As I write this, little more than a 2.5 mile walk from my office (according to Google Maps), the nine members of the U.S. Supreme Court are considering the arguments they recently heard regarding the constitutionality of the Affordable Care Act (ACA). Sometime between now and November, they'll let us know what they think. Depending on the outcome, conservatives may finally achieve in the courts what they could not accomplish at the ballot box or through the legislative process. People who know far more about the Court, the constitution, and the law are having a hard time predicting which way the court will go, how far it will go, and what impact that will have on the Affordable Care Act. So, I won't even hazard a guess.
As the Court heard oral arguments, and court-watchers consulted their tea leaves, I reading story after story of people whose have benefited from the health care reform — and will benefit, if the law stands and more of its provisions are implemented in the next couple of years. Republicans have inveighed against those benefits since the Affordable Care Act's passage, and promised to take them away. Since they may be on the cusp of victory, it's fair: What alternative do conservatives have in mind for millions of American's who will lose the Affordable Care Act's benefits and protections if they win in the Supreme Court what they couldn't in every other arena so far.
We already know the answer, of course. But it bears asking while we wait for the Court — and perhaps even more so after the Court rules.
- What do conservatives have in mind for Janine Urbaniac and her family? Her 14-year-old son has brain cancer, and she says that without the Affordable Care Act, her family might have been dropped by their insurance company. Within three weeks of being hospitalized, her son's medical bills topped $1.1 million. The family worried about hitting their insurer's $5 million lifetime limit, and probably would have if the ACA hadn't eliminated such caps when it was enacted last year. (Note: Ubrbaniac writes that her son is back in school, walking, talking, and working out at the gym.)
- What do conservatives have in mind for Lianne Valenti? Valenti lost her job last July, and her health insurance along with it. She could have continued her former employers policy, but couldn't afford the $600 monthly premium and figured she wouldn't fare much better in the individual market. In October, Valenti began having chest pains. By January they landed her in the emergency room, where she was was told she'd suffered a heart attack, underwent an angioplasty and had stents inserted to keep her arteries open. She now has a bill for $79,000 in medical costs. If the Affordable Care Act stands, in 2014 it will make it far easier for unemployed people like Valenti to find affordable coverage.
- What do conservatives have in mind for Susan Hannon? When her husband turned 65 and was eligible for Medicare, Hannon lost her health insurance. Last year, she was rejected for insurance due to high cholesterol — one of the many pre-existing conditions private health insurers use as reason to deny coverage. Thanks to the Affordable Care Act, Hannon was able to enroll in Maryland's Pre-Existing Condition Insurance Plan (PCIP), which has been providing affordable coverage to people with pre-existing conditions, who are shut out of the private insurance market, for now. Beginning in 2014, the ACA will prohibit insurers from denying coverage or charging more for coverage to people with pre-existing conditions.
- What do conservatives have in mind for Brad Gates? Diagnosed with scoliosis as a child, Gates faced a lifetime of corrective surgeries. In 1994, he went on disability and leave his job at an engineering firm. He's signed on to his wife's employer-provided insurance policy, and is eligible for Medicare due to his disability. Yet, Gates' pre-existing condition has meant fighting with insurance companies over expenses, as bills piled up because expenses went uncovered and procedures were dropped as "too expensive." Gates said his insurer made clear efforts to "get me off their policy."
- What do conservatives have in mind for Caroline Richmond? In November, nine-year-old Richmond collapsed on her way to school, and was rushed to the emergency room. Doctors determined she'd had a stroke, and needed surgery right away. It got worse. Doctors determined the stroke was caused by leukemia. Richmond underwent chemotherapy, and at one point became so ill that she had to be put on a ventilator. Richmond is uninsured, as her self-employed father has been unable to find insurance. Worried that medical bills might be forced in to bankruptcy and lose their home due to medical bills, friends of the Richmond family have turned to fundraisers — placing "Cups for Caroline" in all the homerooms at Caroline's school, and holding bake sales, fish fries and car washes to raise money for Caroline's medical bills.
- What do conservatives have to offer Nathan and his son Thomas? In 2009, Thomas was born with hemophilia — one of the most expensive medical condition one can have. In fact, Thomas hit his lifetime limits with two health insurance companies before he was seven years old. Thanks to the Affordable Care Act Thomas and about 105 million Americans no longer have lifetime limits on their health coverage.
