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Now Can We Start Talking About The Law?

As word of the Supreme Court ruling on the Affordable Care Act exploded across the Twittersphere, one thought came to my mind: would Robin Layman even hear about it? 

Layman, some readers may recall, was a 38-year-old woman I met in rural southeastern Tennessee at a weekend health clinic where hundreds of people, most of them uninsured, came for free care a few weeks ago. Layman will benefit hugely from the Affordable Care Act—she will gain coverage under the Medicaid expansion, which will make it easier for her to afford medication for her high blood pressure, nerve medication for a back injury sustained in the stock room of a dollar store, and mental health care for her depression (she tried to commit suicide last fall, but has not been to a psychiatrist since a week’s stay in a mental hospital because she cannot afford it.) She will also be able to stop worrying about her 18-year-old son, who two years ago sustained severe injuries when hit head-on by a high-on-drugs driver (her son’s girlfriend was killed) and is now at risk of aging out of his Medicaid coverage, which would leave him with no way to pay for his ongoing surgery. Yet Layman had no notion of the huge stakes she had in the ruling. "What new law?" she told me. “I’ve not heard anything about that.”

There’s no way around it: this reaction, which echoed the response I heard from many others at that clinic, is a severe indictment of the Obama administration’s failure to communicate the impact of the Affordable Care Act to the people who will benefit from it most. Now, it’s no mystery why the administration has been shy on this front—the Medicaid expansion, which will account for more than half of the law’s newly covered people, represents a pure expansion of the safety net for the working poor, not something that has traditionally been seen as a political winner. Still, it has been confounding and demoralizing for Democrats to watch the administration failing to fully embrace and promote such a historic achievement—it smacked of the sort of Clintonite, poll-minded defensiveness that Barack Obama was supposed to have left behind.

So why not view Chief Justice John Roberts’ decision to endorse the essence of the law as a break in this pussy-footed approach? If the law is good enough for a George W. Bush nominee who presided over Citizens United and plenty of other conservative rulings, it ought to be good enough for the White House. The fight over the Affordable Care Act now shifts fully into the political realm, with Mitt Romney (the law’s pioneer!) as its last line of attack. Which means that it will be up to Barack Obama and other Democratic candidates to finally be making the forthright, full-throated defense they have until now shied from.

The need for such promotion extends beyond this fall’s election. Even if Obama wins reelection, the court’s ruling has increased the likelihood of ugly fights at the state level, leaving open the prospect that states dead set against the law could reject the expansion of Medicaid eligibility, to a new national threshold of 133 percent of the poverty level, without having to worry about the threat of having federal funding for their existing Medicaid programs withdrawn as punishment. Leave aside that states would be turning down the deal of the century, being able to cover millions of their residents at a 100 percent federal match (later, 90 percent) when more progressive states that have had more generous Medicaid eligibility rates will have to continue paying a far greater share of the cost of covering their residents. Such are the politics of states such as Texas (6 million uninsured) that a huge infusion of federal money to help their own residents may not be enough to overcome rank ideology. But there is one way that state elected officials across the South and West will be encouraged to accept the Medicaid expansion and the federal money that will pay for it: if voters in their state demand it. Which will mean getting the Robin Laymans of the world to vote their self-interest. Which will mean telling Robin Layman and millions like her what they are getting, and what they might lose. Which means that Barack Obama needs to stand up for Obamacare. As I write this, he is doing so in his comments from the White House. But he will need to continue doing so every day until November, and beyond.