The limits of Congress's spending/regulatory power

I found an answer to my legal question.

From the decision:

Permitting the Federal Government to force the States to implement a federal program would threaten the political accountability key to our federal system.  “[W]here the Federal Government directs the States to regulate, it may be state officials who will bear the brunt of public disapproval, while the federal officials who devised the regulatory program may remain insulated from the electoral  ramifications of their decision.”  Id., at 169.  Spending Clause programs do not pose this danger when a State has a legitimate choice whether to accept the federal conditions in exchange for federal funds.  In such a situation, state officials can fairly be held politically accountable for choosing to accept or refuse the federal offer.  But when the State has no choice, the Federal Government can achieve its objectives without  accountability, just as in New York and Printz. Indeed, this danger is heightened when Congress acts under the Spending Clause, because Congress can use that power to implement federal policy it could not impose directly under its enumerated powers. We addressed such concerns in Steward Machine. That case involved a federal tax on employers that was abated if the businesses paid into a state unemployment plan that met certain federally specified conditions.  An employer sued, alleging that the tax was impermissibly “driv[ing] the state legislatures under the whip of economic pressure into the enactment of unemployment compensation laws at the bidding of the central government.” 301 U. S., at 587.  We acknowledged the danger that the Federal Government might employ its taxing power to exert a “power akin to undue influence” upon the States.  Id., at 590. But we observed that Congress adopted the challenged tax and abatement program to channel money to the States that would otherwise have gone into the Federal Treasury for use in providing national unemployment services. Congress was willing to direct businesses to instead pay the  money into state programs only on the condition that the money be used for the same purposes.  Predicating tax  abatement on a State’s adoption of a particular type of unemployment legislation was therefore a means to “safeguard [the Federal Government’s] own treasury.”   Id., at 591.  We held that “[i]n such circumstances, if in no others, inducement or persuasion does not go beyond the bounds of power.”  Ibid

They even answered my high way funding reference! (These guys are good.)

In South Dakota v. Dole, we considered a challenge to a federal law that threatened to withhold five percent of a State’s federal highway funds if the State did not raise its drinking age to 21.  The Court found that the condition was “directly related to one of the main purposes for which  highway funds are expended—safe interstate travel.”  483 U. S., at 208.  At the same time, the condition was not a restriction on how the highway funds—set aside for specific highway improvement and maintenance efforts—were to be used. We accordingly asked whether “the financial inducement offered by Congress” was “so coercive as to pass the point at which ‘pressure turns into compulsion.’”  Id., at  211 (quoting Steward Machine, supra, at 590).  By “financial inducement” the Court meant the threat of losing five percent of highway funds; no new money was offered to the States to raise their drinking ages.  We found that the inducement was not impermissibly coercive, because Congress was offering only “relatively mild encouragement to the States.”  Dole, 483 U. S., at 211.  We observed that “all South Dakota would lose if she adheres to her chosen 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.

So witholding all funds from the states for not expanding their programs is too much like coercion rather than encouragement. And in previous decisions, (such as South Dakota v. Dole), Congress has not directed how to use the funds, rather other requirements for receiving them.

Next steps for the ACA

Hope everyone had a great 4th! Also thankful to have the power back on...

Before heading out for the night, I wanted to opine on some post-SCOTUS-ruling thoughts:

A lot the recent news cycle has shifted from the individual mandate to the the court's ruling on Medicaid. Officially, the courts have ruled that the federal government does not have the right to withdraw funds from states for refusing to comply with the expansion. So now the ball is in the Governors' courts for deciding to expand their Medicaid program - in which the federal government would flip the bill (for 3 years, I believe).

This, actually, came as kind of a surprise.

In the decision, that provision of the law was likened to "holding a gun" to the heads of the states. But - isn't that how all federal programs work? Congress or the bureaucracy creates programs and says that the states must fallow X guidelines in order to receive funding, and changes are made to the program that the

My father actually likened it to road funding. When the federal government funded road construction for the states - they said they had to set certain speed limits. Those requirements have changed over time, and the states have had to comply with them in order to receive their funding. I haven't delved into this issue too much - but there must be another Supreme Court case where this issue has come up...

Anyway - back to the policy talk.

As I said, many governor's (i.e. Republicans) are saying that they will simply turn down the funds and not expand their medicaid programs. This raises a point about the health care bill that has largely been left out of the discussion for some time: How does the bill reduce costs other than through increasing coverage (i.e. through the mandate and medicaid expansion)?

I think this is part of the discussion that Obama should be focusing on when talking about health care - because it gets left out a lot of current debates. Though the conversation among policy wonks seems to be shifting. (See here and here.)

Another key provision of the ACA is the establishment of Accountable Care Organizations (ACO).

I'll write about some of the specifics later - but the general idea is pretty simple. Accountable Care Organizations can consist of health care providers, physicians, and hospitals to better coordinate care for patients.

Two things drive the goals of these organizations: efficiency and low cost of care. They work to provide the most effective treatments at the lowest cost. And what's really great about it - is that it's primarily private-sector driven. I'd love to see how conservatives feel about it if this provision of the bill ever comes to the national spotlight.