Bruns v. Mayhew , 750 F.3d 61 ( 2014 )


Menu:
  •           United States Court of Appeals
    For the First Circuit
    No. 13-1456
    HANS BRUNS and KADRA HASSAN, on behalf of themselves
    and other similarly situated individuals,
    Plaintiffs, Appellants,
    v.
    MARY MAYHEW, Commissioner,
    Maine Department of Health and Human Services,
    Defendant, Appellee.
    APPEAL FROM THE UNITED STATES DISTRICT COURT
    FOR THE DISTRICT OF MAINE
    [Hon. John A. Woodcock, Jr., U.S. District Judge]
    Before
    Howard, Stahl and Thompson,
    Circuit Judges.
    Jennifer A. Archer, with whom Kelly Remmel & Zimmerman, Jack
    Comart, Maine Equal Justice Partners, Zachary L. Heiden and ACLU of
    Maine Foundation were on brief, for appellants.
    Justin B. Barnard, Assistant Attorney General, with whom Janet
    T. Mills, Attorney General, and Doris A. Harnett, Assistant
    Attorney General, were on brief, for appellee.
    April 28, 2014
    HOWARD,      Circuit    Judge.      After   Congress    passed    the
    Personal Responsibility and Work Opportunity Reconciliation Act of
    1996 ("PRWORA"), narrowing the eligibility of non-citizens for
    Medicaid and other federal benefits, the state of Maine responded
    in 1997 by extending state-funded medical assistance benefits to
    certain legal aliens rendered ineligible for Medicaid.                 In 2011,
    the Maine Legislature terminated these benefits.              The appellants
    allege that this termination of their benefits violated their
    rights   under    the    Equal     Protection   Clause   of   the    Fourteenth
    Amendment, and presently appeal from the district court's denial of
    their    motion    for     a   preliminary      injunction.         Finding   no
    constitutional violation, we affirm the district court's denial of
    a preliminary injunction and remand for dismissal.
    I.
    Medicaid is a cooperative federal-state program created
    in 1965 as an amendment to the Social Security Act in order to help
    states provide publicly-funded medical assistance to certain needy
    citizens.   See Nat'l Fed'n of Indep. Bus. v. Sebelius, 
    132 S. Ct. 2566
    , 2581 (2012). A state's participation in the Medicaid program
    is voluntary, but once a state chooses to participate it must
    comply with federal statutory and regulatory requirements in order
    to receive federal matching funds. See 
    42 U.S.C. §§ 1396-1
    , 1396a,
    1396b, 1396c; 
    id. at 2581
    ; 
    id. at 2601, 2604
     (Roberts, C.J., joined
    by Breyer and Kagan, JJ.); Frew ex rel. Frew v. Hawkins, 540 U.S.
    -2-
    431, 433 (2004).       The      eligibility    requirements for Medicaid
    coverage are governed by federal law.             Under the Medicaid Act,
    participating states must provide full Medicaid services under the
    approved state plan to certain groups of individuals who meet the
    eligibility criteria, including "categorically needy" groups.                 See
    42 U.S.C. §§ 1396a(a)(10)(A)(I), 1396d(a); Lewis v. Thompson, 
    252 F.3d 567
    , 570 (2d Cir. 2001). For years, federal Medicaid extended
    medical   assistance      to    eligible   individuals   without     regard   to
    citizenship status or durational residency.              By act of Congress,
    however, the alien eligibility requirements for publicly-funded
    benefits, including Medicaid, changed dramatically in 1996.              See 
    8 U.S.C. §§ 1601-1646
    .
    In enacting PRWORA, Pub. L. No. 104-193, 
    110 Stat. 2105
    (1996)    (also   known    as    the   "Welfare   Reform    Act"),    Congress
    restricted the ability of aliens to access federal public welfare
    benefits, including Medicaid.          See 
    8 U.S.C. §§ 1611
    , 1612, 1621,
    1622.    PRWORA divided non-citizens into categories of "qualified"
    and "non-qualified" aliens, see 
    id.
