You Are The North Carolina Supreme Court Justice

The NC Supreme Court ruled today that a Greensboro man's chemotherapy wasn't covered by medicaid because he was an illegal immigrant and because his medical condition wasn't an emergency. Here's a fun assignment for this weekend: See if you can figure out whether the Supreme Court made the right decision.

Below the fold you'll find the statute that they were interpreting, followed by the court's full (and not ver long at all) opinion. Post your answers in the comments. For extra credit, explain whether the "right" result is morally right or not.

The statute, 42 United States Code &sec;1396b(v):

(v) Medical assistance to aliens not lawfully admitted for permanent residence

(1) Notwithstanding the preceding provisions of this section, except as provided in paragraph (2), no payment may be made to a State under this section for medical assistance furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law.

(2) Payment shall be made under this section for care and services that are furnished to an alien described in paragraph (1) only if--

    (A) such care and services are necessary for the treatment of an emergency medical condition of the alien,

    (B) such alien otherwise meets the eligibility requirements for medical assistance under the State plan approved under this subchapter (other than the requirement of the receipt of aid or assistance under subchapter IV of this chapter, supplemental security income benefits under subchapter XVI of this chapter, or a State supplementary payment), and

    (C) such care and services are not related to an organ transplant procedure.

(3) For purposes of this subsection, the term "emergency medical condition" means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that 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.

And the Court's opinion, by Justice Brady:





HECTOR DIAZ, Petitioner



    On discretionary review pursuant to N.C.G.S. § 7A-31 of
a unanimous decision of the Court of Appeals, 166 N.C. App. 209,
600 S.E.2d 877 (2004), affirming a judgment and order entered on
23 May 2003 by Judge James W. Webb in Superior Court, Guilford
County. On 3 March 2005, the Supreme Court allowed petitioner's
conditional petition for discretionary review as to an additional
issue. Heard in the Supreme Court 14 November 2005.


Ott Cone & Redpath, P.A., by Melanie M. Hamilton,
Thomas E. Cone, and Wendell H. Ott, for petitioner-

    Roy Cooper, Attorney General, by Richard J. Votta,
Assistant Attorney General, for respondent-

        BRADY, Justice.

    This case requires determination of the scope of
coverage and reimbursement for a nonqualifying alien's medical
treatment under federal and North Carolina Medicaid law. Because
we hold the relevant treatment provided to petitioner did not
qualify as treatment for an emergency medical condition, we
reverse the decision of the Court of Appeals.        


    Petitioner Hector Diaz, a native of Guatemala, is “an
alien who is not lawfully admitted for permanent residence or
otherwise permanently residing in the United States under color
of law.” 42 U.S.C. § 1396b(v)(1) (2000). In October of 2000,
Diaz began experiencing sore throat, nausea, vomiting, bleeding
gums, and increasing lethargy, which were later diagnosed as
symptoms of acute lymphocytic leukemia (ALL).  

(See footnote 1)


Doctors at Moses
Cone Memorial Hospital in Greensboro, North Carolina treated
petitioner beginning on or about 21 October 2000. Chemotherapy
treatments commenced shortly thereafter and continued
intermittently until July of 2002.

    At some time during his treatment, petitioner
authorized the medical service provider to seek Medicaid coverage
on his behalf. In the applications for Medicaid coverage
relevant to this appeal, respondent Division of Medical
Assistance (DMA) approved payment for emergency medical services
from 21-22 October 2000 and 9-11 February 2002. DMA denied all
other coverage dates relevant to this appeal as nonemergency
services, and this denial was affirmed on administrative appeal
by a final decision of the Chief Hearing Officer of the North
Carolina Department of Health and Human Services. Consequently,
none of petitioner's chemotherapy treatments at issue were
reimbursed by Medicaid.     Petitioner appealed the final agency decision to the
Guilford County Superior Court, which reversed respondent's
decisions, finding the treatment was provided for an emergency
medical condition and that “payment by Medicaid is not limited to
emergency services; rather, Medicaid shall pay for all care and
services as are medically necessary for the treatment of an
emergency medical condition.” Respondent then appealed to the
North Carolina Court of Appeals, which unanimously affirmed the
decision of the trial court. This Court allowed respondent's
petition for discretionary review and petitioner's conditional
petition for discretionary review, and we now reverse the
decision of the Court of Appeals.



    In cases appealed from administrative tribunals, we
review questions of law de novo and questions of fact under the
whole record test. See N.C. Dep't of Env't & Natural Res. v.
, 358 N.C. 649, 659, 599 S.E.2d 888, 894-95 (2004).

