Photo: Mario Tama/2012 Getty Images

As we wait for a Supreme Court ruling on the Affordable Care Act this week, there is one urgent, overriding moral question at the heart of the health-care fight. Paradoxically, and maddeningly, there has not been any open moral debate over it. That question is whether access to basic medical care ought to be considered a right or something that is earned.

Several reporters have recently filed dispatches showing in human terms what sort of conditions we would be perpetuating in the event that five Republican Supreme Court Justices, or a potential Republican-run government next year, partially or completely nullify the Affordable Care Act. A man will watch the tumor in his leg grow to the size of a melon, and his wife will sew special pants to fit the growing bulge, because he has no insurance. A woman will hobble around for four years on an untreated broken ankle she can’t have repaired. People will line up in their cars and spend the night in a parking lot queuing for a rare free health clinic.

Maybe these stories sound like cheap emotional manipulation. They are actually a clarifying tool to cut through the rhetorical fog surrounding the health-care debate and define the question in the most precise terms.

Opponents of the law have endlessly invoked “socialism.” Nothing in the Affordable Care Act or any part of President Obama’s challenges the basic dynamics of market capitalism. All sides accept that some of us should continue to enjoy vastly greater comforts and pleasures than others. If you don’t work as hard as Mitt Romney has, or were born less smart, or to worse parents, or enjoyed worse schools, or invested your skills in an industry that collapsed, or suffered any other misfortune, then you will be punished for this. Your television may be low-definition, or you might not be able to heat or cool your home as comfortably as you would like; you may clothe your children in discarded garments from the Salvation Army.

This is not in dispute. What is being disputed is whether the punishments to the losers in the market system should include, in addition to these other things, a denial of access to non-emergency medical treatment. The Republican position is that it should. They may not want a woman to have to suffer an untreated broken ankle for lack of affordable treatment. Likewise, I don’t want people to be denied nice televisions or other luxuries. I just don’t think high-definition television or nice clothing are goods that society owes to one and all. That is how Republicans think about health care.

This is why it’s vital to bring yourself face-to face with the implications of mass uninsurance — not as emotional manipulation, but to force you to decide what forms of material deprivation ought to be morally acceptable. This question has become, at least at the moment, the primary philosophical divide between the parties. Democrats will confine the unfortunate to many forms of deprivation, but not deprivation of basic medical care. Republicans will. The GOP is the only mainstream political party in the advanced world to hold this stance.

The maddening thing is that Republicans refuse to advocate the position openly. The more ideologically stringent ones couch their belief in euphemisms, like describing health care as a matter of “personal responsibility.” But even such glancing defenses are too straightforward for most Republican leaders. Instead they simply rail against the specifics of Obamacare and promise to “replace” it, without committing themselves to an alternative path to universal coverage. It is to maintain this pretense of wanting some different solution that John Boehner warns Republicans to hide the unadulterated joy they will feel if the Supreme Court does their work for them.

The maintenance of mass lack of access to medical care is their cause. That is why the Republicans never offered an alternative universal-health-care plan and why the Paul Ryan–authored budget they have embraced repeals Obama’s coverage subsidies and throws millions more off their Medicaid, without any replacement.

Their reason for failing to defend their actual principles is obvious enough: That tens of millions of Americans deservedly lack a right to basic medical treatment is a politically difficult proposition. Thus, they oppose Obamacare without defending the indefensible conditions they actually favor. Their tactic of adding vague gestures toward unspecified future reforms has been so successful that news reports almost uniformly describe the Republican health-care stance as yet-to-be-determined, rather than an outright defense of maintaining health care as an earned privilege rather than a right.

To be sure, the Republican assaults on the particulars of the Affordable Care Act may be heartfelt, even if (in the case of so many) newly acquired. But if Republican objections to Obamacare really did revolve around its policy design, there would be a simple alternative. They could pledge to repeal the law only if they simultaneously replaced it with a reform that was certified by the Congressional Budget Office to cover an equal number of Americans. Of course Republicans have never and would never bind themselves to such a promise. I do wish some reporters would ask Mitt Romney and the GOP leadership why it won’t make repeal conditional on the passage of an alternative universal-coverage scheme.

In the meantime, the Republican politicians, the conservative pundits and philosophers, are all perfectly happy at the prospect that they can win politically without making the case for what they genuinely believe.