Why The Supreme Court Probably Isn’t About To Declare Medicaid Expansion Unconstitutional

The Affordable Care Act does not simply expand access to and participation in the private health insurance market, it also expands access to Medicaid — guaranteeing that all people who earn below 133 percent of the poverty rate can receive Medicaid. This expansion is unusually generous to the states. Although each of the fifty states runs its own Medicaid program, the federal government will pick up 90 percent of the new costs generated by expanding the program to millions more Americans. Nevertheless, the Supreme Court just agreed to consider a strange challenge to this expansion some time next year.

Despite the fact that this expansion will allow each and every state to provide millions more people with affordable health care, and despite the fact that it will do so at minimal cost to those states, the several conservative-led states challenging the Affordable Care Act claim that the Medicaid expansion is unconstitutional because it somehow “coerces” the states into participating in Medicaid. As ThinkProgress explained more than a year ago when this argument was originally raised, it essentially boils down to a claim that Medicaid is unconstitutional because it is too generous, and it has little chance of succeeding in court:

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 [the plaintiffs] 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

Nothing has changed since we originally published those words. Indeed, every single judge to consider the Affordable Care Act’s Medicaid expansion has upheld it. Even Tea Party Judge Roger Vinson, the judge whose error-laden opinion tried to wipe out the entire Affordable Care Act, rejected the plaintiffs’ argument against the Medicaid expansion.

It is mildly troubling that the Supreme Court would agree to hear this issue in the first place, since federal/state partnerships like Medicaid are one of the backbones of America’s safety net. If the Supreme Court were to undermine Congress’ ability to give conditional grants to the states, everything from Medicaid to federal assistance to public schools could fall by the wayside.

Yet there are two reasons to doubt that the Supreme Court is poised to do so. The first is simply the nature of the plaintiffs in this case. It is very rare for this many states to join together on one lawsuit — even if the only real link between those states is the fact that they are currently run by Republicans — and the Supreme Court likely agreed to hear this issue simply out of deference to the extraordinary nature of these plaintiffs.

The second reason is that it is not at all clear how lashing out at federal/state partnerships fosters any real interest in preserving states rights. If the Supreme Court rolls back Congress’ power to provide conditional grants, nothing would prevent Congress from simply cutting the states out of the bargain entirely and assuming total control over programs like Medicaid. The likely outcome of a decision rolling back the ACA’s Medicaid expansion would be to increase the role of the federal government because it would no longer be possible for Congress to trust states to administer major safety net programs.

It is unfortunate that the justices chose to waste their time with a fringe issue that no judge has found to have merit. Nevertheless, there is no reason to doubt that the Affordable Care Act will be upheld.