Ehrlich v. Perez

HARRELL, Judge. Pursuant to Maryland Code (1973, Repl. Vol. 2002), Courts and Judicial Proceedings Article, § 12 — 303(3)(i), 1 Appellants (Defendants below), the Honorable Robert L. Ehrlich, Jr., the Honorable S. Anthony McCann, and the Honorable Nancy Kopp, each sued in his or her official capacity as Governor of Maryland, Secretary of the Maryland Department of Health and Mental Hygiene (“DHMH”), and State Treasurer, respectively, sought appellate review of a preliminary injunction issued by the Circuit Court for Montgomery County. The injunction essentially ordered the payment of medical assistance benefits to Appellees (Plaintiffs in the Circuit Court), comprised of Flor Perez and Ana Perez (minors, by their father and next friend, Fidel Perez); Brayan Herrera, Osvaldo Herrera, and Leslie Herrera (minors, by their mother and next friend, Martha Herrera); and Gabriel Ntitebem, Henry Anu, and Vitalis Atemafac (minors, by their mother and next friend, Ajong Pamela Nkahinjo), 2 under the Medical Assis ⁶⁹⁷ tance Program, Maryland Code (1982, Repl.

Vol. 2005), Health-General Article, § 15-103. 3 Appellees, all residents of Maryland, are lawful permanent resident aliens of the United States who immigrated from their respective foreign countries on or after 4 August 2003. Section 15-103(a)(2)(viii) provides that the State [sjhall provide, subject to the limitations of the State budget and any other requirements imposed by the State, comprehensive medical care and other health care services for all legal immigrant children under the age of 18 years and pregnant women who meet Program eligibility standards and who arrived in the United States on or after August 22, 1996, the effective date of the federal Personal Responsibility and Work Opportunity Reconciliation Act [ 8 U.S.C. § 1601 , et. seq. (1996) (hereinafter “PRWORA”).] The Circuit Court granted the preliminary injunction based, in part, upon its conclusion that Appellees likely would prevail on their claim that the failure of. the State of Maryland to appropriate funds for Fiscal Year (“FY”) 2006 (1 July 2005 through 30 June 2006) for medical benefits, as provided under § 15 — 103(a)(2)(viii), to resident alien children and resident alien pregnant women in Maryland who immigrated to the United States on or after 22 August 1996, while funding similar benefits to citizens and resident aliens in Maryland who immigrated lawfully before 22 August 1996, violated ⁶⁹⁸ Article 24 of the Maryland Declaration of Rights. 4 Appellants filed a timely appeal with the Court of Special Appeals. We issued, on our initiative, a writ of certiorari to the Court of Special Appeals, Ehrlich v. Perez, 391 Md. 577 , 894 A.2d 545 (2006), before our colleagues on the intermediate appellate court could decide the merits of the case, in order to consider: 5 1.

Whether Appellants violated Article 24 of the Maryland Declaration of Rights by not appropriating monies for the State-funded Medical Assistance Program to resident alien children and pregnant women who immigrated to the United States on or after 22 August 1996 (a group not otherwise covered under federal analogous law — Medicaid) where federal law, enacted under the authority held by the Federal Government over national immigration policy, expressly provides the States with complete discretion to provide wholly State-funded medical benefits to this class of legal resident aliens. 2. Whether the Circuit Court was authorized to order, through a preliminary injunction, Appellants to reinstate medical benefits to Appellees, as prescribed under the Medical Assistance Program, both retrospectively from 26 October 2005, the date the original Complaint and Motion for Preliminary Injunction were filed, back to 1 July 2005 and prospectively from 26 October 2005 until final disposition of the case. I. In its written memorandum opinion explaining why it issued the preliminary injunction, the Circuit Court summarized the ⁶⁹⁹ relevant factual and legislative background as follows, in pertinent part: FACTUAL BACKGROUND Based solely on the original Complaint filed on October 26, 2005, the Plaintiffs are comprised of Flor Perez and Ana Perez (by their father and next friend, Fidel Perez); Brayan Herrera, Osyaldo Herrera, and Leslie Herrera (by their mother and next friend, Martha Herrera); and Gabriel Ntitebem, Henry Anu, and Vitalis Aternafac (by their mother and next friend, Ajong Pamela Nkahinjo). They have filed their original Complaint against the Defendants, who are comprised of the Governor (Robert L. Ehrlich, Jr.), the Secretary of the Department of Health and Mental Hygiene (S. Anthony McCann), and the Treasurer (Nancy Kopp) for one count of Violation of Maryland Declaration of Rights.

On the day of the scheduled hearing for the Request for a Preliminary Injunction, the Plaintiffs filed an Amended Complaint, identifying five additional Plaintiffs. However, for purposes of this Preliminary Injunction, the Court viewed the case in light of the facts as set forth in the original Complaint. Generally, the Plaintiffs’ Complaint alleges that the State of Maryland, through Governor Ehrlich’s budgetary authority, discriminated and otherwise unconstitutionally denied certain persons living in the State access to health care [under § 15-103, called the Medical Assistance Program]. The Plaintiffs[ ] further contend that the State relied upon the classification of “alienage” in making their decision to deny health care coverage of these individuals.

