Oral argument: Mar. 28, 2012<\/p>\n
Appealed from: United States Court of Appeals for the Eleventh Circuit<\/a> (Aug. 12, 2011)<\/p>\n Congress established Medicaid in 1965 as way to provide health care to needy individuals in the United States. The program set forth several categories into which potential enrollees could fall. The categories took into account income level, existing medical conditions, and various other factors. The federal government imposes certain conditions on individual state-run Medicaid programs in exchange for federal funding for those programs. In 2010, President Obama signed the Patient Protection and Affordable Care Act, which will expand Medicaid to cover all persons below 133% of the poverty line, regardless of other factors. Florida and several other states filed a lawsuit arguing that this expansion represented an unconstitutional act beyond the scope of Congress\u2019s spending power. Florida argued that the size of the program and lack of a specific alternative to participation effectively coerces states into complying with federal government’s conditions to funding. The Department of Health and Human Services argues that each state has the legal right to abstain from the program, and that the size of the program and the amount of funding involved should not determine whether the conditions are coercive. The Supreme Court’s decision in this case will affect access to health care for needy individuals, the expansiveness of state sovereignty, and the financial burden imposed on the states.<\/p>\n Does Congress exceed its enumerated powers and violate basic principles of federalism when it coerces States into accepting onerous conditions that it could not impose directly by threatening to withhold all federal funding under the single largest grant-in-aid program, or does the limitation on Congress’s spending power that this Court recognized in\u00a0South Dakota v. Dole<\/em>, 483 U.S. 203 (1987), no longer apply?<\/p>\n top<\/a><\/p>\n Whether Congress, through its spending power, has the authority to impose conditions on funding that force states to choose between accepting those conditions and receiving federal funding and not accepting those conditions and forfeiting all federal Medicaid funding.<\/p>\n top<\/a><\/p>\n The Medicaid Program Prior to Expansion<\/em><\/p>\n Congress established Medicaid<\/a> in 1965 to provide federal reimbursement to states that voluntarily funded certain types of health care for specified categories of low-income residents. See Florida v. U.S. Dept. of Health & Human Services<\/a><\/em><\/strong>, 648 F.3d 1235, 1262 (11th Cir. 2011); 42 U.S.C. \u00a71396<\/a>. <\/strong>While the federal government established\u00a0 categories of eligible individuals, states were initially left to their own discretion to establish eligibility requirements for participation. See Brief for Petitioner<\/a><\/em><\/strong>, Florida et al. at 2.<\/strong> While not all states initially chose to participate, Medicaid participation increased considerably over the first few years of the program\u2019s existence. See id.<\/a><\/em><\/strong> at 3. <\/strong><\/p>\n Congress altered Medicaid for the first time in 1972 when it established the Supplemental Security Income for the Aged, Blind, and Disabled<\/a> (\u201cSSI\u201d), which created a single federal program that replaced state-run programs for the aged, blind, and disabled. See id.<\/a> <\/em><\/strong>This shift meant that, in some states, a greater number of individuals would be eligible for SSI assistance than had been eligible for care under state-run programs. See id.<\/a> <\/em><\/strong>at 4. <\/strong>Congress did not mandate that states adopt these eligibility criteria; instead it gave states the option of either expanding coverage to all individuals then eligible under SSI, or maintaining the coverage as it existed under the then current Medicaid plan. See id.<\/a><\/em><\/strong> Following the establishment of SSI, states\u2019 Medicaid participation and coverage continued to expand to the point that the Supreme Court<\/a> recognized that the federal component was essential to a state\u2019s ability to adequately provide healthcare to its residents. See id.<\/a><\/em><\/strong><\/p>\n By the 1980s, every state was participating in Medicaid, and Congress continued to expand the scope of Medicaid coverage. See Brief for Respondent<\/a>,<\/em><\/strong> Dep\u2019t. Health and Human Services <\/em><\/strong>at 6\u20137. <\/strong>The expansions included the imposition of mandatory requirements on the states; for example, coverage of children and pregnant women was required for continued state participation in Medicaid. See id.<\/a> <\/em><\/strong>Congress also encouraged states to expand coverage by increasing the available funding. See<\/em><\/strong> Brief for Petitioner<\/a> <\/em><\/strong>at 6. <\/strong>In most categories, however, Congress continued to allow states the discretion to choose the extent of the coverage they would provide. See id.