To Tim Givhan, Obamacare shouldn't be an excuse for election-year polemics: "It's a lifeline."
A former IT specialist, Givhan tripped on a machine at work and landed on his head, suffering neurological damage. His employer's insurance company wouldn't pay for an operation, saying the outcome was iffy. Plagued by debilitating migraines and tremors, he quit work. His wife, an attorney, divorced him.
Givhan, 49, has moved back to his mother's home in Beloit, Wisconsin. He has no health insurance but expects to get it once the Affordable Care Act, known as Obamacare, takes full effect. "I often think of killing myself," he said. "But I have a 2-year-old son, and I can't do that to him."
Whether the sweeping 2010 law is fully implemented, as President Barack Obama intends, or repealed, as GOP nominee Mitt Romney pledges, no policy difference in next week's election is likely to affect more Americans in their daily lives.
This small Midwestern city - which anthropologist Margaret Mead once called "a microcosm of America" - offers a window into what is at stake. Obamacare is dividing patients and doctors, hospitals and government regulators, workers and employers, constituents and politicians. And here, as elsewhere, many are confused about the law's provisions.
A nationwide Reuters/Ipsos survey shows 49 percent of registered voters favor it, and 51 percent oppose it. At the same time, many who disagree with the legislation support key provisions such as cutting drug costs for seniors, expanding Medicaid coverage for the poor, and banning insurance companies from capping lifetime reimbursements or refusing coverage for preexisting conditions.
Beloit's Community Healthcare Center, where Givhan was picking up a prescription on a recent morning, is tucked in a corner of a shopping mall. It is a tidy place with comfy chairs and wall-to-wall carpeting. Helpful receptionists nod sympathetically behind a glass window. Brochures promote vegetables in your diet.
But the small public clinic is also a place where mounting rage against the machine of American healthcare is palpable. A quarter of the patients lack health insurance. Others are in life-or-death struggles with their insurance companies. Some can't find a surgeon who will take Medicaid.
The Affordable Care Act is expected to cut the number of uninsured Americans by 30 million over the next decade. Lynn Larsen, a clinic administrator, is eager for the law to remain in place.
"Most of our patients are working poor," she said. "Some have 32-hour-a-week jobs at Wal-Mart and can't afford insurance. Others were laid off from factories - their unemployment insurance has run out and they've lost their homes."
The community center, with two family physicians, three registered nurses and a handful of support staff, has no beds. Seriously ill patients are referred to Beloit Memorial Hospital. "But try to find an oncologist who takes an uninsured person," Larsen said. "They want 50 percent up front, and treatment can cost $500,000. If someone has lung cancer and needs charity, they're probably going to die."
In Beloit, a city of 37,000, industry has been shrinking for decades. Shuttered hulks of century-old brick factories, some with broken windows, line the Rock River. On a recent evening a homeless man tended three fishing rods, and pulled out a wriggling sheepshead for his dinner.
The city has fought blight by preserving its historic downtown, building a sculpture-adorned bike path and fostering a farmer's market. The economy is slowly recovering, but unemployment remains high, at 9.9 percent. That's down from 19.1 percent in 2009 after a General Motors plant in nearby Janesville closed.
In a Reuters/Ipsos poll, 55 percent of Americans "strongly agree" with the statement "All Americans have a right to healthcare." Another 21 percent "somewhat agree," and only 10 percent express any disagreement.
With a 130-bed hospital, a $520 million budget and a staff of 1,400, Beloit Health System is the largest employer in town. Its administrators are divided over Obamacare, anticipating reforms with a mixture of hope and dread.
Senior Vice President Timothy McKevett said the law's incentives spurred the hospital to set up an electronic records network. "We had three computer systems which didn't talk to each other," he said.
Under Obamacare, "regional information exchanges will allow a doctor anywhere in the state to see, 'Oh, that patient had a lab test two weeks ago. We don't need to do it again.'"
However, McKevett said the Affordable Care Act will cost the hospital $22 million over 10 years. Even before the law was enacted, Medicare and Medicaid paid less than a quarter of hospital or physician costs for treating recipients. "When we see these patients, we lose money," he said.
