When it comes to the health care reform bill, perfect is the enemy of good. But Republicans are the enemy of everything. And on Sunday, every member of the House GOP will likely vote against the final health care reform bill that will bring coverage to 32 million more Americans, end insurance company abuses involving rescission, pre-existing conditions and lifetime caps on payments, all while slashing the federal budget deficit by $1.3 trillion over the next two decades.
But in saying no in that simple up-or-down vote scheduled for Sunday, Congressional Republicans are choosing to perpetuate the worsening symptoms of an American health care system already in critical condition.
Here, then, are the 10 Republican No's on health care:

1. No Hope for the 50 Million Uninsured
2. No Improvement for 25 Million More Underinsured
3. No Halt to the Rapid Deterioration of Employer-Based Coverage
4. No Help for the 1 in 5 Americans Already Postponing Their Medical Care
5. No Drop in the 62% of Bankruptcies Due to Medical Bills
6. No End to Double-Digit Increases in Business Insurance Premiums
7. No Barrier to Family Premiums Doubling in 10 Years
8. No Reduction of the Near-Monopoly Status in 94% of Insurance Markets
9. No Reversing the Dramatic Decline in Emergency Room Capacity
10. No Rescue for the 45,000 Uninsured Americans Needlessly Dying Each Year
11. No Chance for Failing Red State Health Care

1. No Hope for the 50 Million Uninsured
In 2007, the U.S. Census Bureau placed the number of uninsured people in America at 45.7 million, up from 37 million since the last time Republicans successfully blocked health care reform in 1993. But a February 2009 analysis by the Center for American Progress found that the recession had already added four million more to the rolls of the uninsured, a group which a study by Families USA last March found included 86.7 million Americans over a two-year span. And a July Gallup poll revealed the percentage of American adults without coverage catapulted to 16% from 14.8% since the start of the Bush recession in December 2007. All told, likely another five million people have pushed the ranks of the uninsured over 50 million.
And as the New York Times found last month in "The Cost of Doing Nothing on Health Care," should the Democrats fail to muster the needed votes this weekend, the future is bleaker still:

While estimates vary, the number of people without insurance is expected to increase by more than a million a year, said Ron Pollack, the executive director of Families USA, a Washington consumer advocacy group that favors the Democrats' approach. The Urban Institute, for example, predicts that the number of uninsured individuals will increase from about 49 million today to between 57 million and 66 million by 2019.

2. No Improvement for 25 Million More Underinsured
The crisis doesn't end there. In June 2007, a devastating assessment from the Commonwealth Fund showed fully 25 million more Americans were "underinsured," a staggering 60 percent jump since 2003. As the study showed, the number of "people who have health coverage that does not adequately protect them from high medical expenses" has skyrocketed:

As of 2007, there were an estimated 25 million underinsured adults in the United States, up 60 percent from 2003.

Much of this growth comes from the ranks of the middle class. While low-income people remain vulnerable, middle-income families have been hit hardest. For adults with incomes above 200 percent of the federal poverty level (about $40,000 per year for a family), the underinsured rates nearly tripled since 2003.

All in all, 75 million Americans - 42% of the people in the United States under age 65- have insufficient insurance or simply none at all.
3. No Halt to the Rapid Deterioration of Employer-Based Coverage
Making matters much worse is the rapid deterioration of employer-provided health insurance coverage. A 2007 report from the Economic Policy Institute showed a dramatic decline in employer-provided health care. That drop-off from 64.2% of Americans covered through workplace insurance in 2000 to just 59.7% in 2006 alone added 2.3 million more people to those without coverage. Census data since showed workplace coverage dipped further in 2007, down to an alarming 59.3%. A recent Thomson Reuters survey put the figure for 2009 at a stunning 54.6%. (Data from the U.S. Census revealed that it was only the expansion of government programs including SCHIP and Medicaid which offset the erosion of employer coverage in 2008.)
And recent surveys by National Business Group on Health and the Kaiser Family Foundation found that the situation is quickly worsening. While the NBGH sampling of 507 firms each with over 1,000 employees revealed that 56% will hold workers responsible for a greater share of health care costs next year, the September Kaiser study was grimmer still:

Forty percent of employers surveyed said they are likely to increase the amount their workers pay out of pocket for doctor visits. Almost as many said they are likely to raise annual deductibles and the amount workers pay for prescription drugs.

Nine percent said they plan to tighten eligibility for health benefits; 8 percent said they plan to drop coverage entirely. Forty-one percent of employers said they were "somewhat" or "very" likely to increase the amount employees pay in premiums -- though that would not necessarily mean employees are paying a higher percentage of the premiums.

