Some Tentative Thoughts on the Medicaid Case

In all the hoopla over the individual mandate, most people (myself emphatically included) have not devoted enough attention to the other big Obamacare case before the Court: the 26 states’ challenge to to the part of the act requiring the states to massively expand Medicaid coverage (covering every non-elderly with an income up to 138% of the poverty line) or face the loss of all their federal Medicaid funds. Medicaid is a huge program that represents some 40% of all federal grants to state governments, according to the states’ brief. In cases such as South Dakota v. Dole, the Supreme Court has ruled that Congress has very broad discretion in imposing conditions on spending grants offered to states, but also warned that such conditions are unconstitutional if they are so onerous as to be “coercive.” What qualifies as “coercion” in this context? The Court has never favored us with an explanation, and the whole concept is murky at best.

In this case, the states’ strongest argument is that, if anything is “coercive,” it’s the threat of withdrawing such a massive proportion of all their federal funds, especially after the states have become dependent on Medicaid grants over a period of many years. If this isn’t coercion through funding conditions, it’ hard to see what is. On the other hand, as the federal government points out, it’s hard to draw a clear line here. And, if the states wanted to avoid dependency, they could simply have refused to participate in Medicaid in the first place.

My interpretation of yesterday’s Medicaid oral argument is that there probably aren’t five votes to overturn this part of the law. The liberal justices strongly support the federal government’s position, while several of the conservatives are at the very least on the fence. I conjecture that the real purpose of the Court’s surprising decision to hear this case was to try to develop a clearer definition of what counts as “coercion” rather than a desire to invalidate this part of Obamacare. However, Lyle Denniston of SCOTUSblog – who is much more sympathetic to the federal government’s position than I am – thinks there is a good chance that the law will be struck down.

What should the Court do? I honestly don’t have a very clear answer. My own view is that the coercion test is both unclear and doesn’t have much basis in the text and original meaning of the Constitution. On that I tend to agree with the Court’s liberal justices. On the other hand, the Spending Clause only gives Congress the power to spend money for the purposes of providing for the common defense, paying the federal debt, and advancing the “general Welfare.” I think that the Court is wrong to interpret “general welfare” to include essentially anything that Congress thinks might potentially be beneficial. If that were correct, the power to spend for the common defense and the debts of the United States would be essentially superfluous. I developed this argument in more detail in one of my first academic articles back in 2002. The original meaning of General Welfare is much narrower, as is well explained in this article by John Eastman.

However, fully endorsing my approach or Eastman’s theory would require the Court to reverse important precedents and undercut major existing government programs on which both state governments and large numbers of people have become heavily dependent. It’s both unrealistic and undesirable for the Court to try to do something like that in one fell swoop.

I would therefore prefer for the Court to move incrementally in the direction of tightening up its definition of “General Welfare,” without massively disrupting long-established major existing programs. How best to do that is a very difficult question to which I don’t have any particularly good answer. Eastman, however, presents some interesting arguments about how the coercion theory can be used to bring us closer to the original meaning of “general Welfare” in his amicus brief in the Medicaid case. I tentatively think his approach is probably superior to the available alternatives. But I readily admit that I’m not really sure about how best to deal with this difficult conundrum.

Regardless, it will be interesting to see whether a majority of the justices can agree on a clearer definition of “coercion” and if so what it is.