    Notice: This opinion is subject to correction before publication in the PACIFIC REPORTER. Readers
    are requested to bring errors to the attention of the Clerk of the Appellate Courts, 303 K Street,
    Anchorage, Alaska 99501, phone (907) 264-0608, fax (907) 264-0878, email corrections@akcourts.us.



            THE SUPREME COURT OF THE STATE OF ALASKA

STATE OF ALASKA and THE                         )
COMMISSIONER OF THE                             )    Supreme Court No. S-16123
DEPARTMENT OF HEALTH &                          )
SOCIAL SERVICES,                                )    Superior Court No. 3AN-14-04711 CI
                                                )
                    Appellants,                 )    OPINION
                                                )
    v.                                          )    No. 7334 – February 15, 2019
                                                )
PLANNED PARENTHOOD OF THE                       )
GREAT NORTHWEST,                                )
                                                )

                    Appellee.                   )

                                                )


            Appeal from the Superior Court of the State of Alaska, Third
            Judicial District, Anchorage, John Suddock, Judge.

            Appearances: Stuart W. Goering and Margaret Paton Walsh,
            Assistant Attorneys General, Anchorage, and Jahna
            Lindemuth, Attorney General, Juneau, for Appellants. Susan
            Orlansky, Reeves Amodio LLC, Anchorage, Janet Crepps,
            Center for Reproductive Rights, Simpsonville, South
            Carolina, Autumn Katz, Center for Reproductive Rights, New
            York, New York, and Laura F. Einstein, Planned Parenthood
            of the Great Northwest, Seattle, Washington, for Appellee.
            Kevin G. Clarkson, Brena, Bell, & Clarkson, P.C.,
            Anchorage, Steven H. Aden, Alliance Defending Freedom,
            Washington, D.C., for Amicus Curiae Alaska Physicians for
            Medical Integrity. Jeffrey M. Feldman, Summit Law Group
            PLLC, Seattle, Washington, and Sara L. Ainsworth, Legal
            Voice, Seattle, Washington, for Amicus Curiae Legal Voice.
            James J. Davis, Jr., Northern Justice Project, LLC,
            Anchorage, and Catherine A. McKee, National Health Law
             Program, Carrboro, North Carolina, for Amici Curiae
             Northern Justice Project, LLC and The National Health Law
             Program.

             Before: Stowers, Chief Justice, Winfree, Maassen, Bolger,
             and Carney, Justices.

             CARNEY, Justice.

             STOWERS, Chief Justice, dissenting.


I.    INTRODUCTION
             We are again called upon to determine whether restrictions placed upon
Alaska’s Medicaid funding of abortions violate the Alaska Constitution. A 2014 statute
and 2013 regulation re-define which abortions qualify as “medically necessary” for the
purposes of Medicaid funding. The statute defines medically necessary abortions as
those that “must be performed to avoid a threat of serious risk to the life or physical
health of a woman from continuation of the woman’s pregnancy” as a result of a number
of listed medical conditions; the regulation is similarly restrictive. Planned Parenthood
of the Great Northwest challenged both the statute and regulation as unconstitutional,
and the superior court held that both measures violated the equal protection clause of the
Alaska Constitution. The court reasoned that these measures imposed a “high-risk, high-
hazard” standard on abortion funding unique among Medicaid services, and held that our
2001 decision striking down an earlier abortion funding restriction on equal protection
grounds compelled the same result. The State appeals, arguing that the statute and
regulation should be interpreted more leniently and therefore do not violate the Alaska
Constitution’s equal protection clause.
             We affirm the superior court’s decision. These measures cannot be
interpreted as leniently as the State suggests, and their language compels a “high-risk,
high-hazard” interpretation akin to that adopted by the superior court. This standard

                                           -2-                                      7334

imposes different requirements for Medicaid funding eligibility upon women who choose
to have abortions than it does upon women who choose to carry their pregnancies to
term. The statute’s and the regulation’s facially different treatment of pregnant women
based upon their exercise of reproductive choice requires us to apply strict scrutiny, and
the proposed justifications for the funding restrictions do not withstand such exacting
examination. We therefore conclude that the statute and the regulation violate the Alaska
Constitution’s guarantee of equal protection.
II.    FACTS AND PROCEEDINGS
       A.     Medicaid Coverage In Alaska
              Medicaid is a health insurance program for low-income individuals.1 It was
created by the federal government,2 which sets guidelines for eligibility and requires that
certain benefits be provided.3 The federal government provides matching funds that
subsidize states’ costs in providing such health care.4 Individual states administer the
program in compliance with federal requirements.5 But each state decides whether to




       1
             AS 47.07.010. Medicaid also provides coverage for certain other
individuals. AS 47.07.020 (Medicaid eligible persons).
       2
            See Social Security Act, Pub. L. 89-97, 79 Stat. 286 (1965); 42 U.S.C.
§ 1396-1 (2012).
       3
              See 42 U.S.C. § 1396a (describing requirements for state plans for medical
assistance); § 1396-1.
       4
              Id. § 1396-1.
       5
             Id. (providing for appropriations for payments to states that have received
federal approval of their medical assistance plans).

                                            -3-                                      7334

offer benefits in addition to those required by federal rules, and each state is authorized
to limit services as long as such limits comply with federal standards.6
              Alaska’s Medicaid program funds “uniform and high quality” medical care
for low-income individuals “regardless of race, age, national origin, or economic
standing.”7 Medicaid is administered by the Department of Health and Social Services
(DHSS); it pays for medical services that are “medically necessary as determined by”
statute, regulation, “or by the standards of practice applicable to the provider.”8
Although DHSS’s regulations do not define “medically necessary,” they state that
Medicaid will only pay for services that are “reasonably necessary for the diagnosis and
treatment of an illness or injury, or for the correction of an organic system, as determined
upon review by the department.”9
              Doctors submit requests for Medicaid reimbursement of services provided
to individuals enrolled in the Medicaid program. In Alaska DHSS usually provides
Medicaid reimbursement to doctors without requiring prior authorization or a significant
review of the claims. Where there is concern about cost-effectiveness, efficacy, fraud,
waste, or abuse associated with certain treatments, doctors are required to provide
additional documentation of the need for the treatment. In such situations doctors submit
the documentation with their payment request. This has been the method used for
abortion payments. For a third category of claims, such as surgeries and lengthy
hospitalizations, prior authorizations are required. Virtually all claims, regardless of



       6
              See AS 47.07.030.
       7
              AS 47.07.010.
       8
              7 Alaska Administrative Code (AAC) 105.100(5) (am. 10/1/2011).
       9
              7 AAC 105.110(1) (am. 5/1/2016).

                                            -4-                                       7334

which type of processing they originally received, are subject to Medicaid’s post-
payment review processes, including audits.
       B.     The 1998 Regulation Addressing Medicaid Coverage Of Abortions
              This case arises out of a series of legislative and regulatory measures and
court decisions involving restrictions on Medicaid funding for abortions. In 1998 DHSS
enacted a regulation that brought Alaska’s Medicaid coverage of abortions in line with
the federal Hyde Amendment.10 The Hyde Amendment, originally passed in 1976 by the
United States Congress, prohibits the use of federal funds “to perform abortions except
where the life of the mother would be endangered if the fetus were carried to term; or
except for such medical procedures necessary for the victims of rape or incest.”11 It has
been slightly modified over the years, but remains in effect and continues to limit federal
funding for abortion to these two limited circumstances.12
              In 2001 we affirmed the invalidation of the 1998 regulation based on the
Alaska Constitution’s equal protection clause,13 noting that the regulation’s denial of
funding for “medically necessary abortions”14 was a departure from “the Medicaid
program’s purpose of granting uniform and high quality medical care to all needy




       10
              7 AAC 43.140 (am. 7/1/98).
       11
              Harris v. McRae, 448 U.S. 297, 302 (1980) (quoting Pub. L. 96-123, § 109,
93 Stat. 926).
       12
              See H.R. 7, 115th Cong. (2017).
       13
             See State, Dept. of Health & Soc. Servs. v. Planned Parenthood of Alaska,
Inc. (Planned Parenthood 2001), 28 P.3d 904, 915 (Alaska 2001).
       14
              Id. at 905.

                                           -5-                                       7334

persons of this state.”15 We explained that “a woman who carries her pregnancy to term
and a woman who terminates her pregnancy exercise the same fundamental right to
reproductive choice” and that “Alaska’s equal protection clause does not permit
governmental discrimination against either woman.”16 We applied strict scrutiny because
the regulation “effectively deter[red] the exercise of” the fundamental constitutional right
to reproductive choice “by selectively denying a benefit to those who exercise[d]” that
right.17 We held that the State had failed to present a compelling interest to justify the
discrimination.18 We affirmed the superior court judgment striking down the regulation,
effectively reinstating the general Medicaid requirement of medical necessity that had
been in place before the promulgation of the regulation.19 As a result, the Medicaid
program would pay for an abortion if it was “medically necessary” according to either
the relevant Alaska Medicaid regulations or “the standards of practice applicable to the
provider.”20 This continued until DHSS and the legislature adopted the regulation and
statute at issue in this case.
       C.	    Planned Parenthood Challenges The 2013 Regulation And The 2014
              Statute Regulating Medicaid Coverage Of Abortions
              In 2013 DHSS amended the definitions related to Medicaid regulations to




       15
              Id. at 911 (citing AS 47.07.010 (1972)).

       16
              Id. at 913.

       17

              Id. at 909.
       18
              Id. at 912-13.
       19
              Id. at 905-06, 915.
       20
              7 AAC 105.100(5).

