i wrote a comment a few days ago that's worth a diary http://www.dailykos.com/...
It strikes me that both sides in the Political debate on "King v Burwell" haven't really thought through the whole thing. The Conservatives are sure, if they can somehow get some little comma overturned the entire bill will collapse. The Dems are convinced if the Supremes overturn one element the entire rube goldberg structure will collapse and
both sides are convinced that it will be this. https://www.youtube.com/...
I'm not so sure, I think it will sucketh mightily for a few million people but, it may be useful
more after the orange lepticon
The Drooling teabaggers hate a black president and want to overturn his
big bill that's putting money into the Obama foundation and helping poor
blacks get healthcare...
And Dems are determined to fight the republicans...
But aside from this reflexive fight, lets think about it..
I suspect the Court will be aggressive in overturning this because the conservatives
favor a strict textual construction even to the point of wooden literal interpretation (See Carter v US).
The court is resistant to constitutional arguments but agressive in statutory cases, particularly when the Congress could fix this or the states could fix this. Given there
are some 35 bodies that could fix this, the supremes will be very likely to view it as
a legitimate policy question.
Remember even if you listen to the court and the nutbaggers and say McConnell
and Boehner don't move a bill. The 34 states that aren't doing their own
exchanges can do their own.
The IRS/DHHS could easily pass a reg that allows a state exchange to be a
simple set of web hooks into the Federal exchange. DHHS could easily make
it like those little "Google" search boxes and "Amazon" buy boxes...
i'd suggest the states like Maryland that use the federal exchange could easily do this,
it's a pretty blue state, they aren't going to allow that to change.
So the Supremes will likely say "Hey any state that feels it's behind can just do their own exchange". Now sure there may be another lawsuit, but that is speculative.
Now why i don't think this will be the end of the world.
People say "OMG, the Insurance plans will go into Death spirals"... Yes, yes that's true.
And certainly Georgia, Alabama, Texas, will have that happen...
However it won't cascade nationally.
Health insurance markets are regional in both Cost and Revenue. A regional market
can go bad but not spread, it's why we saw the granularity pre Obamacare.
Health Care is a state wide market not a national market. A doctors practice is local,
a hospital serves an MSA. Even a hospital system basically serves into markets with their costs loaded into individual cities. The scaling efficiency hits at the size of small operating theater. Look at a Lasik Factory. One opthamalic surgeon can process a patient every 5 minutes. Even complex surgery can be optimized if you focus on process work.
http://www.theglobeandmail.com/...
Costs are also primarily a state function.
If you are in the California insurance system, 90% of your costs are in california.
You don't go to NYC for cardiac surgery if you live in Bakersfield, you may go to UCLA but odds are you go to surgery with 100 miles of where you live.
The same applies, people in Texas aren't going to go to California for medical work,
except maybe plastic surgery. Especially the sick. If you aren't insured, you
won't fly to california everytime your diabetes flares up...
So some Palin-like grifters may drift down from Wyoming to California and not pay
for medical bills, but, if you are hurt, and sick, driving a long distance isn't the sort of
thing you want to do.
if we look we can see the prototype in Medicaid expansion.
Some states are doing well some aren't..
http://www.dailykos.com/...
but
louisana is seeing major hospital ER's closing
http://www.dailykos.com/...
http://www.dailykos.com/...
http://www.dailykos.com/...
Now, there are some 12 million people using the ACA exchanges, and say half of them
get shafted... That's 6 million people, mostly in the south, and mountain states.
So, New England does okay, the south and rural west become even less developed.
This results in billions in income transfer to the Blue states and people with choices
will look at ER's closing and decide "Maybe i should take that job in Philadelphia"...
Now some 4 million people and millions more will get shafted....
but this can force people to get out there and crucify their legislators,
and it will cause hospital administrators to get out there and push
to change their state governments.
but we will also see Kentucky doing well, while Tennessee gets worse.
Now i'm sorry for people in South Carolina, but it will also cause people to get out
there and push for change, at the local level.