One hundred thirty-three percent of the federal poverty level. That is the income ceiling the Affordable Care Act set for its Medicaid expansion, and it sits at the center of a brief the federal government filed with the U.S. Supreme Court on February 10, 2012, defending that expansion against a constitutional challenge brought by Florida and a coalition of other states.
The question the brief answers
The case, Florida v. Department of Health and Human Services, No. 11-400, asked whether the ACA’s extension of Medicaid eligibility, reaching individuals with income up to 133% of the poverty line effective 2014, was a valid exercise of Congress’s power to set conditions on federal spending. The government’s brief, filed by the Office of the Solicitor General on behalf of HHS and other federal respondents, argued yes: Congress has broad authority under the Spending Clause to attach conditions to money it appropriates, and the sheer size of Medicaid, or of the federal funding involved, does not strip Congress of that authority.
Medicaid’s expansion, since 1965
Much of the brief’s argument is historical. It traces Medicaid back to its 1965 creation, when eligibility was tied to one of four federal welfare programs. In 1972, Congress replaced three of those with Supplemental Security Income, extending Medicaid eligibility under new federal standards, while letting states elect a “209(b) option” to keep their older 1972 rules instead, paired with a spend-down provision. From the 1980s onward, Congress expanded eligibility repeatedly: the Omnibus Budget Reconciliation Acts of 1989 and 1990 extended coverage to pregnant women and young children up to 133% of poverty, and to children aged 6 through 18 up to 100% of poverty. By 2008, the brief states, Medicaid covered roughly 47 million Americans. As of January 2012, the median state’s Medicaid eligibility cap for parents stood at just 37% of the poverty level for unemployed parents, and 63% for employed parents, with 17 states capping eligibility for working parents below 50% of poverty.
The government’s core argument
Against that backdrop, the brief argues the ACA’s expansion was not unprecedented, and it directly rebuts the states’ claim that provisions within the ACA itself concede the expansion was coercive. It leans heavily on South Dakota v. Dole (1987), the Supreme Court’s controlling framework for conditional federal spending, alongside New York v. United States (1992), Pennhurst State School & Hospital v. Halderman (1981), and Steward Machine Co. v. Davis (1937).
The states’ central objection was that Medicaid had grown so large, and federal funding so dominant within state budgets, that a state could not realistically refuse the expansion and still call its participation voluntary. The brief answers that argument directly rather than sidestepping it: it contends that the size of a federal program is not, on its own, a constitutional defect, and that states have always retained the formal option of declining Medicaid funding entirely, however unattractive that choice might be in practice. Whether an option that is legally available but practically unthinkable still counts as voluntary was, in effect, the real question the brief was trying to answer in the government’s favor.
The brief also argues, as a fallback position, that even if the expansion condition were struck down for states that refuse it, there is no reason to conclude Congress would have wanted the entire Affordable Care Act to fall with it. This severability argument mattered beyond the Medicaid question alone: it was the government’s insurance policy in case the Court agreed with the states on coercion but still wanted to preserve the rest of the law, which is close to what ultimately happened.
Who signed it
The brief’s counsel of record was Solicitor General Donald B. Verrilli, Jr., joined by Tony West, Edwin S. Kneedler, Beth S. Brinkmann, Mark B. Stern, Alisa B. Klein, and Leondra R. Kruger, then an Assistant to the Solicitor General and now a justice of the California Supreme Court, along with agency counsel from Treasury, Labor and HHS. It is a fairly ordinary detail of Supreme Court practice, a large team of government lawyers on one brief, but it is also a small, verifiable record of who argued the government’s side of one of the decade’s most consequential health-law cases.
That team’s presence on the brief is a useful reminder of how Supreme Court litigation actually gets built. A single name appears on the cover as counsel of record, but the substantive drafting is typically distributed across specialists from the Solicitor General’s office and the affected agencies themselves, here spanning the Department of Health and Human Services, the Department of the Treasury, and the Department of Labor, each with its own stake in how Medicaid’s federal-state funding relationship was ultimately defined.
How the Supreme Court actually ruled
The government did not fully prevail on this specific question. On June 28, 2012, the Supreme Court decided the consolidated cases, National Federation of Independent Business v. Sebelius together with the Florida litigation, 567 U.S. 519. Contrary to the position this brief argued, the Court held that the ACA’s Medicaid-expansion provision, structured to threaten states with the loss of all existing Medicaid funding if they declined the expansion, was unconstitutionally coercive under the Spending Clause. Rather than striking the whole Act, the Court’s remedy was to make the expansion optional for states, a middle outcome the brief itself had not proposed, and one that left the rest of the law largely intact while narrowing the specific mechanism this document had defended.