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This is an appeal from a decision of the Arizona Supreme Court upholding the constitutionality of an Arizona statute requiring a year's residence in a county as a condition to an indigent's receiving nonemergency hospitalization or medical care at the county's expense. Held: The durational residence requirement, in violation of Equal Protection Clause, creates an "invidious classification" that impinges on the right of interstate travel by denying newcomers "basic necessities of life." Shapiro v. Thompson, 394 U.S. 618 . Pp. 253-270.
MARSHALL, J., delivered the opinion of the Court, in which BRENNAN, STEWART, WHITE, and POWELL, JJ., joined. BURGER, C. J., and BLACKMUN, J., concurred in the result. DOUGLAS, J., filed a separate [415 U.S. 250, 251] opinion, post, p. 270. REHNQUIST, J., filed a dissenting opinion, post, p. 277.
Mary M. Schroeder argued the cause for appellants. With her on the brief was John P. Frank.
William J. Carter III argued the cause and filed a brief for appellees. *
[ Footnote * ] Sandor O. Shuch and John J. Relihan filed a brief for the Legal Aid Society of Maricopa County as amicus curiae urging reversal.
MR. JUSTICE MARSHALL delivered the opinion of the Court.
This case presents an appeal from a decision of the Arizona Supreme Court upholding an Arizona statute requiring a year's residence in a county as a condition to receiving nonemergency hospitalization or medical care at the county's expense. The constitutional question presented is whether this durational residence requirement is repugnant to the Equal Protection Clause as applied by this Court in Shapiro v. Thompson, 394 U.S. 618 (1969).
Appellant Henry Evaro is an indigent suffering from a chronic asthmatic and bronchial illness. In early June 1971, Mr. Evaro moved from New Mexico to Phoenix in Maricopa County, Arizona. On July 8, 1971, Evaro had a severe respiratory attack and was sent by his attending physician to appellant Memorial Hospital, a nonprofit private community hospital. Pursuant to the Arizona statute governing medical care for indigents, Memorial notified the Maricopa County Board of Supervisors that it had in its charge an indigent who might qualify for county care and requested that Evaro be transferred to the County's public hospital facility. In accordance with the approved procedures, Memorial also [415 U.S. 250, 252] claimed reimbursement from the County in the amount of $1,202.60, for the care and services it had provided Evaro.
Under Arizona law, the individual county governments are charged with the mandatory duty of providing necessary hospital and medical care for their indigent sick. 1 But the statute requires an indigent to have been a resident of the County for the preceding 12 months in order to be eligible for free nonemergency medical care. 2 Maricopa County refused to admit Evaro to its public hospital or to reimburse Memorial solely because Evaro had not been a resident of the County for the preceding year. Appellees do not dispute that Evaro is an indigent or that he is a bona fide resident of Maricopa County. 3
This action was instituted to determine whether appellee Maricopa County was obligated to provide medical care for Evaro or was liable to Memorial for the costs it incurred because of the County's refusal to do so. This controversy necessarily requires an adjudication of the constitutionality of the Arizona durational [415 U.S. 250, 253] residence requirement for providing free medical care to indigents.
The trial court held the residence requirement unconstitutional as a violation of the Equal Protection Clause. In a prior three-judge federal court suit against Pinal County, Arizona, the District Court had also declared the residence requirement unconstitutional and had enjoined its future application in Pinal County. Valenciano v. Bateman, 323 F. Supp. 600 (Ariz. 1971). 4 Nonetheless, the Arizona Supreme Court upheld the challenged requirement. To resolve this conflict between a federal court and the highest court of the State, we noted probable jurisdiction, 410 U.S. 981 (1973), and we reverse the judgment of the Arizona Supreme Court.
In determining whether the challenged durational residence provision violates the Equal Protection Clause, we must first determine what burden of justification the classification created thereby must meet, by looking to the nature of the classification and the individual interests affected. 5 The Court considered similar durational [415 U.S. 250, 254] residence requirements for welfare assistance in Shapiro v. Thompson, 394 U.S. 618 (1969). The Court observed that those requirements created two classes of needy residents "indistinguishable from each other except that one is composed of residents who have resided a year or more, and the second of residents who have resided less than a year, in the jurisdiction. On the basis of this sole difference the first class [was] granted and second class [was] denied welfare aid upon which may depend the ability . . . to obtain the very means to subsist - food, shelter, and other necessities of life." Id., at 627. The Court found that because this classification impinged on the constitutionally guaranteed right of interstate travel, it was to be judged by the standard of whether it promoted a compelling state interest. 6 Finding such an interest wanting, the Court held the challenged residence requirements unconstitutional.
Appellees argue that the residence requirement before us is distinguishable from those in Shapiro, while appellants urge that Shapiro is controlling. We agree with appellants that Arizona's durational residence requirement for free medical care must be justified by a compelling state interest and that, such interests being lacking, the requirement is unconstitutional.
The right of interstate travel has repeatedly been recognized as a basic constitutional freedom. 7 Whatever [415 U.S. 250, 255] its ultimate scope, however, the right to travel was involved in only a limited sense in Shapiro. The Court was there concerned only with the right to migrate, "with intent to settle and abide" 8 or, as the Court put it, "to migrate, resettle, find a new job, and start a new life." Id., at 629. Even a bona fide residence requirement would burden the right to travel, if travel meant merely movement. But, in Shapiro, the Court explained that "[t]he residence requirement and the one-year waiting-period requirement are distinct and independent prerequisites" for assistance and only the latter was held to be unconstitutional. Id., at 636. Later, in invalidating a durational residence requirement for voter registration on the basis of Shapiro, we cautioned that our decision was not intended to "cast doubt on the validity of appropriately defined and uniformly applied bona fide residence requirements." Dunn v. Blumstein, 405 U.S. 330, 342 n. 13 (1972).
The appellees argue that the instant county residence requirement is distinguishable from the state residence requirements in Shapiro, in that the former penalizes, not interstate, but rather intrastate, travel. Even were we to draw a constitutional distinction between interstate and [415 U.S. 250, 256] intrastate travel, a question we do not now consider, such a distinction would not support the judgment of the Arizona court in the case before us. Appellant Evaro has been effectively penalized for his interstate migration, although this was accomplished under the guise of a county residence requirement. What would be unconstitutional if done directly by the State can no more readily be accomplished by a county at the State's direction. The Arizona Supreme Court could have construed the waiting-period requirements to apply to intrastate but not interstate migrants; 9 but it did not do so, and "it is not our function to construe a state statute contrary to the construction given it by the highest court of a State." O'Brien v. Skinner, 414 U.S. 524, 531 (1974).
Although any durational residence requirement impinges to some extent on the right to travel, the Court in Shapiro did not declare such a requirement to be per se unconstitutional. The Court's holding was conditioned, 394 U.S., at 638 n. 21, by the caveat that some "waiting-period or residence requirements . . . may not be penalties upon the exercise of the constitutional right of interstate travel." The amount of impact required to give [415 U.S. 250, 257] rise to the compelling-state-interest test was not made clear. 10 The Court spoke of the requisite impact in two ways. First, we considered whether the waiting period would deter migration:
The appellees here argue that the denial of nonemergency medical care, unlike the denial of welfare, is not apt to deter migration; but it is far from clear that the challenged statute is unlikely to have any deterrent effect. A person afflicted with a serious respiratory ailment, particularly an indigent whose efforts to provide a living for his family have been inhibited by his incapacitating illness, might well think of migrating to the clean dry air of Arizona, where relief from his disease could also bring relief from unemployment and poverty. But he may hesitate if he knows that he must make the move without the possibility of falling back on the State for medical care should his condition still plague him or grow more severe during his first year of residence.
It is true, as appellees argue, that there is no evidence in the record before us that anyone was actually deterred from traveling by the challenged restriction. But neither did the majority in Shapiro find any reason "to dispute the `evidence that few welfare recipients have in fact been [415 U.S. 250, 258] deterred [from moving] by residence requirements.' Indeed, none of the litigants had themselves been deterred." Dunn, 405 U.S., at 340 (citations omitted). An attempt to distinguish Shapiro by urging that a durational residence requirement for voter registration did not deter travel, was found to be a "fundamental misunderstanding of the law" in Dunn, supra, at 339-340: 11
Whatever the ultimate parameters of the Shapiro penalty analysis, 13 it is at least clear that medical care is as much "a basic necessity of life" to an indigent as welfare assistance. 14 And, governmental privileges or benefits necessary to basic sustenance have often been viewed as being of greater constitutional significance than less essential forms of governmental entitlements. See, e. g., Shapiro, supra; Goldberg v. Kelly, 397 U.S. 254, 264 (1970); Sniadach v. Family Finance Corp., 395 U.S. 337, 340 -342 (1969). It would be odd, indeed, to find that the State of Arizona was required to afford Evaro welfare assistance to keep him from the discomfort of inadequate housing or the pangs of hunger but could deny him the [415 U.S. 250, 260] medical care necessary to relieve him from the wheezing and gasping for breath that attend his illness. 15
Nor does the fact that the durational residence requirement is inapplicable to the provision of emergency medical care save the challenged provision from constitutional doubt. As the Arizona Supreme Court observed, appellant "Evaro was an indigent person who required continued medical care for the preservation of his health and well being . . .," even if he did not require immediate emergency care. 16 The State could not deny Evaro care [415 U.S. 250, 261] just because, although gasping for breath, he was not in immediate danger of stopping breathing altogether. To allow a serious illness to go untreated until it requires emergency hospitalization is to subject the sufferer to the danger of a substantial and irrevocable deterioration in his health. Cancer, heart disease, or respiratory illness, if untreated for a year, may become all but irreversible paths to pain, disability, and even loss of life. The denial of medical care is all the more cruel in this context, falling as it does on indigents who are often without the means to obtain alternative treatment. 17
Finally, appellees seek to distinguish Shapiro as involving a partially federally funded program. Maricopa County has received federal funding for its public hospital 18 but, more importantly, this Court has held that whether or not a welfare program is federally funded is irrelevant to the applicability of the Shapiro analysis. Pease v. Hansen, 404 U.S. 70 (1971); Graham v. Richardson, 403 U.S. 365 (1971).
