Obamacare's Forbidden Talking Point

Democratic candidates often avoid talking about the consequences of not expanding Medicaid David Goldman/AP

"Charlene Dill didn't have to die."

That was the first line of an Orlando Weekly story this Wednesday. Dill, a 32-year-old single mother of three, died last month while working an odd job selling vacuum cleaners. Dill was a member of the working poor. She did not have health insurance, which means she couldn't afford the medicine she needed for a heart ailment.

As the story described, Dill fell into a "coverage gap" created when Republican lawmakers in Florida declined to expand Medicaid, a key provision of the Affordable Care Act designed to insure about 15 million poor Americans nationwide. But after the Supreme Court ruled in May 2012 that the expansion was optional, 23 states registered their objections to the law and President Barack Obama by declining to expand the program.

Like Dill, there are now poor Americans in these states who make too much money to qualify for Medicaid—Dill made around $9,000 per year—but too little to qualify for subsidies to buy a plan in the states' insurance marketplaces. According to her best friend, Dill had tried to get insurance under Obamacare, only to realize that she was in the gap.

Lost in the abstract, partisan battles over Obamacare is the fact that health insurance saves lives and a lack of insurance costs lives. A 2012 study found that the Medicaid expansion was responsible for a 6.1 percent drop in total deaths among the non-elderly in states that accepted the expansion. Experts at the Health Affairs journal's blog recently estimated that each state that opted out could result in between about 7,000 and 17,000 deaths.

The life-and-death consequences of health care rarely come up in political debate and even less often in campaigns. Even as Democrats struggle to defend Obamacare in an election year, they haven't rallied around Dill's story, and strategists caution that doing so would be perilous.

"You have to be very careful about how you deal with this," said veteran Democratic strategist Robert Shrum. "I think it will move around by word-of-mouth a lot. But you can't appear to exploit, and you can't exploit this tragedy for political points."

The story is spreading. Liberal outlets including ThinkProgress and The Huffington Post picked it up. New York Times columnist Paul Krugman linked to it in his column Friday. But a politician thinking about the story will probably remember the last few times liberals talked about death in the context of health care—and the condemnation they received for it.

Blogger Ezra Klein learned this the hard way. During the final months of negotiations over Obamacare in 2009, Klein, the new editor-in-chief of Vox.com then at The Washington Post, criticized Senator Joe Lieberman, I-Conn., for a political maneuver that jeopardized the entire reform effort. Citing statistics showing that tens of thousands of Americans die each year without health coverage, Klein concluded that the senator "seems willing to cause the deaths of hundreds of thousands of people in order to settle an old electoral score."

Condemnation was swift, with one of Klein's own colleagues calling the line a "venomous smear." Klein ultimately said he regretted his phrasing.

In a more recent example, Priorities USA Action, a super PAC that supported Obama in the last presidential election, came under attack for running an ad that linked Republican nominee Mitt Romney to a woman who died of cancer without health insurance. In the ad, a Missouri steelworker claimed that Romney's company closed the plant where he worked, resulting in his family losing health insurance. His wife died years later. "I do not think Mitt Romney realizes what he's done to anyone, and furthermore I do not think Mitt Romney is concerned," the man said in the ad.

Fact checkers and news outlets picked the ad apart, and Republicans called it out of bounds. After days of negative attention, Obama eventually distanced himself from the ad, saying, "I don't think that Governor Romney is somehow responsible for the death of the woman."

Representative Alan Grayson, a liberal Democrat from Florida who has spoken out about Dill's death, has a history of raising the issue as part of the health care debate—and facing blowback for it. "The Republicans' health care plan for America: Don't get sick," Grayson said in a 2009 speech on the House floor. "If you get sick, America, the Republican health care plan is this: Die quickly."

"It is still the Republican health care plan," Grayson told Newsweek. "I wish it had turned out otherwise."

Dill's story has been publicized by her best friend, Kathleen Voss Woolrich, who posted her story online. Grayson entered the post into the Congressional Record. "She would be alive today except for the callousness of the Republicans in charge in Tallahassee," he said. He doesn't know if his fellow Democrats will also publicize the incident.

Shrum is vehement that Democrats will survive the upcoming midterm elections only if they run on Obamacare, not away from it. But, he cautioned, "you can go on the offensive without being offensive.

"They have to say that Republicans in Congress, for example, voted to let insurance companies deny coverage for pre-existing conditions," he suggested. In other words, Republican opposition to Obamacare means voting against some of its most popular provisions. "[They] voted to eliminate mammograms for millions of Americans, voted to let insurance companies cut off your coverage when you need it most."

With the midterm elections fast approaching, Republicans have used Americans' individual stories to publicize problems with the law. Most notably, Americans for Prosperity, affiliated with the billionaire brothers Charles and David Koch, has launched ad campaigns in several states featuring personal testimonials, although the accounts are often attacked as false. Meanwhile, Democrats are just testing the waters in pro-Obamacare ads.

One example comes from an outside group in Alaska, called Put Alaska First, supporting Democratic Senator Mark Begich. Without mentioning the law by name, the ad features an Anchorage woman who survived cancer but was denied coverage due to this pre-existing condition. "I now have health insurance again because of Mark Begich," the woman, Lisa Keller, says in the ad. "Because he fought the insurance companies so that we no longer have to."

As in Alaska, the task of defending Obamacare may ultimately fall to outside groups. If Dill's story does become a political point, it's more likely to come from an outside group, like the infamous anti-Romney attack ad, than from a candidate.

For some, the lack of attention on Dill is disappointing.

"I hope that everybody talks about it," Grayson said, wishing it had been front-page news in Florida. "We have to [come to] grips with this, that our decisions are decisions that result in life or death in the same way that if we declare war, our decisions are decisions that result in life or death."