Chaos could ensue if the supreme court strikes down Obamacare

Eight million Americans risk losing their health insurance if the supreme court sides with opponents of the Affordable Care Act next week. The court will be hearing oral arguments in King v Burwell, the latest legal challenge to the act on March 4. If the court rules against ACA, chaos in the healthcare market could ensue. Fewer people with effective access to medical care could lead to an estimated 9,800 deaths per year. And many more would undergo needless suffering and financial calamity.

So what happens if the plug is pulled on ACA? In the majority of states that didn’t establish their own health insurance exchanges, nobody would receive tax credits to help them purchase insurance. The vast majority of these people would also become exempt from the mandate to purchase insurance. But the ACA’s other regulations - including the guarantee of insurance for all applicants - would remain in place. The result would be an an “actuarial death spiral” in which relatively young and healthy people dropped their insurance, insurance becomes more expensive, more people drop their insurance and this repeats until the health insurance markets spin out of control.

It seems crazy to think that Republicans would allow such a disaster to happen. In a response to critics of his infamous argument that some deaths might be a price worth paying for freedom, Michael J Strain of the American Enterprise Instituteasserted that Republicans in Congress “would very likely take measures to address the needs of those who lost their subsidies as a result of the Court’s action”.

To anyone familiar with the actual Republican Congress, these assumptions of decency and rationality can only be described as black comedy. Republican members of Congress have made it abundantly clear that they’re not going to do anything if the supreme court kicks millions of people out of the health insurance markets. Alabama Senator Jeff Sessions’ suggestion that it’s the responsibility of the Democratic minority to come up with a more popular alternative to Obamacare is fairly representative of how unserious Republicans are about the issue.

Unfortunately, the political price Republicans at the federal level for this would pay for this recklessness would be negligible. Most congressional Republicans occupy safe seats, and poorly informed swing voters are likely to blame Obama for bad things that happen with respect to “Obamacare”. This is one reason defenders of the lawsuit have concocted their absurd alternate history of the law, which purports that the Democratic Congress intended for the federally established exchanges to fail, and that it’s their fault if people get screwed. Although that theory is about as credible as theories that Barack Obama was born in Kenya or George W Bush ordered the 9/11 attacks, this probably won’t matter.

A lot of powerful interests - including insurance companies, hospitals and practitioners - will be urging Republicans to act to restore the tax credits taken away by the Court. In purple or blue states with Republican governors or legislatures, this might have some effect.

In solidly red states, though, Republicans have more to fear from irate primary voters who will not accept any compromise on “Obamacare”, and they are very unlikely to act. As Kansas governor Sam Brownback showed last year, in conservative states it’s essentially impossible for any Republican to fail badly enough to be beaten. The real price, then, will be paid by the millions who risk losing the protection offered by health insurance. They would surely feel sick at the thought of this, if only they could afford to.