Not unlike the admonition of the Bible that, "Ye shall have one manner of law, as well for the stranger, as for one of your own country," Leviticus 24:22 (King James Version), the right of interstate travel must be seen as insuring new residents the same right to vital government benefits and privileges in the States to which they migrate as are enjoyed by other residents. The State of Arizona's durational residence requirement for free medical care penalizes indigents for exercising their right to migrate [415 U.S. 250, 262] to and settle in that State. 19 Accordingly, the classification created by the residence requirement, "unless shown to be necessary to promote a compelling governmental interest, is unconstitutional." Shapiro, 394 U.S., at 634 . (Emphasis in original.)
We turn now to the question of whether the State has shown that its durational residence requirement is "legitimately defensible," 20 in that it furthers a compelling state interest. 21 A number of purposes are asserted to be served by the requirement and we must [415 U.S. 250, 263] determine whether these satisfy the appellees' heavy burden of justification, and insure that the State, in pursuing its asserted objectives, has chosen means that do not unnecessarily burden constitutionally protected interests. NAACP v. Button, 371 U.S. 415, 438 (1963).
The Arizona Supreme Court observed:
First, a State may not protect the public fisc by drawing an invidious distinction between classes of its citizens, Shapiro, supra, at 633, so appellees must do more than show that denying free medical care to new residents saves money. The conservation of the taxpayers' purse is simply not a sufficient state interest to sustain a durational residence requirement which, in effect, severely penalizes exercise of the right to freely migrate and settle in another State. See Rivera v. Dunn, 329 F. Supp. 554 (Conn. 1971), aff'd, 404 U.S. 1054 (1972).
Second, to the extent the purpose of the requirement is to inhibit the immigration of indigents generally, [415 U.S. 250, 264] that goal is constitutionally impermissible. 22 And, to the extent the purpose is to deter only those indigents who take up residence in the County solely to utilize its new and modern public medical facilities, the requirement at issue is clearly overinclusive. The challenged durational residence requirement treats every indigent, in his first year of residence, as if he came to the jurisdiction solely to obtain free medical care. Such a classification is no more defensible than the waiting period in Shapiro, supra, of which the Court said:
It is also useful to look at the other side of the coin - at who will bear the cost of indigents' illnesses if the County does not provide needed treatment. For those newly arrived residents who do receive at least hospital care, the cost is often borne by private nonprofit hospitals, like appellant Memorial - many of which are already in precarious financial straits. 23 When absorbed [415 U.S. 250, 265] by private hospitals, the costs of caring for indigents must be passed on to paying patients and "at a rather inconvenient time" - adding to the already astronomical costs of hospitalization which bear so heavily on the resources of most Americans. 24 The financial pressures under which private nonprofit hospitals operate have already led many of them to turn away patients who cannot pay or to severely limit the number of indigents they will admit. 25 And, for those indigents who receive no care, the cost is, of course, measured by their own suffering.
In addition, the County's claimed fiscal savings may well be illusory. The lack of timely medical care could cause a patient's condition to deteriorate to a point where more expensive emergency hospitalization (for which no durational residence requirement applies) is needed. And, the disability that may result from letting an untreated condition deteriorate may well result in the patient and his family becoming a burden on the State's welfare rolls for the duration of his emergency care, or permanently, if his capacity to work is impaired. 26 [415 U.S. 250, 266]
The appellees also argue that eliminating the durational residence requirement would dilute the quality of services provided to longtime residents by fostering an influx of newcomers and thus requiring the County's limited public health resources to serve an expanded pool of recipients. Appellees assert that the County should be able to protect its longtime residents because of their contributions to the community, particularly through the past payment of taxes. We rejected this "contributory" rationale both in Shapiro and in Vlandis v. Kline, 412 U.S. 441, 450 n. 6 (1973), by observing:
The appellees also argue that the challenged statute serves some administrative objectives. They claim that the one-year waiting period is a convenient rule of thumb to determine bona fide residence. Besides not being factually defensible, this test is certainly overbroad to accomplish its avowed purpose. A mere residence requirement would accomplish the objective of limiting the use of public medical facilities to bona fide residents of the County without sweeping within its prohibitions those bona fide residents who had moved into the State within the qualifying period. Less drastic means, which do not impinge on the right of interstate travel, are available and employed 27 to ascertain an individual's true intentions, without exacting a protracted waiting period which may have dire economic and health consequences for certain citizens. See Shelton v. Tucker, 364 U.S. 479, 488 (1960). The Arizona State welfare agency applies criteria other than the duration of residency to determine whether an applicant is a bona fide resident. 28 The Arizona Medical Assistance to the Aged law provides public medical care for certain senior citizens, conditioned only on residence. 29 Pinal County, Arizona, has operated its public hospital without benefit of the [415 U.S. 250, 268] durational residence requirement since the application of the challenged statute in that County was enjoined by a federal court in Valenciano v. Bateman, 323 F. Supp. 600 (Ariz. 1971). 30
The appellees allege that the waiting period is a useful tool for preventing fraud. Certainly, a State has a valid interest in preventing fraud by any applicant for medical care, whether a newcomer or oldtime resident, Shapiro, 394 U.S., at 637 , but the challenged provision is illsuited to that purpose. An indigent applicant, intent on committing fraud, could as easily swear to having been a resident of the county for the preceding year as to being one currently. And, there is no need for the State to rely on the durational requirement as a safeguard against fraud when other mechanisms to serve that purpose are available which would have a less drastic impact on constitutionally protected interests. NAACP v. Button, 371 U.S., at 438 . For example, state law makes it a crime to file an "untrue statement . . . for the purpose of obtaining hospitalization, medical care or outpatient relief" at county expense. Ariz. Rev. Stat. Ann. 11-297C (Supp. 1973-1974). See Dunn, 405 U.S., at 353 -354; U.S. Dept. of Agriculture v. Moreno, 413 U.S. 528, 534 (1973).
Finally, appellees assert that the waiting period is necessary for budget predictability, but what was said in Shapiro is equally applicable to the case before us:
The Arizona durational residence requirement for eligibility for nonemergency free medical care creates an "invidious classification" that impinges on the right of interstate travel by denying newcomers "basic necessities of life." Such a classification can only be sustained on a showing of a compelling state interest. Appellees have not met their heavy burden of justification, or demonstrated that the State, in pursuing legitimate objectives, has chosen means which do not unnecessarily impinge on constitutionally protected interests. Accordingly, the judgment of the Supreme Court of Arizona is reversed and [415 U.S. 250, 270] the case remanded for further action not inconsistent with this opinion.
[ Footnote 2 ] Section 11-297A (Supp. 1973-1974) provides in relevant part that:
[ Footnote 3 ] Thus, the question of the rights of transients to medical care is not presented by this case.
[ Footnote 4 ] Arizona's intermediate appellate court had also declared the durational residence requirement unconstitutional in Board of Supervisors, Pima County v. Robinson, 10 Ariz. App. 238, 457 P.2d 951 (1969), but its decision was vacated as moot by the Arizona Supreme Court. 105 Ariz. 280, 463 P.2d 536 (1970).
An Arizona one-year durational residence requirement for care at state mental health facilities was declared unconstitutional in Vaughan v. Bower, 313 F. Supp. 37 (Ariz.), aff'd, 400 U.S. 884 (1970). See n. 11, infra.
A Florida one-year durational residence requirement for medical care at public expense was found unconstitutional in Arnold v. Halifax Hospital Dist., 314 F. Supp. 277 (MD Fla. 1970), and Crapps v. Duval County Hospital Auth., 314 F. Supp. 181 (MD Fla. 1970).
[ Footnote 5 ] E. g., Weber v. Aetna Cas. & Surety Co., 406 U.S. 164, 173 (1972); Dunn v. Blumstein, 405 U.S. 330, 335 (1972).
[ Footnote 6 ] 394 U.S., at 634 . See also id., at 642-644 (STEWART, J., concurring).
[ Footnote 7 ] Dunn v. Blumstein, supra; Shapiro v. Thompson, 394 U.S. 618 (1969); see Wyman v. Lopez, 404 U.S. 1055 (1972); Oregon v. Mitchell, 400 U.S. 112, 237 (1970) (separate opinion of BRENNAN, WHITE, and MARSHALL, JJ.), 285-286 (STEWART, J., concurring and dissenting, with whom BURGER, C. J., and BLACKMUN, J., joined); Wyman v. Bowens, 397 U.S. 49 (1970); United States v. Guest, 383 U.S. 745, 757 -759 (1966); cf. Griffin v. Breckenridge, 403 U.S. 88, 105 -106 (1971); Demiragh v. DeVos, 476 F.2d 403 (CA2 1973). See generally Z. Chafee, Three Human Rights in the Constitution of 1787, pp. 171-181, 187 et seq. (1956).
[ Footnote 8 ] See King v. New Rochelle Municipal Housing Auth., 442 F.2d 646, 648 n. 5 (CA2 1971); Cole v. Housing Authority of the City of Newport, 435 F.2d 807, 811 (CA1 1970); Wellford v. Battaglia, 343 F. Supp. 143, 147 (Del. 1972); cf. Truax v. Raich, 239 U.S. 33, 39 (1915); Note, Shapiro v. Thompson: Travel, Welfare and the Constitution, 44 N. Y. U. L. Rev. 989, 1012 (1969).
[ Footnote 9 ] Appellees argue that the County should be able to apply a durational residence requirement to preserve the quality of services provided its longtime residents because of their ties to the community and the previous contributions they have made, particularly through past payment of taxes. It would seem inconsistent to argue that the residence requirement should be construed to bar longtime Arizona residents, even if unconstitutional as applied to persons migrating into Maricopa County from outside the State. Surely, longtime residents of neighboring counties have more ties with Maricopa County and equity in its public programs, as through past payment of state taxes, than do migrants from distant States. This "contributory" rationale is discussed, infra, at 266.
[ Footnote 10 ] For a discussion of the problems posed by this ambiguity, see Judge Coffin's perceptive opinion in Cole v. Housing Authority of the City of Newport, 435 F.2d 807 (CA1 1970).
[ Footnote 11 ] In Vaughan v. Bower, 313 F. Supp. 37 (Ariz.), aff'd, 400 U.S. 884 (1970), a federal court struck down an Arizona law permitting the director of a state mental hospital to return to the State of his prior residence, any indigent patient who had not been a resident of Arizona for the year preceding his civil commitment. It is doubtful that the challenged law could have had any deterrent effect on migration, since few people consider being committed to a mental hospital when they decide to take up residence in a new State See also Affeldt v. Whitcomb, 319 F. Supp. 69 (ND Ind. 1970). aff'd 405 U.S. 1034 (1972).
[ Footnote 12 ] See Vlandis v. Kline, 412 U.S. 441, 452 -453, n. 9 (1973).
[ Footnote 13 ] For example, the Shapiro Court cautioned that it meant to "imply no view of the validity of waiting-period or residence requirements determining eligibility [inter alia] to obtain a license to practice a profession, to hunt or fish, and so forth." 394 U.S., at 638 n. 21.
[ Footnote 14 ] Dept. of Health, Education, and Welfare (HEW) Report on Medical Resources Available to Meet the Needs of Public Assistance Recipients, House Committee on Ways and Means, 86th Cong., 2d Sess., 74 (Comm. Print 1961). Similarly, President Nixon has observed: "`It is health which is real wealth,' said Ghandi, `and not pieces of gold and silver.'" Health, Message from the President, 92d Cong., 1st Sess., H. R. Doc. No. 92-49, p. 18 (1971). See also materials cited at n. 4, supra.
