First case where the court ever strikes down spending on the condition that it's unduly coercive. Congress: created Medicaid system for the poor, funding a large portion (states fund the rest). ACA made "serious" changes to medicare: threatens to withdraw all money for Medicaid-dependent citizens. States said it was coercive: couldn't afford to have healthcare without: states budget was 20% for Medicaid. Citizens pay the same in taxes, won't get any taxes back; like a "gun to the head". Chief Justice Roberts, with Justices Scalia, Kennedy, Thomas, Breyer, Alito, and Kagan, concluded that the Medicaid expansion provisions was unconstitutionally coercive as written. Congress does not have authority under the Spending Clause to threaten the states with complete loss of Federal funding of Medicaid, if the states refuse to comply with the expansion. Justices Ginsburg and Sotomayor disagreed, arguing, "Congresss' authority to condition the use of federal funds is not confined to spending programs as first launched. The legislature may, and often does, amend the law."