My CAP colleague and workforce guru Ellen-Marie Whelan is out with a new paper examining how community health centers (CHC) — one of the few portions of the health care law that both Republicans and Democrats can agree on — will help create jobs and stimulate local economies. As if answering the GOP’s age-old mantra of “where are the jobs?,” Whelan argues that at least 400,000 of them are in CHCs.

According to Whelan’s analysis, “the nearly $2 billion investment from the stimulus act, for example, generated $3.2 billion of economic activity in 2009, with health centers generating approximately $20 billion in economic activity for the communities where they are located.” By extension, the new funding for CHCs that’s part of health care reform ( $11 billion over 5 years) “will generate $54 billion in economic activity in 2015, with $33 billion of this a direct result of the additional investment in the new law” — that’s 457,300 jobs by 2015.

Whelan explains the job creation spiral this way: 1) health centers directly employ people in their communities, including key entry-level jobs, training, and other community-based opportunities. 2) health centers then purchase goods and services from local businesses and expand and build new locations. “These new health centers and the businesses that have ramped up to serve the centers also must hire new employees,” she writes. “Every dollar spent and every job created by health centers has a direct impact on their local economies.”

As pretty as these numbers are, they obscure some of the difficulties in getting community health centers off the ground and attracting enough primary care physicians to keep up with the expansion of services. In fact today’s Washington Post reports on the struggles primary care providers face in decidedly rural and underserved districts and the institutional and financial obstacles they have to overcome to keep those clinics running. The government has already invested “$1 billion from the stimulus and the health-care law into the National Health Services Corps to beef up doctor recruitment,” but I suspect that if we’re going to double the number of community center (and provide them with the resources they need) much more will be needed.

Late last week, the 21 right-wing state officials challenging the Affordable Care Act in a federal court in Florida filed a brief defending their right to be in court.  Although much of their brief simply rehashes Virginia Attorney General Ken Cuccinelli’s tired attacks on the provision requiring nearly all Americans to carry insurance, the Florida lawsuit also includes a truly unique attack on the health care safety net.  According to these 21 state governors and attorneys general, the post-ACA version of Medicaid is unconstitutional because it is too generous to the states:

“Medicaid is the single largest Federal grant-in-aid program to the States, accounting for over 40 percent of all Federal grants to States.” Taking Florida as an example, 26 percent of its budget presently is devoted to Medicaid outlays. In recent years, Florida on average has paid 44.55 percent of total Medicaid spending under its program, with the federal government contributing 55.45 percent. For Florida to establish its own Medicaid program offering the same level of benefits that 2.7 million participants now receive, Florida’s outlays would have to be more than doubled, to the point of consuming more than 58 percent of its budget.

The Hobson’s Choice “offered” by Congress inflicts a “strain” on Plaintiff States sovereignty and fiscs that is “equivalent to undue influence.” The Act’s coercion and impact on State sovereignty violate Article I and the Ninth and Tenth Amendments, as alleged in Count Four.

To make sense of this gobbledygook, one must first understand how the Constitution allocates power between the federal government and the states.  On the one hand, Congress is forbidden from simply ordering a state to behave in a certain way — an principle that constitutional lawyers refer to as the “anti-commandeering” doctrine.  On the other hand, Congress has broad authority to entice states into action by offering them a federal grant which provides the state with money, but only if the state agrees to comply with certain conditions.  The state is always free to turn down this grant, but if it takes the money, it has to comply with its agreement to also obey the conditions.

Medicaid is the largest existing conditional grant program, and these right-wing officials essentially argue that, even though they have decided to take the money that Medicaid offers, they can refuse to comply with the conditions on that money because Medicaid is such a good deal than they couldn’t possibly refuse it.

This novel claim is based in a statement in the Supreme Court’s decision in South Dakota v. Dole that “in some circumstances the financial inducement offered by Congress might be so coercive as to pass the point at which ‘pressure turns into compulsion.’”  The justices, however, have literally never held that a conditional grant is “so coercive” as to be unconstitutional, and the lower courts universally reject the claim that Medicaid is unconstitutional just because it is a good deal for the states:

[I]n California v. United States, the Ninth Circuit sustained a Medicaid requirement that States provide emergency medical services to illegal aliens, even though the state contended that it had “no choice but to remain in the [Medicaid] program in order to prevent a collpse of its medical system.”  In Padavan v. United States, the Second Circuit rejected the argument that the same Medicaid requirement amounted to “commandeering” for the obvious reason . . . that state participating in Medicaid is voluntary.  Similarly, in Kansas v. United States, the Tenth Circuit sustained conditions on federal block grants, stating that “the coercion theory is unclear, suspect, and has little precedent to support its application.”

