The Administration That Spent $217 Billion Congress Never Authorized

The Biden White House wanted $400 billion over eight years to expand Medicaid home care. Congress cut it to $150 billion in Build Back Better — which failed. Then stripped it entirely from the Inflation Reduction Act. CMS responded by routing the expansion through state Medicaid agencies instead: expanded waivers, higher reimbursement rates, new caregiver-payment programs. By 2024, Medicaid home-health spending hit $46.4 billion annually — up from $24 billion in 2019. New York alone: $15.67 billion, roughly a third of the national total, through a single program that pays family members as caregivers. Pennsylvania's home-health bill grew more than twelvefold in five years. Source: RCI analysis of CMS T-MSIS federal claims data.

Article I, Section 9: 'No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law.' That clause exists because the Founders watched a British Crown spend without parliamentary consent and decided never again. The mechanism here — agency guidance, waiver expansion, state matching incentives — is the modern workaround. It's not new. Nixon impounded congressionally appropriated funds in 1972-73; Congress passed the Impoundment Control Act in 1974 to reassert the power of the purse. The direction of travel here is the mirror image: spending Congress refused to authorize rather than withholding spending Congress approved. Same constitutional injury, opposite sign.

If the administrative bypass holds as precedent, the appropriations process becomes optional for any administration with a sympathetic program and a compliant agency. The policy here may be defensible — home care is cheaper than nursing homes, and demand is real. But the mechanism is the problem. A Republican CMS can run the same play on any spending priority Congress declines to pass. The institutional damage accrues regardless of who benefits in any given cycle. And the nursing-home savings case collapsed anyway: spending on nursing facilities rose by nearly $5 billion over the same five years, to $46.3 billion, because states raised per-resident reimbursement rates 28%.

Three things to track: (1) Whether the current Congress attaches any riders to CMS appropriations clawing back the waiver expansions — or quietly lets them stand because the spending is now politically embedded in every state. (2) The fraud prosecutions RCI flags around the billing codes driving the spending spike — those cases will surface whether the cost-per-claim surge was workforce-driven or gaming-driven. (3) The Kaiser Family Foundation waiting-list data: Medicaid home-care queues are longer now than in 2019 despite $217 billion spent. If demand is still unmet at that price, the underlying policy case gets harder to make.