For decades, the primary goal of those who would fix the U.S. health system has been to help people without insurance get coverage. Now, it seems, all that may be changing. At least some top Republicans are trying to steer the health debate away from the problem of the uninsured.
The shift in emphasis is a subtle one, but it's noticeable.
Take this exchange between Fox News Sunday host Chris Wallace and Senate Minority Leader Mitch McConnell (R-Ky.) earlier this month, just after the Supreme Court upheld most of President Obama's health law.
Wallace: "What specifically are you going to do to provide universal coverage to the 30 million people who are uninsured?"
McConnell: "That is not the issue. ... The question is how can you go step by step to improve the American health care system? It is already the finest health care system in the world."
Wallace: "But you don't think that 30 million people who are uninsured is an issue?"
McConnell: "Let me tell you what we're not going to do. We're not going to turn the American health care system into a Western European system. That is exactly what is at the heart of Obamacare. They want to have the federal government take over all of American health care."
By "Western European," McConnell means government-run or primarily government-run. Western European countries also pretty much don't have people who don't have health insurance. And by the way, there are closer to 50 million Americans without health insurance; 30 million is the number the health law is estimated likely to cover.
But McConnell isn't the only top Republican saying covering the uninsured should no longer be the top priority.
"Conservatives cannot allow themselves to be browbeaten by failing to provide the same coverage numbers as Obamacare," Sen. Orrin Hatch, R-Utah, told a conference at the conservative American Enterprise Institute. "To be clear, it is a disgrace that so many American families go without health insurance coverage. But we cannot succumb to the pressure to argue on the left's terms."
So if getting more people coverage isn't the goal, what is?
"Conservatives cannot allow themselves to be browbeaten by failing to provide the same coverage numbers as Obamacare. To be clear, it is a disgrace that so many American families go without health insurance coverage. But we cannot succumb to the pressure to argue on the left's terms."
"Your goal should be reducing costs, and expanding individual liberty," said Dean Clancy, who also spoke at the AEI conference. He's legislative counsel for Freedomworks, a group that supports and trains Tea Party activists.
But Clancy says reducing costs doesn't mean doing nothing, even though that's what many of the people he talks to would prefer. "What they don't often understand is the government has already screwed it up significantly, such that we have no choice but to try to reform, to undo the wrong things we've done," he said.
Clancy is only one of many policy types who are trying to convince more Republicans to put expanding coverage on the back burner. Another is Michael Cannon, head of health policy at the libertarian Cato Institute.
Cannon has long questioned the idea that expanding insurance coverage should be the holy grail of health reform.
"The idea that the government should guarantee health insurance to everybody passes as really gospel in health policy circles, without any serious consideration, without any sort of examination of why is it that we want people to have health insurance, is health insurance the best way to serve those goals, could there be lower-cost ways of achieving those goals," he said.
People need to have the freedom not to have insurance if the marketplace is to function properly, he says. "Because if they don't have freedom, if the government is requiring them to purchase health insurance either from a private company or the government, then the government gets to define what health insurance is, and that stifles a lot of innovation in the health insurance and health care delivery markets, and we're suffering under that sort of regulation right now," he says.
But supporters of the health care law say arguments about making the marketplace function better are all a big smokescreen.
"Every once in a while, the Republicans have rare moments of honesty. And so when they say that they don't want to expand coverage, this is one of those rare moments," says Ethan Rome, who runs Health Care for America Now, an advocacy group working to promote and defend the health care law.
"They look around and they see middle-class families and others in need, and what do they want to do? They want to give tax breaks to the super rich," he says. "That's who they are and what they do. And I think that's why they're starting to talk about how they don't want to expand coverage. Because they at least want to be truthful about a couple of things. And those are the ways in which they want to abandon certain populations and be frank about it."
Other analysts see a more calculated political tactic, however, in GOP efforts to downplay coverage expansions. They say it's more like class warfare: Republicans want to paint the health care law as requiring people who already have health insurance to help pay for those who don't. It will be up to supporters to demonstrate how the law is helping those who do have insurance keep it and pay less.
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