     §§ 1611, 1641(b), and further
    restricted eligibility for federal welfare benefits by imposing a
    five-year United States residency requirement for most qualified
    aliens, see id. § 1613.            Although PRWORA authorized states to
    expand the category of qualified aliens eligible for federal
    benefits, it prohibited the states from extending federal benefits
    -3-
    to most aliens residing in the United States for less than five
    years.       See id. § 1612(b).1
    PRWORA    left     the     states    more    discretion      in    the
    dispensation of state public benefits, authorizing the states "to
    determine the eligibility for any State public benefits of an alien
    who is a qualified alien," including qualified aliens residing less
    than five years in the United States.                Id. § 1622(a).      The Maine
    Legislature accordingly responded to PRWORA by enacting Public Law
    1997, chapter 530, section A-16 (the "1997 State Legislation,"
    codified at Me. Rev. Stat. tit. 22, § 3762(3)(B)(2), as amended),
    which empowered the state Department of Health and Human Services
    ("DHHS")       to   provide     medical    assistance      benefits    to   PRWORA-
    ineligible aliens residing in Maine.               Although these benefits were
    purely state-funded, this program was jointly administered with the
    federal-state cooperative Medicaid program for eligible citizens
    and qualified aliens, and both the state-funded program and the
    state Medicaid program became known as "MaineCare."                   In June 2011,
    however, the Maine Legislature passed Public Law 2011, chapter 380,
    section KK-4 (the "2011 State Legislation"), a budgetary measure
    that       terminated   state-funded       non-emergency     medical    assistance
    benefits for PRWORA-ineligible aliens residing less than five years
    in   the     United     States,   essentially       repealing   the    1997      State
    1
    We refer throughout this opinion to aliens absolutely barred
    from federal benefits by PRWORA's five-year residency requirement
    (such as the appellants here) as "PRWORA-ineligible aliens."
    -4-
    Legislation. In September 2011, DHHS sent form termination notices
    to   approximately   500   non-citizens,    informing   them   that   their
    MaineCare benefits were being terminated and that they would remain
    eligible only for emergency care benefits.
    The appellants Hans Bruns and Kadra Hassan represent a
    class of PRWORA-ineligible aliens residing in Maine and rendered
    ineligible for non-emergency medical assistance benefits as a
    result of the 2011 State Legislation.          Bruns filed this class
    action complaint against Mary Mayhew in her official capacity as
    the Commissioner of DHHS in April 2012, and moved for a preliminary
    injunction against enforcement of the 2011 State Legislation.           In
    the complaint, Bruns alleged that the state violated the Equal
    Protection Clause of the Fourteenth Amendment by continuing to
    provide MaineCare benefits to United States citizens while denying
    those benefits to similarly situated non-citizens due solely to
    their alienage.
    The Commissioner opposed the motion for a preliminary
    injunction, and also filed a motion to dismiss the complaint.           In
    November 2012, the district court denied without prejudice the
    Commissioner's    motion    to   dismiss.      Although    the   relevant
    legislative history and statutory provisions strongly suggested
    that the appellants were not similarly situated to United States
    citizens and eligible aliens receiving Medicaid and thus that they
    were not treated unequally by the state of Maine, the district
    -5-
    court concluded that this determination ultimately came too close
    to a factual finding and was therefore inappropriate to resolve on
    a motion to dismiss.
    In March 2013, the district court denied the appellants'
    motion for a preliminary injunction.     The court found that the
    state had effectively operated two separate medical assistance
    programs and that the appellants, as PRWORA-ineligible aliens
    receiving separately-funded benefits from a state program, were not
    similarly situated to recipients of federal Medicaid. Accordingly,
    the court concluded that the appellants were unlikely to succeed on
    the merits of their equal protection claim. Secondarily, the court
    also concluded that the appellants had not established a potential
    for irreparable harm.   This appeal followed.
    II.
    "We review the denial of a preliminary injunction under
    a deferential standard, reversing only upon finding a mistake of
    law, a clear error in fact-finding, or other abuse of discretion."
    Nat'l Org. for Marriage v. Daluz, 
    654 F.3d 115
    , 117 (1st Cir.
    2011).   To obtain a preliminary injunction, a plaintiff "must
    establish that he is likely to succeed on the merits, that he is
    likely to suffer irreparable harm in the absence of preliminary
    relief, that the balance of equities tips in his favor, and that an
    injunction is in the public interest." Winter v. Natural Res. Def.
    Council, Inc., 
    555 U.S. 7
    , 20 (2008). We have recognized the first
    -6-
    two factors, likelihood of success and of irreparable harm, as "the
    most important" in the calculus.    González-Droz v. González-Colón,
    
    573 F.3d 75
    , 79 (1st Cir. 2009).        The appellants argue that the
    district court erred in concluding that they had demonstrated
    neither a likelihood of success on the merits of their equal
    protection challenge nor a likelihood of irreparable harm absent a
    preliminary injunction. Because we hold that the appellants cannot
    succeed on the merits of their claim, we need not consider the
    likelihood of irreparable harm.
