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HEALTH AND HOSPITAL CORPORATION OF MARION 
CTY. v. TALEVSKI 
THOMAS, J., dissenting 

FNHRA’s scheme is illustrative of many modern federal 
spending programs, which often impose obligations directly 
on States as a condition of funding.  For example, as a con-
dition  on  highway  funding,  the  Clean  Air  Act  requires 
States to draft “State implementation plans” if their metro-
politan  areas  fail  to  satisfy  national  ambient  air  quality 
standards.    42  U. S. C.  §§7410  and  7509(a)–(b).    Among
other requirements, these plans must include emission lim-
itations, compliance timetables, source monitoring, permit-
ting systems, enforcement programs, and public participa-
tion.  See §7410(a)(2).  Other examples, spanning virtually 
every domain of national and state policy, abound. 

The ubiquity of such spending conditions, combined with
the Federal Government’s overwhelming financial heft, has
made  Spending  Clause  legislation  an  extraordinarily  po-
tent instrument of federal control.2  Congress and federal 

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§1396r(e)(4)  (“[T]he  State  must  have  implemented  and  enforced  the 
nursing facility administrator standards developed” by the Secretary for 
Health  and  Human  Services);  §1396r(e)(7)(B)(i)(I)  (in  the  case  of  men-
tally ill residents, “the State . . . must review and determine . . . whether 
or not the resident . . . requires the level of services provided by a nursing 
facility” or the services of different institutions). 

2 The power of this tool has grown with the steady increase in federal 
income-tax  revenues  since  the  adoption  of  the  Sixteenth  Amendment.
Although the Revenue Act of 1913 accounted for only 10% of federal rev-
enue, by 1950, the income tax was the Nation’s largest source of revenue, 
and, by 2010, it accounted for a whopping 82% of federal revenue overall.
E. Jensen, Did the Sixteenth Amendment Ever Matter? Does It Matter 
Today? 108 Nw. U. L. Rev. 799, 807, n. 44 (2014).  This explosion of funds 
created unprecedented threats to federalism due to the increased use of 
grants.    Federal  “[m]onetary  grants,  so-called  grants-in-aid,  became
more frequent during the 1930’s, and by 1950 they had reached $20 bil-
lion or 11.6% of state and local government expenditures.”  National Fed-
eration  of  Independent  Business  v.  Sebelius,  567  U. S.  519,  674  (2012) 
(NFIB) (joint dissent of Scalia, Kennedy, THOMAS, and ALITO, JJ.) (cita-
tion and footnote omitted).  “By 1970 this number had grown to $123.7 
billion or 29.1% of state and local government expenditures . . . .  As of 
2010, federal outlays to state and local governments came to over $608