NFIB Sebelius Dissent



133% of the federal poverty line. See §1396a(a)
(10)(A)(i)(VIII). Any State that refuses to expand
its Medicaid programs in this way is threatened with a
severe sanction: the loss of all its federal Medicaid funds.
See §1396c (2006 ed.).

  Medicaid has long been the largest federal program of
grants to the States.  See Brief for Respondents in No. 11-–
400, at 37. In 2010, the Federal Government directed
more than $552 billion in federal funds to the States.  See
Nat. Assn. of State Budget Officers, 2010 State Expendi-
ture Report: Examining Fiscal 2009-–2011 State Spending,
p. 7 (2011) (NASBO Report).  Of this, more than $233
billion went to pre-expansion Medicaid.  See    id., at 47.14
This amount equals nearly 22% of all state expenditures
combined. See id., at 7.

  The States devote a larger percentage of their budgets
to Medicaid than to any other item. Id., at 5.  Federal
funds account for anywhere from 50% to 83% of each
State’s total Medicaid expenditures, see §1396d(b) (2006 ed.,
Supp. IV); most States receive more than $1 billion in
federal Medicaid funding; and a quarter receive more than
14 The Federal Government has a higher number for federal spending
on Medicaid.  According to the Office of Management and Budget,
federal grants to the States for Medicaid amounted to nearly $273
billion in Fiscal Year 2010.  See Office of Management and Bud-
get, Historical Tables, Budget of the U. S. Government, Fiscal Year
2013, Table 12.3—-Total Outlays for Grants to State and Local Gov-
ernments by Function, Agency, and Program: 1940–2013, http://  In that Fiscal Year, total
federal outlays for grants to state and local governments amounted to
over $608 billion, see Table 12.1, and state and local government
expenditures from their own sources amounted to $1.6 trillion, see
Table 15.2.  Using these numbers, 44.8% of all federal outlays to both
state and local governments was allocated to Medicaid, amounting to
16.8% of all state and local expenditures from their own sources.


$5 billion, NASBO Report 47.  These federal dollars total
nearly two thirds—-64.6%—-of all Medicaid expenditures
nationwide.15   Id., at 46.

  The Court of Appeals concluded that the States failed to
establish coercion in this case in part because the ““states
have the power to tax and raise revenue, and therefore can
create and fund programs of their own if they do not like
Congress’’s terms.”” 648 F. 3d 1235, 1268 (CA11 2011); see
Brief for Sen. Harry Reid et al. as   Amici Curiae in No. 11-–
400, p. 21 (“”States may always choose to decrease expendi-
tures on other programs or to raise revenues””).  But the
sheer size of this federal spending program in relation to
state expenditures means that a State would be very hard
pressed to compensate for the loss of federal funds by
cutting other spending or raising additional revenue.
Arizona, for example, commits 12% of its state expendi-
tures to Medicaid, and relies on the Federal Government
to provide the rest: $5.6 billion, equaling roughly one-third
of Arizona’’s annual state expenditures of $17 billion. See
NASBO Report 7, 47.  Therefore, if Arizona lost federal
Medicaid funding, the State would have to commit an
additional 33% of all its state expenditures to fund an
equivalent state program along the lines of pre-expansion
Medicaid. This means that the State would have to allo-
cate 45% of its annual expenditures for that one purpose.
See ibid.

 The States are far less reliant on federal funding for any
other program.  After Medicaid, the next biggest federal
15 The Federal Government reports a higher percentage.  According
to, in Fiscal Year 2010, the Federal Government made
Medicaid payments in the amount of nearly $260 billion, repre-
senting 67.79% of total Medicaid payments of $383 billion.  See / Medicaid-CHIP-Program-Information / By-State / By-