Jimmy Kimmel told an emotional story on Monday about the recent birth of his son, who was born with a life-threatening heart defect. Near the end of the monologue, Kimmel made a plea for the Affordable Care Act, without mentioning it by name. "Before 2014, if you were born with congenital heart disease like my son was, there was a good chance you'd never be able to get health insurance because you had a pre-existing condition," he said. "If your baby is going to die, and it doesn't have to, it shouldn't matter how much money you make. I think that's something that whether you're a Republican, a Democrat, or something else, we all agree on that, right?"
On the same day, Rep. Mo Brooks (R-Ala.) was speaking on CNN, arguing for why people with pre-existing conditions should be taken out of the regular insurance pool and put into "high-risk pools." This is the worst possible way to insure those who might have high health costs, because instead of spreading the risk, it concentrates it (which is why high-risk pools have consistently failed at the state level). But the Republican congressman said this is the proper route to follow, because "it offsets all these costs, thereby reducing the cost to those people who lead good lives. They're healthy. They've done the things to keep their bodies healthy. And right now those are the people who have done things the right way that are seeing their costs skyrocketing." He did allow that there are some people who have pre-existing conditions "through no fault of their own," but tough luck for them.
Though most of his fellow Republicans wouldn't say what Brooks did — at least not out loud — what we have here is a fundamental difference of values. And you have to give Republicans credit: Their effort to dismantle the ACA has cast that difference in sharper relief than Democrats ever managed to accomplish. Finally, all Americans are understanding what this debate is really about.
That isn't to say there aren't lots of practical questions involved; there always are with health care, which makes up one-sixth of our national economy. Or as President Trump said, "Nobody knew that health care could be so complicated," meaning that everyone except for him knew. In theory, people of various political stripes could accept a single solution if they agreed on the goal and it became clear that one solution was the most effective one. But in practice that's seldom the case, and in health care, we don't even agree on the goals.
Let's take this most basic one: Does everyone deserve health coverage, or not? To make an analogy, we have agreed that every child deserves an education, no matter their economic situation. While there are lots of arguments about the details and lots of ways in which parts of our education system fall short, no one disputes the premise that every child should be able to go to school. But we don't have the same consensus when it comes to health care.
In fact, the United States is the only advanced country in the world whose health-care system isn't built on the fundamental premise that everyone — not most people, not those who can afford it, but everyone — should have coverage. One of our two major parties has held universal coverage as a goal for decades, while the other simply does not believe that everyone deserves — and deserves is the right word, to listen to some like Rep. Brooks — to be covered. If you can afford it, good for you. If you can't? Well, we might give you a little help, or we might allow the existence of a government program for those who are truly desperate. But if millions of people wind up without coverage, that's unfortunate but not something we really need to do anything about.
That clash of principle runs through the health-care plans the two parties offer. When Democrats wrote the ACA, they tried very hard to construct a system that would cover everyone, because they saw the existence of tens of millions of uninsured as a profound injustice. Because they chose to graft their reform on to the largely privatized system that already existed, it was full of compromises and kludges and workarounds, but universal coverage was the goal. Republican plans, on the other hand, are built from the premise that we need to get government out of the way and let the market do what it will. If that's a lot better for some people than others, well that's just how markets work.
But they've run into a problem: pre-existing conditions. It turns out that the ACA's ban on insurers denying coverage based on your medical history is hugely, overwhelmingly, spectacularly popular. Yet the latest version of the GOP health plan would allow states to opt out of that ban, potentially eviscerating it.
Proposing to do that is so politically dangerous not only because of the tragedies that result when insurers can slam the door on the sick, but because of the sheer number of people we're talking about. Depending on how you define it, somewhere between a quarter and half of all non-elderly Americans have pre-existing conditions, according to the Department of Health and Human Services (the elderly are covered by Medicare, so they don't have to worry). That's as many as 130 million of us. If you had to buy insurance on the individual market before the ACA took effect and you had an old knee injury or some sinus problems — let alone a chronic condition or a history with a disease like cancer — you know how difficult and costly it could be.
Few people want to go back to those days, yet that's what Republicans are offering. And they've unwittingly changed the debate around health care, heightening the salience of the values that motivate Democrats. We may never again have a debate about a potential health-care reform in which the fate of those with pre-existing conditions isn't one of the primary measures by which that reform will be judged. In the past, Republicans might have been able to push to the side the basic question of whether everyone deserves coverage, no matter who they are or what they've been through. But no longer.