CONSTRUCTION OF 42 U.S.C. § 1396b(v)

    Medicaid is a joint program between participating
states and the federal government. North Carolina chose to
participate and therefore must abide by federal statutory law
governing Medicaid reimbursement by the federal government. See

42 U.S.C. § 1396a (2000). If a state does not follow federal
Medicaid statutes in providing coverage for a patient, that state
risks losing Medicaid reimbursement from the federal government
for that payment. The relevant statute in this case provides thefederal government will not make payment to a state for “medical
assistance furnished to an alien who is not lawfully admitted for
permanent residence or otherwise permanently residing in the
United States under color of law.” Id. § 1396b(v)(1). There is
one exception to this broad rule, and that is for treatment of an
emergency medical condition, not related to an organ transplant
procedure, of an alien who would qualify but for his or her
immigration status. Id. § 1396b(v)(2) (2000). Subsection (v)(3)
defines an “emergency medical condition” as:

    a medical condition (including emergency
labor and delivery) manifesting itself by
acute symptoms of sufficient severity
(including severe pain) such that 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.


Id. § 1396b(v)(3) (2000). The relevant federal and North
Carolina administrative codes are in accord with this definition.
See 42 C.F.R. § 440.255(b)(1) & (c)(1) (2005); 10A NCAC 21B
.0302(c) (June 2004). We must now interpret this statute and
determine whether petitioner's treatments were for an emergency
medical condition.

    When the language of a statute is clear and without
ambiguity, it is the duty of this Court to give effect to the
plain meaning of the statute, and judicial construction of
legislative intent is not required. See Burgess v. Your House
of Raleigh, Inc.
, 326 N.C. 205, 209, 388 S.E.2d 134, 136 (1990). However, when the language of a statute is ambiguous, this Court
will determine the purpose of the statute and the intent of the
legislature in its enactment. See Coastal Ready-Mix Concrete Co.
v. Bd. of Comm'rs of Town of Nags Head
, 299 N.C. 620, 629, 265
S.E.2d 379, 385 (1980) (“The best indicia of that intent are the
language of the statute or ordinance, the spirit of the act and
what the act seeks to accomplish.”). We find the statute in
question to be clear and unambiguous; therefore, we will give
effect to its plain meaning.

    In the leading case on this issue, Greenery
Rehabilitation Group, Inc. v. Hammon
, the United States Court of
Appeals for the Second Circuit held that continuous and
regimented care provided for nonqualified aliens who “suffered
sudden and serious head injuries that necessitated immediate
treatment and ultimately left the patients with long-term
debilitating conditions” was not covered under the Medicaid
program. 150 F.3d 226, 228 (2d Cir. 1998). One of these
patients, Izeta Ugljanin, was “[b]edridden and quadriplegic,”

requiring a feeding tube and extensive nursing care. See id.
Another, Leon Casimir, was unable to walk and required continual
monitoring and medication. He was unable to bathe, dress, eat,
or use the toilet without assistance. See id. at 228-29. A
third patient, Yik Kan, was legally blind. See id. at 229. The
United States District Court for the Northern District of New
York found Ugljanin and Casimir's treatments were for emergency
medical conditions, but that Yik Kan's treatment was not. See
at 231. In reversing the District Court as to the treatmentsfor Ugljanin and Casimir, the Second Circuit wrote: “The
patients' sudden and severe head injuries undoubtedly satisfied
the plain meaning of § 1396b(v)(3). However, after the patients
were stabilized and the risk of further direct harm from their
injuries was essentially eliminated, the medical emergencies
ended.” Id. at 232.

    In arriving at this “stabilization” construction of
subsection 1396b(v)(3), the Second Circuit noted when determining
whether a condition is an emergency medical condition, the key
words are “emergency,” “acute,” “manifest,” and “immediate.” See
Using the common definitions of those words, that court
concluded: “[T]he statutory language unambiguously conveys the
meaning that emergency medical conditions are sudden, severe and
short-lived physical injuries or illnesses that require immediate
treatment to prevent further harm.” Id. This analysis closely
adheres to the clear and unambiguous language of subsection
1396b(v)(3). Accordingly, we find the Greenery decision

    Petitioner contends that once a patient presents with
an emergency medical condition, any and all treatment necessary
for the cure of the underlying cause of the emergency medical
condition must be covered, even when the condition is no longer
an emergency. We disagree. Petitioner's contention, in our
view, is contrary to the plain meaning of the statute. Under
subsection 1396b(v)(3), in order for a nonqualifying alien to be
entitled to Medicaid coverage, his or her condition must require
immediate intervention to prevent the occurrence of any of thethree statutorily enumerated results. See 42 U.S.C. §
1396b(v)(3). The word “immediate” is commonly defined as:
“occurring, acting, or accomplished without loss of time : made
or done at once : INSTANT.” Webster's Third New International
1129 (16th ed. 1971). Therefore, treatment is not for
an emergency medical condition under subsection 1396b(v)(3)
unless one of the statutorily enumerated results is reasonably
expected if immediate treatment is withheld.