- What do conservatives have in mind for Joseph La Mountain? Joseph comes from family with a long history of alcoholism. In 2008, he decided he wanted to stop drinking. When it proved harder than he thought. LaMountain visited his doctor, who prescribed an anti-depressant medication that took away his craving for alcohol. He took it for thirty days, and then stopped. LaMountain found out that wasn't the end of the story when, years later, he was an insurance company declined to cover him, due to a history of "substance abuse and anxiety." The company later offered him coverage — a policy with a $1,500 monthly premium, and a $10,000 out-of-pocket deductible.
- What do conservatives have in mind for Josh R.? Josh, thanks to the Affordable Care Act, was able to get a physical for first time in years. The physical revealed that Josh had severe anemia. As a result, he says he's much healthier than he was before he had the physical. Josh says he wouldn't have been able to afford the physical if he was not on his father's insurance, making him one of 2.5 million young adults who have access to coverage they wouldn't have without and didn't have before the ACA.
There are more stories like this— from and about people who have either been failed by private health insurance, or helped by health care reform — this than I can begin to include in one blog post. Moms Rising has an exhaustive (and even exhausting) compilation of such stories, organized by state. Check out the Obama administration's handy online tool, If you want to figure out how health care reform benefits you.
No matter how different they are from one another, these stories ultimately lead us to has the question Uwe Reinhardt asked: Is there a Republican alternative to the Affordable Care Act?
The answer is simple: No. And yes.
Is there a Republican alternative to health care reform?
No. There is no Republican alternative to the Affordable Care Act. As Reinhardt points out, there is no "serious" Republican plan that proposes to cover all of the uninsured. Not that the ACA — which expands coverage to 30 million, but leaves another 23 million Americans uncovered — does that either, but the CBO says it goes further toward that goal than any other plan with a chance of passing Congress.
No. Jonathan Bernstein noted last month that three (now four) months have passed since House Republicans promised to follow up their vote to repeal the ACA with their own solutions for replacing it. Paul Ryan, David Camp, John Kline, Lamar Smith and Fred Upton called it "a moral imperative." We're still waiting. Republicans have tasked four House committees to draw up alternative plans, but the GOP never gave themselves a deadline.
No. Republicans now have a presumptive nominee in Mitt Romney, but — like the party now warming itself up to settle for him — Romney doesn't have a plan to "replace" the ACA, let alone preserve its benefits for millions of Americans.
Is there a Republican alternative to health care reform?
Yes. It's harder to discern, because it isn't has clearly spelled out or proclaimed as loudly as the intent to repeal. In fact, it's sometimes denied or deliberately obscured. Paul Ryan may say that he doesn't believe that the poor will suffer under his budget. Perhaps he really believes that. But his budget, which is now the Republican budget, would decimate health care spending across several states, with $2.7 trillion in cuts in 10 years — not including the major changes in Medicare.
Yes. Paul Ryan wants voucherize everything — Medicare, Medicaid and employer-provided health insurance.
Yes. He may not have a plant to replace the ACA with anything remotely equivalent, but Mitt Romney has a plan to "reform the tax code to promote the individual ownership of health insurance," that would leave millions of workers with few options but to opt out of the insurance marketplace altogether.
Yes. There' is a Republican alternative to health care reform. It's one that takes us back to the drawing board of health care reform, if the Court's ruling eviscerates it or cripples it so severely that it crumbles.
Yes. There is a Republican alternative to health care reform. It's the one that the audience cheered at Republican debate in Tampa, FL, when Wolf Blitzer questioned Ron Paul about how to pay for medical care for the uninsured.
"A healthy 30-year-old young man has a good job, makes a good living, but decides, you know what? I'm not going to spend $200 or $300 a month for health insurance because I'm healthy, I don't need it. But something terrible happens, all of a sudden he needs it. Who's going to pay if he goes into a coma, for example? Who pays for that?" asked host Wolf Blitzer.
Paul, a medical doctor, first responded by saying American society is primed to believe government would pay for it.
"Well, in a society that you accept welfarism and socialism, he expects the government to take care of him,' he said.
When pressed on the question, Paul responded: "That's what freedom is all about, taking your own risks," to applause from many tea party backers in the audience.
"But Congressman, are you saying that society should just let him die?" asked Blitzer, to which several voices in the audience cried out, "Yes!"
