Political Disclaimer: I have never been a registered member of either major political party, but my preferred candidate in the 2016 presidential election was John Kasich, Republican governor of Ohio. The Republican party in Washington today is beyond recognition to me. While my essay probably appears to be an attack on Republicans, that is simply a result of the fact that Republicans are exclusively behind the current, wholly partisan effort to repeal the Affordable Care Act. There is no way for me to criticize what I see as horrifically bad legislation and related outcomes without criticizing those who are exclusively responsible.

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The House bill (H.R. 1628), the “American Health Care Act of 2017,” which passed the House in May, and the Senate reconciliation bill, the preposterously named “Better Care Reconciliation Act,” recently brought out of secret negotiations in the Senate, are about much more than access to health insurance and health care in the United States. These bills are talismans of what could be a very bleak future, as privileged Republicans in congress and the Whitehouse are sending the unambiguous message that, as a matter of principle, they believe that reducing taxes for the very wealthiest Americans is more important than it is for tens of millions of Americans to have access to health care at all. Let’s be clear: policy debates about the “free market” or mandates aside, the reconciliation bill, in it’s current form, would be an unmitigated disaster for the delivery of health care in the U.S. The current legislation is a moral failure, which, if enacted, would do more damage to the well being of tens of millions of Americans than any other legislation in memory. What is shocking is not the fact that some members of congress support legislation that would devastate millions of American families. What is shocking is that nearly all Republicans in both the House and Senate have either already voted in favor of the legislation or said they would. This is not some theoretical dinner table conversation about the relative pros and cons of government involvement in American health care. The bill, in its current form would completely deny health insurance to tens of millions of Americans who have it now and eviscerate coverage for many millions more. That is not political opinion. It is a hard fact of the proposed repeal legislation.

What could a back room conversation about the effort to repeal Obamacare inside the Republican caucus possibly sound like?

“Well, this bill will increase the number of uninsured to almost fifty million Americans and it’ll be hardest on the lower income and disabled, and a lot of folks will probably lose coverage for pre-existing conditions, and rural hospitals will close, and people struggling with opioid addiction will be out of luck, and bankruptcies will spike, and somewhere over 35,000 people will actually die due to loss of health insurance, but we’ll be able to transfer nearly four hundred billion dollars in tax breaks to our very wealthiest friends (goosebumps) and…this is the best part… we’ll really stick it to Obama out of pure spite! Heck, that’s worth several thousand deaths by itself!!”

It has not always been this way. Over the last 70 years or so, Republican legislators and presidents have supported the common good with everything from the interstate highway system (Eisenhower) to a progressive tax system to preserve social security (Reagan) to the Americans with Disabilities Act (G.H.W. Bush) to global AIDs funding and prescription drug benefits for the elderly (G.W. Bush). There was a time when “conservative” did not mean reactionary and certainly didn’t mean coldly trading the health care of tens of millions of citizens for hundreds of billions in tax breaks for the wealthiest Americans. To be clear, the ACA would eventually face critical funding challenges without modifications, but the current Republican plan is based on a tax mechanism that would make the funding situation much worse! The only way hundreds of billions of dollars can be shifted to wealthy companies and individuals, while cutting taxes earmarked for health care, is to eliminate coverage for upwards of 30,000,000 people and reduce coverage for many tens of millions more through 2026—and that is the core source of opposition and dissonance for so many Americans. It is also a frightening precedent as it demonstrates that the current Republican calculus has no moral “red lines” when it comes to human cost.

What we see in the current health care bills is not only a cavalier attitude by well-off, medically insured (Republican) congressmen, senators, and president toward the least empowered and most at-risk citizens (those who rely on Medicaid for access to health care), but both bills also redirect hundreds of billions of dollars in taxes from that same Medicaid program (which the Senate bill cuts by nearly $1,000,000,000,000—yes, trillion) to the nation’s most wealthy companies and individuals. Moreover, by removing subsidies and tax credits, the House bill and the Senate reconciliation, would also eliminate access to insurance, or usable insurance, to many millions more who do not qualify for Medicaid, but do qualify for financial support to purchase insurance on the ACA exchanges. In fact, based on existing non-partisan Congressional Budget Office (CBO) assessments, the only likely beneficiaries of the current legislation would be young, healthy individuals whose premiums would likely decrease (but who may also lose benefits). The worst off would be low income Americans in their 50s and 60s, and, distressingly, the CBO estimates that in excess of 15,000,000 people would lose health insurance in the first year alone under the Senate reconciliation! The very basic reality is that the proposed repeal of the ACA would have the greatest negative effect on the poor, the near-elderly and elderly, the disabled, and specific groups such as those suffering from opioid addiction and pre-existing conditions. If that were not bad enough, recent research by Harvard University found that roughly one in every 830 people without health insurance dies as a result. In other words, the predicted loss of insurance for approximately 28,000,000 Americans by 2026 would result in nearly 37,000 preventable deaths. It is no small irony that Republicans refer to themselves as the “pro-life” party.

