Abstract

Although the individual mandate was upheld and the Commerce Clause may have been cabined, the decision to strike down a significant element of the “Medicaid expansion” may prove to be the most significant aspect of the Supreme Court’s decision in NFIB v. Sebelius. Under the Affordable Care Act (ACA), States were required to extend Medicaid coverage to all individuals under the age of 65 with incomes below 133 percent of the poverty line, a new “essential health benefits” package was required for all new Medicaid recipients, and the increased costs due to the expansion would be entirely covered by the Federal government through 2016, with the Federal payment gradually decreasing to a minimum of 90 percent of the total cost from the expanded coverage. The element found to be unconstitutional was §1396c of the ACA, which permitted the withdrawal of all Federal Medicaid funds from those States that did not comply with the ACA’s requirements for Medicaid expansion. The effect on access to health care may be significant: roughly half of those expected to gain coverage under the ACA were going to gain it through the Medicaid expansion; it is unclear how many States will choose to opt into that expansion in the absence of §1396c.1 Additionally, the argument offered by the Court to strike down that provision might be used to attack other federal programs—concerning transportation, social services, environmental protection, and others—that have a similar structure. This paper will demonstrate that the argument rests on a theoretical mistake concerning the relationships between coercion, compulsion, and political accountability and that, further, this mistake is not one legally forced upon the Court.