The Public Health Ramifications of Supreme Court’s Rulings

The Supreme Court’s recent trio of landmark rulings—relaxing concealed carry gun laws, overturning Roe v. Wade, and limiting the power of the Environmental Protection Agency (EPA) to regulate power-plant emissions industry wide—have generated all manner of political and judicial blowback. Those who stand to benefit from the rulings applaud the court’s historic actions, and critics condemn them as extreme judicial overreach.

But more important than politics is the very real impact the rulings are likely to have—in both the short and long term—on the health of Americans, whose lives are decidedly affected by any decisions involving pollution, guns, and abortion.

Here are the potential public-health implications of the decisions, and what can we expect over the next years as they work their way into the literal body politic.

More polluted air—and inflammation—for all

Of the recent rulings, West Virginia v. Environmental Protection Agency has the most nationwide impact, if only because all of us share and breathe air, and all of us are thus touched by the smokestack emissions produced by the country’s 3,477 fossil-fueled power plants. The ruling struck down the EPA’s power to cap emissions across that entire sector, concluding that such authority went beyond the regulatory scope of what the 1970 Clean Air Act allowed. That, medical experts say, is bad news for all of us.

Increased carbon emissions will lead to an exacerbation of the already pressing problem of global warming. Last year was the sixth hottest year on record and also marked the 45th consecutive year in which global temperatures rose above the 20th century average, according to the National Oceanic and Atmospheric Administration. Each year, about 12,000 Americans die of extreme heat, found a 2020 study from the National Center for Biotechnology Information.

Read More: How to Cool Down When It’s Really Hot Outside

That figure is likely a gross underestimate, because extreme heat exacerbates all manner of underlying conditions like cardiovascular disease, dementia, COPD, and more—meaning that it’s those conditions, not the temperature, that gets listed as the official cause of death, cautions Dr. Aaron Bernstein, a pediatrician at Boston Children’s Hospital, and the interim director of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health. “It’s hard to disentangle,” Bernstein says. “People don’t have heat listed as the number-one diagnosis on their death certificate.”

It’s not just the temperature, of course, that causes smokestack emissions to be harmful. So do the key pollutants the power plants emit, especially sulfur dioxide, nitrogen oxides, carbon dioxide, mercury, and particulate matter—the last of which causes especially great concern.

According to the EPA, coarse particulate matter is implicated in childhood asthma, a condition that the U.S. Centers for Disease Control and Prevention says afflicts more than 4.2 million American kids 18 years old and younger.

But particulate matter of all sizes is linked to far more than asthma. “Particulate matter is a pro-inflammatory exposure,” says Bernstein. “When these particles get into our bodies, they will light them up, causing damage to everything—the brain, the blood, the heart, the lungs.” Such inflammation, Bernstein says, may exacerbate depression and anxiety and may even be linked to suicide—a connection supported by a meta-analysis published in 2019 in the journal Environmental Health Perspectives. Alzheimer’s disease is also likely exacerbated by air pollution, says Dr. Ceclia Sorensen, professor of emergency medicine and environmental health sciences at Columbia University.

Not all Americans suffer from polluted air to the same degree, and—as so often happens— people of color and lower-income communities get hit the hardest, as the chart below shows. A disproportionate share of fossil fuel-fired power plants in the U.S. are located in or near low-income, non-white, and non-English-speaking communities, as well as communities in which most people have less than a high school education.

“Air pollution is not an equal opportunity killer,” says Bernstein.

Sorensen sees a cruel cycle in this kind of demographic disparity. “People who are already economically disadvantaged are getting bigger medical bills and more health problems, which further cripple their ability to get out of poverty,” she says. “There are huge environmental justice issues across the country—pockets of it in every city, every state, every urban economy.”

Being in public is now more mortally dangerous

A whole different kind of public risk is posed by New York State Rifle & Pistol Association v. Bruen, the Supreme Court’s controversial gun-control ruling. The case involved a New York State law that required gun owners within the state’s borders to have a license to carry a concealed gun outside the home and to show “good cause” to obtain that license. That meant they had to show that their job or some other special circumstance required them to be armed, rather than simply choosing to carry a gun for self-defense. The court struck down the good-cause provision, leaving in place the requirement of a license, but making one dramatically easier to obtain. Six other states—California, Hawaii, Maryland, Massachusetts, New Jersey, and Rhode Island—have similar laws on the books, and theirs are now mooted, too.