Under Obamacare, more Beloiters would be covered by Medicaid, and new efficiency rules for Medicare will take effect. For example, hospitals can be denied reimbursement for some patients who are readmitted after previous stays. Doctors object because patients are often readmitted when they fail to follow instructions, rather than because of hospital negligence.
The hospital has been taking steps to cut costs. By merging with a local doctors group and eliminating duplicative CT-scanners and labs, it is saving $3.4 million a year. But with Obamacare, McKevett said, "We will have to do even more with less."
'THE SYSTEM IS COLLAPSING'
Emergency room doctor Richard Barney, who serves as Beloit Memorial's chief of staff, flatly opposes the law. "We can't afford to provide healthcare to millions more people," he said. "We already have a physician shortage. Not everyone should be able to have a knee replacement because their knee hurts."
Given low reimbursements for private physicians, he said, "Sprained ankles and strep throats end up in our overwhelmed ERs where federal law prohibits enforcing copays. You bill till you are blue in the face, but they're not going to pay a dime. We are the only industry in the world where you can dine and dash."
Barney acknowledges that something must be done: "Healthcare costs are out of control. The system is collapsing before our eyes." He favors parts of Obamacare, including the ban on denying coverage for preexisting conditions and lifting the lifetime coverage cap.
But instead of this "monstrosity of a law," he said, the system should "be fixed piece by piece." Barney is upset that the law fails to curb malpractice suits, which fuel expensive and unnecessary tests. "Billions are spent on defensive medicine, and nobody gives a crap because they're in the back pocket of lawyers," he said.
In the campaign, Democratic ads have mostly avoided the subject of Obamacare, focusing instead on attacking GOP plans to reform Medicare. Republicans and business-funded groups, who launched fierce attacks against Obamacare in the 2010 midterm elections, have continued to use it as campaign fodder.
In one spot, GOP Vice Presidential nominee Paul Ryan, whose congressional district adjoins Beloit, advises, "You should be in charge of your health, not government or insurance bureaucrats."
A Romney ad criticizes Obama for "taxing wheelchairs and pacemakers" and "raiding $716 billion from Medicare" to pay for the program. The Medicare figure, though, is the amount expected to be saved from hospital and doctors' costs under new regulations and does not involve cutting seniors' benefits.
According to the nonpartisan Congressional Budget Office, the law's $938 billion cost over 10 years would be funded by wringing waste from Medicare and Medicaid, along with new levies, such as a tax on generous "Cadillac" insurance plans. The CBO estimates the law would cut the national deficit by $124 billion over a decade.
Several of Obamacare's major provisions do not take effect until 2014, but the ones in place are having an impact. Fairbanks Morse Engine, which employs 370 workers, is among Beloit companies forced to lift a million-dollar lifetime cap for health insurance spending. Several employees with cancer have benefited.
At the city's Bushel & Peck's market, cashier Kat Tow, 23, is now covered by her father's health insurance plan, thanks to the law's ban on companies cutting off children before age 26. Her boyfriend, who has a seasonal job with the city parks, also gets insurance through his parents.
"Obamacare is a godsend," she said.
At the community health center, Johnson Moore, 58, is among the clinic's 5,000 uninsured patients to be affected once the law is fully implemented. Filling out forms on a recent morning, Moore said he has never had insurance, public or private. Since the bakery where he worked went out of business, he has been unable to afford his diabetes medicine.
"It is slowly killing me," he said.
A few seats away, Wanda Taylor, a former restaurant manager, is also counting on the law. Her son Colin, 18, a hemophiliac, will age out of the Medicaid system next year. "It scares me half to death," she said. "Even if he gets a job, he probably won't get health insurance. Most people his age don't."
Neither Moore nor Givhan, the former IT specialist, has been able to get Badgercare, the state's Medicaid program, which is largely reserved for mothers and children. Wisconsin, under Republican Governor Scott Walker, has joined a dozen other states in tightening access to benefits.
Obamacare would move in the opposite direction, adding as many as 11 million to Medicaid, including 170,000 in Wisconsin. Anyone earning up to 133 percent of the poverty line would be covered.