    We are cognizant the Supreme Court of Connecticut has
decided a case factually similar to this one and has held
contrary to our decision today. See Szewczyk v. Dep't of Soc.
, 275 Conn. 464, 881 A.2d 259 (2005). However, in our
opinion, the Connecticut decision applied a much broader
interpretation of the word “immediate” than intended by Congress.
The divided Szewczyk court seemed to rest much of its decision
upon evidence in the record indicating that the nonqualifying
alien in the case would have rapidly died if not provided
treatment. See id. at 468, 881 A.2d at 262. In the case at bar,
while there is no dispute Diaz received appropriate care in the
standard medical course of treatment, there is nothing in the
record that indicated the prolonged chemotherapy treatments must
have been “immediate” to prevent the statutorily enumerated
results. The record in the case sub judice and the record in

Szewczyk differ as to whether immediate treatment was required to
treat the respective conditions of the patients.

    Additionally, while the Szewczyk court purported to
follow the Second Circuit's decision in Greenery for the sake ofuniformity between federal and state law in Connecticut, it added
to the holding in Greenery: “Beyond the analysis of Greenery . .
. we also note that the plain language of § 1936b(v) indicates
that the statute encompasses payment for care beyond that which
is immediately necessary to stabilize a patient.” Id. at 482-83,
881 A.2d at 271. The reasoning behind this statement is the
requirement that the treatment for an emergency medical condition
not be “related to an organ transplant procedure.” 42 U.S.C. §

1396b(v)(2)(C). Because Congress chose to not provide coverage
for emergency medical services related to organ transplant
procedures, the Szewczyk court reasoned that Congress intended
for treatment under the statute to encompass more than
stabilization because organ transplants are “undoubtedly . . .
time-consuming and entail relatively lengthy hospitalizations.”
Id. at 483, 881 A.2d at 271. Presuming Congress would not enact
superfluous legislation, the Szewczyk court assumed it was
unnecessary to exempt coverage for organ transplant procedures if
only short-term stabilization is required. Id. at 483-84, 881
A.2d at 271-72.

    However, the construction of the statute by the Second
Circuit in Greenery and this Court in the case sub judice does
not render subsection (v)(2)(C) a superfluity. Congress simply
provided that even if the only appropriate treatment for an
emergency medical condition was an organ transplant, it had made
a policy decision that the federal government would not reimburse
state Medicaid payments for such a procedure. We are not
persuaded the restriction found in subsection (v)(2)(C) changesthe plain meaning of the word “immediate” found in (v)(3).
Therefore, we follow the federal appellate court's interpretation
of 42 U.S.C. § 1396b in Greenery and decline to follow the
divided fellow state appellate court's interpretation in


    By giving effect to the plain meaning of the statute,
we acknowledge “'[t]he role of the Court is not to sit as a super
legislature and second-guess the balance struck by the elected
officials.'” State v. Bryant, 359 N.C. 554, 565, 614 S.E.2d 479,
486 (2005) (quoting Henry v. Edmisten, 315 N.C. 474, 491, 340
S.E.2d 720, 731 (1986)); see also State v. Revis, 193 N.C. 192,
195, 136 S.E. 346, 347 (1927) (“The Legislature alone may
determine the policy of the State . . . .”). Therefore we defer
to the broad public policy statement of Congress found in
subsection 1396b(v): “[N]o payment may be made to a State under
this section for medical assistance furnished to an alien who is
not lawfully admitted for permanent residence or otherwise
permanently residing in the United States under color of law.”

42 U.S.C. § 1396b(v)(1). The narrow exception to this broad
statement appears in subsection (v)(2), which provides for
treatment of emergency medical conditions if the alien would
qualify but for his immigration status and the “care and services
are not related to an organ transplant procedure.” This
exception is consistent with the public policy clearly
articulated by Congress in 8 U.S.C. § 1601(6): “It is a
compelling government interest to remove the incentive for
illegal immigration provided by the availability of publicbenefits.” The Second Circuit's analysis in Greenery follows the
plain meaning of 42 U.S.C. § 1396b, and our holding is consistent
with both the statute and Greenery.

    Therefore, we hold an emergency medical condition is
one which manifests itself by acute symptoms at the time of
treatment and requires immediate treatment to stabilize the
condition, such that the absence of this treatment would
reasonably be expected to cause any of the three results listed
in 42 U.S.C. § 1396b(v)(3)(A), (B), or (C). The State is not
required to make payment for services provided to treat a
nonqualifying alien's condition, unless it meets the definition
of an emergency medical condition.