On April 7, 2005, the General Assembly enacted the fiscal year 2006 Budget. In mid-June, the Department of Health and Mental Hygiene mailed a notice to all resident alien recipients, including the Plaintiffs named herein, to inform them that their current benefits would end starting June 30, 2005 as a result of the Governor’s decision to eliminate such funding. The notice provided for a right to appeal the ⁷⁰⁰ termination of coverage to the Office of Administrative Hearings (OAH).[ 6 ] The notice also informed the recipients that there were alternative options for publicly subsidized health care coverage. Specifically, the recipients were advised to apply to their local health department for Maryland Children’s Health Program (MCHP) coverage if they are under 19 years of age.

The Department also notified the local health departments in each jurisdiction that funding for this coverage group had been eliminated from the fiscal year 2006 Budget and thereby instructed the local departments to assist persons in this group with finding similar care wherever possible. Despite the Department’s efforts, Plaintiffs, and others similarly situated, have been precluded as a result of their own indigence. Coupled with their inability to pay, most of these programs are unable to provide such necessary services that were previously covered under the Medical Assistance Program. Often times these alternative programs are simply closed to new patients. ⁷⁰¹ LEGISLATIVE BACKGROUND In order to thoroughly understand the issues at hand, it is imperative that this Court outline the Federal and State statutory programs upon which the Plaintiffs previously relied for their health care services.

A. FEDERAL PROGRAMS i Medicaid Medicaid is a federal program established by Title XIX of the Social Security Act. See 42 U.S.C. §§ 1396 -1396v. “Congress has authorized grants to states for the purpose of enabling each state, as far as practicable under the conditions in such state, to furnish medical assistance to persons who are eligible thereof.” 81 C.J.S. Social Security and Public Welfare § 247. Eligible individuals include certain indigent persons, such as the “aged,” “blind” and “disabled.” Medicaid also provides coverage for pregnant women and children who fall below a certain income threshold, in addition to covering medically needy persons, such as elderly persons who are confined to nursing homes and whose medical expenses have exhausted their other assets. If a state chooses to take part in the federal Medicaid program, it must comply with the requirements set forth in Title XIX and its implementing regulations in order to receive federal matching funds.

In Maryland, the federal matching fund is about 50% of the total expenditures. See Federal Matching Shares for Medicaid, 68 Fed. Reg. 67676 (Dec. 3, 2003). ii. Federal Welfare Reform Act On August 22, 1996, Congress enacted legislation that significantly impacted Medicaid coverage for select individuals residing in the U.S. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996, generally know as the “Welfare Reform Act,” was a program designed to further the national immigration policy of “self-sufficiency.” 8 U.S.C. § 1601 (1). The statement of national policy concerning welfare and immigration reads, in part: “It is a compelling government interest to remove the incentive for ⁷⁰² illegal immigration provided by the availability of public benefits.” 8 U.S.C. § 1601 (6).

The Act ultimately rendered non-qualified aliens ineligible for Federal Medicaid benefits, while also creating two categories for qualified aliens. Ali[e]ssa v. Novello, 96 N.Y.2d 418, 426 [, 730 N.Y.S.2d 1 ], 754 N.E.2d 1085 (2001); see also 8 U.S.C. § 1613 . The language states: “An alien who is a qualified alien (as defined in section 1641 of this title) and who enters the United States on or after August 22, 1996, is not eligible for any Federal means-tested public benefit for a period of 5 years beginning on the date of the alien’s entry into the United States with a status within the meaning of the term ‘qualified alien.’ ” 8 U.S.C. 1613(a). Among the provisions of the Welfare Reform Act was the elimination of all benefits for illegal immigrants and other “non-qualified aliens,” with a few limited exceptions such as emergency medical care. 8 U.S.C. § 1613 .

In doing so, Congress divided the two qualified alien categories into two subcategories: (1) qualified aliens who have resided in the U.S. since a time prior to August 22, 1996. Id. Some states were required to provide funding to the first subcategory of qualified aliens. Id.

However, a period of five years residency in the U.S. was required for the second subcategory. Id. Congress then authorized the States to enact any law after August 22,1996, should they choose to compensate this newly designated class of ineligible aliens, provided they use only State funds. B. MARYLAND STATE PROGRAMS i.

Maryland’s Welfare Innovation Act “State participation in Medicaid is voluntary, but if a state participates, it must comply with the federal statutes and regulations governing the programs. However, there is no legal prohibition preventing a state legislature from awarding medical assistance benefits on its own, independent of federal reimbursement.” 81 C.J.S. Social Security and Public Welfare § 247; see also San Lazaro Ass’n, Inc. v. Connell, 286 F.3d 1088 (9th Cir.2002), cert. denied, 537 U.S. 878 , 123 S.Ct. 78 , 154 L.Ed.2d 133 (2002); Westside Mothers ⁷⁰³ v. Haveman, 289 F.3d 852, 2002 [Fed.] FED App. 0172P (6th Cir.2002), cert. denied, 537 U.S. 1045 , 123 S.Ct. 618 , 154 L.Ed.2d 516 (2002). In 1997, the Maryland General Assembly enacted Chapter 593, the “Welfare Innovation Act,” adding Health-General Article § 15 — 103(a)(2)(viii) to the Maryland Annotated Code. This addition thereby authorized the state to provide: “[s]ubject to the limitations in the State budget and any other requirements imposed by the State, comprehensive medical care and other health care services for all legal immigrant children under the age of 18 years and pregnant women who meet Program eligibility standards and who arrived in the U.S. on or after August 22, 1996, the effective date of the federal Personal Responsibility and Work Opportunity Reconciliation Act.” Md. Ann. Code, Health-General Article § 15-103(a)(2)(viii).