                                            -6-	                                      7334

require a more detailed certificate to obtain state Medicaid funding for an abortion.21 The
2013 form22 required doctors to certify that an abortion was required by one of the two
circumstances permitting federal abortion funding under the Hyde Amendment, or that,
“in [his or her] professional medical judgment the abortion procedure was medically
necessary to avoid a threat of serious risk to the physical health of the woman from
continuation of her pregnancy due to the impairment of a major bodily function
including but not limited to one of” 21 listed conditions.23

       21
               In 2012 DHSS had issued a regulation requiring doctors to complete a
certificate to request Medicaid payment for an abortion. 7 AAC 160.900(d)(30) (am.
1/16/2013). Under the 2012 regulation, the doctor had to certify whether an abortion met
the requirements of the federal Hyde Amendment, or, if not, whether an abortion was
“medically necessary.” “Medically necessary” was not defined.
       22
              The regulation, 7 AAC 160.900(d)(30) (am. 2/2/2014), stated only that
DHSS adopts “the Certificate to Request Funds for Abortion, revised as of December
2013.” It was the accompanying certificate, not the regulation itself, that outlined the
new criteria for medical necessity applicable to abortions.
       23
              See 7 AAC 160.900(d)(30). These conditions are: (1) diabetes with acute
metabolic derangement or severe end organ damage; (2) renal disease that requires
dialysis treatment; (3) severe preeclampsia; (4) eclampsia; (5) convulsions; (6) status
epilepticus; (7) sickle cell anemia; (8) severe congenital or acquired heart disease class
IV; (9) pulmonary hypertension; (10) malignancy where pregnancy would prevent or
limit treatment; (11) severe kidney infection; (12) congestive heart failure; (13) epilepsy;
(14) seizures; (15) coma; (16) severe infection exacerbated by the pregnancy; (17)
rupture of amniotic membranes; (18) advanced cervical dilation of more than 6
centimeters at less than 22 weeks gestation; (19) cervical or cesarean section scar ectopic
implantation; (20) pregnancy not implanted in the uterine cavity; and (21) amniotic fluid
embolus.
              If none of the listed conditions applied, a doctor could indicate that an
abortion was necessary due to “another physical disorder, physical injury, physical
illness, including a physical condition arising from the pregnancy” or “a psychiatric
disorder that places the woman in imminent danger of medical impairment of a major
                                                                         (continued...)

                                            -7-                                       7334

              Planned Parenthood brought suit, arguing that the regulation violated the
Alaska Constitution’s equal protection guarantee by singling out abortion among
Medicaid-funded services for a restrictive definition of medical necessity. The superior
court granted a preliminary injunction against enforcement of the regulation in February
2014.
              While Planned Parenthood’s challenge was pending, the legislature codified
a definition of “medically necessary” similar to that in the 2013 DHSS regulation. The
enacted statute, AS 47.07.068, provides that DHSS may not pay for an abortion unless
it is “medically necessary” or the pregnancy was the result of rape or incest. The statute
defines a “medically necessary” abortion as “mean[ing] that, in a physician’s objective
and reasonable professional judgment after considering medically relevant factors, an
abortion must be performed to avoid a threat of serious risk to the life or physical health
of a woman from continuation of the woman’s pregnancy.”24 Planned Parenthood
amended its complaint in May 2014 to include an equal protection challenge to the
statute and filed a second motion asking the court to extend the preliminary injunction
to include the statute as well as the regulation. The court granted the motion, enjoining
implementation of both measures pending the outcome of trial.
              At the conclusion of trial in February 2015 the superior court struck down
both AS 47.07.068 and 7 AAC 160.900(d)(30) on equal protection grounds, finding that
the statute and the regulation impermissibly discriminated against indigent women
seeking abortions. The court found that the legislature intended AS 47.07.068 to
delineate “a high-risk, high-hazard standard that would preclude funding for most


        23
             (...continued)
bodily function if an abortion is not performed.”
        24
              AS 47.07.068(b)(3).

                                            -8-                                      7334

Medicaid abortions.” The court concluded that the statute’s definition of “medically
necessary” covered “only abortions required to avoid health detriments attributable to
the enumerated conditions, either fully realized or demonstrably imminent.” The court
determined that the statute and regulation, so construed, violated the Alaska
Constitution’s equal protection clause, and it permanently enjoined their enforcement.
The State appeals.
III.   STANDARD OF REVIEW
             We use our independent judgment to review matters of constitutional or
statutory interpretation.25 When interpreting a regulation that does not implicate agency
expertise, “we exercise our independent judgment.”26 In the equal protection context our
independent review includes “assess[ing] the nature and importance of the competing
personal and governmental interests at stake, identify[ing] the relevant level of scrutiny
for governmental action, and assess[ing] the means chosen to advance governmental
interests.”27 Whether the classes being compared in an equal protection case are
“similarly situated” is also a legal question reviewed de novo.28



       25
              Premera Blue Cross v. State, Dep’t of Commerce, Cmty. &Econ. Dev., Div.
of Ins., 171 P.3d 1110, 1115 (Alaska 2007).
       26
              See City of Valdez v. State, 372 P.3d 240, 246 (Alaska 2016) (“If no agency
expertise is involved in the agency’s interpretation, we apply the substitution of
judgment standard. Under this standard, we exercise our independent judgment,
substituting it ‘for that of the agency even if the agency’s [interpretation] ha[s] a
reasonable basis in law.’ ” (quoting Tesoro Alaska Petroleum Co. v. Kenai Pipe Line Co.,
746 P.2d 896, 903(Alaska 1987))).
       27
            Planned Parenthood of The Great Nw. v. State (Planned Parenthood 2016),
375 P.3d 1122, 1132 (Alaska 2016).
       28
             Id. at 1136.

                                           -9-                                      7334

IV.    DISCUSSION

              Planned Parenthood argues the Medicaid funding statute is facially
unconstitutional because it unconstitutionally discriminates by treating two classes of
people unequally — women who seek abortions and women who seek to carry
pregnancies to term.29 Statutes “may be found to be unconstitutional as applied or
unconstitutional on their face.”30 “We uphold a statute against a facial constitutional
challenge if ‘despite . . . occasional problems it might create in its application to specific
cases, [it] has a plainly legitimate sweep.’ ”31 “A party raising a constitutional challenge
to a statute bears the burden of demonstrating the constitutional violation.                A
presumption of constitutionality applies, and doubts are resolved in favor of
constitutionality.”32
              To determine whether the challenged statute is constitutional we first
interpret the statute.33 After determining the meaning of the statute, we analyze its
constitutionality under Alaska’s equal protection doctrine.34


       29
             See id. at 1135; see also Nicholas Quinn Rosenkranz, The Subjects of the
Constitution, 62 STAN. L. REV. 1209, 1238 (2010) (“[A] ‘facial challenge’ is nothing
more nor less than a claim that Congress (or a state legislature) has violated the
Constitution.”).
       30
            State v. American Civil Liberties Union of Alaska, 204 P.3d 364, 372
(Alaska 2009).
       31
            State v. Planned Parenthood (Planned Parenthood 2007), 171 P.3d 577,
581 (Alaska 2007).
       32
              See State, Dept. of Revenue v. Andrade, 23 P.3d 58, 71 (Alaska 2001).
       33
            See Estate of Kim ex rel. Alexander v. Coxe, 295 P.3d 380, 386-88
(Alaska 2013).
       34
              See Planned Parenthood 2016, 375 P.3d at 1135-36.

                                            -10-                                        7334

              Similarly, to determine whether the challenged regulation is constitutional
we must interpret the regulation and, once its meaning is determined, assess its
constitutionality under Alaska’s equal protection doctrine.35
       A.     Analysis Of The Statute And Regulation
              This section analyzes two similar but not identical texts: the statute and the
DHSS regulation. We primarily discuss the statute, but our conclusions apply equally
to the regulation except where noted.
              When “interpreting a statute, we consider its language, its purpose, and its
legislative history, in an attempt to ‘give effect to the legislature’s intent, with due regard
for the meaning the statutory language conveys to others.’ ”36 We begin with the text and
its plain meaning, and we use a “sliding-scale approach” to interpret the language.37
“[T]he plainer the statutory language is, the more convincing the evidence of contrary
legislative purpose or intent must be.”38 When “a statute’s meaning appears clear and
unambiguous, . . . the party asserting a different meaning bears a correspondingly heavy
burden of demonstrating contrary legislative intent.”39           If an ambiguous text is
susceptible to more than one reasonable interpretation, of which only one is
constitutional, the doctrine of constitutional avoidance directs us to adopt the



       35
              Planned Parenthood 2001, 28 P.3d 904, 908 (Alaska 2001).
       36
            Alyeska Pipeline Serv. Co. v. DeShong, 77 P.3d 1227, 1234 (Alaska 2003)
(quoting Muller v. BP Expl. (Alaska) Inc., 923 P.2d 783, 787 (Alaska 1996)).
       37
              Ward v. State, Dep’t of Pub. Safety, 288 P.3d 94, 98 (Alaska 2012).
       38
             State v. Fyfe, 370 P.3d 1092, 1095 (Alaska 2016) (quoting Adamson v.
Municipality of Anchorage, 333 P.3d 5, 11 (Alaska 2014)).
       39
              Id. (quoting Univ. of Alaska v. Geistauts, 666 P.2d 424, 428 n.5 (Alaska
1983)).

                                             -11-                                        7334

interpretation that saves the statute.40
              Both the State and Planned Parenthood argue that the text of the statute
unambiguously supports their respective interpretations. Planned Parenthood interprets
the statute to allow Medicaid funding for an abortion only when it is the sole treatment
available to protect a woman against a serious risk of death or impairment of a major
bodily function because of an “explicitly catastrophic” medical condition. The State, on
the other hand, reads the statute to provide “a broad and inclusive definition” of medical
necessity that allows doctors to use their professional judgment when one of “a wide
range of ailments and conditions” elevates the health risks pregnancy poses. The State
asserts that the statute “provides reimbursement for any woman who faces . . . a risk
greater than the baseline risks of pregnancy” or a “non-trivial” health threat. It posits
that such a health threat may sometimes include exacerbation of a physical health
condition because of “medically relevant factors” like poor self-care and a lack of secure
housing.41



       40
              See Estate of Kim ex rel. Alexander v. Coxe, 295 P.3d 380, 388
(Alaska 2013) (explaining that “[t]he doctrine of constitutional avoidance ‘is a tool for
choosing between competing plausible interpretations of a statutory text’ ” such that, if
the statute would be unconstitutional under one and valid under the other, “[our] plain
duty is to adopt that which will save the Act” (first quoting Clark v. Martinez, 543 U.S.
371, 381-82 (2005); then quoting Rust v. Sullivan, 500 U.S. 173, 190 (1991))).
       41
              The parties devoted some time at trial eliciting testimony about what
“medically relevant factors” might include. Several doctors testified that they ask
patients about a wide range of information when they begin treatment, including “life[]
circumstances that affect[] the probability of receiving treatment,” such as whether a
patient works the night shift or has access to reliable refrigeration. The State agrees on
appeal that factors such as a patient’s housing situation and capacity for self-care can be
medically relevant factors in evaluating the risks and hazards faced by, for example, a
diabetic woman.