<\/a><\/em><\/strong><\/p>\n The Health Care Act\u2019s Expansion of Medicaid<\/em><\/p>\n In 2010, President Obama<\/a> signed the Patient Protection and Affordable Care Act<\/a> (\u201cHealthcare Act\u201d), which expanded the Medicaid program to require states to provide healthcare to individuals under the age of 65 receiving income below 133% of the federal poverty level<\/a>. See Florida v. U.S. Dep’t. Health and Human Services<\/a>, <\/em><\/strong>780 F.Supp. 2d 1256, 1262. <\/strong>The Health Care Act provides that the federal government will initially cover the entire cost of care for newly eligible individuals. See id.<\/a><\/em><\/strong> at 1263.<\/strong> After 2016, the amount of federal coverage will decrease slightly each year until 2020, at which point federal cost coverage will remain steady at 90% of the cost of care for individuals made newly eligible under the Healthcare Act. See id.<\/a> <\/em><\/strong><\/p>\n Lower Court Proceedings<\/em><\/p>\n After the passage of the Health Care Act, Florida and twenty-five other states (\u201cthe States\u201d) filed suit, arguing that the expansion of Medicaid was unconstitutional because it violated the Spending Clause of the Constitution and the Ninth and Tenth Amendments. See Florida v. U.S. Dep’t. of Health and Human Services<\/a>, <\/em><\/strong>780 F.Supp. 2d at 1264. <\/em><\/strong>The United States District Court for the Northern District of Florida<\/a> granted summary judgment<\/a> to the government, holding that the Medicaid expansion is constitutional. See id.<\/a> <\/em><\/strong>at 1240\u201341.<\/strong> The States appealed the ruling on the Medicaid claim, but the Eleventh Circuit affirmed the district court, holding that the States failed to demonstrate coercion. See id.<\/a> <\/em><\/strong>at 1328. <\/strong><\/p>\n top<\/a><\/p>\n Florida and its supporters argue that the Medicaid expansion coerces the states into accepting its new requirements by making it financially unfeasible to opt out of Medicaid, and therefore is an abuse of Congress\u2019s spending power and an encroachment on state sovereignty. See<\/em><\/strong> Brief for Petitioner<\/a> at 31\u201332. <\/strong>Supporters of the Department of Health and Human Services, on the other hand, insist that the expansion of Medicaid merely enables, but does not force, the states to expand health coverage at a minimal cost to the states themselves. See Brief of Amici Curiae the States of Oregon et al. (\u201cOregon\u201d)<\/a><\/em><\/strong> in Support of Respondents at 9, 12.<\/strong><\/p>\n Access to Affordable Healthcare and the Financial Burden on the States<\/em><\/p>\n A group of state legislators praise the expansion of Medicaid, and contend that it will allow for an immense reduction in the number of uninsured Americans, with little or no cost to the states. See Brief of Amici Curiae State Legislators from the 50 States, the District of Columbia, and Puerto Rico<\/a><\/em><\/strong> (“Brief of State Legislators”) at 11.<\/strong> Oregon contends that the Health Care Act sets a higher bar for all states by extending mandatory eligibility requirements. See<\/em><\/strong> Brief of Oregon<\/a> <\/em><\/strong>at 19. <\/strong>Oregon argues that Medicaid expansion is a positive development because the Health Care Act facilitates and furthers the ability of leading healthcare states to experiment with different methods of providing health care. See id.<\/a><\/em><\/strong> at 10\u201311. <\/strong><\/p>\n Florida argues that states that fail to meet the onerous requirements of the new Medicaid face the potential loss of billions of dollars of federal aid. See<\/em><\/strong> Brief for Petitioner<\/a> at 39. <\/strong>In support of Florida, the Association of American Physicians (\u201cPhysicians\u201d) adds that health care spending threatens the financial stability of states more than any other factor. See<\/em><\/strong> Brief of Amicus Curiae Association of American Physicians (“Physicians”)<\/a> at 5.<\/strong> The Physicians argue that essentially mandating that states increase health care spending through the expansion of Medicaid places unavoidable fiscal pressure on the states when many of them already struggle financially. See id.<\/a><\/em><\/strong><\/p>\n Oregon, on the other hand, maintains that the Medicaid expansion can be a financial boon to the states. See<\/em><\/strong> Brief of Oregon<\/a> at 13. <\/strong>According to Oregon, the Health Care Act Medicaid expansion is necessary because without it, states could face increased enrollment without the advantage of a proportional increase in federal funding. See id.<\/a><\/em><\/strong> at 12\u201313. <\/strong>Oregon argues that without national reform, states would be practically unable to expand their own Medicaid programs for fear of overburdening their system with applicants from other states that provide fewer health care benefits. See id.<\/a> <\/em><\/strong>at 7. <\/strong>Oregon contends that if Medicaid is expanded across all participating states, enrollment can increase without costs falling to just a few states. See id.<\/a><\/em><\/strong> at 7\u20138.<\/strong><\/p>\n Federalism and State Sovereignty<\/em><\/p>\n On behalf of Florida, the American Civil Rights Union (\u201cACRU\u201d) insists that Congress\u2019s imposition of mandatory requirements on the states directly threatens federalism<\/a>. See<\/em><\/strong> Brief of Amicus Curiae American Civil Rights Union (“ACRU”)<\/a> at 11, 16. <\/strong>The ACRU argues that Congress\u2019s coercion of the states into participation in the expanded Medicaid program interferes with state sovereignty. See id.