In deploring the complexity of the Patient Protection and Affordable Care Act of 2010, many critics have entirely ignored the complexity (and extraordinary irrationality) of the health care status quo ante. If you have any doubts about that, check out Alex MacGillis’ snapshot for TNR of people attending a subsidized care clinic for the uninsured in Tennessee. It’s a reminder that “the uninsured” represent a vast hodgepodge of bad luck, particularly those losing employer-based coverage and/or living in states with tightly limited Medicaid eligibility. Many suffer from chronic illnesses like diabetes that could be significantly ameliorated with regular care they cannot currently afford. For many the current “system” is no system at all, but a series of occasional (and often preventable) medical catastrophes that finally merit treatment:

[T]he safety net in southeastern Tennessee is a patchwork. The main hospital in the area, Southern Tennessee Medical Center in Winchester, receives federal funding to reimburse it for some of the uncompensated care it provides. Hospital CEO Phil Young says it would be better for those patients to arrive with coverage, not least because their conditions would get attention before becoming acute. “It would certainly help us from a funding perspective,” Young said.

In 2008, several local physicians tackled the area’s lack of options for the uninsured by setting up a tiny clinic in a vacant Winchester school building. Nine doctors volunteered a total of about 900 hours last year, seeing people without insurance. But its capacity is limited – just two exam rooms plus a small office with boxes of donated medication. Appointments are booked for the next two months.

Dr. Thomas Smith, who helped set up the clinic, considered it a temporary fix. “We hope we are planned obsolescence,” he said. Smith is ambivalent about the law. But he acknowledges that things need to change in Tennessee: “The current situation is not sustainable.”

“The current situation” will get a lot worse if “ObamaCare” is struck down, and far, far worse if Mitt Romney is elected president and Republicans succeed in implementing his and Paul Ryan’s proposal for a Medicaid block grant with sharply reduced federal funding, not to mention their “market-based reforms” that will gut state insurance regulation. Read about the kind of people MacGillis is writing about, and ask yourself exactly how much they will benefit from the exhilarating freedom to shop for health insurance in the individual market-place. It would be a joke if were not so profoundly unfunny.

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Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.