What Happens to the Uninsured If Health-Care Reform Is Dismantled?

The nearly 50 million Americans without insurance drive up health costs. But GOP alternatives offer no real plan to solve the problem.

A woman visits a free mobile health clinic in Boston. Reuters

ARLINGTON HEIGHTS, Ill. -- When the Republican presidential candidates talk about health care, the discussion usually moves quickly toward the philosophical and the abstract.

Take Rick Santorum's appearance at the Christian Liberty Academy last weekend in this Chicago suburb. Before a raucous crowd, the former senator from Pennsylvania portrayed President Obama's health-care-reform law as an "affront to freedom." In Santorum's telling, the plan is not so much an attempt to reshape the health care system as the worm on a line meant to hook Americans on Big Government. "What tribute won't you pay to the government if they can promise that if you give them more they will ... take care of you?" he asked dramatically.

There's no question that an ideological chasm over Washington's proper role in health care separates Democrats and Republicans. And there's no doubt that some Democratic strategists believe that average Americans will grow more tolerant of activist government if they see it providing them more direct benefits, such as health insurance.

But the debate over health care reform -- which will intensify again next week as the Supreme Court hears oral arguments on challenges to the law's mandate on individuals to buy insurance -- involves more than competing philosophies or political strategies. At its core, it raises an irreducibly tangible question: what, if anything, to do about the nearly 50 million Americans who today lack health insurance?

Those millions of uninsured rarely intrude into the promises from GOP congressional leaders and the party's presidential field to defend liberty by repealing Obama's plan. But ignoring them doesn't make them go away. If the 2012 election rewards Republicans with enough leverage in Washington to erase Obama's initiative, they will face the choice of finding an alternative means to expand coverage or allowing the number of those without insurance to grow, with far-reaching consequences not only for the uninsured but for those with insurance as well.

Without some policy intervention, there's little question that access to health insurance will continue to decline. Since 2000, the number of the uninsured has jumped from 36.6 million to 49.9 million, about one-sixth of all Americans.

That number would have been even higher if an additional 20 million people over that period had not obtained coverage through Medicaid and the Children's Health Insurance Program. This growth partially offset the unrelenting erosion in employer-based care: The share of Americans obtaining coverage from their employer has declined every year since 2000, in good times and bad.

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Ronald Brownstein is Atlantic Media's editorial director for strategic partnerships. More

Ronald Brownstein, a two-time finalist for the Pulitzer Prize for his coverage of presidential campaigns, is Atlantic Media's editorial director for strategic partnerships, in charge of long-term editorial strategy. He also writes a weekly column and regularly contributes other pieces for the National Journal, contributes to Quartz, and The Atlantic, and coordinates political coverage and activities across publications produced by Atlantic Media.

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