    Acute lymphocytic leukemia (ALL) is an acute leukemia
“characterized by replacement of normal bone marrow by blast
cells of a clone arising from malignant transformation of a
hematopoietic stem cell.” The Merck Manual of Diagnosis and
946 (Mark H. Beers, M.D. & Robert Berkow, M.D., eds.,
17th ed. 1999). The presenting symptoms of ALL are “fatigue,
fever, malaise, weight loss,” and other nonspecific symptoms.

See id. at 947. When petitioner sought emergency treatment on or
about 21 October 2000, he presented with severe symptoms, namely
sore throat, nausea and vomiting, bleeding gums, and lethargy.
At the time of his initial treatment in the emergency room, there
is no dispute petitioner presented with an emergency medical
condition. However, soon after his admission to the facility,
petitioner's condition dramatically improved. Duringpetitioner's chemotherapy treatments, his condition was stable
and, therefore, he was no longer entitled to Medicaid coverage.
As testified to by a medical doctor under contract to review
cases for the Medicaid program, if petitioner had not received
chemotherapy treatments, he would have eventually regressed into
a state of an emergency medical condition. However, as also
testified to by that same physician, at the time the chemotherapy
treatments at issue were provided to petitioner, he did not meet
the requirement of having an emergency medical condition. Thus,
it was error for the trial court to reverse the final agency
decision denying coverage for the dates denied. Accordingly, we
reverse the decision of the Court of Appeals and remand the case
to that court with instructions to remand to the trial court for
further proceedings not inconsistent with this opinion.


    Justice TIMMONS-GOODSON did not participate in the
consideration or decision of this case.


Way too hard

Thank goodness for lawyers!

looks legally correct to me

and, since you ask, there's not a whole lot morally right with our medical corporate complex, including (but not exclusive to):

  1. the totally incomprehensible payment system,
  2. the insurance leech industry,
  3. medical student sleep-deprivation brainwash-hazing,
  4. the carrot/stick federal and corporate "research" fund decision-making,
    as well as
  5. the bizarre and completely unethical emphasis on pharmaceuticals and surgical options.

(I wanted to try html list-making)

Nice List!

Thanks for playing, DQ. For what it's worth, I agree.

I don't think you want me to comment

While a bad ankle sprain could have been handled in an orthopaedic surgeon's office, that would have required a 30 minute drive and we didn't know if Katie's ankle was sprained or broken since our typically very stoic daughter was in a great deal of pain. That being said, our visit took over 3 hours and we sat for much of it simply waiting for the hospital staff to finish dealing with quite a few "non emergencies" with illegals. Gotta run

Vote Democratic! The ass you save may be your own.

Illegal Immigrant

You've got to be kidding. This is a question?
The only medical care illegal immigrants should receive is that required to save their lives long enough to ship them back on a plane or boat.
My wife quit being an ER trauma nurse partly due to the FLOOD of illegals who never pay a dime (which I end up paying) who clog our ERs coast to coast, so that honest, hard working Americans SUFFER every time they need treatment. SO we are delayed, unseen and untreated while we pay for both ourselves and them. Any liberal or progressive who thinks its ok for illegals to stay should bleed to death waiting for treatment in an ER, then maybe they will understand.

This is so typical of conservatives

This was a question about the law, plain and simple. There is nothing—zip, zero, zilch—in your answer about the law. There's nothing about whether 42 U.S.C. 1396 was properly interpreted by Justice Brady. Instead, you've got an anecdote about your wife who got mad when whitey had to wait and a wish for liberals to bleed to death. This kind of comment belongs on AM radio.

Anyone who would suggest

that someone else should bleed to death in order to "learn a lesson" is simply a pathetic excuse for a human being. What do you suggest we do with Americans who can't afford health care? Do they get a free pass because they are Americans? No, because before you had the illegal immigrants to whine about you were whining about the working poor. Your President and your Senate and your House have done NOTHING to develop a valid healthcare plan that addresses the needs of all Americans. You voted for these worthless morons, so that makes it your fault.

Liddy Dole was whining that it was the Democrats fault the Senate couldn't pass immigration legislation. Do me a favor. Tell her to learn simple math - the Democrats are in the MINORITY and could not have prevented the Republicans from doing anything they wanted to do. What's that? What's that you say? Ahhhh so it was the Republicans that weren't voting with the Republicans that prevented the Senate from passing the legislation. Ohhhhh.

There's one thing I've learned about Republicans in my 43 years. They'll do anything to keep from accepting responsibility and they will always find something to whine about.

Vote Democratic! The ass you save may be your own.

they're scared

They feel inadequate. They're . . . cars aren't big enough. They gotta get theirs before anyone else does. They are afraid that there isn't enough money/health care/resources/courtesy to go around so they hoard them and then their fears become reality.