Kill the bill, and lots of people, too. Photo: CHRIS KLEPONIS/2010 AFP

On the second anniversary of the signing of Affordable Care Act, the bitterness of the health-care fight remains a core fissure in American politics, and the nature of the fissure is clear. The two parties are fighting over whether access to regular medical care ought to be a right or an earned privilege.

To me, and essentially everybody on the liberal side, the answer to that question is obvious. I’m comfortable with the market creating vastly unequal rewards of many kinds. But to make health insurance an earned privilege is to condemn people to physical suffering or even death because they failed to secure a job that gives them health insurance, or they don’t earn enough, or they happened to contract an expensive illness, or a member of their family did. (If you think I am overstating, you ought to read my friend Jonathan Cohn’s book, Sick, which, in addition to explaining the dysfunctionality of the health care system, offers a gut-wrenching portrait of many Americans who saw their lives destroyed by lack of access to decent medical care.) The principle strikes me as nothing short of barbaric.

Yet the health-care fight increasingly brought that principle to the fore. If you want to see this idea expressed in its rawest (and, I think, most honest) form, here is a rally of protestors against the health-care bill disparaging a man who has Parkinson’s disease:

Their language is instructive. They decry the bill for requiring “handouts,” and insist, “you have to work for everything you get.” Which is to say, they consider universal health care exactly like welfare — a giveaway of something that people rightly ought to earn on their own.

Republican politicians have increasingly come to endorse this same principle, though in less openly cruel ways. They describe the health-care fight as a question of “personal responsibility” — the language of welfare superimposed onto health care.

The root of the problem is that the conservative movement has organized itself around opposition to the redistribution of wealth, and universal health care requires redistribution. Some people will be unable to provide for their own health care, either because they earn unusually low incomes, or because they pose an unusually high actuarial health risk. There are many possible ways to redress this. All of them require, at the most basic level, the provision of resources to the poor and the sick.

And that is something the conservative movement refuses to do. The House Republican budget, which has become the lodestar of conservative public policy, is instructive. It repeals the Affordable Care Act and leaves nothing in its place to cover the uninsured. It further imposes enormous cuts to Medicaid, increasing the uninsured population even further still. It offers no plan to fill the void it creates. This is not because such a plan lies too far outside its breadth — it is a sweeping statement, including such disparate objectives as deregulating the financial industry, and laying out a vision that would stretch decades into the future. It’s a statement of how the Republican Party would allocate resources, and the crystal clear answer is, Republicans oppose allocating resources to cover the uninsured.

The party’s goal could not be any more clear. Oh yes, there have been times concurrent with Democratic efforts to pass health-care reform that Republicans have proposed their own, alternative plans. During the 1994 health-care debate, Republicans in the Senate offered a “free market” alternative to Bill Clinton’s plan. As Clinton’s plan sank and Democrats turned their eyes to the Republican plan, its sponsors abandoned it in droves. Newt Gingrich matter-of-factly conceded, during a recent presidential debate, that he had endorsed an alternative plan during this time merely to stop the Clinton plan.

The same dynamic occurred during the most recent health-care debate, with numerous Republicans “endorsing” an alternative bipartisan plan, but signaling they opposed most of its actual provisions. The Republican plan to cover the uninsured, when it does appear, is always a mirage hovering just beyond reach, dissolving when approached.

But that sort of open advocacy of mass lack of insurance remains the exception. More frequently, conservatives sublimate their belief in the bloodless language of budgets. Charles Krauthammer’s column offers a helpful example. On its face, Krauthammer is merely complaining about the budgetary impact of the Affordable Care Act:

Annual gross costs after 2021 are more than a quarter of $1 trillion every year — until the end of time. That, for a new entitlement in a country already drowning in $16 trillion of debt.

Krauthammer is pulling a subtle and revealing sleight of hand here. In his first sentence, he complains about the gross cost of the health care law — how much total money it expends to cover the uninsured. In the next sentence, he complains about the deficit. The implication is that high gross costs of the bill will worsen the deficit.

But that is false. The Affordable Care Act offsets the cost of expanding coverage by reducing ineffective Medicare spending and raising new revenue. The Congressional Budget Office forecasts that the law will reduce the deficit. In its new update, which Krauthammer cites, it predicts that the law will reduce the deficit by slightly more than it had in its original forecast. It is the gross cost he objects to — the choice to spend $250 billion a year to provide medical care to some 30 million Americans.

Also today, Mitt Romney authors an op-ed about health care. In it, he claims to favor making health insurance available to one and all. He frames his difference with Obama like so:

The reforms I propose for the country could not be more different from Barack Obama’s. They entail no new taxes, no massive diversions of funds away from Medicare, no tax discrimination, and no new bureaucracies.

This has been Romney’s line — he favors the goal of universal coverage, but opposes any methods (taxes, diverting funds from Medicare) to pay for it. He praises his Massachusetts reform as a model, but of course, he managed to design his plan in Massachusetts because the state received a large federal windfall grant. He does not propose to make such a funding stream available to other states. He proposes nothing at all to provide the resources that would allow the poor and sick to obtain coverage.

What Romney does promise, explicitly and forcefully, is to “repeal Obamacare.” Here he is in keeping with what has become almost a blood oath among Republicans. The conservative movement’s fanatical determination to achieve this goal — through the courts, through the election, through sabotage of its implementation by denying funds and refusing to confirm administrators — reveals an even higher level of commitment to the principle of denying health insurance to the undeserving. It is one thing to simply ignore the problem of the uninsured, by failing to act on it when you have power. But to actively crusade to throw vulnerable people off their newly-won health insurance is a higher sin, a sin of commission rather than omission.

In every other advanced country, the provision of universal access to medical care is a public responsibility. In every other advanced country, this principle has been accepted by the mainstream conservative party. Only in the United States does the conservative party uphold the operating principle that regular access to doctors and medicine should be denied to large chunks of the population. This sort of barbarism is unique to the American right.

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