The [statutory provision] provides for medical assistance to this newly excluded class of alien, pregnant women and children deemed ineligible for non-emergency, Federal Medicaid benefits. Although the Maryland State Medicaid program, along with federal matching funds, provides the same medical services as available under the Welfare Innovation Act to both citizens and resident aliens who meet the five-year residency requirement, this new provision is limited to those aliens for whom federal Medicaid eligibility was eliminated by the Welfare Reform Act. Therefore, it is funded entirely with state funds. Here, the State used the authority granted by Congress under the Welfare Reform Act. [The benefits established by the adoption of § 15-103] became known as the Medical Assistance Program.

C. THE MARYLAND STATE BUDGET Every year in Maryland, the Governor submits a proposed budget bill to the General Assembly containing the proposed budgetary measures for the State government for the following fiscal year. Unlike a “give and take” relationship between the Legislative and Executive branches ..., the General Assembly is free to reduce the Governor’s budget ⁷⁰⁴ ary proposals, but it may not increase or amend. See MD Const., Art. 3, § 52(6). Except as expressly mandated by the Constitution or statutes, the Governor has complete discretion over the inclusion of appropriations in the Budget and the amount for the executive branch.

The constitutional mandates relate to funding the public schools, redemption of the State debt, the payment of certain salaries. With the consent of the General Assembly, the Governor can amend or supplement the Budget Bill prior to its passage. Subject to certain exceptions and limitations, the General Assembly has express power only to strike or reduce appropriations in the Budget Bill. However, this express power includes the implied power to condition or qualify.

Richard E. Israel, Archives of Maryland Online, “Maryland’s Budget Process,” [] www.mdarchives.state.md.us/ megafile/msa/speccol/sc2900/sc2908/html/budget.html (last visited December 29, 2005). Despite its ability to “condition” or “qualify” the revisions in the proposed Budget, the General Assembly is precluded from deciding that a particular appropriation is under funded. Maryland’s Legislative branch is powerless to realign the Governor’s proposed spending like[, for example,] the legislatures in New York and Virginia. iv. The Fiscal Year 2006 Maryland Budget: The “Carve-Out” Provision Recently, the fiscal year 2006 Budget as proposed by the Governor eliminated funding for the Medical Assistance Program.

This budget cut essentially carved the aforementioned category of legal, resident aliens out of the State’s final Budget Bill. There are currently no funds available in the budget for the women, who were not pregnant, and children, both who were in this program at the beginning of the current fiscal year — however, [§ 15-103] remains in force. Despite their ability to condition or qualify certain budgetary measures, the Maryland General Assembly never had the option to restore funding to the program, as this ⁷⁰⁵ would have resulted in the General Assembly overstepping its Constitutional boundaries!.] [ 7 ] On 12 January 2006, the Circuit Court issued a written memorandum opinion and order granting Appellees’ Motion for Preliminary Injunction. In its opinion, the Circuit Court explained its view that Appellees satisfied the four requisite elements for issuance of a preliminary injunction.

Specifically, the trial court determined that: the balance of convenience clearly favored Appellees because they suffered great harm as a result of the State’s budget cut; Appellees were irreparably injured as a result of the State’s action because they were unable to afford health care without the unfunded State assistance; the public interest “is best served if the [State is] required to provide benefits to [Appellees] for which they are currently entitled [under § 15 — 103(a)(2)(viii)];” and, finally, Appellees demonstrated that they likely would succeed on the merits of their Article 24 equal protection claim. It is this latter determination to which most of the parties’ attentions are directed on appeal. With regard to the likelihood of success on the merits, the Circuit Court explored the principles of equal protection under Article 24. While acknowledging that Appellees are “appropriately classified as ‘aliens,’ ” the court determined that the allegations pertained to the denial of Appellees’ equal protection right “based on their status as individuals who are legally entitled to State funding [under § 15-103(a)(2)(viii) ] — not as a suspect class.” 8 Thus, rather than focusing upon the “ ‘alien- ⁷⁰⁶ age’ classification” to determine the appropriate standard of review to apply to the State action, the court looked to the “Governor’s decision to cut funding to a legally entitled group of individuals.... ” Recognizing that, in considering equal protection challenges, a rational basis standard of review generally applies to examining State action with regard to economic and social welfare issues, the Circuit Court determined that the “impact on [Appellees] ... is far too disparate to ignore ‘alienage’ as an underlying classification.... ” Therefore, the court reviewed the constitutional claim as to the budget cut under a strict scrutiny standard.

The court then concluded that the State failed to advance a sufficient basis “as to how [its] budgetary interest was compelling enough to overcome strict scrutiny.” The court noted that “cutting welfare funds to legally entitled individuals is certainly not narrowly tailored enough to overcome strict scrutiny.” Consequently, the Circuit Court reasoned that the State failed to meet its burden and determined that Appellees likely would succeed on the merits of their equal protection claim. The Circuit Court ordered “that the benefits payable under the Health-General Article § 15-301, et seq. previously denied to [Appellees] be ... retroactively reinstated” and further ordered “that the benefits payable under the Health-General Article § 15-301, et seq. be ... reinstated until final disposition of this action.” Appellants filed with the Circuit Court a Notice of Appeal to the Court of Special Appeals, an Answer, and a Motion for Stay Pending Appeal on 19 January 2006. Appellees filed an opposition on 23 January 2006. That same day, the Circuit Court issued a separate order staying the part of the preliminary injunction that ordered payment of retrospective benefits, but denied a stay in all other respects.

