Alec MacGillis is a senior editor at The New Republic.
As Robin Layman, a mother of two who has major health troubles but no insurance, arrived at a free clinic here, she had a big personal stake in the Supreme Court's imminent decision on the new national health care law.
Not that she realized that. "What new law?" she said. "I've not heard anything about that."
Layman was one of 600 people who on a recent weekend came from across southeastern Tennessee for the clinic held by Remote Area Medical, a Knoxville-based organization that for two decades has been providing free medical, dental and vision care in underserved areas. Most everyone had spent the night in their parked cars, to get a good spot in line. Daybreak found them massed outside the turreted stone gymnasium of the 150-year-old college, the University of the South, some still wearing pajamas or wrapped in blankets, waiting quietly for the 6 a.m. opening of the doors.
It was Remote Area Medical's 667th clinic. But this one came at an unusual moment: as the Supreme Court deliberates whether to uphold the health care law that will have a disproportionate impact on the sort of people served by the organization.
Layman was hardly the only patient unaware that the law aims to help people like her, by expanding health insurance beginning in 2014. And this gets to the heart of the political dilemma for Democrats: Despite spending tremendous political capital to pass the law, the party is unlikely to win many votes from the law's future beneficiaries, most of whom live in Republican-dominated states in the South and West. In fact, many at the clinic said they don't vote at all.
And that assumes the law survives until 2014. The law's design, with its major provisions kicking in four years after passage, was pragmatic politics at the time. The window would make the law's price-tag lower and allow states time to set up new systems. But the delay's result has been that the law has no natural constituency - its promises have not been clearly conveyed to the people it is designed to help.
This disconnect is seen in Tennessee, where about 15 percent of residents lack coverage - roughly the national average - but the state's largely Republican political leadership has shunned the law. The state's legislature has declined to pass legislation establishing the new insurance "exchange" required by the law; even the Democratic congressman representing the district that includes Sewanee voted against the law, before losing his seat the following fall.
Tennessee's uninsured includes middle class people who can't afford insurance or are turned down for health reasons, but the need is particularly acute among the poor and near poor who don't qualify for Medicaid. In Tennessee, the program covers poor children, pregnant women and the disabled, as well as many parents below a set income threshold, about $28,000 for a family of four, but adults without children in their care are ineligible.
Under the law, Medicaid will expand in 2014 to cover anyone earning up to 138 percent of the poverty level, or about $31,000 for a family of four. Many people above that income who lack employer-provided coverage will receive subsidies to help them purchase private insurance.
Layman and her family offer a stark example of the law's potential impact. Two years ago, her son, then 16, was hit head-on by a speeding driver high on drugs. Her son's girlfriend was killed; he suffered severe internal injuries and recently underwent colon surgery. Now 18, he will soon age out of Medicaid coverage.
And Layman, a gregarious 38-year-old, recently lost coverage for her own considerable problems. She suffers high blood-pressure, for which she takes three medications, purchased at a discount from the county health office. She suffers sciatica stemming from the time eight years ago when a co-worker at a dollar store let slip a heavy box of wrapping paper Layman was handing up to her. Layman lunged for it and badly hurt her back, for which she takes the nerve-pain medication Lyrica.
She also suffers depression, and has been on Prozac for several years. But during a rough spell last fall, she came close to committing suicide. It was on her return home from a week in the psychiatric hospital that she found a letter from the state saying that, as a result of a bump up in her husband's disability payments (he was caught in a front-end loader when he was eight years old), she was now ineligible for Medicaid.
Lacking coverage, she has not seen a psychiatrist since her hospital stay. She played this down: "I can recognize my craziness when it gets out of hand."
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