[ Footnote 15 ] Reference to the tuition cases is instructive. The lower courts have contrasted in-state tuition with "necessities of life" in a way that would clearly include medical care in the latter category. The District Court in Starns v. Malkerson, 326 F. Supp. 234, 238 (Minn. 1970), aff'd, 401 U.S. 985 (1971), quoted with approval from Kirk v. Board of Regents, 273 Cal. App. 2d 430, 440, 78 Cal. Rptr. 260, 266-267 (1969), appeal dismissed, 396 U.S. 554 (1970) (emphasis added):
[ Footnote 16 ] 108 Ariz. 373, 374, 498 P.2d 461, 462 (emphasis added).
[ Footnote 17 ] See Valenciano v. Bateman, 323 F. Supp. 600, 603 (Ariz. 1971). See generally HEW Report on Medical Resources, supra, n. 14, at 73-74; Dept. of HEW, Human Investment Programs: Delivery of Health Services for the Poor (1967).
[ Footnote 18 ] See HEW, Hill-Burton Project Register, July 1, 1947-June 30, 1967. HEW Publication No. (HSM) 72-4011, p. 37. Maricopa County has received over $2 million in Hill-Burton (42 U.S.C. 291 et seq.) funds since 1947.
[ Footnote 19 ] Medicaid, the primary federal program for providing medical care to indigents at public expense, does not permit participating States to apply a durational residence requirement as a condition to eligibility, 42 U.S.C. 1396a (b) (3), and "this conclusion of a coequal branch of Government is not without significance." Frontiero v. Richardson, 411 U.S. 677, 687 -688 (1973). The State of Arizona does not participate in the Medicaid program.
[ Footnote 20 ] Cf. Ely, Legislative and Administrative Motivation in Constitutional Law, 79 Yale L. J. 1205, 1223-1224 (1970); Note, Developments in the Law - Equal Protection, 82 Harv. L. Rev. 1065, 1076-1077 (1969).
[ Footnote 21 ] The Arizona Supreme Court observed that because this case involves a governmental benefit akin to welfare, the "reasonable basis" test of Dandridge v. Williams, 397 U.S. 471 (1970), should apply. In upholding a state regulation placing an absolute limit on the amount of welfare assistance to be paid a dependent family regardless of size or actual need, the Court in Dandridge found it "enough that the State's action be rationally based and free from invidious discrimination." Id., at 487. The Court later distinguished Dandridge in Graham v. Richardson, 403 U.S. 365, 376 (1971), where MR. JUSTICE BLACKMUN, writing for the Court, observed that "[a]ppellants' attempted reliance on Dandridge . . . is also misplaced, since the classification involved in that case [did not impinge] upon a fundamental constitutional right. . . ." Strict scrutiny is required here because the challenged classification impinges on the right of interstate travel. Compare Dandridge, supra, at 484 n. 16, with Shapiro v. Thompson, supra.
[ Footnote 22 ] Shapiro v. Thompson, 394 U.S., at 629 .
[ Footnote 23 ] See Cantor, The Law and Poor People's Access to Health Care, 35 Law & Contemp. Prob. 901, 909-914 (1970); cf. Catholic Medical Center v. Rockefeller, 305 F. Supp. 1256 and 1268 (EDNY 1969), vacated and remanded, 397 U.S. 820 , aff'd on remand, 430 F.2d 1297, appeal dismissed, 400 U.S. 931 (1970).
[ Footnote 24 ] HEW Report on Medical Resources, supra, n. 14, at 74. See generally Health, Message from the President, supra, n. 14; E. Kennedy, In Critical Condition: The Crises in America's Health Care (1973); Hearings on The Health Care Crisis in America before the Subcommittee on Health of the Senate Committee on Labor and Public Welfare, 92d Cong., 1st Sess. (1971).
[ Footnote 25 ] Cantor, supra, n. 23; See E. Kennedy, supra, n. 24, at 78-94; Note, Working Rules for Assuring Nondiscrimination in Hospital Administration, 74 Yale L. J. 151, 156 n. 32 (1964); cf., e. g., Stanturf v. Sipes, 447 S. W. 2d 558 (Mo. 1969) (hospital refused treatment to frostbite victim who was unable to pay $25 deposit). See generally HEW Report on Medical Resources, supra, n. 14, at 74; Hearings on The Health Care Crisis in America, supra, n. 24.
[ Footnote 26 ] "[L]ack of timely hospitalization and medical care for those unable to pay has been considered an economic liability to the patient, the hospital, and to the community in which these citizens [415 U.S. 250, 266] might otherwise be self-supporting . . . ." HEW Report on Medical Resources, supra, n. 14, at 73; Comment, Indigents, Hospital Admissions and Equal Protection, 5 U. Mich. J. L. Reform 502, 515-516 (1972); cf. Battistella & Southby, Crisis in American Medicine, The Lancet 581, 582 (Mar. 16, 1968).
[ Footnote 27 ] See Green v. Dept. of Public Welfare of Delaware, 270 F. Supp. 173, 177-178 (Del. 1967).
[ Footnote 28 ] Ariz. Rev. Stat. Ann. 46-292 (1) (Supp. 1973-1974).
[ Footnote 29 ] 46-261.02 (3) (Supp. 1973-1974).
[ Footnote 30 ] In addition, Pima County, Arizona, did not apply the durational residence requirement between August 1969, when the requirement was found unconstitutional by the Arizona Court of Appeals, Board of Supervisors, Pima County v. Robinson, 10 Ariz. App. 238, 457 P.2d 951, and September 1970, when that judgment was vacated as moot by the Arizona Supreme Court, 105 Ariz. 280, 463 P.2d 536.
The legal and economic aspects of medical care 1 are enormous; and I doubt if decisions under the Equal Protection Clause of the Fourteenth Amendment are equal to the task of dealing with these matters. So far as interstate travel per se is considered, I share the doubts of my Brother REHNQUIST. The present case, however, turns for me on a different axis. The problem has many aspects. The therapy of Arizona's atmosphere brings many there who suffer from asthma, bronchitis, arthritis, and tuberculosis. Many coming are indigent or become indigent after arrival. Arizona does not deny medical help to "emergency" cases "when immediate hospitalization or medical care is necessary for the preservation of life or limb," Ariz. Rev. Stat. Ann. 11-297A (Supp. 1973-1974). For others, it requires a 12-month durational residence.
The Act is not aimed at interstate travelers; it applies even to a long-term resident who moves from one county to another. As stated by the Supreme Court of Arizona in the present case: "The requirement applies to all citizens within the state including long term residents of one county who move to another county. Thus, the classification does not single out non-residents nor attempt to penalize interstate travel. The requirement is uniformly applied." 108 Ariz. 373, 375, 498 P.2d 461, 463. [415 U.S. 250, 271]
What Arizona has done, therefore, is to fence the poor out of the metropolitan countries, such as Maricopa County (Phoenix) and Pima County (Tucson) by use of a durational residence requirement. We are told that eight Arizona counties have no county hospitals and that most indigent care in those areas exists only on a contract basis. In San Antonio Independent School Dist. v. Rodriguez, 411 U.S. 1 , we had a case where Texas created a scheme by which school districts with a low property tax base, from which they could raise only meager funds, offered a lower quality of education to their students than the wealthier districts. That system was upheld against the charge that the state system violated the Equal Protection Clause. It was a closely divided Court and I was in dissent. I suppose that if a State can fence in the poor in educational programs, it can do so in medical programs. But to allow Arizona freedom to carry forward its medical program we must go one step beyond the San Antonio case. In the latter there was no legal barrier to movement into a better district. Here a one-year barrier to medical care, save for "emergency" care, is erected around the areas that have medical facilities for the poor.
Congress has struggled with the problem. In the Kerr-Mills Act of 1960, 74 Stat. 987, 42 U.S.C. 302 (b) (2), it added provisions to the Social Security Act requiring the Secretary of Health, Education, and Welfare to disapprove any state plan for medical assistance to the aged (Medicaid) that excludes "any individual who resides in the state," thus eliminating durational residence requirements.
Maricopa County has received over $2 million in federal funds for hospital construction under the Hill-Burton Act, 42 U.S.C. 291 et seq. Section 291c (e) authorizes the issuance of regulations governing the operation [415 U.S. 250, 272] of Hill-Burton facilities. The regulations contain conditions that the facility to be constructed or modernized with the funds "will be made available to all persons residing in the territorial area of the applicant" and that the applicant will render "a reasonable volume of services to persons unable to pay therefor." 2 The conditions of free services for indigents, however, may be waived if "not feasible from a financial viewpoint."
Prior to the application the state agency must obtain from the applicant an assurance "that there will be made available in the facility or portion thereof to be constructed or modernized a reasonable volume of services to persons unable to pay therefor. The requirement of an assurance from an applicant shall be waived if the applicant demonstrates to the satisfaction of the State agency, subject to subsequent approval by the Secretary, that such a requirement is not feasible from a financial viewpoint." 42 CFR 53.111 (c) (1). 3
So far as I can ascertain, the durational residence requirement imposed by Maricopa County has not been federally approved as a condition to the receipt of Hill-Burton funds.
Maricopa County does argue that it is not financially feasible to provide free nonemergency medical care to new residents. Even so, the federal regulatory framework does not leave the County uncontrolled in determining which indigents will receive the benefit of the resources which are available. It is clear, for example, that the County could not limit such service to whites out of [415 U.S. 250, 273] a professed inability to service indigents of all races because 42 CFR 53.112 (c) prohibits such discrimination in the operation of Hill-Burton facilities. It does not allow racial discrimination even against transients.
Moreover, Hill-Burton Act donees are guided by 42 CFR 53.111 (g), which sets out in some detail the criteria which must be used in identifying persons unable to pay for such services. The criteria include the patient's health and medical insurance coverage, personal and family income, financial obligations and resources, and "similar factors." Maricopa County, pursuant to the state law here challenged, employs length of county residence as an additional criterion in identifying indigent recipients of uncompensated nonemergency medical care. The federal regulations, however, do not seem to recognize that as an acceptable criterion.
And, as we held in Thorpe v. Housing Authority, 393 U.S. 268 ; Mourning v. Family Publications Service, 411 U.S. 356 , these federal conditions attached to federal grants are valid when "reasonably related to the purposes of the enabling legislation." 393 U.S., at 280 -281.
It is difficult to impute to Congress approval of the durational residence requirement, for the implications of such a decision would involve weighty equal protection considerations by which the Federal Government, Bolling v. Sharpe, 347 U.S. 497 , as well as the States, are bound.
The political processes 4 rather than equal protection litigation are the ultimate solution of the present problem. But in the setting of this case the invidious discrimination against the poor, Harper v. Virginia Board [415 U.S. 250, 274] of Elections, 383 U.S. 663 , not the right to travel inter-state, is in my view the critical issue.
These reforms did succeed in raising the quality of cooking. But a restaurant meal became substantially more expensive. A second commission observed that not everyone could afford to eat out. "No one," they said, "should be denied a good meal because of his [415 U.S. 250, 275] income." Furthermore, they argued that chefs should work toward the goal of giving everyone "complete physical and psychological satisfaction." For those people who could not afford to eat out, the government declared that they should be allowed to do so as often as they liked and the government would pay. For others, it was recommended that they organize themselves in groups and pay part of their income into a pool that would undertake to pay the costs incurred by members in dining out. To insure the greatest satisfaction, the groups were set up so that a member could eat out anywhere and as often as he liked, could have as elaborate a meal as he desired, and would have to pay nothing or only a small percentage of the cost. The cost of joining such prepaid dining clubs rose sharply.
