This paper is a reflection on the nature of state opposition to the Patient Protection and Affordable Care Act (PPACA) (2010) popularly known as the Affordable Care Act or simply Obamacare. The Act, signed into force by President Obama on March 23, 2010, represented the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965 but a multi-state constitutional challenge to the individual mandate and the expansion of Medicaid began only minutes after the President signed the Act into force.1
By the time the case reached the U.S. Supreme Court, twenty–six states and their Attorneys-General and/or Governors had joined two private citizens and the NFIB in a suit which, per Florida Senior District Judge Vinson was “not really about our health care system at all. It is principally about our federalist system, and it raises very important issues regarding the Constitutional role of the federal government.”2 In the event, the decision of the U.S. Supreme Court in NFIB v. Sebelius3 upheld the Act’s individual mandate provision. However the Court struck down the companion provisions requiring states to expand Medicaid coverage up to 133% (effectively 138%) of the federal poverty level on the grounds that they were unconstitutionally coercive. The Act imposed a penalty on states that refused to comply with the expansion of Medicaid in the form of forfeiture of all existing Medicaid funding but Congress, wrote Chief Justice Roberts, “has no authority to order the States to regulate according to its instructions. Congress may offer the States grants and require the States to comply with accompanying conditions, but the States must have a genuine choice whether to accept the offer.”4
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