Back in May 2009, the Washington Post touched on the greatest irony of the health care debate just beginning to grip the nation. "The Democrats' No. 1 domestic policy initiative," Alec MacGillis wrote, "is likely to help red America at the expense of blue." You didn't need a crystal ball to see why. The chasm in care and resources was due to "the disproportionate share of uninsured is in the South and the West, the result of employment patterns, weak unions and stingy state governments," MacGillis explained, rightly concluding that health care reform would ultimately "represent a substantial wealth transfer from the North and the East to the South and the West."
Unless, that is, the poorer, sicker and more Republican red states did the unthinkable and said no to the help from their blue state brethren.
Five years later, that tragedy is exactly what has come to pass. While as many as 23 million Americans obtained health insurance during the first enrollment period for the Affordable Care Act, millions more were needlessly left without coverage in the reddest of red states. Because 24 GOP-controlled states rejected Obamacare's Medicaid expansion that virtually pays for itself, seven million residents remain insured. Up to 17,000 of them are projected to needlessly die--every year. By refusing to run their own exchanges, blocking the outreach of "navigators" that Medicare has used with great success for more than 20 years and turning to myriad other obstructionist tactics, states like Rick Perry's Texas, Bobby Jindal's Louisiana and Nathan Deal's Georgia have accomplished what five years ago seemed impossible.
Republicans have made the yawning gap between blue and red state health care worse.

The steep decline in the ranks of the uninsured tells the tale, or at least part of it. Two recent Gallup surveys showed that the percentage of uninsured in the United States dropped from 18.0 percent last fall to 15.6 percent in April, its lowest level since 2008. But most of the newly insured are in those generally Democratic states which embraced Obamacare, cutting their uninsured rates from 16.1 to 13.6 percent, an impressive 2.5 point decline. But the rejectionist red states have hardly moved the needle, with the uninsured rate edging down by only 0.8 percent from 18.7 to 17.9 percent among adults 18 and older.
Those top-level numbers, however, obscure the magnitude of the very real--and completely unnecessary--human suffering in the reddest of red states. California enrolled 1.4 million people under the ACA, while New York signed up 900,000 more. (In the highly regulated Empire State market, premiums fell by half). But as a new assessment this week from the Kaiser Family Foundation revealed, almost 80 percent of the adults caught in the "coverage gap" reside in southern states. Two-fifths of them are white. As dire as KFF's forecasts for GOP-controlled states were in January, the reality is still staggering. Between them, Texas and Florida, two states in which Republicans said no to the Medicaid expansion and impeded just about every other Obamacare initiative they could, those who could been covered constitute almost 40 percent of the national total.

As Kevin Drum concluded, "Republican governors have been almost unanimously dedicated to sabotaging Obamacare and withholding health care from their own residents, and they've been successful." But Drum actually understates the magnitude of the GOP's betrayal of red states residents. As the data have shown for years, health care is worst in those states where Republicans poll best.

That truism was reflected in Gallup's 2012 poll of the insured in America. With almost 28 percent of respondents uninsured, Texas far and away led the nation as well as the "uninsured belt" that stretches across the solidly red south. Led by Mitt Romney's Massachusetts, nine of the top 10 performing states voted for Barack Obama in 2008 and 2012. But tallying up the ranks of the uninsured understates the magnitude of the health care horror story in Red State America. In its 2009 state health care scorecard, the Commonwealth Fund measured performance in providing health care access, prevention and treatment, avoidable hospital use, equity across income levels, and healthy lives for residents. Again, while nine of the top 10 performing states voted for Barack Obama in 2008 and 2012, four of the bottom five (including Arkansas, Mississippi, Oklahoma and Louisiana) and 14 of the last 20 backed John McCain and Mitt Romney. (That at least is an improvement from the 2007 data, in which all 10 cellar dwellers had voted for George W. Bush three years earlier.) Texas, which Gov. Rick Perry claimed in 2010 had the best health care system in the nation, is ranked a moribund 46th.

The situation hasn't gotten any better for Red State America. In March 2012, the Commonwealth Fund performed a similar analysis of the nation's 300-plus metropolitan areas. Twenty eight of the top 30 voted for Barack Obama. All of the lowest ranked 10 percent voted for Mitt Romney.

These dismal numbers reflect something else. Republican-run states don't just have the worst health care systems; they are also home to the unhealthiest residents. In 2009, a UnitedHealth Group funded study examined 22 different indicators and similarly revealed that red state residents are the unhealthiest in America. The 2013 edition of America's Health Rankings (produced by the UnitedHealth Foundation) looked at rates on obesity, smoking, diabetes and physical inactivity and found much the same thing.

Given the ongoing health care crisis in their states, red state Republicans should have been eager to embrace the Affordable Care Act. That goes double for the ACA's expansion of Medicaid. Uncle Sam pays 100 percent of the cost over the first three years; after 2017, the states are on the hook for 10 percent of the price tag. Between 2015 and 2024, the CBO recently concluded, the federal government will be paying 95 percent of the total cost. But that estimate does not include costs rejectionist states will run up by having to reimburse hospitals and other health providers for the care of the uninsured. That's why the Rand Corporation and others' assessments concluded that for most states Medicaid expansion will pay for itself. As Ezra Klein summed it up in 2012:

The deal the federal government is offering states on Medicaid is too good to refuse. And that's particularly true for the red states.