Long ago, most restaurants would have one chef to prepare the food. A few restaurants were more elaborate, with chefs specializing in roasting, fish, salads, sauces, and many other things. People rarely went to these elaborate restaurants since they were so expensive. With the establishment of prepaid dining clubs, everyone wanted to eat at these fancy restaurants. At the same time, young chefs in school disdained going to cook in a small restaurant where they would have to cook everything. The pay was higher and it was much more prestigious to specialize and cook at a really fancy restaurant. Soon there were not enough chefs to keep the small restaurants open.
With prepaid clubs and free meals for the poor, many people started eating their three-course meals at the elaborate restaurants. Then they began to increase the number of courses, directing the chef to "serve the best with no thought for the bill." (Recently a 317-course meal was served.)
The costs of eating out rose faster and faster. A new [415 U.S. 250, 276] government commission reported as follows: (1) Noting that licensed chefs were being used to peel potatoes and wash lettuce, the commission recommended that these tasks be handed over to licensed dishwashers (whose three years of dishwashing training included cooking courses) or to some new category of personnel. (2) Concluding that many licensed chefs were overworked, the commission recommended that cooking schools be expanded, that the length of training be shortened, and that applicants with lesser qualifications be admitted. (3) The commission also observed that chefs were unhappy because people seemed to be more concerned about the decor and service than about the food. (In a recent taste test, not only could one patron not tell the difference between a 1930 and a 1970 vintage but he also could not distinguish between white and red wines. He explained that he always ordered the 1930 vintage because he knew that only a really good restaurant would stock such an expensive wine.)
The commission agreed that weighty problems faced the nation. They recommended that a national prepayment group be established which everyone must join. They recommended that chefs continue to be paid on the basis of the number of dishes they prepared. They recommended that every Gourmandese be given the right to eat anywhere he chose and as elaborately as he chose and pay nothing.
These recommendations were adopted. Large numbers of people spent all of their time ordering incredibly elaborate meals. Kitchens became marvels of new, expensive equipment. All those who were not consuming restaurant food were in the kitchen preparing it. Since no one in Gourmand did anything except prepare or eat meals, the country collapsed.
[ Footnote 1 ] See appendix to this opinion, post, p. 274.
[ Footnote 2 ] Title 42 CFR 53.111 (b) (8) defines that term to mean "a level of uncompensated services which meets a need for such services in the area served by an applicant and which is within the financial ability of such applicant to provide."
[ Footnote 3 ] The waiver of such a requirement requires notice and opportunity for public hearing. 42 CFR 53.111 (c) (2).
[ Footnote 4 ] For the impact of "free" indigent care on private hospitals and their paying patients see Dept. of Health, Education, and Welfare (HEW) Report on Medical Resources Available to Meet the Needs of Public Assistance Recipients, House Committee on Ways and Means, 86th Cong., 2d Sess. (Comm. Print 1961).
[ Footnote 5 ] Foreword to an article on Medical Care and its Delivery: An Economic Appraisal by Judith R. Lave and Lester B. Lave in 35 Law & Contemp. Prob. 252 (1970). [415 U.S. 250, 277]
MR. JUSTICE REHNQUIST, dissenting.
The State of Arizona provides free medical care for indigents. Confronted, in common with its 49 sister States, with the assault of spiraling health and welfare costs upon limited state resources, it has felt bound to require that recipients meet three standards of eligibility. 1 First, they must be indigent, unemployable, or unable to provide their own care. Second, they must be residents of the county in which they seek aid. Third, they must have maintained their residence for a period of one year. These standards, however, apply only to persons seeking nonemergency aid. An exception is specifically provided for "emergency cases when immediate hospitalization or medical care is necessary for the preservation of life or limb . . . ."
Appellant Evaro moved from New Mexico to Arizona in June 1971, suffering from a "chronic asthmatic and bronchial illness." In July 1971 he experienced a respiratory attack, and obtained treatment at the facilities of appellant Memorial Hospital, a privately operated [415 U.S. 250, 278] institution. The hospital sought to recover its expenses from appellee Maricopa County under the provisions of Ariz. Rev. Stat. Ann. 11-297A (Supp. 1973-1974), asserting that Evaro was entitled to receive county care. Since he did not satisfy the eligibility requirements discussed above, 2 appellee declined to assume responsibility for his care, and this suit was then instituted in the State Superior Court.
Appellants did not, and could not, claim that there is a constitutional right to nonemergency medical care at state or county expense or a constitutional right to reimbursement for care extended by a private hospital. 3 They asserted, however, that the state legislature, having decided to give free care to certain classes of persons, must give that care to Evaro as well. The Court upholds that claim, holding that the Arizona eligibility requirements burdened Evaro's "right to travel."
Unlike many traditional government services, such as police or fire protection, the provision of health care has commonly been undertaken by private facilities and personnel. But as strains on private services become greater, and the costs of obtaining care increase, federal, state, and local governments have been pressed to assume a larger role. Reasonably enough, it seems to me, those governments which now find themselves in the hospital business seek to operate that business primarily for those [415 U.S. 250, 279] persons dependent on the financing locality both by association and by need.
Appellants in this case nevertheless argue that the State's efforts, admirable though they may be, are simply not impressive enough. But others excluded by eligibility requirements certainly could make similar protests. Maricopa County residents of many years, paying taxes to both construct and support public hospital facilities, may be ineligible for care because their incomes are slightly above the marginal level for inclusion. These people have been excluded by the State, not because their claim on limited public resources is without merit, but because it has been deemed less meritorious than the claims of those in even greater need. Given a finite amount of resources, Arizona after today's decision may well conclude that its indigency threshold should be elevated since its counties must provide for out-of-state migrants as well as for residents of longer standing. These more stringent need requirements would then deny care to additional persons who until now would have qualified for aid.
Those presently excluded because marginally above the State's indigency standards, those who may be excluded in the future because of more stringent indigency requirements necessitated by today's decision, and appellant Evaro, all have a plausible claim to government-supported medical care. The choice between them necessitated by a finite amount of resources is a classic example of the determination of priorities to be accorded conflicting claims, and would in the recent past have been thought to be a matter particularly within the competence of the state legislature to decide. As this Court stated in Dandridge v. Williams, 397 U.S. 471, 487 (1970), "the Constitution does not empower this Court to second-guess state officials charged with the difficult [415 U.S. 250, 280] responsibility of allocating limited public welfare funds among the myriad of potential recipients."
The Court holds, however, that the State was barred from making the choice it made because of the burden its choice placed upon Evaro's "right to travel." Although the Court's definition of this "right" is hardly precise, the Court does state: "[T]he right of interstate travel must be seen as insuring new residents the same right to vital government benefits and privileges in the States to which they migrate as are enjoyed by other residents." This rationale merits further attention.
The right to travel throughout the Nation has been recognized for over a century in the decisions of this Court. 4 See Crandall v. Nevada, 6 Wall. 35 (1868). But the concept of that right has not been static. To see how distant a cousin the right to travel enunciated in this case is to the right declared by the Court in Crandall, reference need only be made to the language of Mr. Justice Miller, speaking for the Court:
Later cases also defined this right to travel quite conservatively. For example, in Williams v. Fears, 179 U.S. 270 (1900), the Court upheld a Georgia statute taxing "emigrant agents" - persons hiring labor for work outside the State - although agents hiring for local work went untaxed. The Court recognized that a right to travel existed, stating:
The leading earlier case, Edwards v. California, 314 U.S. 160 (1941), provides equally little support for the Court's expansive holding here. In Edwards the Court invalidated a California statute which subjected to criminal penalties any person "that brings or assists in bringing into the State any indigent person who is not a resident of the State, knowing him to be an indigent person." Id., at 171. Five members of the Court found the statute unconstitutional under the Commerce Clause, finding in the Clause a "prohibition against attempts on the part of any single State to isolate itself from difficulties common to all of them by restraining the transportation of persons and property across its borders." Id., at 173. Four concurring Justices found a better justification for the result in the Fourteenth Amendment's protection of the "privileges of national citizenship." 7
Regardless of the right's precise source and definition, it is clear that the statute invalidated in Edwards was specifically designed to, and would, deter indigent persons from entering the State of California. The imposition of criminal penalties on all persons assisting the entry of an indigent served to block ingress as surely as if the State has posted guards at the border to turn indigents away. It made no difference to the operation of the statute that the indigent, once inside the State, would be supported by federal payments. 8 Furthermore, [415 U.S. 250, 283] the statute did not require that the indigent intend to take up continuous residence within the State. The statute was not therefore an incidental or remote barrier to migration, but was in fact an effective and purposeful attempt to insulate the State from indigents.
The statute in the present case raises no comparable barrier. Admittedly, some indigent persons desiring to reside in Arizona may choose to weigh the possible detriment of providing their own nonemergency health care during the first year of their residence against the total benefits to be gained from continuing location within the State, but their mere entry into the State does not invoke criminal penalties. To the contrary, indigents are free to live within the State, to receive welfare benefits necessary for food and shelter, 9 and to receive free emergency medical care if needed. Furthermore, once the indigent has settled within a county for a year, he becomes eligible for full medical care at county expense. To say, therefore, that Arizona's treatment of indigents compares with California's treatment during the 1930's would border on the frivolous.
Since those older cases discussing the right to travel are unhelpful to Evaro's cause here, reliance must be placed elsewhere. A careful reading of the Court's opinion discloses that the decision rests almost entirely on two cases of recent vintage: Shapiro v. Thompson, 394 U.S. 618 (1969), and Dunn v. Blumstein, 405 U.S. 330 (1972). In Shapiro the Court struck down statutes requiring one year's residence prior to receiving welfare benefits. In Dunn the Court struck down a statute requiring a year's residence before receiving the right to vote. In placing reliance on these two cases, the Court [415 U.S. 250, 284] must necessarily distinguish or discredit recent cases of this Court upholding statutes requiring a year's residence for lower in-state tuition. 10 The important question for this purpose, according to the Court's analysis, is whether a classification "`operates to penalize those persons . . . who have exercised their constitutional right of interstate migration.'" (Emphasis in Court's opinion.)