                                           -12-                                      7334

              1.     The text of the statute
              Statutory interpretation begins with the plain meaning of the statutory text.42
If the meaning and intent are clear, we do not apply interpretive canons; a canon of
construction is only “an aid to the interpretation of statutes that are ambiguous or that
leave unclear the legislative intent.”43
              Alaska Statute 47.07.068(a) prohibits Medicaid payment for abortions
“unless the abortion services are for a medically necessary abortion or the pregnancy was
the result of rape or incest.” Subsection (b)(3) defines a “medically necessary abortion”
as one that, “in a physician’s objective and reasonable professional judgment after
considering medically relevant factors . . . must be performed to avoid a threat of serious
risk to the life or physical health of a woman from continuation of the woman’s
pregnancy.”44 Subsection (b)(4) then explains that “ ‘serious risk to the life or physical
health’ includes, but is not limited to, a serious risk to the pregnant woman of (A) death;
or (B) impairment of a major bodily function because of” any of 21 serious conditions
or “another physical disorder, physical injury, or physical illness, including a
life-endangering physical condition caused by or arising from the pregnancy that places
the woman in danger of death or major bodily impairment if an abortion is not
performed.”45


       42
              Ward, 288 P.3d at 98.
       43
             See West v. Municipality of Anchorage, 174 P.3d 224, 229 (Alaska 2007)
(quoting Crump v. State, 625 P.2d 857, 859 (Alaska 1981)) (discussing ejusdem generis
canon of interpretation).
       44
              AS 47.07.068(b)(3).
       45
              AS 47.07.068(b)(4). There are some differences between the statute’s and
regulation’s lists of conditions. Where the regulation lists “severe kidney infection,” the
                                                                             (continued...)

                                            -13-                                       7334

              We conclude that the statute’s text is ambiguous because “threat of a
serious risk” is not defined. The lack of a clear definition creates an ambiguity regarding
whether a woman seeking an abortion will qualify for coverage based on one of the listed
medical conditions that authorize reimbursement for the cost of the procedure. The
parties’ textual dispute centers primarily on subsections (b)(3) and (b)(4) of the statute.
We analyze their arguments below, applying canons of construction and other
interpretive aids to discern the statute’s meaning in order to determine whether it is
constitutional.
                     a.	    The list of medical conditions and the “catch-all”
                            provision
              The parties dispute the significance of the list of medical conditions in
subsection (b)(4) and whether the final “catch-all” provision of the list broadens the
permissive scope of the statute in a way that may affect its constitutionality. Planned
Parenthood argues that the statute requires a woman both to presently suffer from one
of the listed conditions and to be at risk of impairment of a major bodily function because
of that condition before Medicaid will pay for an abortion. In contrast, the State asserts
that the list merely “serves to illuminate the concept of ‘serious risk’ by providing
examples of the very serious complications that can develop during pregnancy.” We
conclude that the catch-all provision does not meaningfully expand the permissive scope
of the statute.
              The statute provides that a “serious risk to the life or physical health” of a
woman means “a serious risk to the pregnant woman of . . . death[] or . . . impairment of

       45
                (...continued)
statute lists “kidney infection.” AS 47.07.068(b)(4)(B)(xi); 7 AAC 160.900(d)(30). Only
the regulation refers to psychiatric or mental health disorders. See AS 47.07.068(b).
Finally, the statute’s catch-all provision is more detailed.                        See
AS 47.07.068(b)(4)(B)(xxii).

                                           -14-	                                      7334

a major bodily function because of” one of 21 conditions.46 The phrase “impairment of
a major bodily function” refers to a serious health problem, though a doctor for Planned
Parenthood testified that the phrase is “not medical terminology.”47 At trial one of the
State’s experts testified that he understood “impairment of a major bodily function” to
mean “a change in the major organ system that . . . I think has the potential to lead to a
life threatening problem.”48 But a condition might have a permanent effect on physical
health without being fairly characterized as causing “impairment of a major bodily
function.” The 21 listed examples further narrow the category of medical conditions that
would qualify a woman for abortion funding. It is not enough for a pregnant woman to
face a serious risk to her life or physical health, or even to face a serious risk of acquiring
one of the conditions listed in subsection (b)(4). The statute instead requires a woman



       46
              AS 47.07.068(b)(4). At oral argument the State argued for the first time
that because the statutory definition of “ ‘serious risk to the life or physical health’
includes, but is not limited to, a serious risk to the pregnant woman,” the statute in fact
covers a much broader range of health conditions than those explicitly listed in
subsection (b)(4). (emphasis added).
       47
             The phrase appears to be used primarily in the context of medical
exceptions to laws restricting abortion. See, e.g., MICH. COMP. LAWS § 722.902(b)
(“ ‘Medical emergency’ means that condition . . . for which a delay in performing an
abortion will create serious risk of substantial and irreversible impairment of a major
bodily function.”); Planned Parenthood of Se. Penn. v. Casey, 505 U.S. 833, 879 (1992)
(reviewing a Pennsylvania statute containing similar language); Isaacson v. Horne, 716
F.3d 1213, 1218 (9th Cir. 2013) (reviewing an Arizona statute containing similar
language). “Major bodily function[]” is also used in the Americans with Disabilities Act
to mean “including but not limited to[] functions of the immune system, normal cell
growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine,
and reproductive functions.” 42 U.S.C. § 12102(2)(B).
       48
             Dr. Steven Calvin is an obstetrician and gynecologist who specializes in
maternal fetal medicine.

                                             -15-                                        7334

to face “a serious risk of death or [of] impairment of a major bodily function” caused by
one of those conditions.49
              Many of the conditions in subsection (b)(4) are quite serious. Preeclampsia,
for example, is an adverse reaction by a pregnant woman’s immune system to paternal
antigens in the placenta. The superior court found that it is “a precursor to numerous
modalities of life threatening damage” during the pregnancy and that it entails a currently
unquantifiable increased risk of heart disease and stroke 20 years in the future. Ectopic
implantation or other implantation outside the uterus will, according to testimony,
“almost always kill the woman before the fetus would be viable.” Other conditions are
less life-threatening but still exacerbated by pregnancy. For example, the superior court
noted that the physical stresses of “pregnancy can cause a woman with heart disease to
advance to a higher class of functional incapacity” or “entail[] a risk of death” for a
woman whose heart defect was previously “relatively asymptomatic.” Likewise, sickle
cell anemia causes low blood oxygen, which triggers pain crises when a patient’s bone
marrow increases production of red blood cells. The elevated metabolic demands of
pregnancy often increase the frequency of pain crises in women with the condition.
There was also testimony that a few of the listed conditions are an odd fit with the list
because the circumstances under which they occur can never lead to an abortion or
because abortion would almost never mitigate the risk faced by a woman. One of these
is amniotic fluid embolus, which one of Planned Parenthood’s experts testified occurs
during labor and delivery and can only be definitively diagnosed in an autopsy.
              The statute’s legislative history also supports a restrictive reading of the list
in subsection (b)(4). A staff member for the bill’s Senate sponsor testified that the
federal Hyde Amendment’s “death portion [was] the foundation” for the statutory text;


       49
              AS 47.07.068(b)(4)(B)(xxii).

                                            -16-                                         7334
the drafters had included an additional provision for “major bodily impairment” in
response to our holding in Planned Parenthood 2001 that Medicaid funding for abortion
could not be limited strictly to the Hyde Amendment’s standards.50 And one of the
State’s medical experts51 testified before the legislature that he had worked with the bill’s
sponsor to develop a “list of conditions that unequivocally threaten the life of a
mother.”52 The expert stated that the list was intended to be such that a doctor would
recommend abortion to a woman with one of the conditions even if she wished to
continue the pregnancy.53
              Although the State correctly notes that the statements of an expert witness
should not be given greater weight than those of legislators, this doctor was not merely
a witness testifying before the legislature; he worked with the bill’s sponsor specifically
to create the list of life-threatening conditions incorporated into the statutory language.54
His testimony therefore reliably informs our understanding of the sponsor’s intent.
Moreover, the Senate rejected an amendment that would have removed the list of
conditions and instead required a doctor to certify an abortion was medically necessary




       50
             Statement of Chad Hutchinson, Staff Member to Sen. John Coghill at
8:11:10-8:11:42, Hearing on S.B. 49 Before the House Fin. Comm., 28th Leg., 2d Sess.
(Feb. 25, 2014).
       51
             Dr. John Thorp is an obstetrician who practices in the area of fetal medicine
and high risk obstetrics.
       52
             Testimony of Dr. John Thorp, at 2:19:41-2:20:56, Hearing on S.B. 49
Before the Sen. Jud. Comm., 28th Leg., 1st Sess. (Feb. 27, 2013) (hereinafter Dr. Thorp
Testimony).
       53
              Id. at 2:21:10-2:21:34.
       54
              Id. at 2:19:41-2:20:56.

                                            -17-                                       7334

based on all the information available to the doctor.55 This rejection suggests the list of
conditions was meant to restrict physicians’ discretion and that this restriction was
important to the legislature’s intent.
              The statute’s list of conditions in subsection (b)(4) includes a final catch-all
provision that reads, “another physical disorder, physical injury, or physical illness,
including a life-endangering physical condition caused by or arising from the pregnancy
that places the woman in danger of death or major bodily impairment if an abortion is
not performed.”56 The State argues that this catch-all provision broadens the permissive
scope of the statute. Because the phrase “another physical disorder, physical injury, or
physical illness” contains no severity requirement,57 this portion of the provision could,
by itself, be interpreted to broaden the scope of the covered conditions. Indeed, a State
medical expert testified that he saw this provision as “a barn door” that provides “a large
opening” for doctors to receive payment for abortions.
              But the language immediately following that phrase explains what is
required for coverage under this provision: “a life-endangering physical condition
caused by or arising from the pregnancy that places the woman in danger of death or
major bodily impairment if an abortion is not performed.”58 This qualifying language
emphasizes the severity of the conditions intended to be covered by the catch-all
provision. The physical condition must not only be “life-endangering,” but it must also,
somewhat redundantly, “place[] the woman in danger of death or major bodily



       55
              2013 Senate Journal 1074-75.
       56
              AS 47.07.068(b)(4)(B)(xxii).
       57
              Id.
       58
              AS 47.07.068(b)(4)(B)(xxii).