    The appellants argue that the termination of their state-
    funded medical benefits under the 2011 Legislation represented
    selective alienage-based treatment by the state of Maine.      In the
    appellants' estimation, the state's action discriminated against a
    suspect class and therefore warrants strict scrutiny, requiring the
    state to demonstrate that the alienage classification advances a
    compelling state interest by the least restrictive means available.
    The Commissioner advances no argument that the 2011 State
    Legislation would survive strict scrutiny.       Instead, the crux of
    the Commissioner's defense, and of the district court's ruling, is
    that Maine did not discriminate against aliens and in favor of
    citizens at all. The Commissioner suggests that the only alienage-
    based distinction implicated in this case was the one drawn by
    Congress in PRWORA, a distinction subject only to deferential
    -7-
    rational basis review in light of the federal government's broad
    authority over immigration and naturalization.
    This case thus intertwines a core question of equal
    protection jurisprudence, concerning the proper scope of comparison
    in determining whether a plaintiff is similarly situated to another
    group or entity treated more favorably under the law, with notions
    of federalism concerning the respective roles of federal and state
    governments in immigration policy and Medicaid alike.                   Before
    turning to the merits of this case, we therefore pause to limn some
    overarching equal protection principles in the context of alienage.
    A.     Equal Protection Framework
    In order to establish an equal protection violation, a
    plaintiff must show state-imposed disparate treatment compared with
    others similarly situated "'in all relevant respects.'" Barrington
    Cove Ltd. P'ship v. R.I. Hous. & Mortg. Fin. Corp., 
    246 F.3d 1
    , 8
    (1st Cir. 2001) (quoting Dartmouth Review v. Dartmouth Coll., 
    889 F.2d 13
    ,   19   (1st   Cir.   1989),    overruled   on    other   grounds    by
    Educadores Puertorriqueños en Acción v. Hernández, 
    367 F.3d 61
     (1st
    Cir. 2004)).       In determining whether two groups are similarly
    situated,    we   have   identified      the   somewhat    imprecise   test   as
    "whether a prudent person, looking objectively . . . would think
    them roughly equivalent."        Dartmouth Review, 
    889 F.2d at 19
    .            Put
    differently, "the proponent of the equal protection violation must
    show that the parties with whom he seeks to be compared have
    -8-
    engaged in the same activity vis-à-vis the government entity
    without such distinguishing or mitigating circumstances as would
    render the comparison inutile."         Cordi-Allen v. Conlon, 
    494 F.3d 245
    , 251 (1st Cir. 2007).
    Alienage,   like   race    and   nationality,    constitutes    a
    suspect classification under the Fourteenth Amendment.          See Graham
    v. Richardson, 
    403 U.S. 365
    , 372 (1971) (invalidating state-imposed
    alienage-based classifications).        Because "[a]liens as a class are
    a prime example of a 'discrete and insular' minority," a state's
    alienage-based    classifications       inherently   raise    concerns     of
    invidious discrimination and are therefore generally subject to
    strict judicial scrutiny.      
    Id.
     (quoting United States v. Carolene
    Prods. Co., 
    304 U.S. 144
    , 152-53 n.4 (1938)).                Though states
    traditionally enjoy broad power to regulate economics and social
    welfare, even the otherwise "valid interest in preserving the
    fiscal integrity of [state] programs" is generally insufficient
    grounds for a state-imposed burden on alienage to survive an equal
    protection challenge.     Id. at 374-75.
    The calculus is markedly different for congressional acts
    distinguishing on the basis of alienage, evaluated under the Due
    Process Clause of the Fifth Amendment.          See Mathews v. Díaz, 
    426 U.S. 67
    , 80-85 (1976) (holding that congressional alienage-based
    restrictions on federal Medicare benefits did not violate due
    process).    Unlike other suspect classifications such as race and
    -9-
    nationality,    congressional    disparate    treatment   of    aliens    is
    presumed   to   rest   on   national   immigration   policy    rather   than
    invidious discrimination. See 
    id. at 79-80
    . Because Congress acts
    with plenary authority when it legislates the rights and benefits
    to be afforded aliens present in this country, such congressional
    acts are appropriately afforded rational basis judicial review.
    See 
    id. at 80-85
    .       States do not share in this plenary federal
    power, though they obviously are impacted by its exercise.               See
    Plyler v. Doe, 
    457 U.S. 202
    , 225 (1982); Hampton v. Mow Sun Wong,
    
    426 U.S. 88
    , 95 (1976) ("Congress and the President have broad
    power over immigration and naturalization which the States do not
    possess.").     The Supreme Court has, however, stated that "if the
    Federal Government has by uniform rule prescribed what it believes
    to be appropriate standards for the treatment of an alien subclass,
    the States may, of course, follow the federal direction."          Plyler,
    
    457 U.S. at
    219 n.19.