Since the Court concedes that "some `waiting-period[s] . . . may not be penalties,'" ante, at 258-259, one would expect to learn from the opinion how to distinguish a waiting period which is a penalty from one which is not. Any expense imposed on citizens crossing state lines but not imposed on those staying put could theoretically be deemed a penalty on travel; the toll exacted from persons crossing from Delaware to New Jersey by the Delaware Memorial Bridge is a "penalty" on interstate travel in the most literal sense of all. But such charges, 11 as well as other fees for use of transportation facilities such as taxes on airport users, 12 have been upheld by this Court against attacks based upon the right to travel. It seems to me that the line to be derived from our prior cases is that some financial impositions on interstate travelers have such indirect or inconsequential impact on travel that they simply do not constitute the type of direct purposeful barriers struck down in Edwards and Shapiro. Where the impact is that remote, a State can reasonably require that the citizen bear some proportion of the State's cost in its facilities. I would think that this standard is not only supported by this Court's decisions, but would be [415 U.S. 250, 285] eminently sensible and workable. But the Court not only rejects this approach, it leaves us entirely without guidance as to the proper standard to be applied.
The Court instead resorts to ipse dixit, declaring rather than demonstrating that the right to nonemergency medical care is within the class of rights protected by Shapiro and Dunn:
The Court, in its examination of the proffered state interests, categorically rejects the contention that those who have resided in the county for a fixed period of time may have a greater stake in community facilities than the newly arrived. But this rejection is accomplished more by fiat than by reason. One of the principal factual distinctions between Starns v. Malkerson, 326 F. Supp. 234 (Minn. 1970), aff'd, 401 U.S. 985 (1971), and Vlandis v. Kline, 412 U.S. 441 (1973), both of which upheld durational residence requirements for in-state university tuition, 14 and Shapiro, which struck them down for welfare recipients, is the nature of the aid which the State or county provides. Welfare benefits, whether in cash or in kind, are commonly funded from current tax revenues, which may well be supported by the very newest arrival as well as by the longtime resident. But universities and hospitals, although demanding operating support from current revenues, require extensive capital facilities which cannot possibly be funded out of current tax revenues. Thus, entirely apart from the majority's conception of whether nonemergency health care is more or less important than continued education, [415 U.S. 250, 287] the interest of longer established residents in capital facilities and their greater financial contribution to the construction of such facilities seems indisputable. 15
Other interests advanced by the State to support its statutory eligibility criteria are also rejected virtually out of hand by the Court. The protection of the county economies is dismissed with the statement that "[t]he conservation of the taxpayers' purse is simply not a sufficient state interest . . . ." 16 The Court points out that the cost of care, if not borne by the Government, may be borne by private hospitals such as appellant Memorial Hospital. While this observation is doubtless true in large part, and is bound to present a problem to any private hospital, it does not seem to me that it thus becomes a constitutional determinant. The Court also observes that the State may in fact save money by providing nonemergency medical care rather than waiting for deterioration of an illness. However valuable a qualified cost analysis might be to legislators drafting eligibility requirements, and however little this speculation may bear on Evaro's condition (which the record does not indicate to have been a deteriorating illness), this sort of judgment has traditionally been confided to legislatures, rather than to courts charged with determining constitutional questions.
The Court likewise rejects all arguments based on [415 U.S. 250, 288] administrative objectives. Refusing to accept the assertion that a one-year waiting period is a "convenient rule of thumb to determine bona fide residence," the majority simply suggests its own alternatives. Similar analysis is applied in rejecting the appellees' argument based on the potential for fraud. The Court's declaration that an indigent applicant "intent on committing fraud, could as easily swear to having been a resident of the county for the preceding year as to being one currently" ignores the obvious fact that fabricating presence in the State for a year is surely more difficult than fabricating only a present intention to remain.
The legal question in this case is simply whether the State of Arizona has acted arbitrarily in determining that access to local hospital facilities for nonemergency medical care should be denied to persons until they have established residence for one year. The impediment which this quite rational determination has placed on appellant Evaro's "right to travel" is so remote as to be negligible: so far as the record indicates Evaro moved from New Mexico to Arizona three years ago and has remained ever since. The eligibility requirement has not the slightest resemblance to the actual barriers to the right of free ingress and egress protected by the Constitution, and struck down in cases such as Crandall and Edwards. And, unlike Shapiro, it does not involve an urgent need for the necessities of life or a benefit funded from current revenues to which the claimant may well have contributed. It is a substantial broadening of, and departure from, all of these holdings, all the more remarkable for the lack of explanation which accompanies the result. Since I can subscribe neither to the method nor the result, I dissent.
[ Footnote 1 ] Ariz. Rev. Stat. Ann. 11-297A (Supp. 1973-1974) reads as follows:
[ Footnote 2 ] The parties stipulated that Mr. Evaro was "an indigent who recently changed his residence from New Mexico to Arizona and who has resided in the state of Arizona for less than twelve months." App. 10. Therefore Mr. Evaro failed to meet only the third requirement discussed in the text.
[ Footnote 3 ] This Court has noted that citizens have no constitutional right to welfare benefits. See, e. g., Dandridge v. Williams, 397 U.S. 471 (1970); San Antonio Independent School Dist. v. Rodriguez, 411 U.S. 1, 33 (1973).
[ Footnote 4 ] Although the right to travel has been recognized by this Court for over a century, the origin of the right still remains somewhat obscure. The majority opinion in this case makes no effort to identify the source, simply relying on recent cases which state such a right exists.
[ Footnote 5 ] The tax levied by the State of Nevada was upon every person leaving the State. As this Court has since noted, the tax was a direct tax on travel and was not intended to be a charge for the use of state facilities. See Evansville Airport v. Delta Airlines, 405 U.S. 707 (1972).
[ Footnote 6 ] The Court also rejected an equal protection argument, concluding: "We are unable to say that such a discrimination, if it existed, [415 U.S. 250, 282] did not rest on reasonable grounds, and was not within the discretion of the state legislature." 179 U.S., at 276 .
[ Footnote 7 ] See the concurring opinions of MR. JUSTICE DOUGLAS (with whom Mr. Justice Black and Mr. Justice Murphy joined), 314 U.S., at 177 , and Mr. Justice Jackson, id., at 181.
[ Footnote 8 ] The Court in Edwards observed: "After arriving in California [the indigent] was aided by the Farm Security Administration, which . . . is wholly financed by the Federal government." 314 U.S., at 175 . The Court did not express a view at that time as to whether a different result would have been reached if the State bore the financial burden. But cf. Shapiro v. Thompson, 394 U.S. 618 (1969).
[ Footnote 9 ] See Ariz. Rev. Stat. Ann. 46-233 (Supp. 1973-1974), which provides that an eligible recipient of general assistance must have "established residence at the time of application."
[ Footnote 10 ] See Starns v. Malkerson, 326 F. Supp. 234 (Minn. 1970), aff'd, 401 U.S. 985 (1971); Vlandis v. Kline, 412 U.S. 441 (1973).
[ Footnote 11 ] See, e. g., Interstate Busses Corp. v. Blodgett, 276 U.S. 245 (1928); Hendrick v. Maryland, 235 U.S. 610 (1915).
[ Footnote 12 ] See Evansville Airport v. Delta Airlines, 405 U.S. 707 (1972).
[ Footnote 13 ] See, e. g., Evans v. Cornman, 398 U.S. 419 (1970); Cipriano v. City of Houma, 395 U.S. 701 (1969).
[ Footnote 14 ] In Vlandis, while striking down a Connecticut statute that in effect prevented a new state resident from obtaining lower tuition rates for the full period of enrollment, we stated that the decision should not "be construed to deny a State the right to impose on a student, as one element in demonstrating bona fide residence, a reasonable durational residency requirement, which can be met while in student status." 412 U.S., at 452 . Starns was cited as support for this position.
[ Footnote 15 ] This distinction may be particularly important in a State such as Arizona where the Constitution provides for limitations on state and county debt. See Ariz. Const., Art. 9, 5 (State); Art. 9, 8 (County). See generally Comment, Dulling the Edge of Husbandry: The Special Fund Doctrine in Arizona, 1971 L. & Soc. O. (Ariz. St. L. J.) 555.
[ Footnote 16 ] The appellees in this case filed an affidavit indicating that acceptance of appellants' position would impose an added burden on property taxpayers in Maricopa County of over $2.5 million in the first year alone. App. 12-17. [415 U.S. 250, 289]
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text:
Stress promotes neuropathological changes that are also seen in Alzheimer's disease. Scientists from the Max Planck Institute of Psychiatry in Munich have discovered that the increased release of stress hormones in rats leads to generation of abnormally phosphorylated tau protein in the brain and ultimately, memory loss.
Protein deposits in nerve cells are a typical feature of Alzheimer's disease: the excessive alteration of the tau protein through the addition of phosphate groups – a process known as hyperphosphorylation – causes the protein in the cells to aggregate into clumps. As a result, nerve cells die, particularly in the hippocampus, a part of the brain that plays an important role in learning and memory, as well as in the prefrontal cortex which regulates higher cognitive functions.
Fewer than ten percent of Alzheimer cases have a genetic basis. The factors that contribute to the rest of the cases are largely unknown. Following up on epidemiological studies, scientists at the Max Planck Institute of Psychiatry hypothesized that adverse life events (stress) may be one trigger of Alzheimer's disease.
In cooperation with colleagues at the University of Minho in Braga, Portugal, the Munich-based researchers have now shown that stress, and the hormones released during stress, can accelerate the development of Alzheimer disease-like biochemical and behavioural pathology. They found increased hyperphosphorylation of tau protein in the hippocampus and prefrontal cortex of rats that has been subjected to stress (e.g. overcrowding, placement on a vibrating platform) for one hour daily over a period of one month. Animals showing these changes in tau also showed deficits in memories that depended on an intact hippocampus; also, animals with abnormally hyperphosphorylated tau were impaired in behavioural flexibility, a function that requires proper functioning of the prefrontal cortex.
These results complement previous demonstrations by the scientists that stress leads to the formation of beta-amyloid, another protein implicated in Alzheimer's disease. "Our findings show that stress hormones and stress can cause changes in the tau protein like those that arise in Alzheimer's disease", explains Osborne Almeida from the Max Planck Institute of Psychiatry.
The next challenge will be to see how applicable the results obtained in animals are to the development of non-familial forms of Alzheimer's disease. "Viewing stress as a trigger of Alzheimer's disease offers exciting new research possibilities aimed at preventing and delaying this severe disease. Moreover, since vulnerability to major depression is known to be increased by stress, it will be interesting to know the role of molecules such as beta-amyloid and tau in the onset and progress of this condition", says Osborne Almeida.

