Blue Islands of Health Care Coverage

Greg Sargent makes a pretty important point today with some help from the Kaiser Family Foundation: there’s no particular reason to believe that an adverse SCOTUS decision in the King v. Burwell case would disrupt the operation of the Affordable Care Act in states that have created their own insurance purchasing excanges:

“In 16 states, plus D.C., the health care system would be functioning exactly as was originally intended with the ACA, with steady movement towards near-universal coverage, and all the protections in place for people with preexisting conditions,” Larry Levitt, a senior vice president with the Kaiser Family Foundation, tells me. “Meanwhile, in all the other states, you would have millions losing coverage and insurance markets thrown into chaos, with premiums increasing and insurers exiting the market altogether….”

If the Court nixes subsidies, as many as six million people could lose then, according to many estimates. The number who lose coverage could rise as insurance markets implode. But subsidies would remain in the 16 states plus D.C. that have their own exchanges. Add in Pennsylvania and Delaware, which are already on track to setting up exchanges, and that’s 18 states plus D.C. In those states, some 2.6 million are currently receiving subsidies, Levitt calculates. That would continue untouched.

Meanwhile, the Medicaid expansion remains in those states and also in the dozen or so states that expanded Medicaid but did not set up exchanges. And that expansion has covered an additional 12.2 million people.

In total, then, according to Levitt’s calculations, even if the Court nixes subsidies and lawmakers do nothing, at least 14.8 million will still be receiving financial help to gain health coverage through Obamacare.

That’s around six million fewer than if the Court leaves the law undisturbed — a serious setback. But still, 15 million newly-insured people is a major achievement. And that’s only as of today; those numbers will likely continue to grow as blue states add people to the exchanges, and as the Medicaid expansion continues adding people in those states and in the red states that have opted into it.

What this means is that Republicans cannot entirely let the courts do the dirty work of getting rid of Obamacare for them and then come along with some “replacement” system that insulates them from blame. They’ll have to take subsidies and Medicaid coverage away from millions of people with their own hands, in full public view. And there will be political as well as health care consequences for that.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.