    Because Medicaid, unlike Medicare, is not solely funded
    and administered by the federal government, this case does not fall
    neatly within the holding of Mathews.          On the other hand, the
    alienage-based distinction in this case does not originate purely
    from state legislation, unlike the restrictions struck down in
    Graham.    Instead, this case presents a Gordian knot of federal and
    state legislation effecting an adverse impact on resident aliens:
    a federal-state cooperative program (Medicaid), the eligibility for
    -10-
    which was subsequently limited on the basis of alienage by federal
    legislation (PRWORA), to which the state of Maine responded by
    first creating, and then terminating, supplemental state-funded
    medical assistance benefits for PRWORA-ineligible aliens only.                 We
    now examine this state legislation in more detail in order to
    properly evaluate the equal protection claim before us.
    B.       MaineCare
    In   concluding      that   the    appellants    were   unlikely    to
    succeed on the merits of their equal protection claim, the district
    court explained that "because there were two separate programs [in
    Maine]    distributing     medical       benefits   to      Medicaid-ineligible
    qualified aliens and citizens . . . [and] citizens were statutorily
    unable to receive health benefits under the same state-sponsored
    program, the Plaintiffs are unable [to] show [that] they were
    similarly situated with citizens for equal protection purposes."
    Bruns v. Mayhew, 
    931 F. Supp. 2d 260
    , 273 (D. Me. 2013).                       It
    arrived at this conclusion after a thorough analysis of the
    "[c]ontours of the [d]isputed [p]rograms," noting inter alia that
    "[t]he    statutorily     mandated      separate    funding    structures      for
    MaineCare, which receives federal and state funds, and the aliens-
    only program, which received only state funds post-PRWORA, is the
    first    indicator   of   [the    programs']     independence";     that   these
    separate funding structures "also signify that the programs were
    separately controlled by the governments that funded them"; and
    -11-
    that "the history of the benefit programs, specifically the federal
    government's express relinquishment of its former obligation to
    provide benefits for qualified aliens subject to the residency
    requirement and the State's decision to assume that obligation only
    underscores their autonomy."     
    Id. at 272-73
    .
    The appellants aver that "[t]he District Court erred as
    a matter of fact and law when it concluded that there was no class
    of citizens who were similarly situated to the Plaintiffs," because
    (in their view) Maine operated a "unitary medical assistance
    benefits program" for citizens and aliens alike.       To evaluate this
    contention, we begin where the district court did -- by examining
    the legal contours through which such publicly-funded benefits have
    been provided to Maine residents.
    As we have explained above, PRWORA seismically shifted
    the landscape of Medicaid funding in 1996. Despite the cooperative
    federal-state   nature   of   Medicaid   benefits,   PRWORA   classifies
    Medicaid as a "federal program" from which many subclasses of
    aliens are excluded, including legal residents who have not yet
    resided in this country for five years.      Participating states are
    statutorily obligated to alter Medicaid benefits available to their
    residents in order to remain compliant with evolving federal law.
    Nevertheless, in enacting PRWORA Congress authorized the states to
    provide purely state-funded welfare benefits to legal aliens, and
    in 1997, the state of Maine enacted legislation to ameliorate the
    -12-
    effects of PRWORA for legal aliens who would have remained eligible
    for Medicaid benefits but for PRWORA.         Maine therefore dispensed
    both the Medicaid medical assistance funds for eligible residents
    and the state supplemental medical assistance funds for PRWORA-
    ineligible alien residents under the auspices of MaineCare.              In
    2011, the state legislature repealed the 1997 State Legislation's
    grant of state supplemental medical assistance benefits for PRWORA-
    ineligible aliens.   At present, publicly-funded medical assistance
    remains available to eligible Maine residents through federal-state
    Medicaid funding still known locally as MaineCare.
    With this context established, we turn to the appellants'
    first contention that the district court erred in construing the
    1997 State Legislation as establishing a new state program distinct
    from Medicaid.    The 1997 State Legislation mandated that "funds
    must be expended"
    [t]o provide financial and medical assistance
    to certain noncitizens legally admitted to the
    United States. Recipients of assistance under
    this   subparagraph   are   limited   to   the
    categories of noncitizens who would be
    eligible for the TANF or Medicaid programs but
    for their status as aliens under PRWORA.
