NFIB Sebelius Roberts

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course as to a suitable minimum drinking age is 5%”” of
her highway funds.  Ibid. In fact, the federal funds at
stake constituted less than half of one percent of South
Dakota’’s budget at the time.  See Nat. Assn. of State
Budget Officers, The State Expenditure Report 59 (1987);
South Dakota v. Dole, 791 F. 2d 628, 630 (CA8 1986).  In
consequence, “”we conclude[d] that [the] encouragement
to state action [was] a valid use of the spending power.””
Dole, 483 U. S., at 212.  Whether to accept the drinking
age change “”remain[ed] the prerogative of the States not
merely in theory but in fact.”” Id., at 211-–212.

  In this case, the financial “”inducement”” Congress has
chosen is much more than “”relatively mild encourage –
ment”—”-it is a gun to the head.  Section 1396c of the Medi-
caid Act provides that if a State’’s Medicaid plan does
not comply with the Act’’s requirements, the Secretary of
Health and Human Services may declare that “”further
payments will not be made to the State.”” 42 U. S. C.
§1396c. A State that opts out of the Affordable Care Act’’s
expansion in health care coverage thus stands to lose not
merely “a “relatively small percentage”” of its existing Medi –
caid funding, but all of it.  Dole, supra, at 211. Medicaid
spending accounts for over 20 percent of the average
State’s total budget, with federal funds covering 50 to 83
percent of those costs.  See Nat. Assn. of State Budget
Officers, Fiscal Year 2010 State Expenditure Report, p. 11,
Table 5 (2011); 42 U. S. C. §1396d(b).  The Federal Gov –
ernment estimates that it will pay out approximately $3.3
trillion between 2010 and 2019 in order to cover the costs
of pre-expansion Medicaid.  Brief for United States 10,
n. 6. In addition, the States have developed intricate
statutory and administrative regimes over the course of
many decades to implement their objectives under existing
Medicaid. It is easy to see how the Dole Court could con-
clude that the threatened loss of less than half of one
percent of South Dakota’’s budget left that State with a  

52

““prerogative”” to reject Congress’’s desired policy, “”not
merely in theory but in fact.””  483 U. S., at 211-–212.  The
threatened loss of over 10 percent of a State’’s overall
budget, in contrast, is economic dragooning that leaves the
States with no real option but to acquiesce in the Medicaid
expansion.12

JUSTICE GINSBURG claims that Dole is distinguishable
because here “”Congress has not threatened to withhold
funds earmarked for any other program.””  Post, at 47. But
that begs the question: The States contend that the ex-
pansion is in reality a new program and that Congress is
forcing them to accept it by threatening the funds for the
existing Medicaid program.  We cannot agree that existing
Medicaid and the expansion dictated by the Affordable
Care Act are all one program simply because ““Congress
styled”” them as such.  Post, at 49.  If the expansion is not
properly viewed as a modification of the existing Medicaid
program, Congress’’s decision to so title it is irrelevant.13
—————–
—————— 12  JUSTICE GINSBURG observes that state Medicaid spending will in-
crease by only 0.8 percent after the expansion.   Post, at 43. That not
only ignores increased state administrative expenses, but also assumes
that the Federal Government will continue to fund the expansion at the
current statutorily specified levels.  It is not unheard of, however, for
the Federal Government to increase requirements in such a manner as
to impose unfunded mandates on the States.  More importantly, the
size of the new financial burden imposed on a State is irrelevant in
analyzing whether the State has been coerced into accepting that
burden.  “”Your money or your life”” is a coercive proposition, whether
you have a single dollar in your pocket or $500.
13 Nor, of course, can the number of pages the amendment occu-
pies, or the extent to which the change preserves and works within
the existing program, be dispositive.  Cf. post, at 49-–50 (opinion of
GINSBURG, J.).  Take, for example, the following hypothetical amend –
ment: “”All of a State’s citizens are now eligible for Medicaid.””  That
change would take up a single line and would not alter any “”operational
aspect[ ] of the program”” beyond the eligibility requirements.   Post, at
49. Yet it could hardly be argued that such an amendment was a
permissible modification of Medicaid, rather than an attempt to foist an
entirely new health care system upon the States.