Case: 18-60227 Document: 00514990219 Page: 1 Date Filed: 06/10/2019 IN THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT United States Court of Appeals Fifth Circuit FILED No. 18-60227 June 10, 2019 Lyle W. Cayce Clerk FORREST GENERAL HOSPITAL; SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER, Plaintiffs–Appellants v. ALEX M. AZAR, II, SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Defendant–Appellee Appeal from the United States District Court for the Southern District of Mississippi Before REAVLEY, ELROD, and WILLETT, Circuit Judges. DON R. WILLETT, Circuit Judge: One tricky area of America’s uniquely complex healthcare “system” is the labyrinth of acronyms and formulae that govern Medicare funding. In this appeal, two Mississippi hospitals insist that the federal government skimped on their Disproportionate Share Hospital (or DSH—pronounced “dish”) payments—special funding to institutions serving large numbers of indigent patients. To determine if the hospitals were rightly compensated, we must determine if a certain DSH-related fraction—specifically the numerator—was rightly calculated. The answer, though, turns less on figuring numbers than on figuring out words. And all language cases share a common denominator: Judges must defer to plain language, not to parties seeking to elude it. Case: 18-60227 Document: 00514990219 Page: 2 Date Filed: 06/10/2019 No. 18-60227 Here, the district court gave “substantial deference” to the interpretation of the Department of Health and Human Services (HHS), which read the relevant statute and regulation to exclude from the numerator Mississippi’s uncompensated care pool (UCCP) patient days. 1 Upshot: smaller numerator, smaller fraction, smaller funding. But HHS’s reading of the fraction was improper, as was the district court’s deference to it. The governing provisions unambiguously require HHS to include such patient days. By excluding instead of including, HHS committed a fraction infraction—and flouted the law’s plain language. As HHS’s position is foreclosed by the text and structure of the relevant provisions, we REVERSE the district court’s judgment and REMAND to the Medicare Administrative Contractor (MAC) to include the UCCP days in the hospitals’ DSH calculation. I. Background A. The Statutory and Regulatory Framework Medicare is a federal health insurance program for the elderly and disabled. 2 It is, as the Supreme Court recently observed, America’s “largest federal program after Social Security,” spending roughly “$700 billion annually to provide health insurance for nearly 60 million aged or disabled Americans, nearly one-fifth of the Nation’s population.” 3 Together, Social Security and Medicare make up about 60 percent of all federal spending. Medicare compensates hospitals for inpatient services under a prospective payment system, which determines national rates for various services. 4 These rates are subject to myriad adjustments. 5 This case deals with 1 Louisiana v. U.S. Army Corps of Eng’rs, 834 F.3d 574, 580 (5th Cir. 2016). 2 See Thomas Jefferson Univ. v. Shalala, 512 U.S. 504, 506 (1994). 3 Azar v. Allina Health Servs., —S. Ct.—, 2019 WL 2331304, at *2 (June 3, 2019). 4 42 U.S.C. § 1395ww(d). 5 See id. 2 Case: 18-60227 Document: 00514990219 Page: 3 Date Filed: 06/10/2019 No. 18-60227 a Medicare adjustment for DSH hospitals—those ...
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