4. No Help for the 1 in 5 Americans Already Postponing Their Medical Care
While Senate Minority Leader Mitch McConnell warns of a dystopian future of reform which "denies, delays, or rations health care," de facto rationing is already today's nightmare for millions of Americans.
An April 2009 Thomson Reuters survey of 12,000 people not only found that 20% of Americans have postponed or delayed medical care. That 1 in 5 figure is a staggering jump from 15.9% in 2006. Other jaw-dropping numbers from that report:

In the most recent survey, 21 percent of U.S. adults expected to have difficulty paying for health insurance or healthcare services in the next three months...

More than 54 percent who skipped care said they missed a doctor visit. Eight percent said they delayed or skipped medical imaging of some sort.

As McClatchy reported last fall, a new Consumers Union survey revealed that due to skyrocketing costs and reductions in coverage, Americans are forced to deny themselves needed medical treatment. Among the findings of CU's poll of a 1,002 respondents:

In the new poll 59 percent said that the cost of their health care had increased more than their other expenses over the past two years. Fifty-one percent said they had faced difficult health care choices in the past year. The most common responses were putting off a doctor visit because of cost (28 percent), not being unable to afford medical bills or medication (25 percent), and putting off a medical procedure because of cost (22 percent).

Twenty-eight percent said they had lost or experienced cutbacks in their health care coverage in the past year. The greatest concerns about health care expressed by respondents were a major financial loss or setback from medical cost due to an illness or accident (73 percent), not being able to afford health care in the future (73 percent), necessary care being denied or rationed by health insurance companies (73 percent), and the prospect of rising costs forcing them to choose between health care and other necessities (64 percent).

5. No Drop in the 62% of Bankruptcies Due to Medical Bills
Often, among those "other necessities" is one's home. Given the deterioration of the employer-provided health coverage and the skyrocketing costs of out-of-pocket care, it's no wonder, as a June 2009 study funded by the Robert Wood Johnson Foundation determined, medical bills are involved in over 60% of U.S. personal bankruptcies:

More than 75 percent of these bankrupt families had health insurance but still were overwhelmed by their medical debts, the team at Harvard Law School, Harvard Medical School and Ohio University reported in the American Journal of Medicine.

"Using a conservative definition, 62.1 percent of all bankruptcies in 2007 were medical; 92 percent of these medical debtors had medical debts over $5,000, or 10 percent of pretax family income," the researchers wrote. "Most medical debtors were well-educated, owned homes and had middle-class occupations."

6. No End to Double-Digit Increases in Business Insurance Premiums
The failure of health care reform would mean there is no end in sight to the skyrocketing insurance premiums paid by businesses and individual Americans alike.
A report last year from the consulting firm PricewaterhouseCoopers forecast employers will face a 9% increase in health insurance costs in 2010. 42% of those business surveyed will pass at least some the new burden on to their workers. As PWC's Michael Thompson concluded in June:

"If the underlying costs go up by 9%, employees' costs actually go up by double digits," he said, noting that will have a "major, major impact" when many employers also are freezing or cutting pay.

As the Washington Post detailed, some business groups themselves are also ringing the alarm bell. A new report from the Business Roundtable concluded, "If current trends continue, annual health-care costs for employers will rise 166 percent over the next decade -- to $28,530 per employee." Antonio M. Perez, chief executive of Eastman Kodak and a leader of the Business Roundtable described the relentless pressure faced by employers and employees alike:

"Maintaining the status quo is simply not an option. These costs are unsustainable and would put millions of workers at risk."

A March report from Goldman Sachs forecast just how much risk. Coming hot on the heels of annual premium increases as high as 39% from Anthem Blue Cross and others, the Goldman Sachs analysis predicted insurance rates for individuals will jump by up to 50% in some markets.
7. No Barrier to Family Premiums Doubling in 10 Years
The implications of these trends for American families are clear. The exponential increases in the private market combined with the looming collapse of employer-based coverage could lead to a typical family health insurance policy to nearly double in cost.
Pointing to data from the actuaries at the Centers for Medicare and Medicaid Services, the Center for American Progress warns that per capita medical costs are forecast to rise by 71% over the next decade. That would catapult the cost of the average family's insurance policy from $13,000 a year to over $22,000 by 2019. And as the New York Times reported just weeks ago:

Even those families that enjoy generous insurance now are likely to see the cost of those benefits escalate. The typical price of family coverage now runs about $13,000 a year, but premiums are expected to nearly double, to $24,000, by 2020, according to the Commonwealth Fund. That equals nearly a quarter of the projected median family income in 2020.

8. No Reduction of the Near-Monopoly Status in 94% of Insurance Markets
As Ezra Klein of the Washington Post noted, the Democratic health care bill addresses one of the Republicans' supposed key goals of enabling "insurance companies compete for your business and you can shop around for the best coverage and price."
But as the Commonwealth Fund revealed in a report titled, "Failure to Protect: Why the Individual Insurance Market Is Not a Viable Option for Most U.S. Families," that is a far cry from today's actual private insurance market, one in which Americans are simply priced out:

Over the last three years, nearly three-quarters of people who tried to buy coverage in this market never actually purchased a plan, either because they could not find one that fit their needs or that they could afford, or because they were turned down due to a preexisting condition.