subset: commoncrawl


text:
Liz Lemon's alter ego attempts to colonize your bedside table this month with her first book, Bossypants. Here, the woman also known as Sarah Palin's better half ruminates on nervous exhaustion and Catherine the Great's frisky horse.
What is your current state of mind?
On the verge of nervous exhaustion, but only for the last seven years.
What is your idea of perfect happiness?
A glass of wine at sunset on Fire Island. / No homework.
What is your greatest fear?
Child, loss or damage thereof.
Which historical figure do you most identify with?
Catherine the Great's horse.
Which living person do you most admire?
Cathy Rigby. She was really good in that stage version of Peter Pan. No joke.
What is the trait you most deplore in yourself?
What is the trait you most deplore in others?
People who are proud of their ignorance.
What is it that you most dislike?
People who mock education as elitist.
What is your greatest extravagance?
Living in New York City.
What do you most value in your friends?
A willingness to come uptown.
What is your favorite journey?
Pulling up to my parents' house for Christmas. Just pulling up, though—not the whole drive.
What is your most treasured possession?
A photo of my parents walking around the Acropolis circa 1965. They look like a poster for Two for the Road.
What do you consider the most overrated virtue?
Natural childbirth.
On what occasion do you lie?
During press junkets for movies.
Which living person do you most despise?
Osama bin Laden. Unless we think he's dead by now, in which case that guy who holds up the GOD HATES FAGS sign.
What or who is the greatest love of your life?
Jeff and Alice Richmond equally, but only because they look exactly alike.
When and where were you happiest?
Anywhere, during the 2 to 24 hours after a successful joke.
If you could change one thing about yourself, what would it be?
I would get 30 hours a day when everyone else gets 24.
What do you consider your greatest achievement?
Providing 200 people with a nice place to work.
If you could change one thing about your family, what would it be?
My husband and I would work less and my daughter would sleep more.
What do you regard as the lowest depth of misery?
September 12, 2001.
What is your favorite occupation?
Being between jobs but having a good one lined up in about a month or so.
What is your most marked characteristic?
Obedience and a long nose. (I might be a collie.)
Who is your favorite hero of fiction?
Veruca Salt, Francie Nolan, Miss Havisham. That's me in a nutshell, actually.
How would you like to die?
I would like to drop dead while introducing the "In Memoriam" clip package at the Emmys … on my 10,000th birthday.
What is your motto?
"Stop reaching for the stars!"


text:
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text:
Nature's Way, Sambucus, Zinc Lozenges with Vitamin C, Honey Lemon, 24 Lozenges
Best By: December 2024
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Shipping Weight:
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Keep out of reach of children. Choking hazard. For your safety each lozenge is individually wrapped. Do not use if pouch is torn or lozenges are unwrapped. To help preserve freshness, keep tightly sealed and store in a cool, dry place.
While iHerb strives to ensure the accuracy of its product images and information, some manufacturing changes to packaging and/or ingredients may be pending update on our site. Although items may occasionally ship with alternate packaging, freshness is always guaranteed. We recommend that you read labels, warnings and directions of all products before use and not rely solely on the information provided by iHerb.
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|Total Carbohydrate
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|Vitamin C (as ascorbic acid)
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|Zinc (as zinc gluconate)
|5 mg
|Organic Black Elder (Sambucus nigra L.) Extract (berry) standardized to BioActives® from 800 mg of premium cultivar elderberries
|12.5 mg
|†Percent Daily Values (DV) are based on a 2,000 calorie diet.
**Daily Value not established.


text:
GitHub is an awesome code repository and code distribution website. It's used by countless people and organizations to develop and release code.
I've wanted to made use of GitHub for a very long time now but the site is built around the Git revision control software. However I instead extensively use Subversion (SVN) in my daily life and have no desire or need to learn Git — everything I currently do requires that I use SVN. Not to mention that the Git experience on Windows is absolutely horrendous.
So I was incredibly pleased to learn that GitHub supports SVN! They added full support way back in October 2011 but I somehow missed the memo.
This is super good news because it means I can now start to distribute my code and projects via my my GitHub page. Nothing is there quite yet but I hope to package up and commit some code to there soon. 🙂