    Eligibility for the TANF and Medicaid programs
    for these categories of noncitizens must be
    determined using the criteria applicable to
    other recipients of assistance from these
    programs.
    Me. Pub. L. 1997, ch. 530, § A-16 (codified at Me. Rev. Stat. tit.
    22,   §   3762(3)(B)(2),   as     amended).       In       the   appellants'
    interpretation,   the   last    sentence   bespeaks    a    single   medical
    -13-
    assistance program provided by the state of Maine for citizens and
    aliens alike.   Parsing its language closely, they suggest that had
    the legislature intended to create a separate and distinct program
    for ineligible aliens, "it would have referenced other recipients
    of 'those programs,' rather than 'these programs.'"
    The appellants, however, gloss over the immediately
    preceding sentence, which expressly limits state assistance to "the
    categories of noncitizens who would be eligible for the TANF or
    Medicaid programs but for their status as aliens under PRWORA."
    This sentence clearly evinces the legislature's awareness that this
    subclass of aliens was ineligible for federally-sponsored Medicaid
    due to "their status as aliens under PRWORA."   We therefore agree
    with the Commissioner's suggestion that "a sensible reading of the
    final sentence" shows only that the legislature intended to utilize
    "the same eligibility standards (save citizenship requirements)"
    for PRWORA-ineligible aliens applying for state assistance as were
    utilized for Medicaid applicants.
    The appellants also allege that, in practice, Maine
    operated a single state healthcare program, MaineCare, which did
    not distinguish between eligible citizens and aliens on the one
    hand and PRWORA-ineligible aliens on the other.     The appellants
    emphasize, inter alia, that the state referred to all public
    medical assistance benefits as "MaineCare" and informed PRWORA-
    ineligible aliens in 2011 that their "MaineCare" benefits were
    -14-
    being changed; that the state applied the same eligibility criteria
    and used the same application form for all MaineCare applicants;
    that citizens and non-citizens received the same "full benefits";
    and that the state occasionally submitted its expenditures on
    PRWORA-ineligible aliens to the federal government, which later
    sought reimbursement from the state. The Commissioner acknowledges
    that the appellants' materials "collectively suggest that the Maine
    Department of Health and Human Services did not distinguish, both
    outwardly and in certain aspects of its internal administration,
    between the Medicaid benefit provided to citizens and eligible
    aliens and the state-created benefit that was provided to Medicaid-
    ineligible aliens."   Nevertheless, the Commissioner maintains that
    public perception and common administration do not render the
    federal-state Medicaid benefits and the state aliens-only benefits
    legally indistinct for equal protection purposes.
    We agree with the Commissioner.    The veneer of a single
    MaineCare program merely obscured the legal reality that, from 1997
    to 2011, MaineCare recipients received benefits from two distinct
    programs: one funded jointly by the federal and state governments,
    with the federal government retaining ultimate authority over,
    inter alia, eligibility criteria; and the other fully funded and
    controlled by the state government.    It was the federal government
    that determined the appellants' ineligibility for Medicaid benefits
    by enacting PRWORA, to which the state responded by extending
    -15-
    equivalent     state-funded   medical      assistance   benefits   to   the
    appellants for a time.
    The Ninth Circuit's analysis in Pimentel v. Dreyfus, 
    670 F.3d 1096
     (9th Cir. 2012), rejecting a comparable equal protection
    challenge to the termination of a state food assistance program for
    PRWORA-ineligible aliens only, is particularly instructive here.
    Like MaineCare, Washington's "Basic Food Program" jointly provided
    state-funded    food   assistance   to     PRWORA-ineligible   aliens   and
    federal Supplemental Nutrition Assistance Program ("SNAP") benefits
    to citizens and eligible aliens.           The agency employed a single
    application form and identical eligibility criteria for all aid
    recipients, and the aid recipients themselves were not informed of
    the source of their benefits.       
    Id. at 1101-02
    .     The state was also
    authorized to issue federal SNAP benefits to ineligible aliens so
    long as it then reimbursed the federal government for the value of
    the benefit and associated administrative costs.          
    Id. at 1100-01
    .
    The Ninth Circuit nevertheless held that "[t]he appearance of a
    single program does not overcome this fact: the two programs are,
    in reality, two separately administered programs funded by two
    distinct sovereigns," leaving the plaintiffs dissimilarly situated
    to SNAP recipients.     
    Id. at 1107
    .       The court elaborated:
    A careful consideration of the contours of the
    SNAP program, including the statutory scheme,
    source   of    funding,   extent    of   state
    involvement, and history, demonstrates that
    SNAP is a federal program which the state
    merely assists in administering, rather than a
    -16-
    state   program    which   receives federal
    assistance, and that its beneficiaries are
    differently situated from, and cannot be
    compared to, [the named plaintiff].
