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The President, the Chief Justice, and the Woman With Cancer

President Obama gave a subdued, if satisfied, statement on Thursday, after learning that the Supreme Court had upheld the Afforable Care Act. But he finished it off with a personal note. He told his fellow Americans about a letter hanging in his office, from an Ohio woman named Natoma Canfield.

Canfield, a breast cancer survivor and self-employed housekeeper, had written the letter in late 2009, as the fate of what would become Obamacare remained very much in doubt. She had gone into debt paying her medical bills, eventually dropping insurance because it had become too expensive for her to afford. She ended up getting charity care at the Cleveland Clinic, after Obama first mentioned her story publicly in 2010. But, Obama said, “I carried Natoma’s story with me every day of the fight to pass this law. It reminded me of all the Americans, all across the country, who have had to worry not only about getting sick, but about the cost of getting well.”

I’ve never met Ms. Canfield, so I can’t tell you anything more about her story. But, like a lot of journalists who write about health care, I’ve met hundreds of people who faced crises like she has. Every story of hardship is different. Some people had no insurance. Others had insurance, only to discover it didn’t cover what they needed. But the common thread in these stories is the fundamental unfairness of it all. Whatever their very human faults or mistakes, these people were all victims of misfortune, sometimes financial and sometimes medical—and, as a result, their livelihoods and in some cases their very lives were at stake. They lived in the richest country in the world, yet paying for basic medical care, something the citizens of every other developed country take for granted, was a struggle.

The Affordable Care Act will not provide relief to all of these people. And the relief it provides will not always be adequate, or without unfortunate side effects. But, if fully implemented, it will mean that every low-income American—officially, those making less than 133 percent of the poverty line—can enroll in Medicaid. It will mean that people who already have decent private health insurance, the kind that large companies provide, will have extra consumer protections. It will mean that people buying private insurance on their own will, no matter what their pre-existing conditions, have access to the same kinds of comprehensive benefits that employees of large firms get.

The Affordable Care Act will also mean that people who now shun private insurance only because it’s too expensive will get generous financial assistance—so that, for example, a family of four with household income of around $50,000 pays only around $4,000 a year. Without the financial assistance, the same policy would be about $14,000. Pundits tend to distinguish health care from the economy. But facts like that are proof that the two are intertwined.

But these changes will take place only if the law stays on the books. It may not. Shortly after the decision, Mitt Romney held a press conference to announce that repealing the Affordable Care Act would be his first priority as president. Congressional Republicans have pledged to the same if they control both houses of Congress.

Sometimes these Republicans vow not just to repeal but also to replace the law; Romney used that phrasing on Thursday, as a matter of fact. But the slogan has been a sick joke. They have no plans to make comprehensive insurance available to all people, regardless of pre-existing conditions. They have no plans to make sure insurance is affordable to all people, by making sure premiums are within everybody’s reach. They have criticisms of the Affordable Care Act and some of them, surely are valid. But they have no proposals that would come anywhere close to accomplishing the same thing. 

It was not always thus. In the 1970s, Richard Nixon endorsed a universal coverage plan. In the 1990s, moderate Republican senators did the same. It was from those Republican plans that Democrats took the template that became the Affordable Care Act. The hope was that co-opting the Republican model would build bipartisan support. Instead, the Republican Party rejected its own model and, eventually, the whole idea of universal health insurance. 

Most Americans don’t grasp this. Very few people understand the law at all. And that includes, as my colleague Alec MacGillis has reported, the very poorest Americans who would arguably benefit the most. But maybe Thursday’s decision can put the choice into starker relief. Most Americans aren’t going to parse Chief Justice John Roberts’ disquisition on the Commerce Clause or ponder the long-term implications his decision will have for federal-state relationships. At most, they will hear a snippet on the news: Supreme Court upholds Obamacare. And then they’ll get on with their lives. That just might be enough to change some perceptions. Whatever alterations Roberts made to constitutional law—a topic, I know, scholars will debate for years—he’s successfully mainstreamed health care reform.

Without the distraction of a court fight and all the silly talk about broccoli it provoked, Obama can reframe the Obamacare debate about as a debate over priorities. Better still, he can talk about it in the same breath as he talks about his opposition to Paul Ryan’s plans for Medicare and Medicaid and taxes—plans, again, that Romney has endorsed. Obama can say, truthfully, that he wants to make sure the poor and middle class have greater security from medical expenses, even if it means that rich people have less money. And he can say, truthfully, that Romney wants the opposite: To take such security away form the poor and middle class, while making sure the rich have more money. 

Making that case will require defending the Affordable Care Act explicitly and enthusiastically. The administration has not always done this well, although, to be fair, it has not been easy. The opponents of health care reform have vastly outspent supporters on advertising for it. News coverage focused on the legislative fight and, more recently, the legal one. But the legislating ended long ago and now the litigating has, too. All that’s left is the actual health care plan—and what it would do for people like Natoma Canfield. 

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