Yup, all but one of the 10 states which stood to benefit most by expanding Medicaid to 133 percent of the federal poverty level (FPL) voted for Mitt Romney. Nine of the 10 benefiting least gave their electoral votes to Barack Obama.

But Klein's chart understates the suffering red state leaders would inflict on their own constituents by passing up the Medicaid expansion the Supreme Court in 2010 made optional. As the Washington Post showed in this July 2012 chart, many of the states which ultimately said no to the Medicaid expansion currently offer far stingier programs than their Democratic counterparts.

The rejectionist red states weren't just choosing to leave roughly seven million people without health insurance. They were preserving the option to cut their existing state Medicaid programs further. Phil Galewitz of Kaiser Health News explained one way that could happen:

As a hypothetical example, if Mississippi opted out of the 2014 expansion of Medicaid, poor childless adults wouldn't gain coverage in that state. At the same time, the state could roll back eligibility for parents with children who are currently enrolled, reducing the number of participants in the program.

And as Glenn Kessler explained in the Washington Post in 2011, it is hard to believe that a state like Mississippi could make it current program any worse:

Mississippi provides some of the lowest Medicaid benefits to working adults in the nation. A parent who isn't working can qualify only if annual family income is less than 24 percent of the poverty line. Working parents qualify only if they make no more than 44 percent of the federal poverty level. Seniors and people with disabilities are eligible with income at 80 percent of the poverty line...
Translated from the federal poverty guidelines, that means a working Mississippi couple with one child could earn no more than $8,150 a year and still qualify for Medicaid, seniors and people with disabilities could earn no more than $8,700, and a pregnant woman could earn no more than $20,000 a year.

Ultimately, several of the states listed in the charts above expanded Medicaid. Thanks to Democratic Gov. Steve Beshear, Kentucky established the Kynect program, which has now enrolled 413,000 residents in Medicaid or private insurance. Arkansas Democratic Gov. Mike Beebe turned to a private option negotiated with the Department of Health and Human Services (HHS) enabling 155,000 newly Medicaid-eligible Arkansans to purchase coverage from insurance companies. And while four hospitals in Georgia have already closed because GOP Gov. Nathan Deal refused to accept Medicaid coverage for over 600,000 Peach State residents, in Mena, Arkansas the 9th Street Ministries free clinic is closing its doors after 16 years because its services are no longer needed by the poor residents who have now obtained health insurance thanks to the Affordable Care Act. It's no wonder the private option approach is very popular among Arkansans, unless they are first informed that it is part of Obamacare. (That's also why Kentucky and Arkansas give Obamacare higher marks than Louisiana and North Carolina. Yet, even in those rejectionist states, residents do not want to repeal Obamacare.)

The Republican saboteurs warning their constituents about "death panels" and "chip implants" aren't just leaving millions of their own residents uninsured and hospitals at risk. They are killing people.
That's the conclusion a team of researchers from Harvard Medical School recently published in Health Affairs. The authors of "Opting Out Of Medicaid Expansion: The Health And Financial Impacts" tallied up the coming body count in the Republican states that rejected the ACA's extension of Medicaid to millions of their residents:

Nationwide, 47,950,687 people were uninsured in 2012; the number of uninsured is expected to decrease by about 16 million after implementation of the ACA, leaving 32,202,633 uninsured. Nearly 8 million of these remaining uninsured would have gotten coverage had their state opted in. States opting in to Medicaid expansion will experience a decrease of 48.9 percent in their uninsured population versus an 18.1 percent decrease in opt-out states. [...]
We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104. Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64. Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.

To put those findings in terms Republicans can understand, up to 3,000 of Rick Perry's Texans will needlessly die each year. Those dead will joined by up to 671 from Scott Walker's Wisconsin, 1,176 in Nathan Deal's Georgia, 2,221 in Rick Scott's Florida and 1,145 in Pat McCrory's North Carolina.

It's no wonder Ohio GOP Gov. John Kasich got biblical on Buckeye State Republicans to extend Medicaid coverage to 300,000 of their state's residents:

"When you die and get to the meeting with St. Peter, he's probably not going to ask you much about what you did about keeping government small, but he's going to ask you what you did for the poor. You'd better have a good answer."

But thus far, most Republican leaders in Washington and in the states are just doubling down. The party's leaders and presidential aspirants, including Mitch McConnell, Rick Perry, Scott Walker and Bobby Jindal are all campaigning on repealing Obamacare. In Kansas and Georgia, Governors Sam Brownback and Nathan Deal, both facing tough reelection battles, signed laws that shift the decision to accept the Medicaid expansion to the GOP-controlled legislatures. And even as Obamacare critic Robert Laszewski is urging Republican governors to follow in Arkansas' footsteps, conservative think tanks are turning to bogus math to undermine the private option Medicaid program in place there.
And all the while, the long-standing blue state health care advantage will continue to grow. But it didn't have to be this way. It still doesn't. The health care deficit in the red states will begin shrinking as soon as their Republican leaders stop saying "no" and start saying, "thank you."
(This piece first appeared at Dailykos.)