Of equal importance, the CBO report also states that the current instability in some ACA markets is not a product of the law itself or of some structural problem in those markets, but rather of President Trump’s threats to end enforcement of requirements to procure insurance as well as threats to de-fund subsidies that support the cost of premiums. In other words, the president has found a way to cynically fulfill his prophecy about problems with Obamacare by creating those problems himself.

And to be clear, there aren’t even good political reasons for Republicans in congress to pursue the current path. The proposed repeal of Obamacare is wildly unpopular. A significant majority of Americans from both parties are opposed to the current legislation and only 17% in recent polls support it. Even among Republicans, well less than half of voters support the current legislation to repeal the Affordable Care Act. While the polls do not explain in depth why so many Americans are against the current efforts in congress, it is not difficult to surmise that there is broad based fear about a future in which Republicans sacrifice the well being of millions of American families for a set of principles that benefits the most well off Americans at the expense of the most vulnerable. That is viscerally frightening to a substantial majority of Americans, including those who voted for Trump and Republican legislators in Congress.

In fact, the negative impact of the repeal of the ACA would be so severe to actual health outcomes, that the American Medical Association has claimed in a letter to Senate leadership, that passage of the bill in its current form would be a violation of the Hippocratic “do no harm” oath. They add in their letter that, “We believe that Congress should be working to increase the number of Americans with access to quality, affordable health insurance instead of pursuing policies that have the opposite effect.” Similarly, in response to the same CBO report, the US Conference of Catholic Bishops issued a statement in which they said, “…the loss of affordable access for millions of people is simply unacceptable… These are real families who need and deserve health care,” followed by, “We pray that the Senate will work in an open and unified way to keep the good aspects of current health care proposals, to add missing elements where needed, and to not place our sisters and brothers who struggle every day into so great a peril on so basic a right (emphasis added).” While fiscal restraint, freedom from mandates, and free markets are all defensible principles, the Republican disregard for the well being of many millions of Americans highlighted by the USCCB is a frankly jarring spectacle to witness.

Of course, providing anything close to universal health insurance coverage is dauntingly expensive and complicated, but the notion of denying basic access, while shifting resources from those most in need to those who are already the most well off, is simply immoral, and that has not been lost on most Americans. In fact, it would seem that the disagreement within the Republican party is between conservatives, and those who are more conservative, about how much pain to inflict on the American public.

Unless you believe that roughly 275 legislators in Washington are that cold hearted (or have that little political self-interest), the only other viable explanation is that the motivation to kill the Affordable Care Act is not about any principle at all, but rather about a deep, nearly pathological need by many Republicans to avenge eight years of the Obama presidency regardless of the human cost. Either way, it is disturbing to contemplate that a majority of members of Congress (and the president) would casually devastate many millions of American families for either reason. It makes them seem frankly unhinged, particularly since there is no critical need to change anything with the Affordable Care act right now. A bipartisan effort to improve the ACA could happen at any time.

To better understand historical context of government involvement in health care, the reason we have Medicare and Medicaid at all is because in the mid 1960s both parties of congress and the president at the time, Lyndon Johnson, recognized that the free market would not and could not support access to health care for those in poverty or near-poverty, by reason of disability, age, and unemployment. While there was certainly opposition to both programs, there was bipartisan support for the principle that even in capitalist systems, there is broad social value, if not moral compulsion, in creating a floor of services, medical and otherwise, funded by society as a whole. The Affordable Care Act (Obamacare) was an attempt, unwieldy but broadly successful, to bring access to medical care for about half of the nearly 50,000,000 Americans who did not have such access prior to 2010.

Of course, there are elements of the Affordable Care Act that are unsustainable in their current form and that would have to be modified at some point regardless. A compelling example is the notion of Medicaid as an “open-ended” (the government simply pays what it costs for each new enrollee) benefit whose cost continues to increase at rates in excess of inflation. While all health care costs have been increasing for decades at rates in excess of inflation, Medicaid (and Medicare) are almost wholly funded by taxpayer dollars. Without a change, those costs alone would eventually eat up virtually all discretionary federal tax receipts, which, of course, is not viable. However, there is a rational, compassionate place between adjusting Medicaid and Medicare expenditures and taxes on the one hand and wiping out access to health care for tens of millions of Americans on the other hand, while redistributing hundreds of billions of dollars from poor Americans back to wealthy ones!

