I like unintended consequences.

On the surface, that seems like a counter-intuitive statement, but there is something in me that likes chaos by one’s own hand. It helps me realize how highly functioning I am when I see the unintended consequences long before they are in the view of the architect. It is with this belief system that I soldier forward today.

As I write this, the world at large has had roughly a day and a half to digest the rather surprising Supreme Court decision upholding the individual mandate portion of the Patient Protection and Affordable Care Act. What is being glossed over is the part of the Act that was thrown out, that being the penalty that was to be assessed if a state chose not to expand Medicaid coverage to fit the provisions in the Act.

As the law was written, if a state chose not to expand Medicaid coverage to the new eligible populations, the total Medicaid funding for that state could be withheld. After yesterday’s ruling, this is no longer the case. Without a clear thought given to the consequences of this ruling, the Supreme Court has now created a federally-subsidized health system that will be unequal based on the political affiliation of state governments.

It is no secret that the Republican side of the political fence in this country considers PPACA to roughly being equal to appointing Benito Mussolini as our Surgeon General. Remember that it was 26 Republican attorneys general from around the country that were plaintiffs in the many lawsuits seeking to throw it away. In the aftermath of yesterday’s decision, Republicans across the country are doubling down on their enmity towards PPACA, with Republican governors balking at Medicaid expansion for newly eligible beneficiaries.

Let’s think about the backdrop of this for a moment with regard to the amount of federal taxes paid by individual states. We have in place a system that pays smaller states much more in federal tax dollars than the federal government collects in taxes from these same states. As an example, Mississippi, a deep-red Southern state, receives $2.02 for every dollar in taxes paid. In contrast, the state of New York, currently headed by a Democratic governor, gets 79 cents for every dollar of taxes paid. This has created an interesting irony; Republican governors complaining about too much government, while at the same time being the highest beneficiaries of federal largesse on the state level.

With Republican-leaning states making it very clear that they are going to deny Medicaid benefits to newly-eligible citizens in their states, a great awakening awaits Republican governors who have spent the better part of our current president’s time in office railing against the evils of the federal government. Their dream of less federal government is about to come true. Medicaid funding that could have been given to their state will now go elsewhere. The result of this would be less federal dollars and a sicker low-income population. This in turn will lead to hospitals in these states dancing on the brink of failure due to the lack of reimbursement for a needlessly uninsured population.

The solution to Red States suddenly becoming the health care equivalent of leper colonies, to hear Republicans tell it since yesterday’s ruling, is complete repeal of PPACA. There is virtually no chance of that happening when Congress returns from their Independence Day break (one of many). With the Supreme Court’s ruling, Republican governors and attorneys general have created a series of unintended consequences for their states that will begin to clash uncomfortably with their newly-discovered hatred for all things government. The definition of “haves” and “have-nots”, as it pertains to our health care delivery system, is about to undergo an ironic transformation.