That’s troubling news in a country reeling from more than 300 mass shootings so far in 2022—even with a modest but real gun safety bill recently passed by Congress and signed into law by President Joe Biden. The more guns people carry, experts worry, the more shootings will naturally result.

“Disagreements outside a bar might turn into gunfire,” says Nick Suplina, senior vice president for law and policy at Everytown for Gun Safety. “It might mean a scary situation in the subway resulting in a person drawing and firing their concealed weapon. There are states that have permitless carry where fender benders [lead to gunfire] because tempers flare.”

Those concerns are more than speculative. One 2017 paper by the National Bureau for Economic Research found that states that weakened their handgun carry laws saw homicide rates increase by 11% and rates of violent crime rise by up to 15% within 10 years of adoption of the laws. A 2022 paper by the same group analyzed the gun laws of 47 cities and found that laws permitting concealed carry were associated with a 29% increase in firearm-related violent crime. “Increased public carry leads to worse public safety outcomes,” Suplina says.

In his dissent in the Bruen decision, Justice Stephen Breyer cited the 45,222 Americans killed by guns in 2020—a number that Jon Lowy, vice president and chief counsel at the anti-gun-violence group Brady, calls “a public health crisis.” Public-health experts agree on that classification. “As leaders in medicine, our unique perspective on firearm violence as a grave public health crisis is informed by scientific research and the clinical experiences of physicians,” said Dr. Jack Resneck, Jr., president of the American Medical Association, in a statement. “In emergency departments across the country, physicians are first-hand witnesses to the catastrophic fallout of firearm violence while caring for victims with devastating, life-threatening injuries that are preventable.”

“Society should address the problem comprehensively,” Lowy says, “which includes strengthening laws regulating guns, more effectively requiring safety features, requiring sales to be more reasonable, and careful public education. These are the sorts of things we do with tobacco and motor vehicle deaths and opioids.”

Of course cars, tobacco and opioids do not have a Constitutional amendment backing them up, and guns do. In light of that, Brady is helping states—especially the ones that have New York-type laws—draft new legislation that can restrict concealed carry as much as possible, consistent with the Bruen decision. The Supreme Court did not forbid carve-outs to the new ruling: for example, allowing prohibitions of concealed carry in “sensitive places” like schools, government buildings, and polling places. Immediately after the decision had been handed down, New York passed a law enumerating 14 such sensitive places, including any place that serves alcohol, any place children gather, entertainment venues, houses of worship, health care and medical facilities, and Manhattan’s Times Square.

Similar laws could follow in other states. But in a country that has more guns than people, the public-health crisis is not going away anytime soon.

Less body autonomy—with riskier outcomes

The most tectonic of the Supreme Court’s recent trio was Dobbs v. Jackson Women’s Health Organization, the decision that overturned the nearly half-century old Roe v. Wade ruling that made abortion a Constitutional right. The incendiary politics of the decision aside, women will face real health implications in a post-Roe era.

The U.S. is already a dangerous place to be pregnant, with a maternal mortality rate of 24 deaths per 100,000 live births—much higher than the rate in comparable advanced nations, as the chart below shows. Among Black women, the rate is especially alarming: 55 deaths per 100,000 live births. Banning or severely restricting abortions means that more high-risk pregnancies that would have been terminated will instead be brought to term, with potentially disastrous results for the mother, as TIME’s Jamie Ducharme has reported.

One 2021 study, for example, found that if the U.S. banned abortion outright, pregnancy-related deaths would rise by 20% overall and by 33% among Black women. Even in 2017, well before the Dobbs ruling, the maternal mortality rate was 28.5 deaths per 100,000 live births in states that had strict gestational age limits on abortion or pre-procedural waiting periods, compared to 15.7 such deaths in states that protected abortion access through the first trimester, according to a study published in the journal Contraception.

Other factors could be contributing as well. States that limited abortion access pre-Dobbs are often those that did not expand Medicaid under the Affordable Care Act and have fewer practicing medical professionals—raising the dangers associated with pregnancy overall. These states are home to a disproportionate number of people of color who are living in poverty.

None of that means that in a post-Roe world, maternal health is likely to suddenly become societally valued. Instead, the always hard work of pregnancy will now become all the more dangerous.

Write to Jeffrey Kluger at [email protected].