As for mandates, no one likes to be told what to do. But to suggest, as Republicans in congress have, that the mandate to purchase health insurance, which is central to the ACA and any other sustainable insurance market, is somehow unique to Obamacare, is at best disingenuous, and at worst, out right dishonest. Our government issues mandates in every sector of our lives, including other forms of insurance! When was the last time you tried to get license plates for a car without having “mandated” liability insurance? Health care providers are mandated to have malpractice insurance. Every 18 year-old male in the U.S. is mandated to sign up for the selective service. Tens of millions of children are mandated to attend school and every day nearly 3,000,000 airline passengers are mandated to show a government ID, sacrifice their privacy, and pay “security fees” to get on a plane. Our daily lives are infused with mandates and the underlying rationale for all of them is that the common good in those cases outweighs individual choice. You cannot legally drive without purchasing auto insurance because of the undue burden that puts on others in society if you cause a wreck. The same argument applies to health insurance. If an individual does not have insurance, but ends up in the emergency room and intensive care after an accident, those who do have insurance will ultimately pay the bill through higher premiums and higher costs for their own health care.

Republican histrionics aside—no, the Affordable Care Act, is not a “disaster;” Hurricane Katrina was a disaster—the fundamental problem with the Affordable Care Act, despite its flaws, is not the law itself, and the problem certainly wasn’t the noble goal of creating access to healthcare for tens of millions of uninsured Americans. The problem is that it was bolted onto an underlying health care system with deep structural flaws, many of which the ACA attempts to address symptomatically rather than causally. If the Republicans in congress and our president were acting in anything approaching good faith, they would be engaged in a bipartisan effort to create lasting, structural solutions to our health care system, even if that means material compromises for both political parties. In comparison, although the ACA was ultimately passed along partisan lines, the initial discussions on the bill were largely bipartisan, including a presidential address to Congress and Whitehouse strategy sessions involving members of both parties. The reason that is not happening now is because the current Republican repeal legislation has absolutely nothing to do with improving the healthcare system. Their motivation is either to create a healthcare system based on free market principles and privilege, regardless of human cost, or their neurotic obsession with poking Obama in the eye, or both. The very name of the Senate reconciliation bill itself, the “Better Care Reconciliation Act,” is laughable on its face. It may be cheaper for some and it may allow others to avoid buying health insurance at all, but in no way does it improve care for anyone.

Let’s be clear that as a society, we either believe that access to some meaningful level of health care is a guaranteed right (as we have done with primary and secondary education), and make collective sacrifices to achieve that goal, or we believe that access to health care is a privilege enjoyed only by those with the financial means to afford it. It’s that simple. Most Americans have said they believe health care is a right. Republicans in Washington, through their repeal legislation, have declared the opposite, and will likely lose the moral and political battle over time.

Let’s also be clear that no broadly effective health care solution, ACA or otherwise, will work long term, in any way approaching “affordable,” without acknowledging a combination of undeniable truths.

Some of those truths are:

• Almost all Americans will have to contribute some level of their own personal financial resources to their own health care.
• Not every American can have access to every medical service, test, treatment, etc., or have such access precisely when they want it. There must be some management of care.
• Covering nearly all Americans will require that some form of government sponsored insurance be part of the solution (Medicaid, Medicare, VA, etc.)
• Covering nearly all Americans will require substantial tax receipts, most of which will come from wealthy Americans and businesses, because they pay most of the taxes collected in the U.S.
• Covering nearly all Americans will require healthy people to pay into insurance pools, which will subsidize less healthy people.
• Some individuals will have to pay for some benefits they never use.
• Some form of centralized negotiation of cost will be necessary for public programs the same way it exists now for privately insured programs (the federal government already does this with the VA health system)

In short, the current Republican effort to repeal the ACA has absolutely nothing to do with improving health care outcomes or the health care system. As confirmed by the non-partisan Congressional Budget Office, it would objectively wipe out access to health care for over fifteen million people in the first year of implementation alone! The Republican effort is about legislating the principle that health care is a privilege only for those who can afford it, while decreasing tax obligations on the wealthiest Americans. Heaven help us if that becomes the driving moral principle for all Republican policy while they have a congressional majority and hold the presidency.