"The bottom line: the entire ACA is upheld"
That's what was on SCOTUSBlog moments after the Supreme Court announced its ruling on the health care law. But it wasn't upheld in the way most observers 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, about Roberts' legacy, and perhaps even to how we understand the divisions in the court.
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, writing for conservatives on the court who said the entire law should have been invalidated, it means health insurance for 33 million more Americans than if he and the conservatives had their way.
Those are big numbers. But behind them are real people, like Eric Richter.
Richter, a 39-year-old resident of Ohio, works at a stone drilling company. He and his wife make $36,000 a year. That's too much to qualify for Medicaid, but too little to easily afford insurance.
"It's hard to pay for the unknown, when you're struggling to cover the known," he told 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. 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 to 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, recently lost 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.
A doctor eventually took an interest in Richter's case and helped him get surgery. The Richters, however, still has no idea how they will pay the bill for the surgery, or for 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 below the poverty line, they get Medicaid, no questions asked.
There is uncertainty between here and 2014. 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.
Ezra Klein writes for The Washington Post.