WASHINGTON Texan Sam Lovett had no health insurance in August 2010 when an emergency hospital stay brought the news from his doctors that his liver was failing and he could die within less than a year without a transplant.
The small distribution center where he worked did not provide health insurance. Lovett, 43, who lives near Comfort, Texas, was not able to buy private coverage on his own because of his already bad health. Though he had the resources to cover routine medical bills, he now needed a $400,000 organ transplant and no doctor or clinic would take him without insurance.
"They were making arrangements to send me to a hospice. One doctor flatly told me that I had a better chance of leaving the hospital dead than alive," said Lovett, who had a history of alcoholism and obesity.
But in the months that followed, Lovett was able to enroll in the Pre-Existing Condition Insurance Plan (PCIP). The program was created by the healthcare law that President Barack Obama, a Democrat, signed in March 2010 despite the united opposition of Republicans in Congress. The program paid for Lovett's transplant surgery at the Mayo Clinic in Phoenix last December.
PCIP is a temporary government program set up to run until 2014, when the Obama healthcare law is due to take full effect and prevent insurance companies from the common practice of denying people coverage due to pre-existing medical conditions. About 60,000 Americans already are receiving medical coverage through the program, according to the Obama administration.
As the U.S. Supreme Court prepares to rule in the next few weeks on whether to overturn the law considered to be Obama's signature domestic policy achievement, Lovett said the choice is very clear for him and others unable to get insurance without the statute's provisions.
"Without this, you're going to die," Lovett said in an interview arranged by the Consumers Union organization, which supports the law. "From my perspective, that's what the Supreme Court will sanction, or not - whether people will be allowed to die because they can't get insurance."
Unlike people in many other rich nations where health insurance is near universal, many Americans struggle without medical coverage even as the country pays more for healthcare than anywhere else in the world. The U.S. healthcare system is a patchwork of private insurance and restrictive government programs that has left tens of millions uninsured.
Many Americans receive health insurance only because their employers provide it as a job benefit. But some companies, particularly smaller employers, do not offer it. People with pre-existing medical conditions often are denied private coverage when they try to buy it on their own.
The Obama law represented the $2.6 trillion U.S. healthcare system's biggest overhaul in nearly 50 years. Twenty-six of the 50 U.S. states - including Lovett's home state of Texas - and a small business trade group challenged the law in court.
The Supreme Court heard three days of historic arguments in March on the fate of the law. A ruling is expected by the end of June.
PCIP is only one facet of a law intended to extend coverage to more than 30 million more Americans, create competitive health insurance exchanges in all 50 states and find new ways to deliver effective healthcare at lower costs.
Opponents of the law say it represents an encroachment by the federal government on the individual right to choose healthcare, meddles in the business of the states, and would saddle consumers with higher costs and less access to care.
Should the high court overturn the law, its provisions could become invalid immediately.
Although conservatives revile the law, Republicans and other critics agree something should be done to give insurance access to people with pre-existing conditions and other health issues. Several Republican bills in Congress would create new insurance pools for extending affordable coverage.
"We need to get rid of the entire thing and start over with a very deliberative process," said Sean Spicer, a spokesman for the Republican National Committee. "There's bipartisan recognition that these are valid concerns that need to be addressed. But we need to do it in a way that doesn't put government in the middle of healthcare."
Mitt Romney, Obama's Republican challenger in the November 6 U.S. election, has called for repealing the law.
If the whole law or key provisions are struck down, it may be tough to get any alternatives through a Congress in partisan gridlock even after the election. Republicans currently control the House of Representatives and Obama's fellow Democrats the Senate.
Republican lawmakers are working on an alternative healthcare agenda should the law be struck down. They may seek to reinstate some of its more popular consumer protections such as a provision, already in effect, that lets young adults remain under their parents' health insurance plans to age 26.
But the uninsured or uninsurable could wait months or years for an alternative plan to help them. Meanwhile, many people without insurance fear that a major illness could lead to astronomical healthcare bills and doom them to bankruptcy.
Statistics show that as many as one in four working-age American adults go without health insurance in a given year, often due to unemployment and other job changes.
Helen Berger of Boise, Idaho, said she has not seen a doctor since her husband, Russ, lost his information technology job 10 months ago.
They had the option of paying to continue to get his former employer's insurance plan under a U.S. law known as COBRA. But the $1,350 monthly premium was way more than they could afford on his $336-a-week government unemployment check.
Her 2-year-old son and 8-year-old daughter are eligible for a government health assistance program for children. The family also qualifies for $400 a month in food stamps.
Joining the state-federal Medicaid program for the poor would mean giving up assets including their home, she said. So Helen, 55, and Russ Berger, 57, are going without coverage until he can find another job or a charitable health clinic.
"We're going in the hole (financially) every month without having to pay any health insurance. And now we're coming up on a year being on unemployment (benefits), not knowing if that will continue," Helen Berger said in an interview arranged by the advocacy group Families USA, which supports the law.
Because information technology specialists like her husband often land jobs as outside contractors without health benefits, Berger said a return to employment likely would mean they would have to buy their own insurance. She said she hopes affordable medical coverage will become available once the state insurance exchanges are launched as scheduled under the Obama law in 2014.
"If anything happens between now and then, we're kind of in a bad place," she said.
Her state, Idaho, also is among those challenging the law.
'I'LL BELIEVE IT WHEN I SEE IT'
Gail Richardson of Stone Mountain, Georgia, said she is skeptical the law will help her, but hopes to qualify for its expanded Medicaid eligibility, which also would begin in 2014.
"I just found out about it and was really happy. I used to think it would benefit a lot of people but not me," she said. "But I still say I'll believe it when I see it."
Richardson, a 59-year-old freelance writer, has autoimmune liver disease and psoriatic arthritis. With an annual income of about $11,000, she said she cannot afford to join the PCIP program that paid for Lovett's liver transplant.
That's because the law requires PCIP coverage to be priced in line with plans for healthy customers in each state. In Georgia, the standard PCIP plan for someone her age costs $470 a month in premiums and can lead to out-of-pocket expenses such as deductibles and co-pays of $5,950 to $7,000.
Richardson is not eligible for Medicaid in Georgia, which is available in the state to adults without children only if they are elderly, disabled, blind, pregnant or suffering from certain forms of cancer. She gets much of her medical needs at discounted prices, or for free from assistance programs offered by drug companies and a supermarket pharmacy chain.
"I pay about $54 for three months' worth of one prescription and get the other two free. My doctor does blood work every six months and charges about $78 per visit, which I repay in monthly installments," Richardson said in an interview arranged by Consumers Union. "You can see how that's dwarfed by the expense of premiums I couldn't possibly afford."
The Obama law would expand Medicaid to cover people with annual incomes of up to 133 percent of the federal poverty level, or about $15,000.
"I'd have peace of mind, knowing that if something serious happened to me, I'd be able to get care," she said.
Her state also was among those challenging the law, including the Medicaid expansion.
(Editing by Michele Gershberg and Will Dunham)