As we wait for a Supreme Court ruling on the Affordable Care Act this week, there is one urgent, overriding moral question at the heart of the health care fight. Paradoxically, and maddeningly, there has not been any open moral debate over it. That question is whether access to basic medical care ought to be considered a right or something that is earned.

Several reporters have recently filed dispatches showing in human terms what sort of conditions we would be perpetuating in the event that five Republican Supreme Court Justices, or a potential Republican-run government next year, partially or completely nullify the Affordable Care Act. A man will watch the tumor in his leg grow to the size of a melon, and his wife will sew special pants to fit the growing bulge, because he has no insurance. A woman will hobble around for four years on an untreated broken ankle she can’t have repaired. People will line up in their cars and spend the night in a parking lot queuing for a rare free health clinic.

Maybe these stories sound like cheap emotional manipulation. They are actually a clarifying tool to cut through the rhetorical fog surrounding the health care debate and define the question in the most precise terms.

Opponents of the law have endlessly invoked “socialism.” Nothing in the Affordable Care Act or any part of President Obama’s challenges the basic dynamics of market capitalism. All sides accept that some of us should continue to enjoy vastly greater comforts and pleasures than others. If you don’t work as hard as Mitt Romney has, or were born less smart, or to worse parents, or enjoyed worse schools, or invested your skills in an industry that collapsed, or suffered any other misfortune, then you will be punished for this. Your television may be low-definition, or you might not be able to heat or cool your home as comfortably as you would like, you may clothe your children in discarded garments from the Salvation Army.

This is not in dispute. What is being disputed is whether the punishments to the losers in the market system should include, in addition to these other things, a denial of access to non-emergency medical treatment. The Republican position is that it should. They may not want a woman to have to suffer an untreated broken ankle for lack of affordable treatment. Likewise, I don’t want people to be denied nice televisions or other luxuries. I just don’t think high-definition television or nice clothing are goods that society owes to one and all. That is how Republicans think about health care.