This week, GOP White House frontrunner Mitt Romney marked the two year anniversary of the Affordable Care Act by declaring the reform law the "national nightmare" he "always predicted." But leaving aside for the moment that Romney repeatedly touted his virtually identical Massachusetts law as a model for the nation, there's a much bigger problem with his call for a "free market, federalist approach" in which "each state should be allowed to pursue its own solution." As Ezra Klein exhaustively documented five years ago, it's almost impossible for even the wealthiest of those state "laboratories of democracy" to achieve universal health care on their own. Worse still, Romney's mythical nightmare future is the horrifying present in the states his party currently represents. As the data show, health care is worst precisely where Republicans poll best.

That point was reinforced last week with the latest Gallup poll on the uninsured 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, 9 of the top 10 performing states voted for Barack Obama in 2008.

But tallying up the ranks of the uninsured understates the magnitude of the unfolding health care horror story in Red State America. Two years ago, the Commonwealth Fund released its 2009 state health care scorecard, which 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, four of the bottom five (including Arkansas, Mississippi, Oklahoma and Louisiana) and 14 of the last 20, backed John McCain. (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.)

In December, the "America's Health Rankings" project echoed those findings. And in 2009, another UnitedHealth Group-funded study similarly showed that red state residents are the unhealthiest in America. With Vermont topping the list and Mississippi bringing up the rear, Americans would do to listen to Dr. Howard Dean and not former Governor Haley Barbour when it comes to the health care debate.

The ironies of the Republicans' crusade to prevent their own constituents from getting health care aren't limited to geography. Left unsaid is that the dynamic of "red state socialism" applies to health care. That is, the one-way flow of blue state tax dollars to Washington DC to fund programs in red states is already at work.

Currently, the $300 billion Medicaid program serves roughly 60 million Americans. On average, the federal government picks up 57 percent of the tab, with poorer states like Mississippi and Alabama getting 75 percent of the funding from Washington. Averaging 21.8 percent of states' spending, Medicaid is now the largest budget item for most. Medicaid not only pays for a third of nursing home care in the United States; it covers a third of all childbirths. In Texas, the figure is one-half.

In May 2009, the Washington Post ("A Red State Booster Shot") explained how national health care reform would ultimately have to work — and have to be funded:

Health-care reform may be overdue in a country with 45 million uninsured and soaring medical costs, but it will also represent a substantial wealth transfer from the North and the East to the South and the West. The Northeast and the Midwest have much higher rates of coverage than the rest of the country, led by Massachusetts, where all but 3 percent of residents are insured. The disproportionate share of uninsured is in the South and the West, the result of employment patterns, weak unions and stingy state governments. Texas leads the way, with a quarter of its population uninsured; it would be at the top even without its many illegal immigrants.

Which is exactly right. With the full implementation of the Affordable Care Act beginning in 2014, federal assistance to under-served red states will only increase. The expansion of Medicaid to families earning 133 percent of the federal poverty level and the availability of subsidies to those at four times the FPL will enable coverage for 30 million more people nationwide.

Nevertheless, Republican state attorneys general are hoping to overturn the Affordable Care Act in the Supreme Court, if not in Congress. Once again, the reddest of red states are most mobilized to undo the dreaded "Obamacare" where the need for it is greatest:

Of course, the final irony of the Republican assault on health care reform is Mitt Romney himself. In Massachusetts, the 2006 health care reform bill then Governor Mitt Romney signed into law lowered the uninsured rate from 10 percent to a national low of two percent. Even with its individual mandate, "Romneycare" is extremely popular enjoying a 3 to 1 margin of support from Bay State residents. Now, a new study by Charles J. Courtemanche and Daniela Zapata published by the National Bureau of Economic Research (NBR) shows that universal coverage in Massachusetts is indeed making people there healthier. As Ezra Klein of the Washington Post summed up their findings:

The answer, which relies on self-reported health data, suggests they did. The authors document improvements in "physical health, mental health, functional limitations, joint disorders, body mass index, and moderate physical activity." The gains were greatest for "women, minorities, near-elderly adults, and those with incomes low enough to qualify for the law's subsidies."

Those Massachusetts residents who benefit from health care reform today fit the same profile of those red staters who will be helped by the Affordable Care Act in the future. (And as MIT professor Jonathan Gruber, who worked on both pieces of legislation, explained, "they're the same f--king bill.") But if Mitt Romney and his Republican allies are successful in repealing The Affordable Care Act, red state Americans will continue to suffer their sadly ironic fate.

That is, health care is worst where Republicans poll best.

(This piece also appears at Perrspectives.)