The Court of Special Appeals issued an order on 7 February 2006 staying the judgments entered on the Circuit Court’s orders, pending appeal, without prejudice to the right of any ⁷⁰⁷ current Appellee, at that time, to seek from the Circuit Court “appropriate limited relief from the stay upon a full and complete showing that (1) in order to avoid a serious risk to his or her health, the Appellee must receive particularized medical treatment prior to April 7, 2006, (2) the Appellee would have coverage for this treatment if the Orders of the circuit court had not been stayed by this Order, and (3) the Appellee will not be provided with necessary treatment unless the circuit court grants appropriate relief.” After Appellants’ brief on the merits was filed in the intermediate appellate court, but before further action could be taken by that court, we issued a writ of certiorari to the Court of Special Appeals on 9 March 2006. Ehrlich, 391 Md. at 577, 894 A.2d at 545.

II

General Standards Applicable to the Review of the Grant of Injunctive Relief “Our review of a preliminary injunction is limited because we do not now finally determine the merits of the parties’ arguments.” LeJeune v. Coin Acceptors, Inc., 381 Md. 288, 300 , 849 A.2d 451, 458 (2004) (citing Department of Transportation v. Armacost, 299 Md. 392, 404 , 474 A.2d 191, 197 (1984)) (Internal quotations omitted). We review only whether the trial court properly granted the preliminary injunction. Fogle v. H & G Restaurant, 337 Md. 441, 456 , 654 A.2d 449, 455 (1995); see also State Dep’t v. Baltimore County, 281 Md. 548, 550 , 383 A.2d 51, 53 (1977) (stating that “it is a rare instance in which a trial court’s discretionary decision to grant or to deny a preliminary injunction will be disturbed by this Court”). In reviewing a trial court’s decision to issue a preliminary injunction, we “determine whether the trial judge exercised sound discretion in examining the four factors that must be found.... ” LeJeune, 381 Md. at 300 , 849 A.2d at 458 (citing Lerner v. Lerner, 306 Md. 771, 776 , 511 A.2d 501, 504 (1986)).

The four factors that the trial judge examines when ⁷⁰⁸ considering the appropriateness of granting a preliminary injunction include: (1) the likelihood that the plaintiff will succeed on the merits; (2) the “balance of convenience” determined by whether greater injury would be done to the defendant by granting the injunction than would result from its refusal; (3) whether the plaintiff will suffer irreparable injury unless the injunction is granted; and (4) the public interest. Armacost, 299 Md. at 404-05 , 474 A.2d at 197 (citing State Dep’t v. Baltimore County, 281 Md. at 554-57 , 383 A.2d at 55 ). The party seeking the preliminary injunction has the burden of adducing facts necessary to satisfy these factors. Fogle, 337 Md. at 456 , 654 A.2d at 456 .

The “failure to prove the existence of even one of the four factors” precludes the grant of injunctive relief. Id. With regard to the factor of the likelihood of success on the merits, “the party seeking the interlocutory injunction must establish that it has a real probability of prevailing on the merits, not merely a remote possibility of doing so.” Id. Yet, “even with respect to a discretionary matter, a trial court must exercise its discretion in accordance with correct legal standards.” LeJeune, 381 Md. at 301 , 849 A.2d at 459 (Citation omitted).

We review de novo a trial judge’s decision involving a purely legal question. Matthews v. Maryland-National Capital Park & Planning Com’n, 368 Md. 71, 92 , 792 A.2d 288, 301 (2002). We apply the more deferential abuse of discretion standard to a trial judge’s ruling involving a balancing of interests. Id.

In the present case, the Circuit Court’s determination of the likelihood of success on the merits is a question of law. See Davis v. Slater, 383 Md. 599, 604 , 861 A.2d 78, 80 (2004) (noting that because “interpretation of the Maryland Declaration of Rights and Constitution ... [is] appropriately classified as [a] question[ ] of law, we review the issue[] de novo”). Consequently, we apply the due novo standard to that factor, but the more deferential abuse of discretion standard to the trial judge’s determinations as to the remaining three factors. ⁷⁰⁹ III. The Parties’ Main Arguments A. Level of Judicial Scrutiny to be Accorded to the Appellants’ Action in the Equal Protection Analysis Appellants assert that the Circuit Court erred in granting the preliminary injunction because Appellees lacked a real probability of prevailing on the merits of their Article 24 claim.

Appellants contend that their failure to appropriate funds for medical benefits to a subcategory of legal aliens who, by virtue of congressional action under PRWORA, were ineligible to receive federal medical benefits is subject to rational basis review under the Supremacy Clause and withstands Appellees’ equal protection challenge under that standard. Under the Supremacy Clause, Appellants contend, consideration of Appellees’ state constitutional claim requires judicial deference to Congress’ plenary power over naturalization and immigration policy. Relying on Mathews v. Diaz, 426 U.S. 67 , 96 S.Ct. 1883 , 48 L.Ed.2d 478 (1976), and Fiallo v. Bell, 430 U.S. 787 , 97 S.Ct. 1473 , 52 L.Ed.2d 50 (1977), Appellants argue that Congress’ power over the admission and naturalization of aliens is complete and broad such that Congress’ actions are subject to narrow judicial scrutiny. Although conceding that the State may not exercise independently a like power over aliens, Appellants maintain that, in adopting the Welfare Reform Act, Congress prescribed a uniform rule for the treatment of an alien sub-class in regard to the provision of medical benefits, which Maryland could follow, citing as support Plyler v. Doe, 457 U.S. 202 , 219 n. 19, 102 S.Ct. 2382 , 2396 n. 19, 72 L.Ed.2d 786 , 800 n. 19 (1982), Toll v. Moreno, 458 U.S. 1 , 102 S.Ct. 2977 , 73 L.Ed.2d 563 (1982), DeCanas v. Bica, 424 U.S. 351 , 358 n. 6, 96 S.Ct. 933 , 47 L.Ed.2d 43 (1976), and Graham, v. Richardson, 403 U.S. 365 , 91 S.Ct. 1848 , 29 L.Ed.2d 534 (1971).

