United States Court of Appeals
Fifth Circuit
F I L E D
UNITED STATES COURT OF APPEALS
April 29, 2005
FIFTH CIRCUIT
Charles R. Fulbruge III
____________ Clerk
No. 04-50649
____________
SOILA COMACHO; SONIA DENISE GROVER; TEXAS
WELFARE REFORM ORGANIZATION; EL PASO COUNTY
HOSPITAL DISTRICT, doing business as R.E. Thomason General
Hospital,
Plaintiffs-Appellees,
versus
TEXAS WORKFORCE COMMISSION; TEXAS HEALTH AND
HUMAN SERVICES COMMISSION; TEXAS DEPARTMENT OF
HUMAN SERVICES,
Defendants-Appellants.
Appeal from the United States District Court
For the Western District of Texas
Before KING, Chief Judge, GARZA, and BENAVIDES, Circuit Judges.
EMILIO M. GARZA, Circuit Judge:
The Texas Workforce Commission (“TWC”) redefined the Texas work requirements under
the federal-state Temporary Assistance for Needy Families (“TANF”) program. The new definition
allows the TWC to terminate medical cash assistance to TANF recipients who fail to ensure their
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children’s immunizations, wellness check-ups, school attendance, or who fail to avoid substance abuse.
The sole issue in this case is whether these new rules are inconsistent with and thus preempted by the
federal Medicaid Act. 42 U.S.C. § 1396 - 1396v. Plaintiffs Soila Camacho1 (“Camacho”), Sonia
Denise Gro ver (“Grover”), the Texas Welfare Reform Organization (“TWRO”), and the El Paso
County Hospital District, doing business as R.E. Thomason General Hospital (“Thomason GH,”
collectively, the “Plaintiffs”) sued TWC, the Texas Health and Human Services Commission
(“THHSC”) and the Texas Department of Human Services (“TDHS,” collectively, the “Defendants”),
seeking relief against enforcement of the new rules. After granting a preliminary injunction, the district
court granted declaratory judgment, preventing TDHS from terminating cash assistance under the
redefinition. The Defendants appeal. We address the declaratory judgment only, as we dismissed the
preliminary injunction appeal as moot.
I
The material facts are undisputed. Camacho was a recipient of TANF and Medicaid, and
reapplied for benefits after being terminated from her job. Grover is currently a recipient of TANF
and Medicaid subject to the challenged rules. TWRO is an organization that advocates on behalf of
its members, including recipients of TANF and Medicaid who are at risk of losing their Medicaid
benefits under the new rules. Thomason GH is a county hospital required by state law to provide
indigent care which, it contends, would lose funding under the new rules. TWC enacted the rules
redefining Texas’s work requirements. TDHS is the state agency authorized to terminate Medicaid
assistance under the new rules. THHSC implements the Texas Medicaid program.
1
The style spells plaintiff’s name “Comacho.” The record, however, indicates that the correct
spelling is “Camacho.”
2
The Plaintiffs filed suit in state district court in Travis County, Texas, seeking a temporary
injunction against the enforcement of the new rules. The Defendants removed the case t o federal
court. The district court granted Plaintiffs’ application for a preliminary injunction. Later, the district
court entered a final judgment, ruling that the new TWC rules are inconsistent with and preempted by
the Medicaid statute. The district court reasoned that recipients could only have their benefits
terminated for “refusing to work” under 42 U.S.C. § 607(d). The district court held that the new rules
imposed requirements in addition to those set forth in 42 U.S.C. § 607(d). Specifically, the district
court declared invalid, “[40 TEX. ADMIN. CODE] . . . [§] 811.2(11)(A) and (B), 811.25(a)(1)(A), and
811.41(d)(3)(A)-(D), to the extent those rules apply the job readiness activities in . . . 811.41(d)(3)
and the parenting skills training in . . . 811.52(4), (5), (6), and (7) as grounds for terminating Medicaid
benefits.”
Defendants appeal. They contend the definition of “job search and job readiness,” an
enumerated work activity under 42 U.S.C. § 607(d), includes ensuring child immunizations, wellness
check-ups, school attendance and abstaining from substance abuse. Thus, they contend that the
district court failed to properly defer to TWC’s reasonable statutory interpretation. Plaintiffs respond
that the plain language of the statute precludes TWC’s redefinitions. Thus, they argue that there is
no deference due and that the district court properly granted declaratory judgment.