Behind that market failure is the rapid emergence of health insurance monopolies in most areas of the United States. The past 13 years have seen over 400 corporate mergers involving health insurers. As the American Medical Association found, "94 percent of insurance markets in the United States are now highly concentrated, and insurers are thriving in the anti-competitive marketplace, raking in enormous profits and paying out huge CEO salaries." As I noted in 2006:

In most states, the AMA concludes, the idea of choice among competing insurance providers is a myth. The study showed that in each of 43 states, a small group of insurers exerts such market dominance as to merit the Justice Department "highly concentrated" market methodology for assessing potential anti-trust action. In 166 of 294 metropolitan areas surveyed, a single insurer controls over half the preferred provider network and HMO underwriting. In North Dakota, for example, Blue Shield owns 90% of the market. It's no wonder that Jim Rohack, an AMA trustee, concluded, "This problem is widespread across the country, and it needs to be looked at."

9. No Reversing the Dramatic Decline in Emergency Room Capacity
Mitch McConnell, George W. Bush, Tom Delay and a laundry list of other Republican leaders have pledged allegiance to the GOP's emergency room solution to the American health care crisis. As they put it, "no American is denied health care in America" because "you just go to an emergency room."
As it turns out, the disturbing trends above are having a cascading effect on waiting times and treatment at American emergency rooms. While high-profile cases of the deaths of untreated ER patients in Los Angeles and New York put a face on the crisis, a 2006 report by the Institute of Medicine revealed that U.S. emergency rooms can barely cope with the volume of patients in the best of circumstances, let alone in the wake of crises such as a terrorist attack or flu epidemic:

The study cited three contributing problems to the rise in emergency room visits: the aging of the baby boomers, the growing number of uninsured and underinsured patients, and the lack of access to primary care physicians.

The report found that 114 million people, including 30 million children, visited emergency rooms in 2003, compared with 90 million visits a decade ago. In that same period, the number of U.S. hospitals decreased by 703, the number of emergency rooms decreased by 425, and the total number of hospital beds dropped by 198,000, mainly because of the trend toward cheaper outpatient care, according to the report.

In 2008, a Congressional panel looked into the ability of the nation's emergency rooms to handle a terrorist attack on the scale of the 2004 Madrid bombings which killed 177 people and injured more than 2,000. The results were unsettling: "None of the 34 U.S. hospitals surveyed earlier this year had the emergency space needed to handle a similar number of casualties."
10. No Rescue for the 45,000 Uninsured Americans Needlessly Dying Each Year
The death spiral of the American health care system - and the scorched earth tactics of the Republican Party to prevent its reform - has a body count.
Back in September, a study by Harvard Medical School found that almost 45,000 Americans die each year due to lack of health insurance. To translate that into a metric even Tea Baggers can understand, that annual death toll exceeds the number of U.S. military personnel killed during the entire Korean War. For its part, Families USA estimates that as many as 275,000 people will die prematurely over the next 10 years because they do not have insurance.
Even using more conservative models, the Washington Post's Ezra Klein noted in December, the $940 billion Democratic health care plan could save 150,000 American lives over a 10-year span. Again, translated into Tea Bagese, that's more than was lost by the United States armed forces during World War I.
11. No Chance for Failing Red State Health Care
As it turns out, Republican obstructionism goes to 11.
In the ultimate irony of this entire debate, health care is worst precisely those states where Republicans poll best. The unhealthiest residents and worst health care systems can be found in those states (especially southern states) which most reliably back the GOP. And if health care reform passes, it will be blue state taxpayers who will fund the improved health care for their red state brethren.
The diagnosis isn't pretty for Republicans committed to denying the health care their constituents need most of all. A 2009 UnitedHealth Foundation analysis of 22 indicators revealed that nine of the top 10 healthiest states voted for Barack Obama in 2008. Conversely, 9 of the 10 cellar dwellers backed John McCain in 2008; four years earlier, the 15 unhealthiest states voted for George W. Bush for President.
In October, the Commonwealth Fund released its 2009 state scorecard for health care access, quality, outcomes and hospital use. There, too, Mississippi led the Republican south in providing dismal health care. Again, while nine of the top 10 performing states voted for Barack Obama in 2008, four of the bottom five (including Arkansas, Mississippi, Oklahoma and Louisiana) and 14 of the last 20 backed John McCain. (That at least is an improvement from the 2007 data, in which all 10 cellar dwellers had voted for George W. Bush three years earlier.)
This week, Georgia Republican Rep. Paul Broun said of the looming health care vote:

"If ObamaCare passes, that free insurance card that's in people's pockets is gonna be as worthless as a Confederate dollar after the War Between The States -- the Great War of Yankee Aggression."

As the numbers show, Broun's reaction should be, "thank you."