What is absolutely clear, affirmed by the text of the 1789 Constitution, by the Tenth Amendment ratified in 1791, and by innumerable cases of ours in the 220 years since, is that there are structural limits upon federal power—upon what it can prescribe with respect to private conduct, and upon what it can impose upon the sovereign States. . See Art. In 1887, Congress established a commission to regulate the railroads by passing. But the health care “market” that is the object of the Individual Mandate not only includes but principally consists of goods and services that the young people primarily affected by the Mandate do not purchase. This will lead insurers to significantly increase premiums on everyone. National Assn. Our deference in matters of policy cannot, however, become abdication in matters of law. Medicaid was created to enable States to provide medical assistance to “needy persons.” See S. Rep. No. See 26 U. S. C. §36B(c) (1)(B)(ii) (excepting from the income limit individuals who are “not eligible for the medicaid program . . I agree with The Chief Justice that the Anti-Injunction Act does not bar the Court’s consideration of this case, and that the minimum coverage provision is a proper exercise of Congress’ taxing power. low-level radioactive waste.’ ” 505 U. S., at 169 (quoting 42 U. S. C. §2021c(a)(1)(A)). Rather, it would give practical effect to the Legislature’s enactment. For the reasons stated, I agree with The Chief Justice that, as to the validity of the minimum coverage provi- sion, the judgment of the Court of Appeals for the Eleventh Circuit should be reversed. The Sixth Circuit and the D. C. Circuit considered the question but determined that the Anti-Injunction Act did not apply. Congress is simply requiring States to do what States have long been required to do to receive Medicaid funding: comply with the conditions Congress prescribes for participation. I, §8, cl. See Nat. And if the industry does increase premiums, then there is a seri- ous risk that its products—insurance plans—will become economically undesirable for many and prohibitively ex- pensive for the rest. If Congress can reach out and command even those furthest removed from an interstate market to participate in the market, then the Commerce Clause becomes a font of unlimited power, or in Hamilton’s words, “the hideous monster whose devouring jaws . The  latter directive would be superfluous if the former invoked the Anti-Injunction Act. In addition, the States have developed intricate statutory and administrative regimes over the course of many decades to implement their objectives under existing Medicaid. Congress’ spending power, we concluded, “does not include surprising participating States with postacceptance or ‘retroactive’ conditions.” Id., at 24–25. Nor does any other provision state that references to taxes in Title 26 shall also be “deemed” to apply to the individual mandate. Under that theory, Congress may order individuals to buy health insurance because the failure to do so affects interstate commerce, and could un-dercut the Affordable Care Act’s other reforms. It can assuredly do that, by exercising the powers accorded to it under the Constitution. of Ed., 470 U. S. 656, 659–660 (1985) (enforcing restriction added five years after adoption of educational program)). California objected, arguing that the change impermissibly deprived it of a right to withdraw from Social Security. We do doubt the authority of this Court to put them there. Those failures—joined with the similar failures of others—can readily have a substantial effect on interstate commerce. Congress’s use of the Taxing Clause to encourage buying something is, by contrast, not new. That is because the “Framers split the atom of sovereignty[,] . The ACA is over 900 pages long. See §4980I (high-cost insurance plans); 42 U. S. C. §§300gg(a)(1), 300gg–4(b) (community rating); §§300gg–1, 300gg–3, 300gg–4(a) (guaranteed issue); §300gg–11 (elimination of coverage limits); §300gg–14(a) (dependent children up to age 26); ACA §§9010, 10905, 124 Stat. See ante, at 16 (“Everyone will eventually need health care at a time and to an extent they cannot predict.”). That clause specifies that “[i]f any provision of this chapter, or the application thereof to any person or circumstance, is held invalid, the remainder of the chapter, and the application of such provision to other persons or circumstances shall not be affected thereby.” §1303. See 42 U. S. C. §§300gg–1, 300gg–3, 300gg–4(a) (2006 ed., Supp. For instance, those who did not purchase insurance could be subjected to a surcharge when they do enter the health insurance system. The most straightforward reading of the individual mandate is that it commands individuals to purchase insurance. Exam- ples include federal requirements to report for jury duty, 28 U. S. C. §1866(g) (2006 ed., Supp. 1, and from “the foundation of the Nation sharp differences of opinion have persisted as to  the true interpretation of the phrase” “the general welfare.” Butler, 297 U. S., at 65. When Congress makes grants to the States, it customarily attaches conditions, and this Court has long held that the Constitution generally permits Congress to do this. Three considerations allay this concern. That group makes up a larger percentage of the total population than those without health insurance. Today we resolve constitutional challenges to two provisions of the Patient Protection and Affordable Care Act of  2010: the individual mandate, which requires individuals to purchase a health insurance policy providing a minimum level of coverage; and the Medicaid expansion, which gives funds to the States on the condition that they provide specified health care to all citizens whose income falls below a certain threshold. Const., Art. IV). 