                                            -18-                                        7334

impairment.”59 This duplicative reference to the danger of death, as well as the fact that
the language of the catch-all provision almost exactly mirrors the current language of the
Hyde Amendment,60 indicates how serious a condition must be to qualify for coverage
under the catch-all provision.
              The meaning of the catch-all provision is also shaped by the list of
conditions preceding it. Physicians for both parties testified that these conditions are
serious and, for some, life-threatening. Under the interpretive canon ejusdem generis,
when a general term follows specific terms, the general term “will be interpreted in light
of the characteristics of the specific terms, absent clear indication to the contrary.”61 The
specific terms here are serious conditions that can be life-threatening, so a non-listed
condition must be similarly dangerous to qualify for coverage under the catch-all




       59
              Id.
       60
             The 2014 version of the federal Hyde Amendment provided that federal
funds could not be used for abortion coverage unless:
              the pregnancy is the result of an act of rape or incest; or . . .
              a woman suffers from a physical disorder, physical injury, or
              physical illness, including a life-endangering physical
              condition caused by or arising from the pregnancy itself, that
              would, as certified by a physician, place the woman in danger
              of death unless an abortion is performed.
Consolidated Appropriations Act, 2014, Pub. L. No. 113-76, §§ 506-507, 128 Stat. 409
(2014).
       61
              See City of Kenai v. Friends of Recreation Ctr., Inc., 129 P.3d 452, 459
(Alaska 2006) (quoting West v. Umialik Ins. Co., 8 P.3d 1135, 1141(Alaska 2000));
ejusdem generis, BLACK’S LAW DICTIONARY (10th ed. 2014) (“A canon of construction
holding that when a general word or phrase follows a list of specifics, the general word
or phrase will be interpreted to include only items of the same class as those listed.”).

                                            -19-                                       7334

provision. We therefore conclude that the catch-all provision does not meaningfully
expand the permissive scope of the statute.62
                     b.     The meaning of “threat of serious risk”
              The statute provides that a “medically necessary abortion” is one that “must
be performed to avoid a threat of serious risk to the life or physical health” of a pregnant
woman.63 The statute defines “serious risk to the life or physical health” in great detail,64
but the precise meaning of “threat of serious risk” is contested by the parties. The State
asserts that the language significantly attenuates the statute’s severity because both
“threat” and “risk” entail probabilities: a woman is not required to face a “serious risk
to [her] life or physical health” to qualify for Medicaid funding; she is merely required
to face a threat of such risk. Planned Parenthood argues that, because all pregnant
women face an elevated health risk, the State’s reading would cover all pregnant women
and thereby render the rest of the statute superfluous.
              “Threat of serious risk” is not an expression with a recognized legal
meaning in Alaska or elsewhere in the United States.65 In the absence of prior

       62
               The dissent’s argument at page 6 that we should elevate the catch-all phrase
“by itself” in order to uphold the statute disregards the long-established legal rules that
must govern our analysis.
       63
              AS 47.07.068(b)(3).
       64
              AS 47.07.068(b)(4).
       65
             This expression occurs in several statutory provisions creating medical
emergency exceptions to laws about abortion or about prescription of opioids to minors.
See OHIO REV. CODE ANN. §§ 2919.12(C)(2), 2919.121(D), 3701.791(A),
3719.061(A)(1)(b) (West 2016); 35 PA. STAT. AND CONS. STAT. ANN. § 52A01 (West
2016). Although the phrase has been quoted twice in our abortion jurisprudence, neither
we nor any other court have construed its meaning. See Planned Parenthood 2016, 375
P.3d 1122, 1159 n.18 (Alaska 2016) (Stowers, J., dissenting); Planned Parenthood
                                                                         (continued...)

                                            -20-                                       7334

interpretations of this language, its meaning must be established by the text and context
of the statute.
              “Risk” can mean “[t]he possibility of suffering harm or loss; danger” or “[a]
factor, thing, element, or course involving uncertain danger”66 — for example,
“Professional snowboarders take many risks.” It can also mean, in a more statistical
sense, “chance of loss” or “degree of probability of such loss”67 — for example,
“Bicycling without a helmet entails a risk of head injury.” Used alone, “risk” tends to
encompass the combination of probability and hazard, leaving the specific hazards to
context and the reader’s imagination. But when connected to an explicit hazard (“risk
of ____”), “risk” generally means probability.
              Although AS 47.07.068(b)(3)’s reference to “serious risk to the life or
physical health of a woman” uses “risk” alone, and not as part of the phrase “risk of
____,” the next section, (b)(4), goes on to define “serious risk” to mean “serious risk . . .
of . . . death[] [or] . . . impairment of a major bodily function.”68 In this context, “risk”
is most naturally read as the probability of the specified harm.
              Like “risk,” “threat” may connote two slightly different concepts. The
American Heritage Dictionary defines “threat” as “[a]n indication of impending danger




       65
            (...continued)
2007, 171 P.3d 577, 580 n.7 (Alaska 2007).
       66
             THE AMERICAN HERITAGE DICTIONARY OF THE ENGLISH LANGUAGE 1514
(5th ed. 2016).
       67
              Id.

       68

              AS 47.07.068(b)(4) (emphasis added).

                                            -21-                                       7334

or harm.”69 The expression “threat of ____” may be read in two ways. One emphasizes
the sense of “threat” as hazard: we might read “a threat of flooding” as an impending
hazard consisting of flooding. The other emphasizes the sense of “threat” as relatively
high probability: “a threat of frost overnight” implies a reasonable likelihood of frost.
              In the context of the statute, only the first sense of the word “threat” is
appropriate. As we have explained, “risk” as used in the statute must mean probability.
If “threat” also meant probability, then the statute’s “threat of serious risk . . .
of . . . death[] or impairment” would mean “probability of serious probability . . . of death
or . . . impairment.”70 As the State would have us read the statutory text, this multiplying
of probabilities would mean that the statute covers abortions even when there is a
relatively low absolute risk of serious harm, as long as the doctor has an articulable
medical reason for believing the woman faces a greater degree of risk than normal. The
statute’s text, however, provides no reason to draw the line at “higher than normal risk.”
Because all pregnant women face some risk of pregnancy-induced conditions like
preeclampsia, the statute would sanction funding for all abortions if read to include such
an attenuated health risk. But such an interpretation would render the limiting language
and list of conditions in subsection (b)(4) superfluous71 and is not supported by the
available legislative history. There is no indication in the legislative record that “threat



       69
             THE AMERICAN HERITAGE DICTIONARY OF THE ENGLISH LANGUAGE 1813
(5th ed. 2016).
       70
              AS 47.07.068(b)(3)-(4).
       71
               See Kodiak Island Borough v. Exxon Corp., 991 P.2d 757, 761 (Alaska
1999) (“We . . . presume ‘that the legislature intended every word, sentence, or provision
of a statute to have some purpose, force, and effect, and that no words or provisions are
superfluous.’ ” (quoting Rydwell v. Anchorage Sch. Dist., 864 P.2d 526, 530-31 (Alaska
1993))).

                                            -22-                                       7334

of serious risk” was meant to play the attenuating role the State has proposed. If the
legislature had intended “threat of serious risk” to significantly reduce the severity of the
statute’s restrictions, we would expect to see some discussion of that phrasing and its
effect somewhere in the legislative history. But the legislative record contains no such
discussion.
              We therefore construe “threat of serious risk [of death, or of impairment
from a listed harm]” to mean “impending hazard consisting of a serious probability [of
death, or of impairment from a listed harm].”72 This interpretation does not require that
a woman suffer one of the listed conditions for her abortion to be covered by Medicaid,
but it also does not mean that suffering from a listed condition is sufficient.
                     c.	    Coverage of mental health conditions and lethal fetal
                            anomalies
              The statute does not explicitly refer to mental health or include any
psychological disorders in its list of conditions.73 The catch-all provision specifically
limits its coverage to “another physical disorder, physical injury, or physical illness.”74
But a psychological condition that entails a serious risk of death could conceivably be
covered by subsection (b)(4)(A), which permits coverage for “serious risk to the
pregnant woman . . . of death” without the caveat that the risk of death must be presented
by a physical condition.
              At trial the State argued that this provision of the statute could be
interpreted to cover “only a very extreme mental health condition” where a woman was

       72
              This is essentially what the superior court did when it resolved the
interpretive challenge by construing the phrase to mean “threat [consisting] of a serious
risk.” (Alteration in original).
       73
              See AS 47.07.068(b)(4)(B).
       74
              AS 47.07.068(b)(4)(B)(xxii) (emphasis added).

                                            -23-	                                      7334

suffering from “suicidal ideation where there was a risk of death.” We agree. The
statute cannot be construed to cover any other mental health condition, or to cover
women with mental health conditions like bipolar disorder whose medications pose a risk
to the fetus.75
                  The legislative history indicates that lawmakers intended to exclude mental
health from the statutory definition of medical necessity. The House rejected an
amendment that would have recognized medical necessity where “a psychiatric
disorder . . . places the woman in imminent danger of medical impairment of a major
bodily function.”76 The bill’s Senate sponsor, when asked why bipolar disorder was not
covered by the bill, replied that he believed, based on medical testimony and expert
advice, that “most psychological conditions were not a threat to the health of a pregnant
woman.”77




       75
              There are numerous conditions that may be treated with medications that
can affect or disturb the development of a fetus. We discussed bipolar disorder as an
example of such a mental health condition in our Planned Parenthood 2001 decision.
28 P.3d 904, 907 (Alaska 2001) (“[W]omen who suffer from conditions such as . . .
bipolar disorder face a particularly brutal dilemma as a result [of the] regulation —
medication to control their own . . . symptoms can be highly dangerous to a developing
fetus. Without funding for medically necessary abortions, pregnant women with these
conditions must choose either to seriously endanger their own health by forgoing
medication, or to ensure their own safety but endanger the developing fetus by
continuing medication.”).
       76
                  2014 House Journal 2337.
       77
           Statement of Sen. John Coghill at 8:24:44-8:26:20, Hearing on S.B. 49
Before House Fin. Comm., 28th Leg., 2d Sess. (Feb. 25, 2014).

                                              -24-                                     7334

              The statute also does not cover abortions when the fetus suffers from a fatal
anomaly.78 The statute79 states that an abortion must be necessary to avoid the risk of
harm to the life or physical health of a pregnant woman.80 The text does not leave room
to consider an abortion medically necessary based on the suffering of the fetus. The
bill’s sponsor indicated that he believed fatal fetal abnormalities would be covered under
the bill’s catch-all provision.81 But this statement, unsupported by other evidence from
the legislative history, is not sufficient to overcome the plain meaning of the statute.82
The statute therefore cannot reasonably be interpreted to cover abortions in the case of
fatal fetal anomalies.
              The State urges us to apply the canon of constitutional avoidance, arguing
that the superior court improperly ignored a reasonable interpretation of the statute that
would have been constitutional. The canon of constitutional avoidance requires us to
choose the constitutionally permissible interpretation from among reasonable
interpretations of an ambiguous statute.83 But the legislative history makes clear that the
State’s interpretation, which the dissent embraces, is not reasonable in this case. The


         78
            Trial testimony referred to examples of such anomalies, including
anencephaly, a neural tube defect in which there is no covering for the brain, and renal
agenesis when the fetus has no kidneys.
         79
              As well as the certificate required by the regulation.
         80
              See AS 47.07.068(b)(3); 7 AAC 160.900(d)(30).
         81
             Sen. John Coghill at 9:13:49-9:14:11, SB 49 Rebuttal to Planned
Parenthood and testimony from Saturday, March 30, 2013, House Fin. Comm., Hearing
on S.B. 49, 28th Leg., 1st Sess. (Apr. 1, 2013).
         82
              See State v. Fyfe, 370 P.3d 1092, 1095 (Alaska 2016).
         83
              See Estate of Kim ex rel. Alexander v. Coxe, 295 P.3d 380, 388 (Alaska
2013).