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World Exclusive: Han Solo And Chewbacca Final Concept Artwork For STAR WARS: THE FORCE AWAKENS !!
This is the real deal folks! I received these concept art images directly from my top STAR WARS source and so you know these are absolutely legit. This is the same source that gave us the exclusive information years ago that STAR WARS VII, VIII & IX are coming and that the original cast would be involved. I have complete and absolute trust in this source, so have a look and enjoy!
These are absolutely final iterations of concept art for Episode VII.
I am loving the artwork here. Looks like a gorgeous watercolor (by hand?) with Solo's name in grey at the bottom right and Chewbacca may be a pastel or digitally done. I'll leave you guys to zoom in and do further analysis which I'm sure you will be doing, but Han Solo in particular definitely looks the hero role! And that's an awesome full length coat he's got on! Definitely has a western brown leather feel to it as opposed to his black and white fashions of the original series.
He definitely still has it! There are few actors that can carry a role like Harrison Ford and I can't wait for him to revisit this iconic character. Back behind the wheel of the Millennium Falcon!
Speaking of iconic roles, how about Solo's good ol' buddy Chewbacca? Check him out! I don't see too much in the way of difference with Chewy except for perhaps some aging going on. Maybe some of you eagle eyed Star Wars fans can spot some differences that I'm not.
Chewy does look quite pensive in the artwork. What's on his mind? Looks a little worried about something.
Anyway, I hope you enjoy the early look at these pieces of final concept art while you can. I suspect Lucasfilm will want to have these removed soon. Just a guess.
I will have more STAR WARS and AVATAR exclusives coming up soon. You KNOW I will :-) Have a happy holidays everyone! Nothing beats an early gift right?
STAR WARS EPISODE VII: THE FORCE AWAKENS will open on December 18, 2015.


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None of this, this nor this worked in setting my default editor. Haven't tried this, I'm afraid it won't work either.
So how do I set the default editor to
emacs or possibly
emacsclient in 13.04 through the CLI/terminal?
Double-clicking on a text file still opens up to
I specifically say 13.04 because I had no problem in doing so in 11.04 from which I recently upgraded from.


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In Practice: Jonathan Biss
It's tough to concentrate on the rigors of Beethoven with jackhammers pounding in your ears. So when they started demolishing the building next to Jonathan Biss, he moved his piano out of his apartment into a separate studio, away from the commotion. "I would get up in the morning, the piano wasn't there, and I had to leave my apartment to go practice and I've decided that's a much more productive way of working," he says. Biss needs a good working environment for his massive project. He's begun a nine year deep-dive into Beethoven, learning and recording all 32 of the composer's piano sonatas. We eavesdropped on Biss, working through Beethoven's vigorous Piano Sonata No. 5, during an unexpected Manhattan heat wave.
Producers: Mito Habe-Evans, Anastasia Tsioulcas; Audio Engineer: Kevin Wait; Production Assistants: Amanda Ameer, Nick Michael; Executive Producers: Anya Grundmann, Keith Jenkins
Copyright 2021 NPR. To see more, visit https://www.npr.org.


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You know you've had a disappointing massage experience when you leave a session feeling mentally and physically dissatisfied. Whether you had a hard time relaxing, you weren't comfortable with the therapist's massage approach, room temperature is not to your liking, or the music or lighting, there are many internal and external factors that can come into play during a massage session.
To make the most of your next massage, adopt the following four tips before, during and after your session so you can maximize your experience and leave feeling relaxed and refreshed.
Find the Best Massage Therapist for You
Finding a massage therapist that you're compatible with and comfortable with in regard to personality and massage delivery techniques can make or break your satisfaction. At Massage Bliss, our massage therapists are given different pressure levels. When you initially call our studio, you will be placed with the best massage therapist to fit your needs. It's important to know that every massage therapist has a unique approach and specific areas they focus on. You're welcome to do research prior to a massage to make sure a therapist's approach aligns with your goals and expectations, or we can place you with one that fits your goals.
Communicating your specific aches or pains with the therapist both prior to starting the session and during the session is also important to ensure your needs will be met during the massage.
If you have specific problems or issues you want addressed, it's a really good idea to check out a therapist's resume, certifications and continuing education, Being honest and upfront with the therapist also is essential so that everybody is on the same page about the purpose of the massage from the beginning."
Be Early and Be Prepared
Rushing around and running late for a massage session will only lead to a sub-par experience, since you aren't giving your mind and body time to pause and prepare for a relaxing experience. To get the most benefits out of your massage session, We recommends that you arrive at the studio at least 15 minutes ahead of the appointment to fill out paperwork, use the restroom and decompress any stress you've encountered throughout the day.
When you're lying on the table waiting for the therapist to come in to start the massage, it also can be helpful to take a few deep breathes to clear your mind and prepare your body to melt into the warm, comfortable table.
When clients are running behind, everyone feels rushed and stressed. Being early is being on time when you get a massage. It allows you to be prepared and ready so your experience is everything you want it to be."
Leave Your Thoughts At The Door
One of the biggest obstacles to a successful massage experience is letting outside stresses, devices and frustrations sneak into the massage room with you. Both massage therapists and clients need to make concentrated efforts to remove distractions that can negatively affect the outcome of the session such as cell phones, memories of a heated discussion or home and work stress.
As you're in a session, try not to think about all of the things that are stressing you out. Whether it's good or bad, leave your attitudes and frustrations at the door so you can have a more relaxing experience.
As a therapist, I have to leave all of my personal things at the door as well. People feed off each other's energies so I can't come in being mad at the world. I do a couple stretches and breathing exercises before a session to help clear my mind and prepare for the massage. It can be helpful for clients to do this as well.
Adopt a Relaxed Post-Massage Routine
After you've taken at least an hour out of your day to focus on relaxing and unwinding during your massage session, the last thing you want to do is run out into the world full speed ahead. Instead, We advise that the best post-massage prescription is to head home to a relaxing environment where you can take a hot bath with Epsom salt to relieve any soreness and keep your muscles loose.
The best day to schedule a massage is when you can just chill out afterward. If you get a massage and then spend the rest of the day rushing around or doing strenuous exercise, you're not going to enjoy the full benefits of the massage. We do a lot of work to fix things during a massage. So you don't want to undo it all by doing too much for the rest of the day."
Getting a massage is great for relaxing your mind and body, but reaping the benefits of a massage long after the session ends is when you can really start establishing total health and wellness. The next time you schedule a massage, maximize your experience by following these simple but effective tips before, during and after your session.


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Look, nobody doesn't like Duckie. We get it. He's sweet, smart, funny - and that's before we even get to the fact that he, by all accounts, kept showing up for work on Two and a Half Men even when the notion of "work" turned into an utter farce. I suspected he was a good dude -- it seems like he'd have to be, to get through that kind of thing and still stay on the show (contracts help here, too) -- and then when he won, I was sure of it.
Because the first words out of his mouth weren't "Oh thank you all so much" but instead "there's been a terrible mistake". He knew he didn't deserve the best actor award at all. Now, he was all "I'd have given it to Jim Parsons" while I, personally, would have had Larry David and Don Cheadle have a quip-off for it – but the point is he's self-aware enough to know his work didn't warrant it.
What do you do if that happens? Winning something that's not exactly for you and your work kinda feels dirty, right? Like a consolation prize, or hush money, or something? I mean I don't know his life but I don't imagine this is going to suddenly start raining parts down on him or anything. It's not a "real" win in that he's suddenly going to be seen in a whole new light, right?
So if that's the case, can you still relish the win, or is it tainted? Does Jon Cryer have a consolation Emmy? Are those the ones that wind up living in the bathroom?


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The Office of Arts & Cultural Affairs is accepting applications for the 2012 CityArtist Projects program that supports Seattle-based individual artists working in the visual, literary and media arts.
CityArtist Projects is an annual funding program that provides support to individual Seattle artists to develop and present new, in-progress or remounted works taken to the next stage. Funding is offered to artists in clusters of disciplines in the visual, media and literary arts and performing arts in alternate years.
Priority will be given to quality art projects that focus on public benefit defined as community impact and access. Projects will be rated on their ability to address at least one of these four elements: engage new audiences, develop partnerships, create access through education and public awareness opportunities and/or present in non-traditional venues.
Artists can apply for set awards of either $2,000 or $4,000. Projects must be presented between May and December 2012 and include a public presentation.
A link to the online application is available at www.seattle.gov/arts. The application deadline is Tuesday, Nov. 1, 2011. For more information, contact Irene Gómez at email@example.com or (206) 684-7310.


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Ahhhh! If you get freaked out by pigeons, wait until you see a whole writhing mass of the winged rats trapped inside a catapult-sprung net. Truly terrifying. And apparently the solution to Spain's big pigeon problem.
Pigeons have been deemed a "plague" in Barcelona, spreading disease and pooping all over Gaudi's beautiful buildings. To curb the destruction, the city is trying to catch 65,000 of the birds, roughly 25% of the pigeon population, over the next year and a half. While some birds are being trapped in traditional cages and relocated outside of the city, others are subject to private pigeon trappers' kooky catapulted nets.
Cruel? Maybe! But a plague's a plague, I guess? And anyway if you don't think that resulting video is the craziest thing you've seen today, you are just totally in-coo-rrect. [Wired]


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Established in 1902 as a sumi ink stick manufacturer in Japan, Kuretake has grown into a brand of quality artist tools for fine arts, illustration, graphic design, paper crafts, scrapbooking and signage.
Kuretake Co. Ltd. is family owned and all ZIG products are still made in Nara, Japan. ZIG is a registered trademark owned by Kuretake Co. Ltd.
The ZIG Memory System is designed for scrapbooking, journaling and cardmaking with water-based pigment ink to preserve treasured memories.
The ZIG Sign product line is versatile and highly suitable for decorating chalkboards, whiteboards, windows, mirrors and a variety of porous and non-porous surfaces, including plastic, metal and wood!


