PPACA Amicus Brief Rundown: Medicaid

As oral arguments commence today in the U.S. Supreme Court for the case of Florida v. HHS, the constitutionality of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) will soon be determined.  During oral arguments, two questions will be addressed: (1) whether it is coercion for Congress to force states to expand Medicaid as directed by PPACA or lose federal Medicaid funding and (2) whether, if the individual mandate is found to be unconstitutional, the rest of PPACA can remain valid.  This article will look at the Medicaid funding issue.

The 11th Circuit found that, with regard to the expansion of Medicaid issue, the expansion is not “unduly coercive” and that states have a choice as to whether to participate in the expansion of Medicaid.  A number of parties having an interest in the outcome of the matters have submitted amicus curiae (friend of the court) briefs in support of each side of the issues.  A couple of amicus briefs filed with regard to the Medicaid expansion issue are spelled out below. 

Briefs arguing that Medicaid expansion provisions are unconstitutional

A brief filed by the Association of American Physicians and Surgeons (AAPS) argues that the PPACA provisions calling for the expansion of Medicaid “do not fall within the scope of congressional powers enumerated in the Constitution.”  AAPS, which according to its brief is “dedicated to the highest ethical standards of the Hippocratic Oath and to preserving the sanctity of the physician-patient relationship,”  has a stake in the outcome of this issue in that it has recently filed its own claims of unconstitutionality regarding PPACA and the outcome may affect its rights and the rights of its members.  The non-profit, considered to conservative, argues that PPACA should be found unconstitutional in its entirety. 

Specifically, AAPS’ arguments center around the idea that expanding Medicaid would place an enormous burden on state budgets, some of which are already in a precarious condition.  AAPS argues that the federal government owes a fiduciary duty to the states since the funding of Medicaid is achieved through a joint effort and requires each party to be aware of the financial pressures the other faces. 

Further, the duty to provide for the “general welfare” stemming from Article 1, Section 8 of the Constitution is meant to limit the taxing power of the government; it is not meant to provide a power to spend.  Also, the doctrine of Separation of Powers is violated since federal and state spending is set to auto-pilot by setting future spending for the future Congresses. 

Another brief claiming that the expansion of Medicaid is unconstitutional is that filed by a group of 101 economists that have “studied, researched, and participated in the national policy discussion relating to the healthcare markets.”  They argue that these provisions of PPACA  “unconstitutionally coerce the States by threatening a loss of all federal Medicaid funds if a State does not accept [PPACA’s] considerable expansion of Medicaid eligibility.”  This group, made up of Nobel laureates, former senior government officials, and research university faculty, have lobbied for health care reform but opine that PPACA will worsen the inflation in health care costs.

The economists’ argument centers around the distinction between encouraging a state to enact a federal policy and coercing it to do so.  The crux of the issue is that states must be left with “a real, and not merely a theoretical,” choice between adopting a policy and forgoing funds contingent on compliance.  Under PPACA, they argue, should a state be unable to enact the significant expansion of Medicaid eligibility required under PPACA, it will lose all federal funding for Medicaid and will likely be unable to provide the Medicaid program at all.  States would be unable to turn down the federal funding and continue to provide Medicaid benefits at its current level, or at least without providing some other health care funding for low-income residents.

The economists offer to assist the court in understanding the effect declining Medicaid funding would have on states.

Briefs in support of HHS with regard to Medicaid expansion

The American Hospital Association (AHA), along with the Association of American Medical Colleges, Catholic Health Association of the United States, Federation of American Hospitals, National Association of Children’s Hospitals, and National Association of Public Hospitals and Health Systems, (referred to collectively as the “associations”) filed an amicus brief in Florida v. HHS, as it often does in other cases involving health care, arguing in support of HHS.

The AHA, as an organization, seeks to improve the health of communities it serves and provide affordable health care to all.  The associations, collectively, have an interest in the outcome of this case because they, as health care providers, are at the heart of federal and state cooperative health care programs.  They believe that the coercion theory argued by opponents would prevent Congress from ensuring that Medicaid operates effectively and innovatively into the future. 

The associations stress that the consequences of the coercion argument must be considered; Congress has modified Medicaid many times in the past, even with regard to eligibility, to ensure that the system continues to “[run] smoothly.”  The associations warn that if the coercion theory argued by the opponents were law, no modifications could be made to Medicaid or any other federal program unless all of the participating states agreed to the change.  The associations propose three reasons why the coercion arguments should be rejected: (1) the theory is unworkable; (2) if there is a coercion theory it should be limited to situations where Congress is trying to impede states’ police powers; and (3) even if there is a coercion theory, it should not apply here because the decision faced by states is not coercive but is merely a difficult political decision.

 A group of 539 state legislators from the 50 states, the District of Columbia and Puerto Rico filed an amicus brief stating that they believe PPACA to be constitutional and are working to implement its provisions.  They state that they have an interest in the expeditious resolution of this matter and to represent their constituents that do not agree with the constitutional challenges to PPACA.   

The legislators argue that (1) PPACA supports the existing federal-state partnership on health care, (2) the coercion theory is constitutionally baseless, (3) the opponents’ claims regarding limits on the power to tax and spend for the general welfare are not supported by the Constitution. 

A direct quote from the legislators’ brief sums up their argument succinctly:  “[the opponents’] argument has little to do with the Constitution, and far more to do with the desire to obtain a judicial “do-over” on the Affordable Care Act, trying to get this Court to craft a health care reform law that is more to [their] liking.”

There are supporters for both sides of the Medicaid expansion argument, but we will have to see which side the Court comes down on.  Stay tuned for continuing coverage…