It is necessary to apply this relaxed standard of scrutiny to both federal and state laws that follow a federal classification because “[i]t ⁷¹⁰ would make no sense to say that Congress has plenary power in the area of immigration and naturalization and then hold that the Constitution compels the states to refrain from adhering to the federal guidelines [when a state denies state-funded welfare benefits to certain aliens],” quoting Sudomir v. McMahon, 767 F.2d 1456, 1466 (9th Cir.1985) (applying rational basis review in rejecting equal protection challenge to the State’s denial of State-funded welfare benefits to a sub-class of aliens). Appellants offer that the reason for the Maryland budget cut was to achieve a cost savings of seven million dollars (equal to the amount of funds appropriated in the Medical Assistance Program in Fiscal Year (“FY”) 2005, inclusive of the estimated number of individuals of the legal alien sub-class to which Appellees belong) of the four billion dollar budget appropriated for medical assistance health care costs generally. They maintain that Congress provided a “sufficient showing of a facially legitimate and bona fide reason” to discriminate against the relevant alien sub-class in the provision of federal Medicaid benefits, by including legislative findings in the Welfare Reform Act. These legislative findings provide that the provisions of the Welfare Reform Act were necessary to achieve the national immigration policy of encouraging self-sufficiency and removing incentives for illegal immigration.

The Act’s findings also provide that a State choosing not to provide non-emergency medical benefits to aliens excluded from federal benefits by the Welfare Reform Act, as Maryland did in the FY 2006 Budget, “shall be considered to have chosen the least restrictive means available for achieving the compelling governmental interest of assuring that aliens be self-reliant in accordance with national immigration policy,” quoting 8 U.S.C. § 1601 (7). Appellants argue that the Supremacy Clause restrains Maryland State courts from disregarding Congress’ direction in this area of immigration policy. Finally, as to the correct standard of review to be applied to the Article 24 challenge, Appellants assert that the Welfare Reform Act grants Maryland the ability to determine whether and to what extent it will use State funds to provide non- ⁷¹¹ emergency medical benefits to resident aliens who do not meet the five-year residency requirement, see 8 U.S.C. §§ 1622 (a), 1624(a), provided that any prohibitions, limitations, or restrictions imposed by Maryland are not more restrictive than the prohibitions, limitations, or restrictions imposed under comparable federal programs, see 8 U.S.C § 1624(b). 9 Appellees, on the other hand, maintain (as Appellants seem to concede) that the budget cut of State-funded medical assistance to certain resident aliens was a classification based upon alienage, and is therefore a suspect classification, relying on Murphy v. Edmonds, 325 Md. 342 , 601 A.2d 102 (1992), and Graham, supra, 403 U.S. 365 , 91 S.Ct. 1848 , 29 L.Ed.2d 534 . Appellees argue that, because Appellants used a classification based on alienage in cutting State-funded medical assistance to the relevant sub-class of legal aliens depending on their length of residency in the United States, a court reviewing the State action must apply the strict scrutiny standard, see, e.g., Graham, 403 U.S. at 370-76 , 91 S.Ct. at 1851-54 , 29 L.Ed.2d at 540-44 , Nyquist v. Mauclet, 432 U.S. 1, 8 , 97 S.Ct. 2120, 2125 , 53 L.Ed.2d 63, 70 (1977), and Takahashi v. Fish & Game Comm’n., 334 U.S. 410, 418-22 , 68 S.Ct. 1138, 1142-44 , 92 L.Ed. 1478, 1486-89 (1948).

Appellees and Appellants agree that if Congress prescribed a truly uniform rule or standards for the treatment of aliens and a State abided by that rule or applied properly those standards when it chose to discriminate against or between resident aliens within its territory, a reviewing court should apply a rational basis scrutiny to determine whether the State action violated equal protection rights. The parties part ways thereafter. Appellees assert ⁷¹² that PRWORA provides no uniform rule or evaluative standards with regard to decisions involving State-funded medical assistance programs because PRWORA leaves unbridled discretion to the individual States to decide how each will treat the class of resident aliens that immigrated to the United States on or after 22 August 1996 and therefore have not resided in the United States for five years. Thus, Appellees argue that the appropriate standard of review of the State action here is strict scrutiny.

