{ "id": "R42367", "type": "CRS Report", "typeId": "REPORTS", "number": "R42367", "active": true, "source": "EveryCRSReport.com, University of North Texas Libraries Government Documents Department", "versions": [ { "source": "EveryCRSReport.com", "id": 410401, "date": "2012-07-17", "retrieved": "2016-04-06T21:44:59.502640", "title": "Medicaid and Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis", "summary": "In March 2010, Congress passed the Patient Protection and Affordable Care Act (ACA). The ACA, among other things, requires states to expand Medicaid eligibility or lose Medicaid funding. Following the enactment of the ACA, state attorneys general and others brought several lawsuits challenging various provisions of the act on constitutional grounds. In National Federation of Independent Business (NFIB) v. Sebelius, the Supreme Court, among other things, decided that the enforcement mechanism for the ACA Medicaid expansion, withdrawal of all Medicaid funds, was a violation of the Tenth Amendment. The Court went on to hold, however, that the remedy was to sever that enforcement mechanism, effectively making state participation in the Medicaid expansion voluntary.\nIn the 1987 case of South Dakota v. Dole, the Supreme Court held that, in order for a federal grant condition imposed on a state to pass constitutional muster under the Spending Clause, the condition must be related to the particular national projects or programs to which the money was being directed. In addition, in order to comply with the limits of the Tenth Amendment, the level of funds withheld for failure to comply with that condition cannot be coercive. In a controlling opinion in NFIB, Justice Roberts suggested that this analysis may vary based on the type of grant condition that was at issue. It is unclear, however, whether NFIB significantly changed the Dole analysis, or whether the combination of factors that led the Court\u2019s decision to limit how ACA Medicaid expansion would be enforced is likely to be repeated.\nFor instance, if a grant condition is directly related to the expenditure of federal funds in a state program or activity, then, according to Justice Robert\u2019s opinion in NFIB, the condition is usually constitutional under the Spending Clause. Or even if a grant condition is only generally related to the policy goals of the underlying grant, NFIB suggests that withdrawal of all program funds would still, in most foreseeable cases, be constitutional under the Spending Clause and the Tenth Amendment. If a grant condition is unrelated to the general policy goals of the underlying grant, however, then it is most likely unconstitutional under the Spending Clause. This latter standard, however, has been in place since the Dole case, and no court has ever struck down a federal law on this basis. \nJustice Roberts\u2019 concern in NFIB arguably dealt with a different question: whether a grant condition attached to a new and independent program (here, the Medicaid expansion) which threatens the funding of an existing program (here Medicaid) is constitutional. In such cases, if the withholding of federal funding represents a significant portion of a state\u2019s budget, and there are distinguishing factors among the programs, then that condition may be unconstitutionally coercive under the Tenth Amendment. Justice Roberts did not identify a standard to determine what level of withholding funds would be coercive, or specify what kind of distinguishing factors were necessary. He did conclude, however, that withdrawal of federal program funds which made up 10% of an average state\u2019s budget represented a \u201cgun to the head\u201d and was a form of \u201ceconomic dragooning.\u201d \nHow courts are to consider grant withdrawals below 10%, however, is not addressed by the Roberts\u2019 opinion, and Justice Roberts declined to speculate where such a line would be drawn. It should be noted, however, that few federal programs even approach the level of Medicaid funds provided to the states. Thus, if the 10% threshold and the need for distinguishing factors mark the outer limits of Congress\u2019s power, then the case may have minimal effect on existing or future federal grant conditions.", "type": "CRS Report", "typeId": "REPORTS", "active": true, "formats": [ { "format": "HTML", "encoding": "utf-8", "url": "http://www.crs.gov/Reports/R42367", "sha1": "90f58698c14d89f6762dd8a48a3d7e2d6eae8cf8", "filename": "files/20120717_R42367_90f58698c14d89f6762dd8a48a3d7e2d6eae8cf8.html", "images": null }, { "format": "PDF", "encoding": null, "url": "http://www.crs.gov/Reports/pdf/R42367", "sha1": "a89885d16da5c5604c8d7900024f5f433ecb4805", "filename": "files/20120717_R42367_a89885d16da5c5604c8d7900024f5f433ecb4805.pdf", "images": null } ], "topics": [ { "source": "IBCList", "id": 2164, "name": "Federalism" }, { "source": "IBCList", "id": 3746, "name": "Health Care Reform" }, { "source": "IBCList", "id": 594, "name": "Medicaid and CHIP" } ] }, { "source": "University of North Texas Libraries Government Documents Department", "sourceLink": "https://digital.library.unt.edu/ark:/67531/metadc816783/", "id": "R42367_2012Feb21", "date": "2012-02-21", "retrieved": "2016-03-19T13:57:26", "title": "Federalism Challenge to Medicaid Expansion Under the Affordable Care Act: Florida v. Department of Health and Human Services", "summary": null, "type": "CRS Report", "typeId": "REPORT", "active": false, "formats": [ { "format": "PDF", "filename": "files/20120221_R42367_52186a7749d3bef3efae0fcbdf869df1ab9b480b.pdf" }, { "format": "HTML", "filename": "files/20120221_R42367_52186a7749d3bef3efae0fcbdf869df1ab9b480b.html" } ], "topics": [] } ], "topics": [ "Constitutional Questions" ] }