II
In 1996, Congress reformed welfare with the Personal Responsibility and Work Opportunity
Reconciliation Act (“PRWORA”). PRWORA replaced Aid to Families with Dependent Children with
Temporary Assistance to Needy Families. 42 U.S.C. § 601 - 619. The purpose of the new program
is “to increase the flexibility of States in operating a program designed to” meet certain goals including
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“end[ing] the dependence of needy parents on government benefits by promoting job preparation,
work, and marriage.” 42 U.S.C. § 601(a). As a condition of receiving TANF grants, states must
ensure that certain percentages of recipients participate in “work activities.” 42 U.S.C. § 607(a).
PRWORA lists twelve work activities:
(1) unsubsidized employment;
(2) subsidized private sector employment;
(3) subsidized public sector employment;
(4) work experience (including work associated with the refurbishing of publicly
assisted housing) if sufficient private sector employment is not available;
(5) on-the-job training;
(6) job search and job readiness assistance;
(7) community service programs;
(8) vocational educational training (not to exceed 12 months with respect to any
individual);
(9) job skills training directly related to employment;
(10) education directly related to employment, in the case of a recipient who has not
received a high school diploma or a certificate of high school equivalency;
(11) satisfactory attendance at secondary school or in a course of study leading to a
certificate of general equivalence, in the case of a recipient who has not completed
secondary school or received such a certificate; and
(12) the provision of child care services to an individual who is participating in a
community service program.
42 U.S.C. § 607(d)(1)-(12). A recipient is engaged in work if he or she is participating in one or more
of these activities for at least thirty hours per week in certain proportions. 42 U.S.C. § 607(c). A
state must submit a plan outlining its proposal to “[r]equire a parent or caretaker receiving assistance
under the program to engage in work (as defined by the State) once the State determines the parent
or caretaker is ready to engage in work.” 42 U.S.C. § 602(a)(1)(A)(ii). The plan must “[e]nsure that
parents and caretakers receiving assistance under the program engage in work activities in accordance
with section 607.” 42 U.S.C. § 602(a)(1)(A)(iii).
When an individual refuses to participate in a work activity, PRWORA requires the state to
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“(A) reduce the amount of assistance otherwise payable to the family pro rata (or more, at the option
of the State) . . . ; or (B) terminate such assistance, subject to such good cause and other exceptions
as the State may establish.” 42 U.S.C. § 607(e)(1). In addition to losing TANF assistance for refusing
to work, a recipient may lose Medicaid benefits. 42 U.S.C. § 1396u-1(b)(3)(A)(iii) (giving states the
option to terminate medical assistance for refusing to work pursuant to 42 U.S.C. § 607(e)(1)(B)).
A
Medicaid, authorized under Title XIX of the Social Security Act of 1965, is a cooperative
federal-state program t hrough which the federal government provides financial aid to states that
furnish medical assistance to eligible low-income individuals. See 42 U.S.C. § 1396 - 1396v; see also
Atkins v. Rivera, 477 U.S. 154, 156 (1986); Louisiana v. United States Dep’t. of Health and Human
Servs., 905 F.2d 877, 878 (5th Cir. 1990). States electing to participate in the program must comply
with requirements imposed by the Act and regulations of the Secretary of Health and Human
Resources. See Evergreen Presbyterian Ministries, Inc. v. Hood, 235 F.3d 908, 915 (5th Cir. 2000)
(“The [Medicaid] program is voluntary; however, once a state chooses to join, it must follow the
requirements set forth in the Medicaid Act and in its implementing regulations.”). The federal
government and states share the costs of medical care for eligible participants.
The Medicaid Act allows states to terminate medical assistance in certain circumstances.
Specifically, the Act states
Option to terminate medical assistance for failure to meet work requirement.
(A) Individuals receiving cash assistance under TANF
In the case of an individual who--
(i) is receiving cash assistance under a State program funded under part A of
subchapter IV of this chapter,
(ii) is eligible for medical assistance under this subchapter on a basis not related to
section 1396a(l) of this title, and
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(iii) has the cash assistance under such program terminated pursuant to section
607(e)(1)(B) of this title (as in effect on or after the welfare reform effective date)
because of refusing to work,
the State may terminate such individual’s eligibility for medical assistance under this
subchapter until such time as there no longer is a basis for the termination of such
cash assistance because of such refusal.
42 U.S.C. § 1396u-1(b)(3) (emphasis added). Therefore, states have the option to terminate a
recipient’s medical assistance for “refusing to work.”
