 7 and 9, 1979) (remarks of Rep.

Corman, Rep. Pepper, and Rep. Bingham) (proposing amendment to § 1611(e)

to forestall reduction of benefits until after eligible individual has

been institutionalized in a Medicaid institution for three months); Staff

of the Senate Committee on Finance, The Supplemental Security Income

Program, 95th Cong., 1st Sess., 109-115 (Comm. Print 1977) (advocating

legislative amendments standardizing the monthly stipend to

institutionalized persons).

[23] When a legal distinction

is determined, as no one doubts that it may be between night and day,

childhood and maturity, or any other extremes, a point has to be fixed or

a line has to be drawn, or gradually picked out by successive decisions,

to mark where the change takes place. Looked at by itself without regard

to the necessity behind it the line or point seems arbitrary. It might as

well or nearly as well be a little more to one side or the other

t may be between night and day,

childhood and maturity, or any other extremes, a point has to be fixed or

a line has to be drawn, or gradually picked out by successive decisions,

to mark where the change takes place. Looked at by itself without regard

to the necessity behind it the line or point seems arbitrary. It might as

well or nearly as well be a little more to one side or the other. But when

it is seen that a line or point there must be, and that there is no

mathematical or logical way of fixing it precisely, the decision of the

legislature must be accepted unless we can say that it is very wide of any

reasonable mark." Louisville Gas Co. v. Coleman , 277 U.S. 32, 41

(11928) (Holmes, J., dissenting).

[24] The amount of money, and

the number of people potentially involved, are not inconsiderable.

Although the appellees do not agree, the Secretary estimates that the

annual cost of implementing the District Court's order nationwide would

approximate $30 million. Memorandum in Reply to Appellees' Motion to

Affirm 3. In 1979, a total of almost 2.2 million people were receiving SSI

benefits for disabilities, an increase of over 900,000 from January 1974.

See Social Security Bulletin 49 (Table M-24) (June 1979). Further, of all

the disabled adults who applied for benefits between January 1974 and July

1975, 1.1% were denied eligibility by reason of their residence in a

public institution. See S. Rep. No. 95-1312, p. 7 (table) (1978).