Paul Clement, the attorney representing the 26 states challenging the… (Chip Somodevilla, Getty…)
One of the most striking take-aways from this week's U.S. Supreme Court hearings on the healthcare reform law was the steadfast insistence on the part of Republicans to deny affordable and accessible medical treatment to as many people as possible.
The party is determined to maintain the status quo of healthcare being a privilege and not a right — putting us at odds with just about every other developed nation on the planet and, not coincidentally, resulting in about 50 million people being uninsured.
The bulk of attention this week was on Tuesday's hearing on the so-called mandate, the reform law's requirement that most people sign up for health insurance or face a modest tax penalty. Judging from some of the questions posed by conservative justices, this is where the law may fall apart.
But some of the most telling remarks came a day later when the attorney representing 26 Republican-led states argued that the law's expansion of Medicaid violates states' rights and represents an act of coercion by the federal government, even though the federal government, and not the states, will foot the bill for nearly all of that additional coverage.
This is a key piece of the reform puzzle. As it stands, the law won't provide coverage to all 50 million now left to fend for themselves (and thus pass along the cost of their care to other taxpayers and ratepayers). It will instead bring about 30 million into the insurance fold.
More than half of that number — about 17 million — will receive insurance through Medicaid. Mostly we're talking about low-income people who are not currently eligible for the program in most states.
Paul Clement, the lawyer for the states, argued that the federal government is twisting the arms of state officials by putting current Medicaid funds on the line. In other words, if states don't agree to expand coverage, they could lose the billions they now receive for the program.
This is a breathtaking assertion on a number of levels. First, no one forces a state to participate in Medicaid. If it doesn't like the federal government's terms, it can walk away from the program.
Second, if a state participates in Medicaid so it can insure some people, why wouldn't it be in favor of any move that allows it to insure more people?
Then there's the core belief among Republicans that the public sector has virtually no role to play in extending health coverage to as many people as possible, even when the private sector has failed miserably in meeting this responsibility.
As I wrote earlier this month, Republican attacks on the mandate as a threat to freedom and liberty ignore the real-world realities of the insurance business.
By allowing people to avoid buying insurance until they need it, and then requiring insurers to cover anyone who comes knocking at their door regardless of medical condition, you create a risk pool of exclusively sick people.
This is a recipe for financial catastrophe, all but ensuring that premiums rocket skyward and thus making health insurance less affordable and accessible for everyone. That's not political ideology talking; it's simple economics.
Opposing an expansion of Medicaid is no less reckless. As things stand, family insurance rates are now as much as $1,500 higher annually because of the cost of treating the uninsured, according to a study by the advocacy group Families USA.
If we can all agree that having tens of millions of people uninsured is not just a national disgrace but also an unfair financial burden for people who do have insurance, then one of our priorities must be to extend coverage to as many people as we can.
This has been accomplished in part by the reform law's provision that young adults can stay on their parents' plans to age 26. According to census figures, young adults are the age group least likely to have health insurance.
In terms of income, nearly two-thirds of the uninsured are in households making less than $50,000 a year. Expanding Medicaid eligibility would thus be the most effective and efficient means of bringing coverage to this segment of the population.
Needless to say, all these problems would be moot if the United States followed the example of its economic peers in Europe and Asia and adopted some sort of Medicare-for-all system guaranteeing universal coverage.
But since that's not going to happen any time soon, our sole alternative is to work within the existing system. And that means some sort of requirement that everyone have health coverage — a proposal originally championed by the conservative Heritage Foundation and embraced by leading Republican politicians (until they realized it was actually a Marxist plot to destroy the healthcare system).
It also means opening the door wider to lower-income folk through the Medicaid program, which, subsidized almost entirely by the federal government, is hardly an abrogation of states' rights and is instead more akin to a gift from Washington.