                                           -25-                                      7334

statute’s text is ambiguous because “threat of a serious risk” is not defined. We do not
find the catch-all provision meaningfully expands the statute’s coverage. Thus we read
“threat of a serious risk” to mean an impending hazard consisting of a serious probability
of death, or of impairment because of a listed harm.
              2.     The text of the regulation
              Although the regulation is structured somewhat differently from the statute,
we apply similar analytical methods to interpret its text.84 As we have discussed, a
woman must suffer a threat of serious risk of death or impairment of a major bodily
function caused by one of the listed medical conditions in order to be eligible for
Medicaid funding for an abortion according to the statute.85
              The regulation introduces its list of medical conditions differently. The
regulation requires a doctor to certify that an abortion “was medically necessary to avoid
a threat of serious risk to the physical health of a woman from continuation of her
pregnancy due to the impairment of a major bodily function including but not limited to
one of the following” conditions.86 Pursuant to the regulation each listed condition is
itself an “impairment of a major bodily function” or a “serious risk to the physical health



       84
              See Pease-Madore v. State, 414 P.3d 671, 675 (Alaska 2018); Wilson v.
State, Dep’t. of Corr., 127 P.3d 826, 829 (Alaska 2006). Though we apply similar
methods to interpret the regulation and the statute, the regulation is not entitled to the
same presumption of constitutionality. See State, Dep’t of Revenue v. Andrade, 23 P.3d
58, 71 (Alaska 2001) (explaining the canon of constitutional avoidance “recognizes that
the legislature, like the courts, is pledged to support the state and federal constitutions
and that the courts, therefore, should presume that the legislature sought to act within
constitutional limits”); Planned Parenthood 2001, 28 P.3d 904, 913 (Alaska 2001).
       85
              AS 47.07.068(b)(4)(B)(xxii).
       86
            See 7 AAC 160.900(d)(30) (adopting the revised Certificate to Request
Funds for Abortion).

                                           -26-                                      7334

of the woman.”87 This contrasts with the statute, under which suffering from such a
condition does not suffice unless there is also a threat of serious risk of death or
impairment of a major bodily function caused by the pregnancy.88 A serious risk of
acquiring any of the listed conditions is therefore sufficient for coverage under the
regulation. However, as with the statute, the risk posed to a woman’s health must be
greater than the baseline health risk inherent in pregnancy — otherwise this entire
portion of the regulation would be surplusage.
             A second difference from the statute is the regulation’s catch-all provision,
which covers “another physical disorder, physical injury, [or] physical illness, including
a physical condition arising from the pregnancy.”89 The regulation does not include the
statute’s additional language emphasizing the danger of death; it simply indicates that
physical conditions caused by pregnancy fall under the catch-all provision. But like the
statute, the preceding listed conditions constrain the meaning of the catch-all under the
canon of ejusdem generis. Considering the regulation’s inclusion of the listed conditions
in the definition of “serious risk to the physical health of the woman” with the catch-all
provision demonstrates that the regulation is somewhat less restrictive than the statute.
             A third difference is the regulation’s treatment of mental health conditions.
One of the conditions listed in the regulation is “a psychiatric disorder that places the
woman in imminent danger of medical impairment of a major bodily function if an
abortion is not performed.” Although the statute’s coverage of mental health conditions
is effectively limited to suicide, the regulation appears to cover imminent and serious
self-harm short of suicide. But as one testifying physician noted, these cases “represent

      87
             Id.
      88
             See AS 47.07.068.
      89
             See 7 AAC 160.900(d)(30).

                                          -27-                                      7334

a tiny fraction of patients with psychiatric symptoms.” The regulation thus covers
psychiatric disorders to a very limited extent and does not significantly expand coverage
beyond the statute.
             Overall the regulation is less restrictive than the statute in its requirement
that the pregnancy pose a serious risk to the physical health of the woman. The
regulation has a slightly broader catch-all provision and it permits coverage for more
mental health conditions. But these differences are not sufficiently less restrictive to
meaningfully differentiate coverage under the statute and the regulation.90
             Having determined the statute and regulation’s meanings, we must
determine whether they are permissible under the Alaska Constitution. To do this, we
assess whether these measures result in unequal treatment of different classes of women,
identify the constitutional interest at stake, the State’s interest in adopting these
measures, and the method the State has employed to address its interest.
      B.     Equal Protection Under The Alaska Constitution
             “[A] party raising a constitutional challenge to a statute bears the burden
of demonstrating the constitutional violation. A presumption of constitutionality applies,
and doubts are resolved in favor of constitutionality.”91 “But a statute infringing on a




      90
             We do not address the issue of whether the passage of the statute impliedly
repealed the regulation. This was raised below but not addressed on appeal, so we
therefore do not address it. But we note that to the extent that the regulation expands
coverage and exceeds the agency’s statutory authority, it is invalid. See Muller v. BP
Exploration (Alaska) Inc., 923 P.2d 783, 792 n.9 (Alaska 1996); Powers v. State, Public
Emp.’s Ret. Bd., 757 P.2d 65, 67 (Alaska 1988) (“[R]egulations made by an agency
which exceed its statutory authority are invalid.”).
      91
             Harrod v. State, Dep’t of Revenue, 255 P.3d 991, 1000-01 (Alaska 2011)
(quoting State, Dep’t of Revenue v. Andrade, 23 P.3d 58, 71 (Alaska 2001)).

                                          -28-                                       7334

constitutionally protected right deserves close attention,”92 and “the State bears a high
burden to justify” such laws.93
              When equal protection claims are raised, the question is
              whether two groups of people who are treated differently are
              similarly situated and therefore are entitled to equal treatment
              under the constitution. In order to determine whether
              differently treated groups are similarly situated, we look to
              the state’s reasons for treating the groups differently.[94]
We begin by determining the appropriate comparison classes.95 We then evaluate
whether “the challenged law has a discriminatory purpose or is facially discriminatory —
i.e., whether the classes are treated unequally.”96 Our ultimate determination of whether
the classes are similarly situated is a legal question: whether, “[u]nder the applicable
scrutiny level . . . the stated rationales for the [law] justify discriminating between” the
comparison classes.97




       92
             Planned Parenthood 2016, 375 P.3d 1122, 1133 (Alaska 2016) (citing
Planned Parenthood 2001, 28 P.3d 904, 912 (Alaska 2001); Commercial Fisheries Entry
Comm’n v. Apokedak, 606 P.2d 1255, 1261 (Alaska 1980); Planned Parenthood of Cent.
N.J. v. Farmer, 762 A.2d 620, 633 (N.J. 2000)).
       93
              Planned Parenthood 2001, 28 P.3d at 912.
       94
            Planned Parenthood 2016, 375 P.3d at 1135 (emphasis omitted) (quoting
Pub. Emps.’ Ret. Sys. v. Gallant, 153 P.3d 346, 349 (Alaska 2007)).
       95
              Id. at 1135.
       96
              Id.
       97
              Id. at 1136.

                                           -29-                                       7334

               Planned Parenthood has brought a facial challenge to the statute and
regulation, seeking to invalidate them in toto, as enacted.98 Against such challenges, “we
will uphold the statute even if it might occasionally create constitutional problems in its
application, as long as it ‘has a plainly legitimate sweep.’ ”99
               1.    Comparison classes
               The statute and regulation at issue impose different eligibility criteria on
pregnant women based on their choice whether to obtain an abortion.100 In Planned
Parenthood 2001, we explained that
               a woman who carries her pregnancy to term and a woman
               who terminates her pregnancy exercise the same fundamental
               right to reproductive choice. Alaska’s equal protection clause
               does not permit governmental discrimination against either
               woman; both must be granted access to state health care



         98
               See State v. Am. Civil Liberties Union of Alaska, 204 P.3d 364, 372 (Alaska
2009).
         99
              Planned Parenthood 2016, 375 P.3d at 1133 (quoting Planned Parenthood
2007, 171 P.3d 577, 581 (Alaska 2007)). The State argues that a facial challenge is
inappropriate and that we should defer decision on the statute’s overall constitutionality
until a patient or provider brings an “as-applied” challenge against an actual denial of
payment. But Planned Parenthood’s argument is that the statute is unconstitutional
because it creates a discriminatory standard, not because it would deny funding in
particular instances where it would violate the constitution to do so. If the standard is
discriminatory, there is no “sweep” of circumstances in which denial of payment under
the statute and regulation is “plainly legitimate” or without similar constitutional
concerns; in such circumstances “every litigant with standing would necessarily succeed
in challenging the statute based upon [the] same reasoning.” Scott A. Keller & Misha
Tseytlin, Applying Constitutional Decision Rules Versus Invalidating Statutes In Toto,
98 VA. L. REV. 301, 326 (2012). Planned Parenthood’s facial challenge is therefore
appropriate.
         100
               See AS 47.07.068; 7 AAC 160.900(d)(30).

                                           -30-                                      7334

             under the same terms as any similarly situated person.[101]
The most appropriate comparison classes are therefore Medicaid-eligible women who
seek funding for abortion and Medicaid-eligible women who seek funding for natal and
prenatal care.
             2.     Unequal treatment of comparison classes
             We employ a three-step equal protection analysis:
             First, it must be determined at the outset what weight should
             be afforded the constitutional interest impaired by the
             challenged enactment . . . . Depending upon the primacy of
             the interest involved, the state will have a greater or lesser
             burden in justifying its legislation.
             Second, an examination must be undertaken of the purposes
             served by a challenged statute. Depending on the level of
             review determined, the state may be required to show only
             that its objectives were legitimate, at the low end of the
             continuum, or, at the high end of the scale, that the legislation
             was motivated by a compelling state interest.
             Third, an evaluation of the state’s interest in the particular
             means employed to further its goals must be undertaken.
             Once again, the state’s burden will differ in accordance with
             the determination of the level of scrutiny under the first stage
             of analysis. At the low end of the sliding scale, we have held
             that a substantial relationship between means and ends is
             constitutionally adequate. At the higher end of the scale, the

      101
              28 P.3d at 913. In that decision, we also compared the State’s treatment of
women seeking abortions with its treatment of other Medicaid patients in general. Id.
at 908 (“The State, having established a health care program for the poor, may not
selectively deny necessary care to eligible women merely because the threat to their
health arises from pregnancy.”). But the more relevant comparison for the purposes of
our equal protection analysis in this case is the State’s different treatment of women
depending on their decision whether to carry their pregnancy to term. This is because,
as we explain below, the State’s different treatment of these two groups has a material
impact on the exercise of their fundamental right of reproductive choice.

