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In the wake of this week's Supreme Court ruling on the Affordable Care Act, Republican governors are talking tough about turning down expanded federal Medicaid spending that would enable insurance coverage for millions of their residents. Louisiana's Bobby Jindal, who warned the "frightening" Court decision could lead to penalties for those who "refuse to eat tofu," insisted "we're going to do what we can to fight it." And while Mississippi's tea party chairman called for open rebellion, Magnolia State GOP leaders responded by declaring, "we are going to do everything we can for that not to happen."

Sadly, the Republican governors' answer to the Roberts Court should have been simply, "thank you." After all, in keeping with the practice of red state socialism under which blue state taxpayers pick up the tab for their more conservative brethren, "the federal government would pick up all the costs in the first few years and at least 90 percent of the expenses after that." And as the data show, health care is worst where Republicans poll best.

That point was reinforced with a recent Gallup poll on the uninsured in America. With almost 28 percent of respondents uninsured, Texas far and led the nation as well as the "uninsured belt" that stretches across the solidly red south. Led by Mitt Romney's Massachusetts, 9 of the top 10 performing states voted for Barack Obama in 2008.

But tallying up the ranks of the uninsured understates the magnitude of the unfolding health care horror story in Red State America. Two years ago, the Commonwealth Fund released its 2009 state health care scorecard, which measured performance in providing health care access, prevention and treatment, avoidable hospital use, equity across income levels, and healthy lives for residents. Again, while nine of the top 10 performing states voted for Barack Obama in 2008, four of the bottom five (including Arkansas, Mississippi, Oklahoma and Louisiana) and 14 of the last 20 backed John McCain. (That at least is an improvement from the 2007 data, in which all 10 cellar dwellers had voted for George W. Bush three years earlier.)

In December, the "America's Health Rankings" project echoed those findings. And in 2009, another UnitedHealth Group funded study similarly showed that red state residents are the unhealthiest in America. With Vermont topping the list and Mississippi bringing up the rear, Americans would do well to listen to Dr. Howard Dean and not former Gov. Haley Barbour when it comes to the health care debate.

The ironies of the Republicans' crusade to prevent their own constituents from getting health care aren't limited to geography. Left unsaid is that the dynamic of "red state socialism" applies to health care. That is, the one-way flow of blue state tax dollars to Washington D.C. to fund programs in red states is already at work.

Currently, the $300 billion Medicaid program serves roughly 60 million Americans. On average, the federal government picks up 57 percent of the tab, with poorer states like Mississippi and Alabama getting 75 percent of the funding from Washington. Averaging  percent of states' spending, Medicaid is now the largest budget item for most. Medicaid not only pays for a third of nursing home care in the United States; it covers a third of all childbirths. In Texas, the figure is one-half.

In May 2009, the Washington Post ("A Red State Booster Shot") explained how national health care form would ultimately have to work—and have to be funded:

Health-care reform may be overdue in a country with 45 million uninsured and soaring medical costs, but it will also represent a substantial wealth transfer from the North and the East to the South and the West. The Northeast and the Midwest have much higher rates of coverage than the rest of the country, led by Massachusetts, where all but 3 percent of residents are insured. The disproportionate share of uninsured is in the South and the West, the result of employment patterns, weak unions and stingy state governments. Texas leads the way, with a quarter of its population uninsured; it would be at the top even without its many illegal immigrants.
Which is exactly right. With the full implementation of the Affordable Care Act beginning in 2014, federal assistance to under-served red states will only increase. The expansion of Medicaid to families earning 133 percent of the federal poverty level (FPL) and the availability of subsidies to those at four times the FPL will enable coverage for over 30 million more people nationwide. (Of these, the Urban Institute estimated that 8.1 million Americans would have their insurance paid for in full by the expansion of Medicaid. Another 10.9 million people would receive subsidies to buy private insurance in the new state exchanges, while only 7.3 million, 2 percent of the total U.S. population, would be required to purchase a health plan using their own resources alone.)

All told, the nonpartisan CBO forecast the states would be on the hook for $60 billion in new costs over the first decade. As the Center on Budget and Policy Priorities explained:

Claims that states will bear a significant share of the costs of the Affordable Care Act's (ACA) Medicaid expansion -- and that this will place a heavy financial burden on states -- do not hold up under scrutiny. Congressional Budget Office (CBO) analysis indicates that between 2014 and 2022, the ACA's Medicaid expansion will add just 2.8 percent to what states spend on Medicaid, while providing health coverage to 17 million more low-income adults and children. In addition, the Medicaid expansion will produce savings in state and local government costs for uncompensated care, which will offset at least some of the added state Medicaid costs.

Nevertheless, South Carolina's Nikki Haley, Florida's Rick Scott and many of the same GOP governors who brought the suit against the Affordable Care Act have said they will reject the new dollars from Washington. The result, as the Christian Science Monitor and the New York Times each reported, "The poorest adults—primarily parents and other adults working for low wages—will be left out in the cold":

"We are concerned many states will choose not to expand coverage," Bruce Siegel, president of the National Association of Public Hospitals and Health Systems, said Thursday in a statement released following the court's decision. "In the 26 states that participated in the federal lawsuit, more than 27 million people have no insurance," he added, and many of those who would have been eligible for Medicaid in 2014 "might no longer have that option."
But if Mitt Romney has his way, the impact in the states will be much, much worse. (This, despite evidence from Oregon and his home state of Massachusetts that expanded coverage is delivering dramatic benefits in terms of improved health outcomes.) Along with Paul Ryan and Congressional Republicans, Romney doesn't merely seek the repeal of the Affordable Care Act, but wants draconian cuts to Medicaid spending while turning over what remains as block grants to the states.

We already know how that story ends. As Ezra Klein detailed last year, "Twenty states implemented benefit restrictions in the past year. In fiscal year 2010, 39 states implemented Medicaid provider rate cuts or freezes (up from 33 in fiscal year 2009), and 37 states have provider rate restrictions planned for the next fiscal year." Or as Jonathan Cohn put it:

That's not to say plenty of governors wouldn't take advantage of block grant status to change their Medicaid programs in ways they cannot now. They surely would--by capping enrollment, thinning benefits, increasing co-payments, and so on.
All, Republicans proudly proclaim, in the name of states' rights. Apparently, among them is the right to miserable dismal health care for their red state residents.
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