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. See also Brief for Health Care for All, Inc., et al. This incentive, Congress had good reason to believe, would reduce the number of uninsured and, correspondingly, mitigate the adverse impact the uninsured have on the national health-care market. Withholding $614.7 million, equaling only 0.19% of all state expenditures combined, is aptly characterized as “relatively mild encouragement,” but threatening to withhold $233 billion, equaling 21.86% of all state expenditures combined, is a different matter. The Anti-Injunction Act, by contrast, says nothing about the procedures to be used in assessing and collecting taxes. have a rational basis for finding a chosen regulatory scheme necessary to  the protection of commerce, our investigation is at an end.” Katzenbach, 379 U. S., at 303–304. See Bennett v. New Jersey, 470 U. S. 632, 634–635 (1985) (citing Pub. With no exchanges, there are no purchases on the exchanges; and with no purchases on the exchanges, there is nothing to trigger the employer-responsibility assessment. 25  The joint dissenters also rely heavily on Congress’ perceived intent to coerce the States. And the companies must pay new taxes. Today’s holding does not affect the continued ap-plication of §1396c to the existing Medicaid program. The Federalist No. The Medicaid provisions of the Affordable Care Act, in contrast, require States to expand their Medicaid programs by 2014 to cover all individuals under the age of 65 with incomes below 133 percent of the federal poverty line. The reach of the Federal Government’s enumerated powers is broader still because the Constitution authorizes Congress to “make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers.” Art. See Dept. See United States v. South-Eastern Underwriters Assn., 322 U. S. 533, 545, 552–553 (1944) (Congress may regulate “the methods by which interstate insurance companies do business.”). . Put simply, Congress may tax and spend. But see ante, at 51–52; post, at 47–48 (joint opinion of Scalia, Kennedy, Thomas, and Alito, JJ.). This case concerns two powers that the Constitution does grant the Federal Government, but which must be read carefully to avoid creating a general federal authority akin to the police power. Congress assumed States would have no choice, and the ACA depends on States’ having no choice, because its Mandate requires low-income individuals to obtain insurance many of them can afford only through the Medicaid Expansion. Post, at 17. Revised Statutes of Missouri, Missouri law . At bottom, The Chief Justice’s and the joint dissent ers’ “view that an individual cannot be subject to Commerce Clause regulation absent voluntary, affirmative acts that enter him or her into, or affect, the interstate mar- ket expresses a concern for individual liberty that [is] more redolent of Due Process Clause arguments.” Seven-Sky, 661 F. 3d, at 19. We have no way of knowing how many States will accept the terms of the expansion, but we do not believe Congress would have wanted the whole Act to fall, simply because some may choose not to participate. To the contrary, such a requirement would rigidify Congress’ efforts to empower States by partnering with them in the implementation of federal programs. 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. The principal standard the ACA sets is that the state program cover adults earning no more than 133% of the federal poverty line. In short, given §1304, this Court’s construction of §1304’s language in Bowen, and the enlargement of Medicaid in the years since 1965,23 a State would be hard put to complain that it lacked fair notice when, in 2010, Congress altered Medicaid to embrace a larger portion of the Nation’s poor. With the present statute, by contrast, there are many ways other than this unprecedented Individual Mandate by which the regulatory scheme’s goals of reducing insurance premiums and ensuring the profitability of insurers could be achieved. The same analysis here suggests that the shared responsibility payment may for constitutional purposes be considered a tax, not a penalty: First, for most Americans the amount due will be far less than the price of insurance, and, by statute, it can never be more.8 It may often  be a reasonable financial decision to make the payment rather than purchase insurance, unlike the “prohibitory” financial punishment in Drexel Furniture. Const., Art. When contemplated in its extreme, almost any power looks dangerous. But we have done so. Is not the power to compel purchase of health insurance much lesser? The Medicaid expansion thus violates the Constitution by threatening States with the loss of their existing Medicaid funding if they decline to comply with the expansion. But it is a blatant violation of the constitutional structure when the States have no choice. 1, permits the conditioning of a State’s continued receipt of all funds under a massive state-administered federal welfare program upon its acceptance of an expansion to that program. The expansion is effectuated by §2001 of the ACA, aptly titled: “Medicaid Coverage for the Lowest Income Populations.” 124 Stat. Resolving this controversy requires us to examine both the limits of the Government’s power, and our own limited role in policing those boundaries. That being so, I see no reason to undertake a Commerce Clause analysis that is not outcome determinative. 27, 2012). involved commercial activity. See ACA §§1563(a)(1), (2), 124 Stat. IV). Instead, the Clause is “ ‘merely a declaration, for the removal of all uncertainty, that the means of carrying into execution those [powers] otherwise granted are included in the grant.’ ” Kinsella v. United States ex rel. It may also be read as imposing a tax on those who go without insurance. The Federal Government does not have the power to order people to buy health insurance. The syllabus constitutes no part of the opinion of the Court but has been prepared by the Reporter of Decisions for the convenience of the reader.

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