Furthermore, Appellees contend that Appellants’ reason for the budget cut (cost savings) is not a sufficiently compelling state interest to justify its discrimination against an alien sub-class when fashioning its medical assistance plan budget, citing, e.g., Graham, 403 U.S. at 374 , 91 S.Ct. at 1853-54 , 29 L.Ed.2d at 543 (“[A] State’s desire to preserve limited welfare benefits for its own citizens is inadequate to justify ... making noncitizens ineligible for public assistance benefits ... and restricting benefits to citizens and longtime resident aliens.”), and Shapiro v. Thompson, 394 U.S. 618 , 89 S.Ct. 1322 , 22 L.Ed.2d 600 (1969). Appellees bring to our attention that a similar medical assistance funding restriction adopted in New York, based on alienage, was found to be unconstitutional, under state and federal equal protection guarantees, in Aliessa v. Novello, 96 N.Y.2d 418 , 730 N.Y.S.2d 1 , 754 N.E.2d 1085 (2001). The Court of Appeals of New York in Aliessa concluded that, in contrast to the federal government, States may only discriminate against immigrants in State-funded programs if the federal government has prescribed by uniform rule what it believes to be appropriate standards for the treatment of an alien sub-class, citing language from footnote 19 in Plyler v. Doe. Aliessa, 754 N.E.2d at 1096 (discussing Graham).

The court concluded that, by enacting PRWORA, Congress did not establish a uniform rule for States regarding the provision of medical assistance to legal immigrants because Congress left to the States’ discretion the development of their own individualized policies regarding the provision of State-funded medical assistance to legal immigrants. Aliessa, 754 N.E.2d at 1098 . Because New York’s termination of State-funded bene ⁷¹³ fits to resident aliens was not pursuant to a uniform federal rule or set of criteria, our sister high court reviewed the State action under the strict scrutiny test, concluded that it did not pass that review, and held that the State action violated the Equal Protection guarantees of the federal and New York constitutions. Id.

The legal reasoning applied by the court in Aliessa applies, it is submitted by Appellees, with equal force to the present case. B. Judicial Action Possibly Implicating State Budget Appropriations Limitations Appellants claim that the Circuit Court lacked the authority to issue a preliminary injunction requiring expenditure of State funds to pay for medical benefits that were not appropriated in the FY 2006 Budget. Appellants’ argument is based on the contention that Maryland law does not permit constitutional and statutory requirements governing public expenditures to be overborne by a violation of Article 24 of the Declaration of Rights. Appellants characterize the Circuit Court’s order as an illegal order for the expenditure of unappropriated funds, in contravention of Article III, § 32 of the Maryland Constitution (which provides that State funds must be appropriated through the comprehensive executive budget procedure pursuant to Article III, § 52); see also Md. Act. for Foster Child, v. State, 279 Md. 133, 148 , 367 A.2d 491, 499 (1977); Judy v. Schaefer, 331 Md. 239, 250 , 627 A.2d 1039, 1044-45 (1993); Dorsey v. Petrott, 178 Md. 230, 242 , 13 A.2d 630, 636 (1940); Philip Morris v. Glendening, 349 Md. 660, 681 , 709 A.2d 1230, 1240 (1998).

Maryland Code (1985, Repl. Vol. 2006), State Finance and Procurement Article, §§ 7-205, 7-234(a) and (c) likewise prohibits the expenditure of State funds not appropriated properly by law and provides for the removal of any State officer or employee who violates that prohibition. Appellants contend that the Circuit Court’s “departure from the requirements of the Constitution” in granting the prelimi ⁷¹⁴ nary injunction is not justified by a likely equal protection violation under Article 24 because the Maryland Declaration of Rights would not trump the express demands of the Constitution. Rather, Appellants posit that if there exists a conflict between Article 24 and the specific provisions of the Maryland Constitution governing budget and appropriations requirements, then the specific provisions prevail, relying on Commission on Medical Discipline v. Stillman, 291 Md. 390, 410-11 , 435 A.2d 747, 757-58 (1981), and Broadwater v. State, 306 Md. 597 , 602 n. 2, 510 A.2d 583 , 585 n. 2 (1986).

By expressly providing that the prohibition against unappropriated expenditures applies to “any order,” Article III, § 32 forecloses the possibility that the constitutional provisions establishing budget and appropriations requirements may be suspended or evaded by the expedient of a court order. Characterizing the Circuit Court’s preliminary injunction order as an appropriation of funds from the State Treasury, Appellants maintain that the constitutional prerequisites for a lawful expenditure of State funds are not satisfied here and that there has been no appropriation for the benefits that the preliminary injunction orders be paid. Thus, Appellants argue, the payment of funds may not be ordered or made from the State Treasury to satisfy the preliminary injunction. Appellees counter that the Circuit Court possessed the authority to fashion the preliminary injunction as it did.

First, Appellees assert that the Governor’s budgetary authority, although far-reaching, is subject to fundamental constitutional limitations, including Article 24. This Court can give both Article 24 of the Declaration of Rights and Article III, §§52 and 32 of the Maryland Constitution full effect, as part of an integrated document, by requiring the Executive not to violate the Declaration of Rights in the course of exercising his budgetary authority, a reading that Appellees posit is required by both the history of the Budget Amendment and its subsequent interpretations by this Court. Appellees also contend that Article III, § 32 pertains to legislative orders, not judicial orders, relying on Dorsey, supra, 178 Md. at 237 , 13 A.2d at ⁷¹⁵ 634, and Philip B. Perlman Debates of the Maryland Constitutional Convention of 1867. The Circuit Court did not order the direct expenditure of specific funds; rather the injunctive order “was designed to remedy a constitutional violation and protect [Appellees] from irreparable harm, while leaving the mechanism for rectifying the constitutional violation entirely up to Appellants.” Appellees argue that because the Budget Bill provides for a lump sum appropriation, of which some small portion is restricted for specific purposes (for example, the FY 2005 budget provided for a total of approximately $4 billion for medical care provider costs, of which some portion is used for medical assistance), the general language of the appropriation leaves significant leeway to the DHMH to move funds within broad categorical appropriations in order to satisfy the court’s order.