To his credit, Paul did not agree with the audience, but he didn't offer much in the way of solutions beyond returning to "the old days" when the ill and indigent (and these days, one serious illness can make anyone indigent) had to depend upon charity.
"No. I practiced medicine before we had Medicaid, in the early 1960s, when I got out of medical school. I practiced at Santa Rosa Hospital in San Antonio, and the churches took care of them. We never turned anybody away from the hospitals," said Paul to additional applause. "And we've given up on this whole concept that we might take care of ourselves and assume responsibility for ourselves. Our neighbors, our friends, our churches would do it. This whole idea, that's the reason the cost is so high. The cost is so high because they dump it on the government, it becomes a bureaucracy," he added.
Yes. There is a Republican alternative to health care reform. It takes us back to what we had for the nation's first 150 years ago, when 65% of the elderly did not have health insurance ," when more than one in four elderly went without medical care due to costs, and one in three seniors were living in poverty.
Paul's assertion that "in the days before Medicare and Medicaid, the poor and elderly were admitted to hospitals at the same rate they are now, and received good care," just doesn't stand up to the statistics we have for that period. And despite Paul's belief that "our neighbors, our friends, our churches would do it," his libertarian approach just won't work.
It didn't work in an era when America had numerous charitable hospitals, and it won't work now that we have very few. And charitable institutions have their limits for those facing chronic or life-threatening illness. They are often forced, through no fault of their own, to ration care and force patients to endure long waiting periods, because they have more patients than resources. The outcome is nearly the same as the result of the "universal-care-via-the-emergency-room" approach that conservatives favor so much it even came up during oral arguments at the Supreme Court.
What if there isn't enough charity? The phenomenon of families and communities holding bake sales and car washes, setting out jars or passing the hat to raise money for vital medical care has become commonplace.
I think most people know how such efforts go, in fact. For a long time, a solitary glass jar sat on the counter of our local convenience store, seeking donations towards the medical expenses of a much-loved longtime resident whose own unexpected tragedy had left an impossible financial burden. Barbecues, church socials, yard sales, bake sales or whatever else can be cobbled together; a town of any size will have something like that every weekend, if you follow the flyers or the signs, all dedicated towards raising just a few hundred dollars here and there to put a dent in the hundreds of thousands needed. Cancer, heart disease, or an accident; a husband, a mother, a child, a best friend. You cannot live in America without seeing it. So does it work? Do churches contribute a hundred thousand, here and there? When was the last bake sale you attended that raised $50,000? The last yard sale? Just how much change can fit in a glass jar on a countertop, once you count it all up?
Conservatives like Ron Paul, Newt Gingrich and David Brooks continuously extoll the virtues of charity, yet ignore that — as Peter Drier pointed out — in no other civilized nations would families face the "double tragedy of debilitating illness and deep debt." They ignore "people in other well-off countries view America's lack of universal health care as cruel and barbaric, as indeed it is." They fail to ask, "In what kind of society do we allow teachers and firefighters to rely on charity to help pay their medical bills?"
That we still live in a reality where people have to go begging for money to pay for medical care (and avoid going bankrupt) even after passing health care reform shows that we have a long way yet to go. Conservatives have yet to offer a solution, because they don't see that there are problems that need to be solved.
Whether or not it's a crisis that millions of Americans are uninsured or underinsured, that thousands lose their health insurance every day, or that tens of thousands die every year because they lack health insurance is a matter of perspective. The same goes for the economic crisis, the foreclosure crisis, or any other crisis.
Depending on your perspective, there's nothing wrong with hundreds of thousands, or even millions losing their homes to foreclosure. (Even if deregulating the finance sector made it easier to sell them time bombs, in the form of mortgages, that went off long after the people who really matter made an easy buck and moved on.) There's nothing wrong with millions of people having no health insurance, and thus no access to affordable, quality care. There's nothing wrong, because it's all right, and there's no need to do anything about it.
I wrote that a little over two years ago, as part of a seven part series on the morality of health care reform. Nothing I've seen or heard from conservatives since then suggests much has changed. Indeed, their "solutions" are likely to take us back, not to the status quo before the Affordable Care Act, but even farther back to the status quo before Medicare, Medicaid, and a lot more.
Conservatives will no doubt howl with indignation at the suggestion that their "do nothing" alternative to health care reform is to just "Let us die." But they haven't offer much more of an alternative than just that.