Let’s roll back the clock a bit and do a “what it.”
What if last week’s big U.S. Supreme Court decisions, the ones on health care and same-sex marriage, had gone the other way?
It would have set the stage for a debacle in blue and red.
Let’s imagine that, in the case of King v. Burwell, a majority of justices had agreed that when Congress wrote in the voluminous Affordable Care Act that federal tax subsidies should be available for insurance policies purchased in marketplaces “established by the state,” it meant that literally and exclusively. Subsidies are available only in state-based exchanges and not the federal marketplace used by more than 30 of the states.
Now we have a situation in which only some states, mostly those on the coasts and with more liberal voters and officeholders, are able to offer citizens federal subsidies for health insurance. In those states, people can continue to see doctors. Health insurance markets remain intact. Hospitals and medical providers continue to be paid. Economies flourish. That is the outcome for the blue states.
Prospects for the red states are much different. Most of them didn’t create insurance exchanges, mostly because conservative leaders couldn’t bring themselves to cooperate with any aspect of the Affordable Care Act. So more than 6 million of their citizens now stand to lose federal income-based subsidies.
Only people with serious health problems can be expected to pay for their newly expensive health insurance policies. Others will drop their insurance, stop seeing doctors and seek treatment only in cases of emergencies. Hospitals and health care networks will lay off workers and face hard times. The ripple effects will spread throughout state economies.
And let’s suppose that the Supreme Court’s 5-4 Obergefell v. Hodges decision had swung the other way, with a majority of justices rejecting marriage equality.
Same-sex marriages would continue to be carried out and recognized only in the blue states. Red state politicians would stick to promoting old fears and taboos that the citizens of the United States are rapidly shaking off.
Red states would pay the price for intolerance. Bright young people would think twice about attending their colleges and universities. Companies would balk at locating in states that make it known same-sex workers aren’t welcome. Conventions and tourism would move quickly to the blue states.
Red state politicians and voters can say they don’t want to live in an America where health insurance is a government entitlement (unless it’s Medicare), and where their notion of marriage as a union between one woman and one man is disrupted.
But, as we are seeing from the emerging divide between states that accepted Medicaid expansion and those such as Missouri and Kansas that continue to refuse it, there is a cost to holding on to dogmas. On health and economic outcomes, the Medicaid expansion states are pulling ahead.
Kansas Gov. Sam Brownback and certain Missouri Republicans can harrumph about “activist judges,” but Supreme Court justices did them a favor last week by taking choices on health care and gay marriage out of their hands. They won’t have to watch while life and economies get better in the blue states and worse in their own.
To reach Barbara Shelly, call 816-234-4594 or send email to firstname.lastname@example.org. On Twitter @bshelly.