Walker, who beat back a union-sponsored recall election in June, contends Obamacare "would require the majority of people in Wisconsin to pay more money for less healthcare."
He returned $38 million in federal funds allocated to Wisconsin for setting up insurance exchanges under the law, saying he hopes it will be repealed. The exchanges, which would give the state's half-million uninsured a central place to compare and buy plans, are to take effect in 2014.
Ignorance of the law's benefits is widespread. Among two dozen Beloiters interviewed during a recent visit, few could name even a single Obamacare provision. None were aware that, under the law, nearly 2 million Wisconsonites have been able to get free preventive services such as mammograms and colonoscopies with no copays.
None were aware that the law has saved Wisconsin Medicare recipients $84 million on prescription drugs since 2010; or that insurance companies are now banned from dropping people when they get sick; or that Wisconsonites got $10.4 million in insurance refunds because companies must now spend 80 percent of healthcare premiums on care.
"What does Obamacare do?" asked Jennifer Lorenz, a nurse at Beloit Memorial Hospital, genuinely puzzled. "I don't know the specifics." An Obama supporter, she was nonetheless unsure if she favors the law.
A few Beloiters were aware that Obamacare would require all Americans to have insurance - the so-called individual mandate. In the Reuters/Ipsos national survey, when questions detailing the law's specifics were posed, that so-called individual mandate was the only provision with less than majority backing. Asked about "requiring all U.S. residents to own health insurance," 40 percent agreed, 36 percent disagreed and 23 percent were undecided.
None of the Beloiters interviewed were aware that the law would offer subsidies for purchasing insurance to those with incomes between 133 percent and 400 percent of the poverty level.
'A SICK-CARE SYSTEM'
At his apple stand in Beloit's Saturday farmer's market, Brian Van Laar said he opposes Obamacare. "I don't think the government should get more involved in healthcare," he said. "The constitution doesn't say it should."
Van Laar, whose orchard is a side business, has a day job as an engineer for an appliance manufacturer. With the new law ensuring coverage to individuals through insurance exchanges, "People at work are worried that the company will stop offering benefits," he said. "They'll just kick us over to Obamacare and say, 'You're on your own.'"
Under the law, employers who cancel their plans would be liable for penalties. Nonetheless, Jeffrey Klett, a Beloit agent who handles benefits for 70 companies, said, "I have two larger clients thinking about doing away with health insurance altogether. Clients ask, 'Am I better off just paying the fine?' There's a lot of uncertainty."
John Bottorff, vice president for human resources at Fairbanks Morse Engine, predicts that "most employers will want to continue to provide healthcare coverage. If you drop it, you could be at a competitive disadvantage in attracting and retaining employees."
In the Reuters/Ipsos survey, 72 percent of voters favored the Obamacare provision that requires companies with more than 50 employees to offer health insurance. Only 28 percent were opposed.
Despite the ambivalence of his colleagues, Larry Bergen, director of Quality Reporting and Community Health at the hospital, calls Obamacare "a fabulous step in the right direction. More people will have insurance, so they won't put off seeing doctors until they have a crisis."
Bergen would have preferred a "single payer system" such as Medicare, rather than a law that relies primarily on private insurance companies. "People say the Canadian and British systems have flaws, but those countries have better life expectancy and less infant mortality than we do," he said.
"We don't have a healthcare system - we have a sick-care system. Fifty percent of health dollars are spent on the sickest 5 percent. If you're sick, we do great things, like an angioplasty in the middle of a heart attack. But people can't get in to see a primary care doctor."
Proponents of the law expect millions more to get treatment for high blood pressure to avoid a stroke, take cholesterol-lowering drugs to ward off a heart attack or get early diabetes intervention to prevent a gangrenous foot amputation.
"People can criticize the law, and we'll have a chance over the years to make it better," said Timothy Cullen, a former Blue Cross executive who represents Beloit in the state senate. Presidents have tried for a century to get healthcare for all Americans, he added. "They all failed and Obama succeeded. It's long overdue."
The Reuters/Ipsos database is now public and searchable here.