    
    Id. at 1108
    ; see also Hong Pham v. Starkowski, 
    16 A.3d 635
    , 654-55
    (Conn. 2011) (examining the contours of Medicaid and finding
    plaintiffs,    PRWORA-ineligible            aliens     formerly      receiving
    supplemental   state   medical    assistance         benefits,    dissimilarly
    situated to Medicaid recipients "[i]n light of the scope of federal
    control over the federal Medicaid program and the extent to which
    the federal government funds that program").
    Contrary    to   the   appellants'        suggestion    that     Maine
    operated a single state medical assistance program for all state
    residents, we therefore agree with the district court's conclusion
    that MaineCare comprised two separate medical assistance programs:
    federal-state cooperative Medicaid and a state supplemental program
    for   PRWORA-ineligible     aliens    only.          When   it   repealed    the
    supplemental aliens-only program, the state of Maine did not
    deprive the appellants of a benefit that it continued to provide to
    citizens -- or to anyone else, for that matter.             Consequently, the
    appellants cannot point to any similarly situated individuals who
    remain "engaged in the same activity vis-à-vis the government
    entity."   Cordi-Allen, 
    494 F.3d at 251
     (emphasis added); see also
    Hong Pham, 16 A.3d at 650 ("[T]he equal protection clause does not
    require the state to treat individuals in a manner similar to how
    others are treated in a different program governed by a different
    -17-
    government."); Pimentel, 670 F.3d at 1107; Soskin v. Reinertson,
    
    353 F.3d 1242
    , 1255-56 (10th Cir. 2004); Khrapunskiy v. Doar, 
    909 N.E.2d 70
    , 76-77 (N.Y. 2009).2
    The fact that Maine voluntarily participated in Medicaid
    does not alter our analysis.     By the appellants' logic, Maine's
    continued voluntary participation in Medicaid and compliance with
    PRWORA violated the Equal Protection Clause, requiring the state to
    either withdraw from Medicaid altogether or to create an equivalent
    state-funded   medical   assistance   benefit   for   PRWORA-ineligible
    aliens.   Of course, Maine did the latter for a time; according to
    the appellants, the state's termination of those equivalent state-
    funded benefits placed it in violation of the Equal Protection
    2
    In light of this distinction between federal and state
    action, we find the appellants' cases unpersuasive. Aliessa ex
    rel. Fayad v. Novello, 
    754 N.E.2d 1085
     (N.Y. 2001), addressed a
    state's discretionary imposition of alienage-based criteria for
    purely state-funded benefits, rendering the plaintiff aliens
    similarly situated to citizens still receiving these benefits.
    (The New York Court of Appeals itself later underscored this
    distinction in Khrapunskiy, 909 N.E.2d at 76-77.) Although Ehrlich
    v. Perez, 
    908 A.2d 1220
     (Md. 2006), invalidated the termination of
    a state-funded benefits program for PRWORA-ineligible aliens only,
    the Maryland court relied heavily on Aliessa without addressing
    this distinction. As for Unthaksinkun v. Porter, No. 11-588, 
    2011 WL 4502050
     (W.D. Wash. Sept. 28, 2011), Finch v. Commonwealth
    Health Insurance Connector Authority (Finch II), 
    959 N.E.2d 970
    (Mass. 2012), and Finch v. Commonwealth Health Insurance Connector
    Authority (Finch I), 
    946 N.E.2d 1262
     (Mass. 2011), these cases
    involved Medicaid "demonstration programs" rather than federal-
    state cooperative Medicaid programs per se.      See Finch II, 959
    N.E.2d at 974, 981 (explaining that Massachusetts' Commonwealth
    Care program, although federally-subsidized, was "State-initiated,"
    "entirely State-run," "entirely under State control, and not bound
    by uniform Federal rules").
    -18-
    Clause, just as it would have been had it never extended those
    benefits in the first place.
    The Equal Protection Clause does not place the state in
    such a Procrustean bed.          The fact that Congress discriminated on
    the basis of alienage in enacting PRWORA does not also establish
    alienage-based      discrimination      by     Maine   merely   because      of   its
    continued Medicaid participation and required compliance with
    PRWORA.    While the federal government determines certain baseline
    eligibility      requirements     and    selects       particular     classes     of
    categorically needy persons who are eligible to receive Medicaid
    benefits,    a   state,     by   choosing      to   participate     in    Medicaid,
    generally adopts the grouping of federal eligibility requirements
    as a whole.      Like the Hong Pham court, we therefore conclude that
    if Maine can be said to have "discriminated" at all, it only did so
    on   the    basis    of     federal     Medicaid       eligibility,      a   benign
    classification subject to mere rational basis review.                    See id. at
    659; cf. Soskin, 
    353 F.3d at 1255-56
    .