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Former Vice President Dick Cheney's new memoir revives the fierce battles over U.S. national security policies after the September 11 attacks as it rips open old wounds among aides to President George W. Bush.
Cheney describes his upbringing on the Wyoming prairie where he hunted jackrabbits and learned to fish before turning his attention to his eight years in the Bush White House, where he pushed a "go-it-alone" world view that enraged his critics.
The book, "In My Time," has grabbed headlines for Cheney's attempts to settle scores with foes such as former secretaries of state Colin Powell and Condoleezza Rice.
Powell accused Cheney of taking "cheap shots" at his former colleagues.
Rice, in an interview with Reuters on Wednesday, said she did not appreciate Cheney's "attacks on my integrity."
Beyond such skirmishes, the book also highlights how far the national security debate has shifted as the United States prepares to mark the 10-year anniversary of the attacks on the Pentagon and the World Trade Center in New York.
Cheney's unapologetic defense of policies he advocated, such as harsh interrogations of terrorism suspects and interventionist foreign policy, surprised few in Washington.
Perhaps more surprising was the marked shift away from the vision championed by Cheney, who won many of the policy arguments in the early Bush years only to see his influence wane in the Republican president's second term.
"The majority of what is associated with Cheney and what Cheney embraces in the book -- a unilateralist, American exceptionalist, 'our way or the highway' approach to the world -- has been completely abandoned," said David Rothkopf, a former Clinton administration official and author of a book about the White House National Security Council.
U.S. war-weariness after Iraq and Afghanistan has become so pronounced that advocacy of a muscular U.S. foreign policy pushed by former Republican presidential candidate John McCain in 2008 has gotten little emphasis among Republicans vying to challenge President Barack Obama in 2012.
And Republican lawmakers were among the most vocal in questioning Obama's decision to intervene in Libya in March.
Rothkopf noted that the manner of intervention, in which the Obama administration insisted on multilateralism and wanted other countries to take the lead, is the reverse of the approach favored by Cheney.
While Cheney pushed a hawkish approach toward Iran and Syria and even suggested bombing a Syrian nuclear reactor in 2007, the idea of U.S. military intervention in either of those two countries is not currently part of the national dialogue.
On counterterrorism policies, one of Obama's first acts when he took office in 2009 was to disavow harsh interrogations and promise to close the U.S. military prison at Guantanamo Bay, Cuba -- though the detention center remains open to this day because the administration has struggled with a lack of feasible alternatives.
In his book, Cheney puzzled over Obama's view that the facility harms America's image in the world even though Bush himself expressed sympathy for that perspective in a 2006 news conference in which he said he'd prefer to close Guantanamo if an alternative could be found.
"It's not Guantanamo that does the harm, it is the critics of the facility who peddle falsehoods about it," Cheney writes.
Still, Peter Feaver, a former Bush adviser, said there is more continuity in the national security policies than Obama and his aides acknowledge.
Feaver cited as examples the indefinite detentions of some terrorism suspects, the reversal of the promise to close Guantanamo and the expansion of drone attacks to go after militants in Pakistan.
"When it comes to the legal edifice of the war on terror and the tools that are used, the Obama administration is a lot closer to the Bush administration than the Obama campaign was."
"Part of that is because the Bush administration moved somewhat from where it was in 2002 to where it was, say in 2006," Feaver said, noting that even harsh interrogations were scaled back under Bush before being rejected by Obama.
Cheney's chief adversaries during Bush's first term were Powell and his deputy, Richard Armitage.
Cheney portrays Rice as naive and in one passage says she "tearfully" came to his office to discuss her regrets about a policy argument. Rice challenged the notion that she ever came to Cheney's office tearfully about anything.
Powell has described Bush's national security team during the first term as so dysfunctional, there were not only differences of opinion but views that could not be reconciled.
The back-and-forth over the book seems to support that characterization.
Cheney, who wielded unprecedented power as vice president, began to see his clout decline after Rice, a longtime friend and close aide of Bush, moved from her role as national security adviser to secretary of state in early 2005.
His influence decreased further when his ally and former mentor Donald Rumsfeld was replaced as defense secretary by the more moderate Robert Gates, who went on to serve in the Obama administration.


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We suspect many of you are occupied with new toys that Santa brought. But if that's not enough, we've put together this collection of books that will keep you reading during the rest of the holidays.
"No Other Story" by Cuthbert Soup, for ages 8 to 12: This is the third book in a series that tells the tale of the Cheeseman family, which is Ethan Cheeseman and his three "smart, polite, attractive and relatively odor-free children."
There is no mother is central to the plot, which involves time travel, dinosaurs, Vikings and, yes, gravy-flavored ice cream.
Even if you haven't read the earlier books in the series — "A Whole Nother Story" and "Another Whole Nother Story" — you'll find this story exciting and mostly laugh-out-loud funny. While you probably need to be at least 8 to read this book to yourself, it would make a great family read-aloud.
Ask your parents to curl up on the couch or in front of a fire to read a few chapters.
"The Santa Trap" by Jonathan Emmett, illustrated by Poly Bernatene, for ages 5 and older: We're really hoping that none of you reading this is as bad a kid as Bradley Bartleby. Because even Santa finds it hard to put Bradley on a "nice" list.
In fact, Santa won't give Bradley anything but socks, and bad, bad Bradley is fed up with that. So he sets out to trap Santa and steal all the toys that Santa is carrying for good girls and boys.
This funny, beautifully illustrated story will have you talking about the importance of "being good for goodness' sake."
"Let's Make Some Great Fingerprint Art" by Marion Deuchars, for age 5 and older: All you need to enjoy this book is your finger, an inkpad and your imagination. We bet you didn't know that two thumbprints can create a heart or that those same two prints can create pigs, cats, bees or even the alphabet.
The book is filled with clever ideas, but we think the best part is that it will inspire you to come up with more of your own.
"Twelve Kinds of Ice" by Ellen Bryan Obed, illustrated by Barbara McClintock, for age 8 and older: This is a short (just 64 pages) and beautiful book that tells the story of one winter's worth of ice. It starts with the thin ice that forms on a pail of water during the first freeze and continues with the ice that is perfect for a skating party.
Even when winter draws to a close and what's left of the ice are the thawed-out mittens, you know that some ice always remains: the ice of your memories.
"Mira's Diary: Lost in Paris" by Marissa Moss, for ages 9 to 12: Mira is searching for her lost mother, and even if she's looking in the right place, perhaps she is looking in the wrong time. The story moves quickly because it's written as diary entries.
It's a very adventurous tale, but it includes some historic characters and raises fascinating questions about trying to change the past.
Mira's second adventure, "Mira's Diary: Home Sweet Rome," will be published in April.
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This article explores three processes involved in attending to evidence of students' thinking, one of the Mathematics Teaching Practices in Principles to Actions: Ensuring Mathematical Success for All. These processes, explored during an activity on proportional relationships, are discussed in this article, another installment in the series.
Sherin Gamoran Miriam and James Lynn
Sarah K. Bleiler-Baxter, Sister Cecilia Anne Wanner O.P., and Jeremy F. Strayer
Explore what it means to balance love for mathematics with love for students.
Clayton M. Edwards, Rebecca R. Robichaux-Davis, and Brian E. Townsend
Three inquiry-based tasks highlight the planning, classroom discourse, positive results, and growth in one class's journey.
Ron Lancaster
Since its inception, the Mathematical Lens column has provided teachers with resources to use with their students to make connections between mathematics and the world around us through the use of photographs. The editors and the dozens of teachers who submitted material for columns have taken all of us on a journey around the world to discover where mathematics lives. These columns have offered teachers a license to do mathematics everywhere and to travel far with their students with a full tank of resources.
Stephen Phelps
Edited by Anna F. DeJarnette
A monthly set of problems targets a variety of ability levels.
Jo Boaler
Engage your learners through tasks proven to significantly promote reasoning and problem solving, which touch on many of the Mathematics Teaching Practices in Principles to Actions: Ensuring Mathematical Success for All. These tasks are discussed in this article, another installment in the series.
Michelle Cirillo and Jenifer Hummer
Use these ideas to diagnose and address common conceptual obstacles that inhibit students' success.


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Of Darwyn Cooke and critical joints
Today is a good day at Hero Banking Central, as we just deposited a $10,000 check (!) from our ol' pal Darwyn Cooke from his now-famous "12 Days of Christmas" auctions last month.
Yep, 10 large is a good haul, but wait 'til you hear what Dar has up his sleeve for NEXT year. Think "even bigger," think "even better." And in the interim, next time you see Darwyn, thank him—he deserves it!
The deposit is well-timed, as yesterday was the day 1960s war comics legend Russ Heath went under the knife for knee replacement surgery. We're happy to report that the surgery was a success, and Russ is resting comfortably. He'll need the rest, as rehab is several months long, but if there's one tough SOB who will get through it, even at age 84, it's Russ Heath. Hero has been and will be along for the ride to help Russ out as well, of course.
Meantime, we HEARTILY encourage you to send get-well cards and good wishes to Russ in care of Hero Initiative at:
Hero Initiative
11301 Olympic Blvd., #587
Los Angeles, CA 90064
Jim McLauchlin
Russ Heath photo by Lori Matsumoto