Setting aside the wealth of constitutional law rejecting the governors and attorneys general’s position, it’s also somewhat baffling why they would want to make this argument in the first place.  Taken to its logical end, the state officials’ argument would render generous grants from the federal government to the states unconstitutional.  One marvels at how state leaders can believe that they are serving their constituents by trying to drain money out of their own budgets.

Moreover, these officials grossly exaggerate the ACA’s impact on their states’ budgets.  Although the ACA increases the number of people eligible for Medicaid benefits, the federal government will reimburse the states for 100 percent of the costs of these new beneficiaries for the first two years that the law is in effect, and will continue to pay at least 90 percent of these costs in the future.  This is one reason that many states can actually expect to save money because of the ACA.

The American Spectator’s Phil Klein argues that while repealing all or portions of the health care law remains a longshot, many conservatives are now focusing on defunding some of the most unpopular provisions. The idea has been batted around by House Minority Leader John Boehner (R-OH) and John McCain (R-AZ) almost immediately after the law passed, but as Klein describes, the idea is picking up some serious traction.

Republicans speculate that they could defund the most unpopular provisions through the appropriations process, offering “an amendment to the committee that targeted a provision of the law, adding the language, ‘No funds shall…” One strategy under consideration is to envelop the defunding amendments in abortion language, and peel off the votes of several old members of the so-called Stupak coalition:

One of the most effective tactics Republicans could use, he said, would be to pass an appropriations bill that includes the more restrictive language on abortion championed by Rep. Bart Stupak, who ultimately caved and supported a bill that did allow for public funding (though he vehemently denies it). Such a move would provoke a fight in which pro-choice Democrats would once again have to choose between ObamaCare and limits on private abortion coverage.

“If you put the Stupak language in an appropriations bill, you can win the message war and remind the public that this is what ObamaCare does, and that it’s always going to do this unless you repeal it,” Cannon said. Even if Republicans ultimately flinch, “We could spend weeks and weeks talking about how ObamaCare covers abortion and making it less and less popular.”

Depending on how the midterm elections turn out, some of these strategies may, in fact, prove successful. (Since pro-life Democrats came perilously close to placing the abortion issue ahead of health reform.) But as Klein rightly notes in his article, Republicans should be careful what they wish for. Former Republican House Speaker Newt Gingrich’s efforts to shut down the government in 1995 were incredibly unpopular with the American public. His personal disapproval ratings reached a high of 65 percent, and former House Majority Leader Tom DeLay said that Gingrich “made the mistake of his life.” In 1996, even Gingrich himself admitted that “‘our strategy failed’ because Mr. Clinton and his allies, instead of surrendering and making a budget deal, ‘were tougher than I thought they would be.’”

Should Republicans pursue this strategy, however, it’s far from certain that they’ll succeed. As Gail Wilensky, administrator of CMS under George H. W. Bush, explained last month, “it has been very difficult historically to do this type of a starving unless you have a very large majority behind you.” “So you could technically see this as a way to go after all those thing that are not mandatory funding. But a lot of the activity in this early period is, I think not at risk,” she said.

Several months ago, Virginia passed a law prohibiting the federal government from requiring individuals to purchase health insurance coverage, establishing “unique standing” to challenge the federal health care law in court. Last week, a federal judge ruled that the Virginia lawsuit can proceed and Virginia Governor Bob McDonnell and Attorney General Ken Cuccinelli have taken to the airwaves to celebrate their victory.

But yesterday, during an appearance on CNN’s State of the Union, McDonnell suggested that his opposition to the federal mandate does not mean that he would oppose requiring compulsory insurance on the state level. Asked if he’d approve of a Virginia mandate, McDonnell implied that he might, and stressed that his opposition to the federal requirement is grounded in his interpretation of the commerce clause and the tenth amendment:

CROWLEY: If the state of Virginia, in the form of the legislature, passed a bill saying you must pass — you must have health insurance, would that be all right?

MCDONNELL: It might be, under the state constitution. But this goes to the heart and soul of our federal system, what the 10th amendment means….But if the federal government can use the commerce clause to tell the citizens of Virginia or Michigan or any other state that they must buy a good or a service, and if they don’t, they’re going to get fined, then there’s virtually no limits to federal power.

Watch it:

McDonnell is espousing traditional tenther beliefs: health care policy should be left to the states, where each can decide about the need for an individual requirement. It’s a sentiment shared by Mitt Romney and other prominent conservatives, but I suspect it will come as a surprise to some of the Libertarian supporters that make up the anti-health reform coalition. Without directly endorsing the mandate, one of its most vocal opponents is admitting that state governments can force individuals to purchase coverage. He’s saying that it’s a policy worth considering and that’s significant.