B
In 2003, the Texas legislature passed new legislation implementing PRWORA. The statute
states, “[t]he department shall require each adult recipient to sign a bill of responsibilities that defines
the responsibilities of the state and of the recipient and encourages personal responsibility.” TEX.
HUM. RES. CODE ANN. § 31.0031(a). In addition, “[t]o the extent allowed by federal law, [THHSC]
. . . may deny medical assistance for a person who is eligible for financial assistance but to whom that
assistance is not paid because of the person’s failure to cooperate [with the requirements of the
responsibility agreement].” TEX. HUM. RES. CODE ANN. § 31.0032(c).
THHSC subsequently issued a rule stating that “(TANF)-level medical assistance recipient
whose TANF cash assistance was terminated pursuant to . . . [42 U.S.C. § 607(e)(1)(B)] because
of refusing to work without good cause is ineligible for Medicaid until there is no longer a basis for
the termination of cash assistance because of such refusal, as provided by . . . 42 U.S.C. § 1396u-
1(b)(3).” 1 TEX. ADMIN. CODE § 374.11.
TWC then promulgated rules of implementation. Section 811.2(11) defines persons “engaged
in work” for 42 U.S.C. § 607 purposes as those individuals who cooperate with “(A) all requirements
set forth in the family employment plan, . . . ; and (B) all TANF Core and Non-Core activities . . .
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.” 40 TEX. ADMIN. CODE § 811.2(11). The relevant TANF core activities include “job search and job
readiness assistance” which is described in 40 TEX. ADMIN. CODE § 811.41. 40 TEX. ADMIN. CODE
§ 811.25(a)(1)(A). This includes
(A) activities associated with maintenance of their children's health and dental
checkups, as required by §3.301 of this title;
(B) activities associated with maintenance of their children's immunizations, as
required by §3.301 of this title;
(C) activities necessary to ensure their children's school attendance, as required by
§3.301 of this title; and
(D) activities necessary to abstain from the use, possession, or sale of controlled
substances, and to abstain from alcohol abuse, including participation in counseling.
40 TEX. ADMIN. CODE § 811.41(d)(3). The family employment plan references the recipient’s
“responsibility to participate in job readiness activities as set forth in § 811.41(d).” 40 TEX. ADMIN.
CODE § 811.23(e). TANF non-core activities include
(4) instruction on the necessity of maintaining children's health to include
immunizations and dental checkups; (5) instruct ion on the necessity of ensuring
children's school attendance; (6) instruction on the necessity of abstaining from using,
possessing, or selling controlled substances; and (7) instruction on the necessity of
abstaining from abusing alcohol.
40 TEX. ADMIN. CODE § 811.52. Thus, under TWC’s new rules, medical assistance can be terminated
for those recipients who fail to ensure their children’s immunizations, wellness check-ups, school
attendance or who fail to avoid substance abuse.
III
The only issue in this case is whether the termination of medical assistance pursuant to 40 TEX.
ADMIN. CODE § 811.2(11)(A) and (B) is authorized by 42 U.S.C. § 607(e)(1)(B). We review
questions of statutory interpretation de novo. Evergreen Presbyterian Ministries, 235 F.3d at 918.
The Defendants contend that the district court failed to properly defer to TWC’s interpretation of 42
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U.S.C. § 607(d)(6), i.e., “job search and job readiness.” The Plaintiffs argue that the plain language
of the statute unambiguously precludes TWC’s interpretations and, thus, deference is inapplicable.
“When construing a federal statute that has been interpreted by an administrative agency,
courts look first to the language of the statute.” Houston Police Officers’ Union v. City of Houston,
330 F.3d 298, 302 (5th Cir. 2003). “If the intent of Congress is clear, that is the end of the matter;
for the court, as well as the agency, must give effect to the unambiguously expressed intent of
Congress.” Chevron U.S.A., Inc. v. Natural Res. Def. Council, Inc., 467 U.S. 837, 842-43 (1984).
“If the statute is ambiguous, however, ‘the court does not simply impose its own construction on the
statute, as would be necessary in the absence of administrative interpretation. Rather, . . . the
question for the court is whether the agency’s answer is based on a permissible construction of the
statute.’” Houston Police Officers’ Union, 330 F.3d at 302-03 (quoting Chevron, 467 U.S. at 843).
Generally, a statute is ambiguous if it is “capable of being understood in two or more possible senses
or ways.” Chickasaw Nation v. United States, 534 U.S. 84, 90 (2001).