                                           -31-                                    7334

              fit between means and ends must be much closer. If the
              purpose can be accomplished by a less restrictive alternative,
              the classification will be invalidated.[102]
                     a.     The constitutional interest at stake
              In the first step of our analysis, we “evaluat[e] the importance of the
personal right infringed upon to determine the State’s burden in justifying its
differential” treatment.103 A statute or regulation that burdens the exercise of a
constitutional right “is subject to the most searching judicial scrutiny,”104 and “it has long
been established that a law burdening the fundamental right of reproductive choice
demands strict scrutiny.”105 The challenged legislation need not expressly forbid the
exercise of the right; we also apply strict scrutiny “where the government, by selectively
denying a benefit to those who exercise a constitutional right, effectively deters the
exercise of that right.”106 Such scrutiny is particularly called for where, as in this
instance, the rejection of one option inevitably requires the other.


       102
             Planned Parenthood 2016, 375 P.3d at 1137 (alteration in original)
(quoting Alaska Pac. Assurance Co. v. Brown, 687 P.2d 264, 269-70 (Alaska 1984)).
       103
              Id.
       104
               See Planned Parenthood 2001, 28 P.3d at 909 (“The regulation at issue in
this case affects the exercise of a constitutional right, the right to reproductive freedom.
Therefore, the regulation is subject to the most searching judicial scrutiny, often called
‘strict scrutiny.’ ”) (footnote omitted).
       105
              Planned Parenthood 2016, 375 P.3d at 1137-38 (citing Planned
Parenthood 2001, 28 P.3d at 909). The State argues that our holding in Planned
Parenthood 2001 that “a law burdening the fundamental right of reproductive choice
demands strict scrutiny” was dicta. But our strict scrutiny analysis in Planned
Parenthood 2001 was the primary reasoning for our decision, and we have treated it as
authoritative. See id. (citing Planned Parenthood 2001, 28 P.3d at 909).
       106
              Planned Parenthood 2001, 28 P.3d at 909.

                                            -32-                                        7334

              Planned Parenthood argues that strict scrutiny applies because, by creating
a unique, more onerous, and abortion-specific definition of medical necessity that departs
from the physician-discretion standard applied to other Medicaid services, the State
“selectively den[ies] a benefit to those who exercise a constitutional right.”107 The State
argues that the measures do not selectively deny a benefit because the State will provide
payment for abortion “so long as [the procedure] meets the across-the-board requirement
for all Medicaid services — that the service is needed to protect the patient’s health.”108
              “[W]e look to the real-world effects of government action to determine the
appropriate level of equal protection scrutiny.”109        Strict scrutiny applies to the
challenged measures because they discriminate between classes of pregnant women
based on their “choice whether or when to bear children” in a manner that deters the free
exercise of that choice.110 The State argues that Medicaid funding for many types of
medical services is similarly restricted, so AS 47.07.068 does not uniquely burden
women’s exercise of the choice to seek an abortion. But the State’s funding of
healthcare services unrelated to natal and prenatal care does not dictate our analysis here,

       107
              See id.
       108
              We held in Planned Parenthood 2001 that the government “is
constitutionally bound to apply neutral criteria in allocating health care benefits” and
referred to existing restrictions related to “medical necessity, cost and feasibility” as
examples of “politically neutral criteria.” Id. at 910. But the State’s argument assumes
that medical necessity is inherently a neutral criterion. Our holding was that neutral
criteria must underlie the State’s funding restrictions, not that any definition of medical
necessity is per se neutral. See id. If that were so, the legislature could have overruled
Planned Parenthood 2001 simply by reenacting the invalidated regulation in the form
of a definition of medical necessity.
       109
              Id.
       110
            See Valley Hosp. Ass’n. v. Mat-Su Coal. for Choice, 948 P.2d 963, 968
(Alaska 1997).

                                           -33-                                       7334

because the State’s subsidy of other forms of treatment does not influence the exercise
of a pregnant woman’s fundamental right to choose whether to keep or terminate her
pregnancy.111
              Dissenting in the 1980 United States Supreme Court case Harris v. McRae,
Justice Brennan explained how disparate government subsidies for medical expenses
associated with childbirth and abortion affect fundamental rights:
              A poor woman in the early stages of pregnancy confronts two
              alternatives: she may elect either to carry the fetus to term or
              to have an abortion. In the abstract, of course, this choice is
              hers alone, and the Court rightly observes that the Hyde
              Amendment “places no governmental obstacle in the path of
              a woman who chooses to terminate her pregnancy.” But the
              reality of the situation is that the Hyde Amendment has
              effectively removed this choice from the indigent woman’s
              hands. By funding all of the expenses associated with
              childbirth and none of the expenses incurred in terminating




       111
               The challenged statute and regulation are uniquely severe in comparison
to these other Medicaid restrictions. Perhaps the only other Medicaid service similarly
restricted is waiver services for “children with complex medical conditions,” who must
have “a severe, chronic physical condition that results in a prolonged dependency on
medical care or technology to maintain health and well-being” and who must
“experience[] periods of acute exacerbation or life-threatening conditions” requiring
either “frequent or life-saving administration of specialized treatment or . . . mechanical
support devices.” 7 AAC 130.205(d)(1)(C)-(D), (F) (am. 7/1/2013). Less severe
restrictions apply to certain other services. For example, hysterectomies must be
“performed for medical reasons” and not purely for sterilization. 7 AAC 110.420(a)(2),
(b) (eff. 2/1/2010). And payment for cosmetic surgery is prohibited unless “required”
for “repair of an injury,” “improvement of the functioning of a malformed body
member,” or “correction of a visible disfigurement that would materially affect the
recipient’s acceptance in society.” 7 AAC 105.110(4)(A)-(C) (am. 7/1/2013). But most
Medicaid services are not restricted in this way, and DHSS noted that its fiscal agent
“generally presumes that a physician provided a medically necessary service.”

                                           -34-                                      7334

              pregnancy, the Government literally makes an offer that the
              indigent woman cannot afford to refuse.[112]
In Planned Parenthood 2001113 we expressed our own disagreement with the Court’s
decision in Harris, and Justice Brennan’s logic implicitly underlay our decision: the
State burdens the exercise of a fundamental right for indigent people when it only
subsidizes the inevitable alternative.114
              Virtually all medical services for indigent Alaskan women who choose to
give birth fall under Medicaid’s omnibus definition of “medically necessary” as
something determined “by the standards of practice applicable to the provider.”115
Expectant mothers generally receive state funding automatically when a doctor submits
the bill. Yet an indigent woman seeking state funding for an abortion under the new
measures cannot obtain coverage unless a doctor certifies that her “abortion must be
performed to avoid a threat of serious risk to [her] life or physical health.”116 This
difference results in the coercive effect that troubled Justice Brennan: an indigent
woman whose condition falls outside the new, abortion-specific definition of medical
necessity will discover that she alone must pay for the medical costs associated with


       112
            448 U.S. 297, 333-34 (1980) (Brennan, J., dissenting) (citation omitted)
(quoting Harris, 448 U.S. at 315).
       113
              28 P.3d at 911 n.52.
       114
              Several other state courts striking down Medicaid abortion funding
restrictions on equal protection grounds have relied on similar logic as that expressed in
Justice Brennan’s dissent. See, e.g., Comm. to Defend Reprod. Rights v. Myers, 625 P.2d
779, 793 (Cal. 1981); Moe v. Sec’y of Admin. & Fin., 417 N.E.2d 387, 402 (Mass. 1981);
Women of State of Minn. by Doe v. Gomez, 542 N.W.2d 17, 29 (Minn. 1995).
       115
              See 7 AAC 105.100(5).
       116
              AS 47.07.068(b)(3).

                                            -35-                                    7334

abortion — but if she chooses childbirth, the government will pay any bill that her doctor
submits.117 Thus “the government, by selectively denying a benefit to those who exercise
a constitutional right, effectively deters the exercise of that right.”118
              The State warns that application of strict scrutiny to the measures here
could endanger all Medicaid funding by subjecting all of the State’s limits on Medicaid
coverage to strict scrutiny based on the fundamental right “to make decisions about
medical treatments for oneself or one’s children.”119 We do not believe that it will have
such a sweeping impact.
              Disparate restrictions on government funding for women based on their
choice of either abortion or childbirth deter the exercise of a fundamental right because
pregnant women in that position are locked in a binary dilemma: the rejection of one
option inevitably entails the embrace of the other. Few other Medicaid treatments
present this dilemma. For instance, Medicaid pays for tubal ligations and vasectomies
with no special restrictions but will not pay for infertility or impotence services.120 The
government in that situation arguably funds one exercise of a fundamental right and not
the other, but it does not create a deterrent or incentive effect. A woman denied funding
for fertility treatment is not compelled to obtain a tubal ligation. But biological reality
requires that a woman who cannot afford a medical abortion must carry her pregnancy
to term. A woman who cannot afford to obtain a medical abortion is also legally
prevented from obtaining an abortion otherwise. Alaska law requires abortions to be



       117
              See Harris, 448 U.S. at 333-34 (Brennan, J., dissenting).
       118
              Planned Parenthood 2001, 28 P.3d at 909.
       119
              Huffman v. State, 204 P.3d 339, 346 (Alaska 2009).
       120
              7 AAC 105.110(10), (11).

