Seven years ago, more than a quarter of direct care workers, including certified nursing assistants, lacked health insurance.

Why? Many of them were part-time, earning around $10.50 an hour. In as much as they had access to coverage through employers, it was often a choice between making the rent, feeding their family or choosing health insurance. Some had pre-existing conditions, which made costs even higher or meant there wasn’t a plan available. Most states made Medicaid available only for the most impoverished, the pregnant or those with dependent children.

Well, some of you think, that’s not our problem. People choose to work for us. People chose to have children. People choose to work part-time. People choose to drop out of school.

People choose to make bad choices. People choose to be poor.  

The last sentence is the crux of what Rep. Jason Chaffetz (R-UT) was saying in his defense of the new GOP “repeal and replace” plan, called the American Health Care Act. (We’re confident the American Health Care Association loves this acronym, I’ll note sarcastically.) Chaffetz compared an investment in one’s own healthcare as a choice over “getting that new iPhone.” Later he said, “People need to make a conscious choice, and I believe in self-reliance.”

Putting aside the dubious math involved (a new iPhone costs around $800, a year of individual insurance costs $4,617, which is not factoring in deductibles or copays, according to this analysis) Chaffetz’s comments get to the root of what many of us — even the most liberal — struggle with: What are the limits of personal responsibility and what can government do?

That’s a broad question, so let’s break it down to what the new plan would mean for long-term care. As McKnight’s Editor James M. Berklan wrote this week, providers feel the new plan is a disaster for Medicaid reimbursements. But it’s also worth remembering how much it will hurt your lowest-level employees.

Direct care workers (which includes home health workers, not only CNAs) still do hard work for little pay, and there’s little indication that’s going to change. Before 2010, there was a bitter irony to how many workers spend every day in a healthcare facility with the very sick and frail, battling away germs, yet could not afford health insurance.

Then came the Affordable Care Act. I will be the first to admit it’s not perfect. But it contributed to a 26% reduction in the uninsured rate among healthcare workers, according to a report released this week from PHI. Medicaid coverage among nursing home workers increased from 16% to 19% between 2010 and 2014. The uninsured rate among nursing home workers dropped from 28% to 20% after the ACA was passed.

I was surprised at a McKnight’s online commenter who flippantly asked about our original news article, “What’s the next article going to read? Repealing the ACA causes cancer???” Yes, actually. What health insurance does is allow you to visit a doctor. It lets you to get a pap smear, mammogram, mole check and colonoscopy, which are literally tests that catch cancer. (Hey, look at that, the correct use of the word literally.) I understand the commenter was being snarky, but I’d like to reiterate that health insurance may not always save a life, but it often does.

Putting aside the thorny moral issue of whether supporting the stripping of health insurance from your lowest paid employees makes you feel bad, there’s also the practical question of what less health insurance means for the industry workforce.

Job loss: It’s expected that around 3 million jobs could be lost nationwide by 2021. Almost a million are in healthcare, according to research from George Washington University

Less money for states: It’s estimated that gross state products could decline by $256 billion in 2019, the same analysis found. These losses would trigger reductions in state and local tax revenues, which would mean about $48 billion gone over five years. That’s also not factoring in the need for states to pony up again for more uncompensated care.

Losing workers due to injury and illness: CNAs are always going to be at risk for injury. Putting aside worker compensation claims, think about the direct care staff who saw a physician for their back pain, worked with a specialist to get their diabetes under control or went on medication for high blood pressure in the past few years. Not to mention all of those women who work for you who didn’t get pregnant due to the ACA allowing them to have birth control. (I stand by an earlier blog that essentially said if the contraception mandate goes away you should stand at the doors of your facility handing out birth control.) All of those factors result in people who are more physically able to show up for work.

As Stephen Pimpare wrote this week, “Chaffetz was articulating a commonly held belief that poverty in the United States is, by and large, the result of laziness, immorality and irresponsibility.”

You can be a Republican, and still not let him manipulate you into thinking that’s true.

Follow Elizabeth Newman @TigerELN.