Appellees also highlight that, in recent years, when the State’s medical assistance expenditures exceeded budget projections, Appellants did not deny coverage to eligible recipients, but instead, routinely included in the annual Budget Bill amounts to cover the prior year’s deficiency.

IV

We consider first whether the failure to fund as to Appellees (and the sub-class of legal aliens of which they are a part) the Medical Assistance Program for FY 2006, i.e., the budget cut, violates the principles of equal protection embodied in Article 24 of the Maryland Declaration of Rights. Article 24 and the Equal Protection Clause of the Fourteenth Amendment are in pan materia, and we generally apply them in like manner and to the same extent. Hornbeck v. Somerset Co. Bd. of Educ., 295 Md. 597, 640 , 458 A.2d 758, 781 (1983). Although the two are capable of divergent application, “[w]e have, however, long recognized that decisions of the [U.S.] Supreme Court interpreting the equal protection clause of the federal constitution are persuasive authority in cases involving the equal treatment provisions of Article 24.” Id.

(citing Attorney General v. Waldron, 289 Md. 683, 704-05 , 426 A.2d 929, 940-41 (1981), and Bureau of Mines v. George’s Creek, ⁷¹⁶ 272 Md. 143, 156 , 321 A.2d 748, 755 (1974)). See also Kirsch v. Prince George’s County, 331 Md. 89, 96-97 , 626 A.2d 372, 375-76 (1993); Murphy v. Edmonds, 325 Md. 342, 354 , 601 A.2d 102, 108 (1992). Consequently, even though Appellees ground their equal protection challenge solely on Article 24, we shall consider the argument in light of both cases interpreting and applying the Equal Protection Clause of the Fourteenth Amendment and Article 24 of the Maryland Declaration of Rights. Differing standards have evolved for reviewing classifications challenged under the equal protection guarantees: In most instances when a governmental classification is attacked on equal protection grounds, the classification is reviewed under the so-called “rational basis” test.

Generally under that test, a court “ ‘will not overturn’ ” the classification “ ‘unless the varying treatment of different groups or persons is so unrelated to the achievement of any combination of legitimate purposes that [the court] can only conclude that the [governmental] actions were irrational.’ ” Gregory v. Ashcroft, 501 U.S. 452 , [471], 111 S.Ct. 2395, 2406 , 115 L.Ed.2d 410, 430 (1991), quoting Vance v. Bradley, 440 U.S. 93, 97 , 99 S.Ct. 939, 943 , 59 L.Ed.2d 171, 176 (1979). See Pennell v. San Jose, 485 U.S. 1, 14 , 108 S.Ct. 849, 859 , 99 L.Ed.2d 1, 16 (1988). A statutory classification reviewed under the rational basis standard enjoys a strong presumption of constitutionality and will be invalidated only if the classification is clearly arbitrary. See, e.g., Briscoe v. P.G. Health Dep’t, 323 Md. 439, 448-449 , 593 A.2d 1109, 1113-1114 (1991); Hargrove v. Board of Trustees, [ ] 310 Md. [406, 423, 529 A.2d 1372, 1380 (1987)]; State v. Wyand, [ ] 304 Md. [721, 726-27, 501 A.2d 43, 46 (1985)]; Whiting-Turner Contract.

Co. v. Coupard, 304 Md. 340, 352 , 499 A.2d 178, 185 (1985); Department of Transportation v. Armacost, 299 Md. 392, 409 , 474 A.2d 191, 199 (1984); State v. Good Samaritan Hospital, 299 Md. 310, 328 , 473 A.2d 892, 901 , appeal dismissed, 469 U.S. 802 , 105 S.Ct. 56 , 83 L.Ed.2d 7 (1984); Montgomery Co. v. Fields Road, 282 Md. 575, 579-580 , 386 A.2d 344, 347 (1978). ⁷¹⁷ Where, however, a statutory classification burdens a “suspect class” or impinges upon a “fundamental right,” the classification is subject to strict scrutiny. Such statutes will be upheld under the equal protection guarantees only if it is shown that “ ‘they are suitably tailored to serve a compelling state interest.’ ” Broadwater v. State, 306 Md. 597, 603 , 510 A.2d 583, 585 (1986), quoting Cleburne v. Cleburne Living Center, 473 U.S. 432, 440 , 105 S.Ct. 3249, 3254 , 87 L.Ed.2d 313, 320 (1985). See, e.g., Graham v. Richardson, 403 U.S. 365, 372 , 91 S.Ct. 1848, 1852 , 29 L.Ed.2d 534, 541-542 (1971) (“classifications based on alienage, like those based on nationality or race, are inherently suspect and subject to close judicial scrutiny”); Shapiro v. Thompson, 394 U.S. 618, 634 , 89 S.Ct. 1322, 1331 , 22 L.Ed.2d 600, 615 (1969) (“in moving from State to State ... appellees were exercising a constitutional right, and any classification which serves to penalize the exercise of that right, unless shown to be necessary to promote a compelling governmental interest, is unconstitutional”); Kramer v. Union Free School District, 395 U.S. 621, 627 , 89 S.Ct. 1886, 1889-1890 , 23 L.Ed.2d 583, 589 (1969) (classification impinging upon the right to vote). See also O.C. Taxpayers v. Ocean City, 280 Md. 585, 594 , 375 A.2d 541, 547 (1977) (“we are ... here dealing with the right to vote, and thus the classification is subject to ... special scrutiny”).

