The Kansas Medicaid authority denied the request of an observant Jehovah’s Witness for an out of state medical procedure. Her religious beliefs obligated her to seek a procedure that no hospital within the state would perform. The Kansas Court of Appeals found that the denial violated the Free Exercise Clauses of the US and Kansas Constitutions. Stinemetz v. Kansas Health Policy Authority, 2011 WL 1662788 (Kan. App. May 4, 2011).
Mary D. Stinemetz was a resident of Kansas and a practicing Jehovah’s Witness in need of a liver transplant. She was also a beneficiary of the Kansas Medical Assistance Program (Medicaid). Because her religious beliefs required she not receive blood transfusions, her only option was to undergo a procedure known as a bloodless liver transplant. Unfortunately, no hospital in her home state of Kansas was willing to perform the procedure. However, a hospital in Nebraska was willing to perform the procedure.
She requested authorization for the out-of-state procedure from the Kansas Health Policy Authority (KHPA) in charge of overseeing Medicaid in the state. Though KHPA would have authorized the procedure if a Kansas hospital had been willing to perform it, the KHPA denied authorization to have the procedure done at the Nebraska hospital. KHPA informed Stinemetz that her religious requirements did not make the out of state service a “medical necessity.” Stinemetz appealed the decision to an administrative hearing, which affirmed the initial denial. She appealed again to the KHPA State Appeals committee, which reaffirmed the initial conclusion that “religious preference does not meet the medical necessity criteria.”
Stinemetz next challenged the denial in court by seeking judicial review of the administrative decision. She argued that the denial violated her rights under the First Amendment of the US Constitution and Section 7 of the Kansas Constitution Bill of Rights by conditioning a life saving public benefit on transgressing a deeply held religious belief. The district court affirmed the denial of the out-of-state authorization on the grounds that the agency’s action did not violate the Constitution. She appealed the district court’s decision to the Court of Appeals of Kansas.
The court of appeals first examined whether Stinemetz properly preserved the issue of the constitutionality of the administrative denial. KHPA argued that she failed to preserve the issue for judicial review. The court noted that because administrative agencies cannot rule on constitutional issues, parties can raise them for the first time in court. The court also found that Stinemetz did raise the constitutional issues at the administrative level, and adequately substantiated her claims by providing sufficient testimony and other forms of evidence.
The court next inquired whether the administrative denial violated the First Amendment of the United States Constitution. The court had “unlimited review” of the constitutionality of an administrative agency’s decision. It concluded that the administrative denial violated the First Amendment of the Constitution. The court followed the Supreme Court’s decision in Employment v. Smith, 494 U.S. 872 (1990). In Employment v. Smith, the Supreme Court “essentially removed the strict scrutiny or compelling interest test from the Free Exercise Clause analysis.” Under Employment v. Smith, regulations that are generally applicable and constitutional that have an incidental effect on the free exercise of religion do not violate the First Amendment. There are two exceptions to this general rule from Employment v. Smith. First, the “hybrid exception” requires courts to impose stricter scrutiny when other constitutional rights are also implicated along with the Free Exercise Clause. This exception was not applicable here.
The second exception, known as the “individual exemption exception,” applied to this case. Under the “individual exemption exception,” if a state can make an individual exemption to its rules about providing benefits, it cannot withhold exemptions from those claiming “religious hardship.” Here, the KHPA had discretion on a case-by-case basis to make exemptions to its rules and authorize out-of-state procedures. Under Employment v. Smith and the Free Exercise Clause, the “individual exemption exception” applied and the administrative agency’s decision was subject to strict scrutiny. In other words, KHPA could not withhold an exemption from Stinemetz without a compelling state interest. The court could find no compelling state interest. Consequently, the court concluded that the denial violated the Free Exercise Clause of the U.S. Constitution.
The court also examined whether the denial violated section 7 of the Kansas Constitution Bill of Rights. It adopted a four step test from the Minnesota Court of Appeals’s decision in Shagalow v. State Dept. of Human Services, 725 N.W.2d 380 (Minn.App. 2006). This standard, according to the court, is more protective of the free exercise of religion than the U.S. Constitution’s standard. First, the court accepted that Stinemetz’s religious belief was sincere. Second, conditioning the life-saving benefit on violating deeply held religious belief was a burden on her free exercise of religious belief. Third, KHPA could show no compelling state interest in denying the out-of-state authorization. Finally, with no compelling state interest, KHPA also could not show that it employed the least burdensome means to achieve its interest. The court concluded that the denial violated the Kansas constitution.