                                            -36-                                     7334

performed by a licensed physician.121
              Because we are unpersuaded that applying strict scrutiny to the statute and
regulation before us would endanger all Medicaid funding, and because the constitutional
issue at stake is fundamental, we apply strict scrutiny to both of the challenged measures.
                     b.     The State’s interest
              The State must show that the measures serve a compelling state interest in
order for the statute and regulation to withstand strict scrutiny.122 The State asserts an
interest in limiting the provision of medical care to that which is “medically necessary,”
thereby ensuring the financial viability of the Medicaid program as a whole. It argues
that “the feasibility of a program like Medicaid depends on the ability to set limits. The
State could not afford, nor would the public tolerate, a Medicaid program that paid for
any medical service or treatment a Medicaid beneficiary wants.” Legislators’ concern
for Medicaid’s fiscal viability is generally supported by the record. The Senate sponsor’s
staff member stated that one impetus behind the bill was the Senator’s “reasonable
belief” that Medicaid has been paying for non-medically necessary abortions,123 and the
bill’s House sponsor characterized the bill as a “fiscal bill.”124
              But the legislative record contains no evidence that Medicaid had actually
funded non-medically necessary abortions. The Senate sponsor later acknowledged that


       121
              AS 18.16.010(a)(1).
       122
           See Planned Parenthood 2016, 375 P.3d 1122, 1138 (Alaska 2016);
Planned Parenthood 2001, 28 P.3d at 909.
       123
             Statement of Chad Hutchinson, Staff Member to Sen. John Coghill at
1:38:27-1:38:38, Hearing on S.B. 49 Before the House Jud. Comm., 28th Leg., 1st Sess.
(Mar. 29, 2013).
       124
            Rep. Gabrielle LeDoux at 1:12:46-1:12:55, Hearing on H.B. 173 Before the
House Jud. Comm., 28th Leg., 1st Sess. (Mar. 29, 2013).

                                            -37-                                     7334

the legislature had not determined whether the bill would save the State any money.125
And DHSS’s fiscal note regarding the proposed legislation stated that the Department
was unable to determine the bill’s impact on expenditure due to a lack of data.126 This
lack of evidence about the bill’s fiscal impact casts doubt on legislators’ statements that
it was intended to resolve a fiscal problem. If the State is arguing that it has a compelling
interest in saving money, we have rejected cost savings alone as a legitimate state interest
to discriminate.127 We assume without deciding that the State may have a compelling
interest in ensuring the financial viability of Medicaid,128 but even assuming so does not
change the outcome in this case.
                     c.     The means employed to accomplish the State’s interest
              Under strict scrutiny we examine whether the means-to-end fit between the


       125
            Sen. John Coghill at 9:15:39-9:15:47, Hearing on S.B. 49 Before the Sen.
Fin. Comm., 28th Leg., 1st Sess. (Apr.1, 2013).
       126
             House Fin. Comm., DHSS Fiscal Note of S.B. 49, 28th Leg., 1st Sess.
(Feb. 28, 2014).
       127
               See State v. Schmidt, 323 P.3d 647, 663 (Alaska 2014) (explaining that,
even under minimum scrutiny, the State’s legitimate interest in cost savings was not
sufficiently related to discriminatory classification because “ ‘cost savings alone are not
sufficient government objectives under our equal protection analysis.’ The government
can adequately . . . minimize cost without discriminating between similarly situated
classes.” (quoting Herrick’s Aero-Auto-Aqua Repair Serv. v. State, Dep’t of Transp. &
Pub. Facilities, 754 P.2d 1111, 1114 (Alaska 1988))).
       128
              See AS 47.07.010 (“It is equally a matter of public concern that providers
of [Medicaid] services . . . should operate honestly, responsibly, and in accordance with
applicable laws and regulations in order to maintain the integrity and fiscal viability of
the state’s medical assistance program.”); U.S. v. Lee, 455 U.S. 252, 258-59 (1982)
(holding that the federal government’s “interest in assuring mandatory and continuous
participation in and contribution to the social security system is very high” because such
participation “is indispensable to the fiscal vitality of the social security system”).

                                            -38-                                       7334

State’s purpose and the challenged measures is sufficiently close.129 Our equal protection
analysis does not ask what interests might justify restricting funding for abortion
specifically, but what interests would justify treating abortion differently from childbirth
and other pregnancy care — the statute and regulation should be neither under-inclusive
nor over-inclusive.130 The State bears the burden of proving “that the means it has
chosen to advance [its] goals are well-fitted to the ends.”131
              We have recognized that the State may limit Medicaid expenditures by
employing neutral criteria such as medical necessity to prioritize funds.132 But the State’s
argument about the fiscal implications of AS 47.07.068 and 7 AAC 160.900(d)(30) is
unconvincing. An abortion costs the State significantly less than a hospital delivery.
Evidence at trial established that abortions range in cost from $650-$750 during the first
trimester to $900-$1,000 during the second trimester. In contrast the superior court
found that “[a] typical hospital delivery costs Medicaid approximately $12,000.”133 If
the abortion funding restrictions divert a significant number of Medicaid-eligible women
toward childbirth and its additional expenses, as the State conceded similar restrictions

       129
              See Alaska Pac. Assurance Co., 687 P.2d at 270.
       130
              See Planned Parenthood 2016, 375 P.3d at 1139 (“If the means-to-end fit
between the State’s purpose and the Notification Law is not close enough — if the
Notification Law is under-inclusive or over-inclusive — then it will not survive strict
scrutiny.” (citing State v. Ostrosky, 667 P.2d 1184, 1193 (Alaska 1983))).
       131
              Planned Parenthood 2001, 28 P.3d 904, 909 (Alaska 2001).
       132
               See Planned Parenthood 2001, 28 P.3d at 910 (noting that the State may
use criteria such as “expense, medical feasibility, or the necessity of particular services”
in allocating healthcare benefits); Alaska Pac. Assurance Co., 687 P.2d at 272.
       133
             Even accounting for the 50% matching subsidy that the federal government
provides for most Medicaid procedures other than abortion, pregnancy and delivery care
remains significantly more expensive to the State on average.

                                           -39-                                       7334

would in Planned Parenthood 2001,134 then, as Planned Parenthood argues, the funding
restrictions will “undermine, rather than further, the State’s interest in reducing costs.”
              Even if measures are not financially counterproductive in practice, they are
an under-inclusive means of accomplishing the State’s objectives. The State claims there
is no need to put similar restrictions on medical services offered to pregnant women
carrying to term because such services “almost always serve to protect the health of the
woman or fetus.” But the State offers no support for this claim, and evidence in the
record supports the opposite conclusion. A State expert testified that there are a number
of elective pregnancy-related treatments such as scheduled Caesarean sections and
inductions of labor “that mothers might request that . . . may not be in their best interests
medically in the long run.” And a Planned Parenthood expert witness testified that the
American College of Obstetrics and Gynecology has recently been scrutinizing elective,
or “non-medically indicated,” Caesarean sections and inductions of labor. Yet both of
these “non-medically indicated” procedures, which do not necessarily serve to protect
the health of the mother, are funded by Medicaid, and neither one requires special
certification of medical necessity. The measures are thus under-inclusive; the statute and
regulation single out only one among multiple purportedly “elective” procedures
available to pregnant women for restrictive funding requirements.
              We conclude that the statute and regulation are not narrowly tailored to
meet the ends of preserving Medicaid funds, and the State has not shown that the
differences between the affected classes justify the discriminatory treatment imposed by
AS 47.07.068 and 7 AAC 160.900(d)(30).




       134
              See 28 P.3d at 911.

                                            -40-                                       7334
V.   CONCLUSION
        The judgment of the superior court is AFFIRMED.




                                 -41-                     7334

STOWERS, Chief Justice, dissenting.
              The doctrine of constitutional avoidance “is a tool for
              choosing between competing plausible interpretations of a
              statutory text.” Under this tool, “as between two possible
              interpretations of a statute, by one of which it would be
              unconstitutional and by the other valid, [our] plain duty is
              to adopt that which will save the Act.”[1]
              In State, Department of Health & Social Services v. Planned Parenthood
of Alaska, Inc. (Planned Parenthood 2001), this court ruled that the State must provide
Medicaid funding for medically necessary abortions.2 The court did not define the term
“medically necessary.”3
              Planned Parenthood 2001 addressed a challenge to a state regulation that
limited Medicaid funding for abortions. The regulation mirrored federal criteria for
funding of abortions — the so-called “Hyde Amendment” — which provides that federal
funds may not be used to pay for an abortion unless the pregnancy threatens the woman’s
life or is the result of rape or incest.4 The superior court held that the State’s regulation
violated the Alaska Constitution’s right to privacy.5 On appeal, this court affirmed on a
different basis, ruling that the regulation violated the Alaska Constitution’s equal
protection clause because it denied funding for medically necessary care for low-income




       1
                     Estate of Kim ex rel. Alexander v. Coxe, 295 P.3d 380, 388 (Alaska
2013) (emphasis added) (first quoting Clark v. Martinez, 543 U.S. 371, 381-82 (2005);
then quoting Rust v. Sullivan, 500 U.S. 173, 190 (1991)).
       2
                     28 P.3d 904 (Alaska 2001).
       3
                     Id.
       4
                     Id. at 907 n.8.
       5
                     Id. at 907.

                                            -42-                                       7334

Alaskans.6 But the court limited its holding to the requirement that the State fund
medically necessary abortions, stating that the case did “not concern State payment for
elective abortions.”7
             After this court’s decision, the State adopted the definition for “medically
necessary” abortions that the superior court had incorporated into its injunction. The
superior court defined “medically necessary” abortions as “those abortions certified by
a physician as necessary to prevent the death or disability of the woman, or to ameliorate
a condition harmful to the woman’s physical or psychological health.” This was to be
“determined by the treating physician performing the abortion services in his or her
professional judgment.”
             Eventually state officials attempted to create a standard that would
effectively distinguish between elective and medically necessary abortions.8 In 2013 the
Department of Health and Social Services (DHSS) adopted a regulation defining when
an abortion is “medically necessary” for purposes of Medicaid coverage.9 Planned
Parenthood brought suit, arguing that the regulation violated Alaska’s equal protection
guarantee by singling out abortion among Medicaid-funded services under a restrictive
definition of medical necessity. The superior court agreed with Planned Parenthood and
granted a preliminary injunction against the regulation.




      6
                    Id. at 913.
      7
                    Id. at 905.
      8
                   Minutes, Sen. Fin. Comm. Hearing on S.B. 49, 28th Leg., 1st Sess.
(March 29, 2013), http://www.akleg.gov/pdf/28/M/SFIN2013-03-290908.PDF.
      9
                    7 Alaska Administrative Code (AAC) 160.900(d)(30)(2015).