    Like    other    courts     facing      similar   post-PRWORA     equal
    protection claims, we therefore conclude that the state was under
    no constitutional obligation to "fill the gap" created by PRWORA by
    extending equivalent state-funded benefits to federally-ineligible
    aliens.    See Korab v. Fink, No. 11-15132, 
    2014 WL 1302614
    , at *2,
    *9 (9th Cir. Apr. 1, 2014); Pimentel, 670 F.3d at 1109; Hong Pham,
    16 A.3d at 661; Khrapunskiy, 909 N.E.2d at 77; cf. Sudomir v.
    -19-
    McMahon, 
    767 F.2d 1456
    , 1465-66 (9th Cir. 1985). Because Maine was
    not obligated to extend equivalent state-funded benefits to the
    appellants in the first place, it follows that the termination of
    those benefits does not violate the Equal Protection Clause.                     See
    Pimentel, 670 F.3d at 1109-10; Hong Pham, 16 A.3d at 661.
    As     a    last   stand,   the    appellants     rely   on   Graham's
    proclamation that Congress "does not have the power to authorize
    the individual States to violate the Equal Protection Clause." 
    403 U.S. at 382
    .        More   specifically,      they    contend    that   "[t]he
    Commissioner cannot seek shelter for her equal protection violation
    in Congress's enactment of PRWORA" because PRWORA did not "create
    a national uniform immigration policy with respect to access to
    medical care," and instead left "the decision of whether to provide
    medical assistance for medically indigent non-citizens who have
    been in the country less than five years to the individual states."
    However, as we have explained above, the appellants' argument rests
    on the assumption that a state's mere participation in Medicaid,
    subject to PRWORA's mandatory eligibility restrictions, represents
    alienage-based         discrimination.        Because    we   conclude    that   the
    state drew no distinctions on the basis of alienage, Graham's
    proscription does not apply here, and we therefore need not reach
    -20-
    the question of whether Maine acted in accordance with uniform
    federal policy.3
    In short, the disparate treatment challenged by the
    appellants is not attributable to legislation enacted by the state
    of Maine.   Instead, the appellants are experiencing the impact of
    a congressional decision -- PRWORA's mandatory five-year residency
    requirement -- restricting their eligibility for public welfare
    benefits, including federal-state cooperative programs such as
    Medicaid.     As a result, there is no class of similarly situated
    citizens with whom the appellants can be compared vis-à-vis the
    state of Maine.      We therefore conclude that the appellants' equal
    protection claim fails on the merits and that the district court
    properly    denied    the   appellants'    request   for   a   preliminary
    injunction.
    C.       Dismissal
    One final task remains.       The Commissioner requests that
    we remand and order the district court to dismiss this case
    outright.     The request is a sound one.      We may remand a case for
    dismissal after reviewing a district court's preliminary injunction
    3
    Even assuming arguendo that Maine discriminated on the basis
    of alienage in declining to extend state-funded benefits to PRWORA-
    ineligible aliens, we question whether the state's action would in
    fact run afoul of Graham. We need not decide the question today,
    but we note that both the Ninth and Tenth Circuits have held that
    PRWORA represents a uniform federal policy such that a state's
    exercise of its discretion under 
    8 U.S.C. §§ 1612
    (b) and 1622(a)
    garners only rational basis review under Plyler. See Korab, 
    2014 WL 1302614
    , at *8; Soskin, 
    353 F.3d at 1255
    .
    -21-
    order, see First Med. Health Plan, Inc. v. Vega-Ramos, 
    479 F.3d 46
    ,
    50-51 (1st Cir. 2007), and we do so here.
    In order to survive a motion to dismiss, a complaint
    "must provide fair notice to the defendants and state a facially
    plausible legal claim."      Ocasio-Hernández v. Fortuño-Burset, 
    640 F.3d 1
    , 12 (1st Cir. 2011). "Non-conclusory factual allegations in
    the complaint must [] be treated as true, even if seemingly
    incredible," 
    id.,
     but a court is "'not bound to accept as true a
    legal conclusion couched as a factual allegation,'" Bell Atl. Corp.
    v. Twombly, 
    550 U.S. 544
    , 555 (2007) (quoting Papasan v. Allain,
    
    478 U.S. 265
    , 286 (1986)).
