If the Supremes strike down health care, what next?

Almost certainly, the most important political story in the country that will occur next week will be the Supreme Court’s ruling on the constitutionality Affordable Care Act. It’s supposed to come down on Monday or Thursday, and the activist lists I’m on are abuzz with plans to take to the streets once the verdict is in.

What will actually happen is pretty much impossible to say. Early on, experts scoffed at the possibly of the Supremes striking down the ACA, but the oral arguments seemed to have changed a lot of folks’ minds. My brother the lawyer is of the view that a Court that was capable of handing down the Citizens United ruling is capable of sinking to untold levels of depravity. Concerning the possible ACA verdict, at this point, to quote the old Hollywood saw, nobody knows anything.

If the Act, or significant parts of it, are struck down, there will be much to discuss and analyze: what impact the Court’s ruling will have on the election this fall, how progressives should carry on the fight for universal health care, what — if anything — we can do about the disturbingly far-right extremism of the current Court, etc. One question that particularly interests me is, assuming that the Act is struck down, should the states enact their own version of ACA? Just this week, in my home state of Illinois, I read this article about a group of health care advocates and small businesses who are urging legislators to create a statewide health insurance exchange. And certainly, if the Supremes overturn all or major parts of the ACA, it seems logical to look to the states to try to enact some version of it.

But enacting ACA at the state level could be problematic. The states would need federal funds to expand Medicaid and subsidize health care premiums for uninsured folks who can’t afford to buy insurance. A universal health care program at the state level with a mandate could work reasonably well, or would at least be a decided improvement over the status quo — as Massachusetts’ plan is, for example. But a plan without a mandate — such as the one in Washington state — would be sure to fail over the long run. The reason for this is simple: if there’s not a mandate, the only people who would purchase the insurance would be sick people, which would in turn drive up the cost of insurance so much that eventually no one would be able to afford it, and health insurance companies would go out of business (or, as happened in Washington, move out of state). The basic model of health insurance requires that healthy people buy insurance, because that in effect subsidizes the cost of insurance for sick people.

At the federal level, the alternative to trying to build a universal care system would be to gradually expand access until you have most people covered. Perhaps you would keep the part of ACA that allows young people to stay on their parents’ insurance until they’re 25. Maybe the age for eligibility for Medicare would be lowered (though that’s certainly not what DC elites of either party seem to want). Perhaps COBRA could be extended or insurance for kids could be expanded.

Ultimately, though, universal care at the national level is the vision that is most rational economically, and also the most just. Unfortunately, American institutions (H/T Lemieux) have long thwarted the progressive dream of a comprehensive national health care system. And frankly, I’m skeptical whether, even if the ACA is upheld, its major provisions will take effect and it will work out as planned. The right is prepared to manipulate our political institutions to their benefit and fight tooth and nail to prevent the ACA from being a success. But at this point, barring as always my fervent hope of some radical reordering of society that makes previously undreamt of things possible, it’s the best hope we’ve got. So I’m hoping like hell Anthony Kennedy doesn’t totally lose his mind over this one. A slim reed, I know, but there we are.

Kathleen Geier

Kathleen Geier is a writer and public policy researcher who lives in Chicago. She blogs at Inequality Matters. Find her on Twitter: @Kathy_Gee