“We have consistently held that a regulation should be construed to give effect to the natural
and plain meaning of its words.” S.D. ex rel. Dickson v. Hood, 391 F.3d 581, 595 (5th Cir. 2004).
Both Defendants and Plaintiffs claim that the plain meaning of the statute supports their arguments.
Defendants contend that recipients are more likely to obtain and keep jobs if they are not incapacitated
by substance abuse and their children are healthy and in school. Thus, they argue, the requirements
of 40 TEX. ADMIN. CODE § 811.41(d)(3) fall under the plain language of § 607(d)(6), i.e., “job search
and job readiness.” Plaintiffs argue that no reasonable interpretation of “job search and job readiness”
includes the failure to ensure child immunization, wellness check-ups, school attendance and the failure
to refrain from substance abuse. We find the Plaintiffs’ argument more persuasive.
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A recipient’s medical assistance may be terminated for refusing to participate in the twelve
work activities enumerated in 42 U.S.C. § 607(d). 42 U.S.C. § 607(e)(1)(B). None of the twelve
work activities include child immunizations, wellness check-ups, school attendance or avoidance of
substance abuse. The closest work activity, “job search and job readiness” cannot be construed to
encompass ensuring child immunizations, wellness check-ups, school attendance and refraining from
substance abuse. The plain and natural meaning of § 607 does not support the contention that a
recipient’s assistance could be terminated for “refusing to work” when the recipient is working full-
time. “Job search and job readiness” precede employment. Recognizing this, Congress limited the
number of weeks of job search and readiness assistance that may count as a work activity, 42 U.S.C.
§ 607(c)(2)(A)(i), whereas one would have to continuously ensure compliance with 40 TEX. ADMIN.
CODE § 811.41(d)(3).
There are numerous activities that bear some relation to obtaining and keeping work; however,
Texas cannot use these activities to terminate medical assistance. Texas cannot add additional
requirements for Medicaid eligibility. See Jones v. T- H-, 425 U.S. 986 (1976) (affirming a three-
judge dist rict court’s holding that a Utah regulation was inconsistent with Title XIX because of an
additional requirement for obtaining medical assistance ); Carleson v. Remillard, 406 U.S. 598 (1972)
(invalidating a state law preventing children whose fathers were serving in the military from receiving
AFDC benefits because Congress did not intend to exclude a class of benefit recipients).
In addition to the plain language of the actual provision, the rest of the statute strongly
suggests that TWC’s interpretations are impermissible. When interpreting a portion of a statute,
courts must consider the statute in its entirety. Lexecon, Inc. v. Milberg Weiss Bershad Hynes &
Lerach, 523 U.S. 26, 36 (1998) (“[A] statute is to be considered in all its parts when construing any
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one of them.”). Other sections of TANF address the personal responsibility requirements of 40 TEX.
ADMIN. CODE § 811.41(d)(3). Section 608(b)(3) authorizes states to reduce TANF assistance for
failure to comply with an imposed “individual responsibility plan,” which “may include a requirement
that the individual . . . keep school age children in school, immunize children, attend parenting and
money management classes.” 42 U.S.C. § 608(b)(2)(A)(ii). Similarly, § 604 provides penalties for
a parent’s failure to ensure that dependent minor children attend school. 42 U.S.C. § 604(i).
Defendants claim that these sections, which provide only for a reduction in TANF assistance,
complement the states’ flexibility and do not preclude the option to terminate medical assistance for
the same infractions. For this proposition, Defendants cite § 608(b)(3), which states “[i]n addition to
any other penalties required under the State program funded under this part, the State may reduce, by
such amount as the State considers appropriate, the amount of assistance otherwise payable under the
State program to a family that includes an individual who fails without good cause to comply with an
individual responsibility plan signed by the individual.” 42 U.S.C. § 608(b)(3).
The Plaintiffs contend that these sections indicate that Congress wanted to give states the
flexibility to reduce TANF for various personal responsibility failures. Had Congress wanted to give
states the option to terminate medical assistance for these failures, it could have easily done so. We
find this argument persuasive. “‘[W]here Congress includes particular language in one section of a
statute but omits it in another . . . . , it is generally presumed t hat Congress acts intentionally and
purposely in the disparate inclusion or exclusion.’” Keene Corp. v. United States, 508 U.S. 200, 208
(1993) (quoting Russello v. United States, 464 U.S. 16, 23 (1983)).