    In its order denying without prejudice the Commissioner's
    motion to dismiss for failure to state a claim, the district court
    was decidedly skeptical as to the merits of the appellants' equal
    protection claim, and allowed the case to go forward "despite some
    misgivings."    Bruns v. Mayhew, No. 12-131, 
    2012 WL 5874812
    , at *13
    (D. Me. Nov. 20, 2012).       Nevertheless, the district court felt
    constrained by the deferential pleading standard and found "the
    line between factual allegation and legal conclusion [] too murky
    for a clean and decisive resolution," because in its opinion the
    question   of   whether   Maine   operated   separate   medical   benefits
    programs appeared to be "a factual issue."        
    Id. at *9, *13
    .
    In opposing dismissal, the appellants agree with the
    district court's reasoning and also point to the Ninth Circuit's
    -22-
    analysis in Pimentel, which looked to the "the statutory scheme,
    source of funding, extent of state involvement, and history" to
    determine whether recipients of state-funded food assistance were
    similarly situated to federal SNAP recipients.                    670 F.3d at 1108.
    The appellants err, however, in framing Pimentel's analysis as a
    "factual inquiry."         The Pimentel court focused almost exclusively
    on the legal contours of the federal and state food assistance
    programs, and not at all on the plaintiffs' factual allegations
    regarding the administration and appearance of the programs.
    Indeed,   the     court     explicitly     stated,        "The     statutory     scheme
    establishes that the SNAP program is federal."                        Id. (emphasis
    added).
    Likewise, both the appellants' underlying complaint and
    our own analysis in this case are grounded in law rather than fact.
    The appellants set forth Maine's purportedly unconstitutional
    legislative      actions    in     a   section       of   their    complaint     titled
    "Statutory Framework," separate from the "Factual Allegations"
    section describing the individual appellants' medical conditions
    and   denial     of   benefits.         That    section      is    rife   with    legal
    conclusions, stating inter alia that "PRWORA did not prescribe a
    uniform   rule    for     the     treatment     of    aliens";     that   "[a]lthough
    MaineCare      benefits     for    [PRWORA-ineligible]            non-citizens    were
    exclusively state-funded while United States citizen benefits were
    jointly funded by the federal and state governments, this did not
    -23-
    create an independent state Medicaid program for lawful permanent
    residents in Maine"; and that the 2011 Legislation "den[ied] non-
    citizens lawfully residing in Maine full MaineCare coverage while
    allowing similarly situated United States citizens to retain those
    same MaineCare benefits."
    In finding no equal protection violation in this case, we
    have taken as true the appellants' allegations that Maine's state-
    funded    supplemental   medical   assistance   benefits   for   PRWORA-
    ineligible aliens were jointly administered with, and outwardly
    indistinguishable from, the Medicaid benefits enjoyed by citizens
    and eligible aliens. We reject only their legal conclusions, which
    we are under no obligation to accept.        See Twombly, 
    550 U.S. at 555
    .
    The appellants alternatively suggest that even if strict
    scrutiny is unwarranted, dismissal is nevertheless inappropriate
    because they are entitled to discovery on the question of whether
    Maine's actions would violate the Equal Protection Clause under
    more deferential review.      More specifically, they suggest that
    discovery may uncover evidence of a discriminatory animus against
    aliens, invalidating the state's action even under rational basis
    review.     This argument is doubly flawed.        First, as we have
    explained above, as a matter of law, Maine did not discriminate on
    the basis of alienage at all.      Second, and more fundamentally, the
    appellants' underlying complaint does not allege discriminatory
    -24-
    animus on the part of the state, nor does it anywhere suggest that
    Maine's actions violated the Equal Protection Clause even under
    rational basis review.      The appellants therefore cannot salvage
    their complaint now by invoking such a claim for the first time.
    See Alicea v. Machete Music, No. 12-1548, 
    2014 WL 888909
    , at *6
    (1st Cir. Mar. 7, 2014) ("The plaintiffs' failure to adequately
    raise this argument below dooms it on appeal."); Iverson v. City of
    Boston, 
    452 F.3d 94
    , 102 (1st Cir. 2006) ("[T]heories not squarely
    and timely raised in the trial court cannot be pursued for the
    first time on appeal.").
    III.
    For the foregoing reasons, the appellants have failed to
    state a claim under the Equal Protection Clause.           We therefore
    affirm the district court's denial of a preliminary injunction and
    remand   with    instructions   that   the   appellants'   complaint   be
    dismissed.
    -25-