One reason comprehensive health care reform cleared Congress earlier this year, after failing so many times before, is that the status quo had grown unacceptable to so much of the medical community.
Over time, that inescapable fact may prove the most important line of defense for a law already facing intensifying (and diversifying) legal and legislative challenges from a resurgent Republican Party. For all of the turmoil around reform, few of the health industry’s key players would be entirely satisfied reverting to the trends that were straining the system before reform passed. And, like them or loathe them, the alternatives to President Obama’s blueprint that Republicans have offered so far are not likely to alter those dynamics much one way or another.
The backdrop to the passage of health care reform was a decade of steadily rising costs and declining access. The number of the uninsured increased in every year but one during George W. Bush’s presidency, growing from 38.4 million in 2000 to 46.3 million in 2008. In a mirror image, the share of Americans receiving coverage from their employers declined with every year of Bush’s presidency.
As the economic downturn continued last year, the number of the uninsured jumped to 50.7 million. The share of Americans receiving insurance at work fell to the lowest level ever recorded. And the share of uninsured Americans rose to about one person in six. That was the highest level that the Census Bureau has ever reported, and yet even that figure understates the problem because it includes seniors and children, many of whom are covered by public programs. In the working-age population (people aged 18 to 64), the share of Americans without health insurance last year soared past 22 percent. In a separate analysis released this week, the federal Centers for Disease Control and Prevention reported that nearly one-third of working-age, middle-income Americans lacked insurance for at least part of the past year.
Republicans, with their sweeping victories last week, acquired much greater ownership of this problem. Republicans retained the governorships in Texas and Florida, the two states with the largest percentages of uninsured residents (26 and 22 percent respectively), and also won governorships in heavily uninsured New Mexico (nearly 22 percent) and Nevada (21 percent). In all, Republicans will now control the governorships in seven of the 10 states with the highest proportion of the uninsured (only Arkansas, California, and North Carolina defy the trend) and in 14 of the top 20 states. Fully 29.5 million people now lack insurance in states that will have Republican governors, compared to 20.5 million in states that will be led by Democrats. (A couple of gubernatorial races remain uncalled.)
In the House, the “un-insurance” rate remains higher in districts held by Democrats than Republicans, largely because the former represent so many low-income, inner-city areas. But the gap isn’t that large. An analysis of Census Bureau data show that about one in seven people in Republican-controlled House districts lack health insurance, compared with just under one in six in Democratic districts. Fully 99 House Republicans next year will represent districts in which the percentage of uninsured residents exceeds the national average.
Those millions of uninsured people, and the public and private costs tied to them, will not disappear if the health care law is repealed. “The challenge for Republicans is that they now represent states and areas with [many of] the highest rates of un-insurance,” says Neera Tanden, who served as counselor in the Health and Human Services Department during the health care fight. “That means costs are shifted onto people who have insurance in those areas. It also means the uninsured tax the public and private hospitals and other resources in those areas.”
Whatever else can be said about the “replace” component of the GOP promise to “repeal and replace” Obama’s health care plan, it’s difficult to argue that it does anything meaningful to reverse the ongoing erosion of coverage. The plan that House Republicans offered last year and reaffirmed in their campaign “pledge” proposes controlling health care costs by limiting medical-malpractice lawsuits and allowing insurance policies sold in any state to be sold in every state (an idea even the insurance industry has traditionally opposed for its potential to undermine quality coverage). But it would do little directly to expand access. Analyzing the GOP plan last November, the Congressional Budget Office calculated that by 2019 it would reduce the number of uninsured by only about 3 million, leaving well over 50 million Americans uncovered. The health reform law is projected to cover about 33 million of the uninsured by then.
Most Republican officeholders appear entirely comfortable accepting unprecedented numbers of uninsured Americans as the new normal. But the doctors, hospitals, mayors, and public health officials (not to mention insurers and drug companies) that they represent may prove less sanguine about coping with such a rising tide. Over the next few years, that could make the medical community itself the critical variable in determining whether Republicans can pull the plug on Obama’s ambitious and embattled reforms.
This article appears in the November 13, 2010, edition of National Journal Magazine.