Finally, there are classifications which have been subjected to a higher degree of scrutiny than the traditional and deferential rational basis test, but which have not been deemed to involve suspect classes or fundamental rights and thus have not been subjected to the strict scrutiny test. Included among these have been classifications based on gender (Mississippi University For Women v. Hogan, 458 U.S. 718, 723 , 102 S.Ct. 3331, 3335 , 73 L.Ed.2d 1090, 1097 (1982); Craig v. Boren, 429 U.S. 190 , 97 S.Ct. 451 , 50 L.Ed.2d 397 (1976); Reed v. Reed, 404 U.S. 71 , 92 S.Ct. 251 , 30 L.Ed.2d 225 (1971)), 10 discrimination against illegitimate ⁷¹⁸ children under some circumstances (Weber v. Aetna Casualty & Surety Company, 406 U.S. 164 , 92 S.Ct. 1400 , 31 L.Ed.2d 768 (1972); Levy v. Louisiana, 391 U.S. 68 , 88 S.Ct. 1509 , 20 L.Ed.2d 436 (1968)), a classification between children of legal residents and children of illegal aliens with regard to a free public education (Plyler v. Doe, 457 U.S. 202, 217-218, 224 , 102 S.Ct. 2382, 2395, 2398 , 72 L.Ed.2d, 786, 799-800, 803 (1982)), and a classification under which certain persons were denied the right to practice for compensation the profession for which they were qualified and licensed (Attorney General v. Waldron, supra, 289 Md. at 716-728 , 426 A.2d at 947-954 ). (Some alterations in original). Murphy, 325 Md. at 355-57 , 601 A.2d at 108-09 .

See also Kane v. Board of Appeals, 390 Md. 145 , 171 n. 18, 887 A.2d 1060 , 1075 n. 18 (2005). Classifications based on alienage employed by a State “are inherently suspect and are therefore subject to strict judicial scrutiny whether or not a fundamental right is impaired.” Graham, 403 U.S. at 376 , 91 S.Ct. at 1854 , 29 L.Ed.2d at 544 . See also Murphy, 325 Md. at 356 , 601 A.2d at 109 ; Nyquist v. Mauclet, 432 U.S. 1 , 97 S.Ct. 2120 , 53 L.Ed.2d 63 (1977) (holding that a New York statutory provision barring certain resident aliens from State financial assistance for higher education violated the Equal Protection Clause of the Fourteenth Amendment after applying strict judicial scrutiny and finding that New York failed to offer a compelling governmental interest to justify the discrimination); Graham, 403 U.S. at 371-72 , 91 S.Ct. at 1852 , 29 L.Ed.2d at 541-42 (“[T]he [U.S. Supreme] Court’s decisions have established that classifications based on alienage, like those based on nationality or race, are inherently suspect and subject to close judicial scrutiny. Aliens as a class are a prime example of a ‘discrete ⁷¹⁹ and insular’ minority for whom such heightened judicial solicitude is appropriate.”) (Footnotes and citations omitted); Takahashi, 334 U.S. 410, 420 , 68 S.Ct. 1138, 1143 , 92 L.Ed. 1478, 1488 (concluding that a California statute violated the equal protection guarantee of the Fourteenth Amendment when it used a federally created racial ineligibility for citizenship as a basis for barring Japanese resident aliens from obtaining commercial fishing licenses, stating that “the power of a state to apply its laws exclusively to its alien inhabitants as a class is confined within narrow limits”). 11 Statutory discrimination within the larger class of legal resident aliens, providing benefits to some aliens, but not to others, is nonetheless a classification based on alienage.

Nyquist, 432 U.S. at 7-9 , 97 S.Ct. at 2124-25 , 53 L.Ed.2d at 69-71 (rejecting a claim that a New York statutory provision barring certain resident aliens from State financial assistance for higher education did not impose a classification based on alienage); Graham, 403 U.S. at 371, 376 , 91 S.Ct. at 1851-52, 1854 , 29 L.Ed.2d at 541, 544 (stating that a State statutory classification where otherwise qualified citizens living in a State are entitled to assistance benefits without regard to length of national residency, but aliens must have lived in this country for a number of years in order to qualify for aid, is an inherently suspect classification and is subject to strict scrutiny). 12 ⁷²⁰ Where a federal statute distinguishes between citizens and aliens (and sub-classes of aliens), the U.S. Supreme Court applies a more relaxed standard of review than the strict scrutiny standard of review applied to comparable State statutes. In Mathews v. Diaz, supra, 426 U.S. at 84 , 96 S.Ct. at 1889 , 48 L.Ed.2d at 492 , the Court upheld a federal statute that conditioned an alien’s eligibility for participation in a federal medical insurance program on continuous residence in the United States for a five-year period and admission for permanent residence. The Court noted the broad power over naturalization and immigration pursuant to which Congress regularly enacts rules governing aliens. Mathews, 426 U.S. at 79-80 , 96 S.Ct. at 1891 , 48 L.Ed.2d at 489-90 .

The Court also acknowledged that decisions regarding the relationship between the United States and aliens may implicate our country’s relations with foreign powers — an arena more appropriately left to the federal legislative and executive branches of government than to the federal judiciary. Mathews, 426 U.S. at 81 , 96 S.Ct. at 1892 , 48 L.Ed.2d at 490-91 . The Court therefore applied a relaxed standard of review to a federal law that distinguished between sub-classes of aliens by conditioning an alien’s