ARLINGTON, Virginia - The U.S. Supreme Court on Thursday ruled that President Barack Obama’s health-care reform law is constitutional, including a requirement that most Americans buy health insurance. Most now get health insurance through their employers, but many workers are not able to get coverage at work. Those workers often don't earn enough to buy insurance on their own, but they are not poor enough to qualify for the free government care known as Medicaid.
For 25 years, Wilber Smith of Arlington, Virginia, had health insurance through his job as a steam engineer. Then he lost his job and his insurance. A few months later, he was diagnosed with cancer. He tried to get health insurance, but he says he was turned down by every provider he contacted. Sales people told him his pre-existing health condition -- cancer --barred him from obtaining coverage.
"It was no everywhere and a quick no," he recalls. "They were like, 'Now? Now you are coming to us?' I never needed it before because I had always had it."
Smith then found his way to the Arlington Free Clinic in Arlington, Virginia, where he went through chemotherapy and radiation treatment for free, paying only $5 each for some prescriptions and nothing at all when he couldn't afford to pay. The clinic, which treats 1,600 of Arlington's roughly 20,000 uninsured, is funded mostly by foundations and private donors.
"Most of our patients work," says Jody Kelly, director of Clinical Administration at the Arlington Free Clinic. "That's perhaps a myth about people at free clinics. That they don't have jobs."
Kelly says the clinic's patients include day laborers, nannies, painters and housekeepers -- people in jobs where employers don't typically provide health coverage.
And, Kelly says, by the time patients reach her door, they are already very sick.
"Our patients typically face the choice of buying food, paying rent or seeing a doctor, and you are probably going to take care of the other two before you come here, " she says. "We have a lot of diabetics, people with cancer, diagnosed or undiagnosed, high blood pressure. It's one of those things that kind of builds on itself because you are ill and you are not treated, and then you get more ill."
Extending health care coverage to more of the 50 million people in the United States without health insurance is part of President Barack Obama's sweeping healthcare reform legislation. It's called the Patient Protection and Affordable Care Act, widely known as "Obamacare," and it is set to take effect in 2014. But the U.S. Supreme Court will rule Thursday on the constitutionality of the law.
The legislation not only would extend coverage to more uninsured Americans but also expand the government's free health care service known as Medicaid to millions of low-income childless adults who currently don't qualify. Parts of the law are popular, including a provision that allows adults under age 26 to stay on their parents' health insurance plans.
Other aspects are more controversial. At the heart of the new law is what's called an individual mandate. It requires all U.S. citizens to purchase health insurance either through private companies, their employer or state-sponsored exchanges. Failure to do so is subject to fines.
Supporters of the mandate say it's critical to the law's success, because it increases the number of people paying for insurance while making sure that healthy people don't opt out until they need it. But 26 states have rejected this part of the legislation. And they argue that, if the individual mandate is ruled unconstitutional, then the entire law must go. Critics of the mandate say Republicans and Democrats alike oppose it.
"Repubilicans are against it because they see it as an impingement on their personal freedom," says Ed Haislmaier, who works on healthcare policy at the conservative-leaning Heritage Foundation in Washington. "The Democrats are against it because they don't like health insurance companies in the first place, and they don't like to be told they have to go buy from someone they don't like."
Haislmaier and his colleagues at Heritage support a more consumer-driven system, where patients have a wide variety of healthcare plans to choose from, outside of what their employers offer. In this scenario, people who have always been covered remain covered, even if they get sick.
"What has happened in this system for too long is that the patient has kind of been second or third in line behind everybody else," Haislmaier says.
In the consumer-directed plan he envisions, there might be one health insurance company that cares for all diabetics, for example. If you are a diabetic, that company would offer the most competitive rates and the lowest-cost medications for your condition. Your employer wouldn't matter. Liberals see this as a way to free employers from providing health insurance to their workers.
Meantime, each day at the Arlington Free Clinic, the waiting room fills with patients. Most have been chosen by lottery.
"We get about 150 people here a month who would like to become patients, and of that number, we can take only about 25," Jody Kelly says.
Wilbur Smith falls into a category that President Obama's legislation is designed to help cover: people who are not poor enough to qualify for Medicaid but too poor to afford health insurance on their own. Under the president's plan, Smith would be insured, even with his pre-existing cancer. But Smith says that even if he had secured health insurance, he would have struggled to pay the premiums, which can cost many thousands of dollars each year.
He says he never thought much before about health insurance. And people who criticized the health care system annoyed him.
"I had always had it and I thought, 'What are they complaining about?'" he says. "You don't get hurt, you don't fall down but so many times, an accident here or there, what are they complaining about?"
Now he knows.
His cancer makes it difficult for him to talk, but he says he is grateful for the care he has been receiving.
"It's a big burden lifted," he says.
There are a multitude of theories on how the Court will rule Thursday. Will it uphold the legislation in full or strike it down in full? Will parts of the law survive and, if so, which parts? No matter what the court decides, a study by the Pew Research Center says the public won't be happy. Pew researchers found that fewer than half of Americans will approve of the court's ruling.