Ah, to be in a red state after health reform!

Supporters of the Affordable Care Act breathed a sigh of relief after Thursday’s Supreme Court ruling. Yet many remain worried about the decision’s Medicaid section.

Although the court upheld the constitutionality of expanding Medicaid, it also ruled that the federal government may not withhold all of a state’s Medicaid funding to induce a state’s participation in ACA’s Medicaid expansion.

In an op-ed titled “Pyrrhic Victory” in Friday’s New York Times, Neal Katyal expressed a common concern:

[U]ntil now, it had been understood that when the federal government gave money to a state in exchange for the state’s doing something, the federal government was free to do so as long as a reasonable relationship existed between the federal funds and the act the federal government wanted the state to perform.

In potentially ominous language, the decision says, for the first time, that such a threat is coercive and that the states cannot be penalized for not expanding their Medicaid coverage after receiving funds …

This was the first significant loss for the federal government’s spending power in decades. The fancy footwork that the court employed to view the act as coercive could come back in later cases to haunt the federal government.

I understand the worry – particularly since the court’s reasoning seems (to me, a non-lawyer) quite unconvincing. By making ACA’s Medicaid expansion optional, the Justices open the possibility that millions of people could be left uninsured in purple and red states.

I wonder, though, if this decision might perversely turn out to liberals’ advantage. For generations, blue-state liberal Democrats have promoted social policies that provide impressive subsidies to poor red-state residents. For just as long, the major foes of such policies have been conservative red-state politicians who have often bitterly opposed expanded social provision for their own constituents.

The New Deal was aptly described as an arrangement whereby the South was forced against its will to accept billions of dollars every year. The same dynamic pertained during many debates over traditional welfare and for Medicaid. It was certainly the case for the Affordable Care Act.

Red states most need ACA’s Medicaid expansion …

When the Affordable Care Act was hanging in the balance, I noted in the New Republic that many wavering politicians represented districts that had much to gain from the new law. My colleague Louis Woynarowski graciously mapped these patterns for every House member considered to be on the fence in firedoglake’s fantastic whip count. Each district is shaded to represent the percentage of nonelderly adults who lacked health coverage. In case Edward Tufte reads this blog, I added representatives’ votes on the original House bill, too. Individual districts of some wavering politicians included 100,000 people lacking insurance coverage. Many still voted no on the final bill.

NPR’s Peter Overby noted that 53 of the 100 congressional districts with the highest uninsurance rates were represented “either by Republican lawmakers who are fighting the overhaul, or by conservative Blue Dog Democrats who have slowed down and diluted the overhaul proposals.”

… but will governors refuse to implement it?

Many red-state governors and representatives rail against the evils of Medicaid and other programs. These same politicians then quietly accept billions of dollars in subsidies to their districts and states. Mitt Romney might ascend to the presidency and enact “repeal and replace” when he takes office. If not, conservative politicians will face some genuine “put-up or shut-up” moment before 2014.

Whatever Governors Perry or Bryant might believe about ACA, thousands of Texas and Mississippi hospitals, nursing homes, and physicians need the money to care for literally millions of people. Other local constituents need this money, too, particularly during our current period of economic distress. Between 2014 and 2019, Texas is slated to receive more than $50 billion in additional federal funds for ACA’s Medicaid expansion, with the federal government picking up more than 95 percent of total costs.

States can always turn down the money. Some Tea Party constituencies may fight for such a course. Judging by this chart, I’m betting they will lose out to a much larger group of service providers, low-income, elderly, and disabled citizens.

However this works out, there’s something healthy for American democracy in asking states to openly confront these choices.

Harold Pollack is Helen Ross Professor of Social Service Administration, and Faculty Chair of the Center for Health Administration Studies at the University of Chicago. He has written about health policy for the Washington Post, New York Times, New Republic,  The Huffington Post and many other publications. His essay, “Lessons from an Emergency Room Nightmare,” was selected for The Best American Medical Writing, 2009.