                                          -43-                                      7334

              In 2014 the Alaska Legislature passed a law creating a slightly different
definition of medical necessity.10 The resulting statute, AS 47.07.068, provides that
Medicaid will not pay for abortion services unless they are for a medically necessary
abortion or the pregnancy is the result of rape or incest.11 The statute defines when an
abortion is medically necessary:
              “medically necessary abortion” means that, in a physician’s
              objective and reasonable professional judgment after
              considering medically relevant factors, an abortion must be
              performed to avoid a threat of serious risk to the life or
              physical health of a woman from continuation of the woman’s
              pregnancy.[12]
The statute further defines “serious risk to the life or physical health” to include, but not
be limited to, “a serious risk to the pregnant woman of (A) death; or (B) impairment of
a major bodily function because of” any one of 21 enumerated medical conditions, with
a catch-all provision:
              another physical disorder, physical injury, or physical illness,
              including a life-endangering physical condition caused by or
              arising from the pregnancy that places the woman in danger
              of death or major bodily impairment if an abortion is not
              performed.[13]
              Planned Parenthood amended its complaint to include the statute, and the
superior court extended its preliminary injunction to enjoin the statute. After trial the



       10
                      Act of July 16, 2014, ch. 8, § 2, 2014 Alaska Sess. Laws 1 (codified
at AS § 47.07.068).
       11
                     AS 47.07.068(a). The provision for pregnancies resulting from rape
or incest mirrors the federal Hyde Amendment. See 42 U.S.C. § 1397ee(c)(1) (2012).
       12
                      AS 47.07.068(b).
       13
                      AS 47.07.068(b)(4).

                                            -44-                                       7334

superior court struck down both AS 47.07.068 and 7 AAC 160.900(d)(30) on equal
protection grounds, finding that the enactments impermissibly discriminated against
indigent women seeking abortions. The court found that the legislature intended
AS 47.07.068 to delineate “a high-risk, high-hazard standard that would preclude funding
for most Medicaid abortions.” The court concluded that the statute’s definition of
“medically necessary” covered “only abortions required to avoid health detriments
attributable to the enumerated conditions, either fully realizable or demonstrably
imminent.” The court determined that the statute and regulation, so construed, violated
Alaska’s equal protection clause, and the court permanently enjoined their enforcement.
              The State appeals, arguing that the statute and regulation can — and
should — be interpreted to avoid finding them unconstitutional. The State argues, among
other things, that the statute is entitled to a presumption of constitutionality: a “well­
established rule of statutory construction” requires courts “if possible [to] construe
statutes so as to avoid the danger of unconstitutionality.”14 It argues “[n]ot only are
statutes presumed constitutional, but any doubts are resolved in favor of
constitutionality.”15 This rule, the State asserts, “is based on the recognition ‘that the
legislature, like the courts, is pledged to support the state and federal constitutions and
that the courts therefore, should presume that the legislature sought to act within
constitutional limits,’ ”16 and “also recognizes that ‘[d]ue respect for the legislative branch
of government requires that [the court] exercise [its] duty to declare a statute



       14
                     State, Dep’t of Revenue v. Andrade, 23 P.3d 58, 71 (Alaska 2001).
       15
                     See Alaskans for a Common Language, Inc. v. Kritz, 170 P.3d 183,
192 (Alaska 2007).
       16
                    See State v. Rice, 626 P.2d 104, 108 (Alaska 1981) (citing Kimoktoak
v. State, 584 P.2d 25, 31 (Alaska 1978)).

                                             -45-                                        7334

unconstitutional only when squarely faced with the need to do so.’ ”17
              This court affirms the superior court’s decision, holding that the language
of the enactments “compels a ‘high-risk, high-hazard’ interpretation akin to that adopted
by the superior court . . . [that] imposes different requirements for Medicaid funding
eligibility upon women who choose to have abortions than it does upon women who
choose to carry their pregnancies to term.”18
              I disagree with the court’s interpretative choice. The language of the statute
and regulation does not “compel” anything: the language is what it is. It is the court that
chooses to construe the language in a manner that leads to the conclusion that the
enactments are unconstitutional. Where the court goes astray, in my opinion, is its failure
to give anything other than lip-service to a well-recognized canon of statutory
interpretation: the doctrine of constitutional avoidance. In Estate of Kim ex rel.
Alexander v. Coxe, we explained that
              [t]he doctrine of constitutional avoidance “is a tool for
              choosing between competing plausible interpretations of a
              statutory text.” Under this tool, “as between two possible
              interpretations of a statute, by one of which it would be
              unconstitutional and by the other valid, [our] plain duty is to
              adopt that which will save the Act.”[19]
              The court’s opinion expressly acknowledges that if an ambiguous statute or
regulation “is susceptible to more than one reasonable interpretation, of which only one
is constitutional, the doctrine of constitutional avoidance directs us to adopt the


       17
                     See State v. ACLU of Alaska, 204 P.3d 364, 373 (Alaska 2009).
       18
                     Op. at 2-3 (emphasis added).
       19
                    295 P.3d 380, 388 (Alaska 2013) (footnotes omitted) (first quoting
Clark v. Martinez, 543 U.S. 371, 381-82 (2005); then quoting Rust v. Sullivan, 500 U.S.
173, 190 (1991)).

                                           -46-                                       7334

interpretation that saves the statute” or regulation.20 But the court fails to make any real
effort to construe the challenged provisions to avoid finding the statute and regulation
unconstitutional. To the contrary, in reading the main opinion it becomes evident the
court goes to great lengths in construing the statute and regulation to ensure that the
conclusion of unconstitutionality is inevitable.
              The State offers an alternative interpretation that would “save” the
enactments. Under AS 47.07.068, the State will fund an abortion when a physician
determines that a woman’s condition indicates that continuing her pregnancy could put
her at serious risk of physical impairment. The State argues AS 47.07.068 employs a
broad and inclusive definition of when an abortion is medically necessary for purposes
of Medicaid coverage. The court acknowledges the State’s arguments in support of
“saving” the statute. For example, the court explains:
              The statute’s list of conditions in subsection (b)(4) includes a
              final catch-all provision that reads, “another physical disorder,
              physical injury, or physical illness, including a life-
              endangering physical condition caused by or arising from the
              pregnancy that places the woman in danger of death or major
              bodily impairment if an abortion is not performed.” The State
              argues that this catch-all provision broadens the permissive
              scope of the statute. Because the phrase “another physical
              disorder, physical injury, or physical illness” contains no
              severity requirement, this portion of the provision could, by
              itself, be interpreted to broaden the scope of the covered
              conditions. Indeed, a State medical expert testified that he
              saw this provision as “a barn door” that provides “a large
              opening” for doctors to receive payment for abortions.[21]
              I would accept the State’s argument and, applying the doctrine of


       20
                  Op. at 11 and n.40 (quoting Estate of Kim, 295 P.3d at 388). The
court acknowledges that “the statute’s text is ambiguous.” Op. at 14.
       21
                     Op. at 11-12 (emphasis added) (footnotes omitted).

                                            -47-                                      7334

constitutional avoidance, construe the statute just so, interpreting the statute, and
particularly its catch-all provision, to broaden the scope of covered conditions and thereby
avoid the constitutional impediment.22
              The challenged regulation, 7 AAC 160.900(d)(30), is virtually identical to
AS 47.07.068, except in its broader provision for mental health conditions.            The
regulation authorizes Medicaid coverage to “avoid a threat of serious risk to the physical
health of the woman” due to “a psychiatric disorder that places the woman in imminent
danger of medical impairment of a major bodily function if an abortion is not performed.”
The regulation thus covers not only psychiatric disorders that threaten a woman’s life,
like depression with suicidal ideation, but also psychiatric disorders that threaten the
woman’s physical health, such as anorexia or self-neglect caused by depression or other
mental illnesses, if the physician believes an abortion is needed to avoid these harms.23

       22
                This is what the sponsor of the bill intended. I give one example. The court
states that “[t]he statute also does not cover abortions when the fetus suffers from a fatal
anomaly . . . . The text does not leave room to consider an abortion medically necessary
based on the suffering of the fetus. The bill’s sponsor indicated that he believed fatal
fetal abnormalities would be covered under the bill’s catch-all provision.” Op. at 25
(citing letter from Senator John Coghill to Senate Finance Committee Members (Apr. 1,
2013), http://www.akleg.gov/basis/Bill/Detail/28?Root=SB%20%2049#tab5_4). “But,”
the court continues, “this statement, unsupported by other evidence from the legislative
history, is not sufficient to overcome the plain meaning of the statute.” Op. at 25. Under
the doctrine of constitutional avoidance and as a matter of respect for the legislature, I
would accept this clear and significant item of legislative history — it is the statement
of intent and understanding by the bill’s sponsor, after all — as a sufficient basis to
broadly interpret the catch-all provision as the bill’s sponsor understood and intended it.
       23
                     Medicaid generally does not cover treatment sought solely to
alleviate distress caused by life’s circumstances, short of actual diagnosed mental
disorders. Medicaid is limited to providing care that protects basic health and does not
provide all care that would optimize physical or mental well-being. See 7 AAC
105.110(1) (services not eligible for Medicaid coverage if “not reasonably necessary for
                                                                           (continued...)

                                           -48-                                       7334

              To conclude, I believe that AS 47.07.068 and AAC 160.990(d)(30) can and
should be interpreted broadly as the State argues to obviate the constitutional infirmities
that this court’s rigid construction finds. I believe that the legislature can constitutionally
determine as a matter of state policy what is “medically necessary” for purposes of
expenditure of limited state dollars to fund Medicaid abortions. I believe the court today
fails to give respect to the legislature’s proper role but instead substitutes its judgment for
that of the legislature. Finally, nothing in Alaska’s equal protection clause requires the
State to subsidize non-medically-necessary abortions for Medicaid-eligible women
simply because it provides them with medically necessary healthcare. I respectfully
dissent.




       23
              (...continued)
the diagnosis and treatment of an illness or injury, or for the correction of an organic
system”). A mental health condition is grounds for coverage only if it poses a risk to the
woman’s life or physical health. The evidence at trial showed that no published studies
indicate that abortion is effective as treatment for mental disorders triggered or
exacerbated by pregnancy, nor that it is endorsed as such by professional medical
societies. Planned Parenthood’s own witnesses appear to agree. Dr. Bibeault, a perinatal
psychiatrist, was not aware of any studies that identify abortion as a treatment for
perinatal mental illness. Dr. Meltzer-Brody, also a perinatal psychiatrist, was not aware
of any such studies either, nor had she discussed abortion as a treatment in her own
published work on perinatal depression. Dr. Meltzer-Brody also conceded that the
medical profession does not view abortion as an approach to treating mental disorders:
“I don’t think abortion is ever discussed as a treatment in the same way we consider
medication treatment or psychotherapies . . . . I think that’s because the medical
profession sees ending a pregnancy as a very serious decision, but I don’t think it’s
bandied about as considered treatment.”


                                             -49-                                        7334

