Court rules for the uninsured

“The bottom line: the entire ACA is upheld.”

That’s what SCOTUSBlog wrote moments after the Supreme Court announced its ruling on the health-care law. But it wasn’t upheld in the way most thought it would be. The decision was 5-4, with Chief Justice John Roberts siding with the Court’s liberals, and Justice Anthony Kennedy casting his vote with the conservatives.

This will be covered, in many quarters, as a political story. It means President Barack Obama — and Solicitor General Don Verrilli — are popping the champagne. It means that Mitt Romney and the Republicans who were fighting the health care law have suffered a setback. It will be covered in other quarters as a legal story: It is likely to be central to Roberts’ legacy, and perhaps even to how we understand the divisions in the Court going forward.

And, to be sure, it’s all those things. But those stories don’t capture the effect this decision will have on ordinary Americans.

The individual mandate, by bringing healthy people into the insurance market and lowering premiums, means health insurance for between 12.5 million and 24 million more Americans than if the mandate was struck down. And as Kennedy said in his dissent that the conservatives on the Court believed the entire law should have been invalidated, it means health insurance for 33 million more Americans than if Kennedy and the conservatives had their way.

Those are big numbers. But behind them are real people. People like Eric Richter.

Richter, a 39-year-old resident of Ohio, works at a stone drilling company. He and his wife made $36,000 a year. That’s too much to qualify for Medicaid, but too little to easily afford insurance. So Richter didn’t purchase insurance. “It’s hard to pay for the unknown, when you’re struggling to cover the known,” he told Sabrina Tavernise of the New York Times. “I know it sounds irresponsible, but that’s just the way it was. It’s a game of roulette you hope you’re going to win.”

Then Richter discovered a tumor growing up his leg. He first tried home remedies, cutting out sugar and eating beets, having read somewhere that it might help. But it kept growing. His wife sewed him new pants to accommodate the “melon-sized” lump. He stood in church, because it was too painful to sit down. He was turned away from a needed scan because he lacked insurance. In April, doctors in the emergency room told Richter his tumor was malignant. His wife desperately tried to find an insurer that would cover them. No one would. The tumor was, of course, a pre-existing condition.

Perhaps nothing in Richter’s story speaks to the cruel reality of the American health care system better than this: Richter’s wife, Dani, was recently let go from her job at an electronic records firm. For most families, this would be a tragedy. For the Richters, it might be a lifesaver. The loss of income pushed them well beneath the poverty line, and that might mean they qualify for Medicaid. “We’re back to crossing our fingers,” Mrs. Richter told Tavernise.

Richter has had some good luck, too. A doctor eventually took an interest in his case and helped him get surgery. The family, however, still has no idea how they will pay the bill for the surgery, or for his needed follow-up care.

The passage of the Affordable Care Act means that, come 2014, people like the Richters get guaranteed health care coverage. If their income is less than 133 percent of the poverty line, they receive Medicaid (unless their state rejects federal Medicaid dollars for the expansion, something the Court made it easier for them to do). If their income is between 133 percent and 400 percent, they receive some level of subsidies. At $36,000, the Richters would be paying less than $200 a month, and no insurer can turn them away. If they are now below the poverty line, they get Medicaid, no questions asked.

There is uncertainty between here and 2014. In particular, Mitt Romney could win the election and repeal the law entirely, meaning none of the 30 million Americans expected to gain coverage under the law get it.

But the particular roulette wheel that began spinning when Republicans took to the courts to invalidate the Affordable Care Act has come to a stop. And the Richters have won. They can finally uncross their fingers.

Ezra Klein is a columnist for The Washington Post.