For most of the past 100 years, there has been a bipartisan consensus that enacting legislation to ensure that every American has access to health insurance is a national priority, even as Republican and Democrats disagreed on how to get there. The Washington Post’s Ezra Klein notes that as recently as 2007 Senator Jim DeMint (R-SC), now a Tea Party favorite, sent a letter to then-President George W. Bush offering to work with him to pass legislation that would “ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage.”
Senator DeMint could have been channeling President Teddy Roosevelt, who first called for universal coverage in 1912. Teddy, of course, was a Republican.
Much has changed in five years. Earlier this week, Senate Minority Leader Mitch McConnell was asked by Fox News how the GOP planned to address the more than 30 million uninsured who will lose access to health insurance if the Affordable Care Act is repealed, and he replied “that is not the issue.” His position is now the mainstream consensus among most Republicans—enacting legislation to provide coverage to all Americans is no longer the party’s objective. None of the “replace” plans offered so far by the GOP—selling insurance across state lines, health savings accounts, or medical liability reform—do much of anything to reduce the number of uninsured.
Which is too bad. The country could surely use a spirited debate between the parties on how to make sure Americans have health insurance coverage they can afford. We know that the GOP hates Obamacare and will do everything it can to make it go away. But I wish it would offer an alternative that shows us how they would cover everyone that costs less, doesn't raise taxes, uses free market principles, and has a smaller role for government, if such a thing is possible, instead of saying that the uninsured are not the issue. In other words, do what the 2007 version of Jim DeMint advocated, and develop a plan to “ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs.” This would be a debate worth having in this election year.
And in my mind, and in ACP's view, the uninsured ARE the issue. Today, the Annals of Internal Medicine published a commentary from me, asking whether the Affordable Care Act, as changed by the Supreme Court, is a milestone or detour on the road to universal coverage. My answer is that it is both: it will expand coverage to tens of millions, but the Supreme Court's decision on the Medicaid provision opens up the possibility that in some states, coverage would be available to everyone except the poor. I don't know how anyone could reasonably justify making an explicit policy decision to shut out the poorest among us from coverage. Yet that's what the Supreme Court decision allows, and what some states, regrettably, are threatening to do.
My Annals article quotes Dr. Atul Gawandes's observation that “[M]any levers of obstruction remain; many hands will be reaching for them. For all that, the Court's ruling keeps alive the prospect that our society will expand its circle of moral concern to include the millions who now lack insurance. Beneath the intricacies of the Affordable Care Act lies a simple truth. We are all born frail and mortal—and, in the course of our lives, we all need health care. Americans are on our way to recognizing this.”
I hope he is right, and that Republicans and Democrats alike will once again agree that the uninsured are the issue, and that our society must expand its circle of moral concern to include the millions who now lack health insurance. And then debate how best to get them insured, instead of saying that this isn't the issue.
Today's question: Do you agree or disagree that the uninsured aren't the issue?