<\/a> <\/em><\/strong>at 11, 15. <\/strong>The ACRU argues that the Health Care Act\u2019s expansion of Medicaid disrupts this balance, overreaching the limits of Congress\u2019s power by removing the states\u2019 discretion in their application of Medicaid. See id.<\/a> <\/em><\/strong>at 15\u201316.<\/strong><\/p>\n The Department of Health and Human Services (\u201cHHS\u201d) and its supporters agree that Congress\u2019s spending power, if unconstrained, could undermine State authority and local policy preferences. See Brief of Oregon<\/a><\/em><\/strong> at 7. <\/strong>However, HHS argues that Medicaid expansion does not exceed the constitutional limits of Congress\u2019s spending power, which includes the power to set conditions with which the states must comply in exchange for the benefit of federal funds. See<\/em><\/strong> Brief for Respondent<\/strong><\/a> at 21\u201322.<\/strong> Similarly, Oregon insists that the Health Care Act\u2019s expansion of Medicaid does not usurp the flexibility and autonomy of the states. See id.<\/a> <\/em><\/strong>at 9\u201310. <\/strong>In fact, Oregon argues, far from crippling the power of the states, federal action can aid the states in pursuing their desired policies. See id.<\/a><\/em><\/strong> at 7\u20138. <\/strong>A group of state legislators argue that Medicaid expansion actually furthers cooperation between the federal government and the states by allowing states that want to make health care more widely available achieve their goals through voluntary partnership with the federal government. See Brief of State Legislators<\/a><\/em><\/strong> at 6. <\/strong>Oregon contends that the Court\u2019s acceptance of Florida\u2019s coercion argument would halt this federal and state cooperation, freezing Medicaid in time and preventing it from meeting changing healthcare needs. See Brief of Oregon<\/a> <\/em><\/strong>at 27. <\/strong><\/p>\n top<\/a><\/p>\n Constitutional Limitations on the Congressional Spending Power<\/em><\/p>\n Florida argues that the Supreme Court should reaffirm the limitations of Congress\u2019s spending power<\/a> by declaring the Medicaid expansion contained in the Health Care Act unconstitutional. See<\/em><\/strong> Brief for Petitioner<\/a>, Florida et al. at 24, 32<\/strong>. Florida asserts that if the Supreme Court fails to rule in its favor, the court will have failed to limit the spending power in any way. See id.<\/a> <\/em><\/strong>at 32. <\/strong>Florida argues that because this case involves a particularly serious abuse of the spending power, the precedent set by a ruling against Florida would mean future spending power acts would never fall outside of constitutional limitation. See id.<\/a><\/em><\/strong> Florida maintains that in United States v. Butler<\/em><\/a>, the Supreme Court held that Congress may not use its spending power as an \u201cinstrument for total subversion of the governmental powers reserved to the individual states.\u201d See id.<\/a> <\/em><\/strong>at 26.<\/strong> Florida maintains that upholding the Medicaid expansion provision would represent an unprecedented increase in Congressional power and would violate the holding of Butler<\/em>. See id.<\/a> <\/em><\/strong>at 32.<\/strong> Florida argues that the expansion of Medicaid is the federal government commandeering tax dollars to coerce the states. See id.<\/a><\/em><\/strong> at 40\u201341.<\/strong> The federal government is prohibited from taking such actions to use state governments to accomplish what would be unconstitutional for the federal government to do itself. See id.<\/a><\/em><\/strong> at 29.<\/strong> If such action is upheld, Florida argues, all measures to restrict the power of the federal government will become meaningless. See id.<\/a><\/em><\/strong> at 32.<\/strong> Florida argues that with this as precedent, Congress will have the ability use the spending power to circumvent constitutional restrictions. See id.<\/a> <\/em><\/strong>at <\/em><\/strong>59.<\/strong> Florida argues that the anti-coercion doctrine must be taken seriously and should apply here to prevent a limitless federal government. See id.<\/a><\/em><\/strong><\/p>\n In contrast, the Department of Health and Human Services (\u201cHHS\u201d) argues that the Congressional spending power is broad, and that the expansion of Medicaid falls within this power. See<\/em><\/strong> Brief for Respondent<\/a>, Department of Health and Human Services at 20, 24. <\/strong>HHS argues that the restrictions on the spending power of Congress enumerated in South Dakota v. Dole<\/em><\/a> allow Congress to spend to promote the general welfare, as long as conditions on funding are made clear and unambiguous and the conditions are related to the federal program. See id.<\/a><\/em><\/strong> at 21\u201322.<\/strong> HHS contends that as long as Congress complies with the restrictions, Congress has broad power to advance its policy objectives through the use of the spending power. See id.<\/a><\/em><\/strong> at 22.<\/strong> HHS maintains the expansion of Medicaid is a valid use of this very power. See AFFORDABLE CARE ACT, MEDICAID, SPENDING POWER, FEDERALISM<\/h2>\n
Question presented<\/h2>\n
Issue<\/h2>\n
Facts<\/h2>\n
Discussion<\/h2>\n
Analysis<\/h2>\n