Defendants contend that § 602 expressly permits Texas to define “work activities.” Section
602 obligates states to outline how they will “[r]equire a parent or caretaker receiving assistance under
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the program to engage in work (as defined by the State) . . . .” 42 U.S.C. § 602(a)(1)(A)(ii) (emphasis
added). As the Plaintiffs correctly argue, however, this plan must still be “in accordance with § 607
of this title.” 42 U.S.C. § 602(1)(1)(A)(iii) (emphasis added). Thus, while Texas has flexibility to
define work activities, it must do so within the confines of 42 U.S.C. §607(d)(1)-(12).
Defendants place great weight on the preamble to TANF regulations, which states, “we chose
not to define the individual work activities . . . in favor of giving States greater flexibility.”
Temporary Assistance for Needy Families Program (TANF), 64 Fed. Reg. 17,720, 17,776 (April 12,
1999). Once again, TWC is limited by 42 U.S.C. § 607(d). “As a fundamental rule of statutory
interpretation, specific provisions trump general provisions.” Navarro-Miranda v. Ashcroft, 330 F.3d
672, 676 (5th Cir. 2003). Section 607(d)(1)-(12) defines the broad parameters of “work activities.”
While states have great flexibility within those parameters, they are still bound by them. The preamble
does not broaden the scope of the plain language of § 607(d).
Defendants’ reliance on the doctrine of cooperative federalism fails to exempt them from the
plain language of § 607(d)(1)-(12). “[T]he Medicaid statute . . . is designed to advance cooperative
federalism.” Wisconsin Dep’t of Health and Family Servs. v. Blumer, 534 U.S. 473, 495 (2002).
When interpreting statutes based on cooperative federalism, the Supreme Court has explained, “we
have not been reluctant to leave a range of permissible choices to the States, at least where the
superintending federal agency has concluded that such latitude is consistent with the statute’s aims.”
Id. (emphasis added). Here, TWC’s interpretation of the clear language of § 607 is impermissible.
Thus, the doctrine of cooperative federalism is inapplicable.
Defendants proffer a letter from the Assistant Secretary for Children and Families of the
Department of Health and Human Services to support their contention that TWC rules are consistent
11
with § 607(d). The letter, written to Congressman Lloyd Doggett, states that “no conflict between
Texas’ rules and current Federal law is readily apparent.” Plaintiffs’ contention that the letter
addresses TANF and not Medicaid is irrelevant because 42 U.S.C. § 1396u-1(b)(3)(A)(iii) expressly
references § 607(e)(1)(B) of TANF. The letter, however, still receives no legal weight. First, the
“plain language of the statute i s otherwise.” Kai v. Ross, 336 F.3d 650, 655 (8th Cir. 2003). In
addition, “the letter is not a regulation of the Department of Health and Human Services, nor is it part
of generally published advice, for example, a practice manual distributed nationwide.” Id. Thus, the
letter is only considered for its inherent persuasive value, which we find minimal.
The requirements of 40 TEX. ADMIN. CODE § 811.41(d)(3) are inconsistent with the plain
language of 42 U.S.C. § 607(d)(1)-(12). None of the twelve work activities listed in § 607(d) include
child immunizations, wellness check-ups, child school attendance or substance abuse avoidance. Had
Congress intended to include these requirements, it easily could have. Indeed, elsewhere Congress
provided sanctions for these failures. See 42 U.S.C. §§ 604(i), 608(b)(2)(A)(ii). Since “the intent of
Congress is clear, that is the end of the matter; for the court, as well as the agency, must give effect
to the unambiguously expressed intent of Congress.” Chevron, 467 U.S. at 842-43. Thus, we need
not address deference to TWC’s interpretation.
IV
The district court judge properly concluded that 40 TEX. ADMIN. CODE § 811.2(A) and (B)
are inconsistent with the federal Medicaid statute, as they impose additional requirements for obtaining
benefits. Accordingly, the district court’s order declaring invalid 40 TEX. ADMIN. CODE § 811.2(A)
and (B), § 811.41(d)(3)(A)-(D), to the extent they apply the job readiness activities in § 811.41(d)(3)
and the parenting skills training in § 811.52(4), (5), (6), and (7) as grounds for terminating Medicaid
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by defining, or to the extent Defendants otherwise redefine by rule or through the personal
responsibility agreement that recipients must sign, “work” or “work requirements” or “work activities”
or “job readiness” to include obtaining children’s immunizations, check-ups, school attendance, or
refraining from substance abuse, or any other non-work requirements for purposes of Medicaid
eligibility is AFFIRMED.
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