SEWANEE, Tenn. – As Robin Layman, a mother of two who has major health troubles but no insurance, arrived at a free clinic here, she had a big personal stake in the Supreme Court’s imminent decision on the new national health care law.

Not that she realized that. “What new law?” she said. “I’ve not heard anything about that.”

Layman was one of 600 people who on a recent weekend came from across southeastern Tennessee for the clinic held by Remote Area Medical, a Knoxville-based organization that for two decades has been providing free medical, dental and vision care in underserved areas. Most everyone had spent the night in their parked cars, to get a good spot in line. Daybreak found them massed outside the turreted stone gymnasium of the 150-year-old college, the University of the South, some still wearing pajamas or wrapped in blankets, waiting quietly for the 6 a.m. opening of the doors.

It was Remote Area Medical’s 667th clinic. But this one came at an unusual moment: as the Supreme Court deliberates whether to uphold the health care law that will have a disproportionate impact on the sort of people served by the organization.

Layman was hardly the only patient unaware that the law aims to help people like her, by expanding health insurance beginning in 2014. And this gets to the heart of the political dilemma for Democrats: Despite spending tremendous political capital to pass the law, the party is unlikely to win many votes from the law’s future beneficiaries, most of whom live in Republican-dominated states in the South and West. In fact, many at the clinic said they don’t vote at all.

And that assumes the law survives until 2014. The law’s design, with its major provisions kicking in four years after passage, was pragmatic politics at the time. The window would make the law’s price-tag lower and allow states time to set up new systems. But the delay’s result has been that the law has no natural constituency – its promises have not been clearly conveyed to the people it is designed to help.

This disconnect is seen in Tennessee, where about 15 percent of residents lack coverage – roughly the national average – but the state’s largely Republican political leadership has shunned the law. The state’s legislature has declined to pass legislation establishing the new insurance “exchange” required by the law; even the Democratic congressman representing the district that includes Sewanee voted against the law, before losing his seat the following fall.

Tennessee’s uninsured includes middle class people who can’t afford insurance or are turned down for health reasons, but the need is particularly acute among the poor and near poor who don’t qualify for Medicaid. In Tennessee, the program covers poor children, pregnant women and the disabled, as well as many parents below a set income threshold, about $28,000 for a family of four, but adults without children in their care are ineligible.

Under the law, Medicaid will expand in 2014 to cover anyone earning up to 138 percent of the poverty level, or about $31,000 for a family of four. Many people above that income who lack employer-provided coverage will receive subsidies to help them purchase private insurance.

Layman and her family offer a stark example of the law’s potential impact. Two years ago, her son, then 16, was hit head-on by a speeding driver high on drugs. Her son’s girlfriend was killed; he suffered severe internal injuries and recently underwent colon surgery. Now 18, he will soon age out of Medicaid coverage.

And Layman, a gregarious 38-year-old, recently lost coverage for her own considerable problems. She suffers high blood-pressure, for which she takes three medications, purchased at a discount from the county health office. She suffers sciatica stemming from the time eight years ago when a co-worker at a dollar store let slip a heavy box of wrapping paper Layman was handing up to her. Layman lunged for it and badly hurt her back, for which she takes the nerve-pain medication Lyrica.

She also suffers depression, and has been on Prozac for several years. But during a rough spell last fall, she came close to committing suicide. It was on her return home from a week in the psychiatric hospital that she found a letter from the state saying that, as a result of a bump up in her husband’s disability payments (he was caught in a front-end loader when he was eight years old), she was now ineligible for Medicaid.

Lacking coverage, she has not seen a psychiatrist since her hospital stay. She played this down: “I can recognize my craziness when it gets out of hand.”

State-by-state solutions?

Opponents of the Affordable Care Act, such as Mitt Romney, say it should be replaced with a state-by-state approach. Romney’s home state, Massachusetts, is the pioneer – Romney signed a 2006 law that has extended coverage to nearly all residents.

But many other states have demonstrated little political will to help people obtain health coverage. In some, such as Texas and Virginia, the threshold for Medicaid eligibility is so stringent that parents earning $10,000 a year are too well-off to qualify.

States that have made an effort to offer subsidized coverage, as Tennessee did in the 1990s, have typically found that costs became unsustainable when people in poor health enrolled at higher rates than healthier ones. It is that problem that the individual insurance mandate in the national law, the crux of the Supreme Court case, is meant to address.

As it stands, the 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 safety net is most threadbare in Grundy County, the hilly region to the east of Winchester, the poorest county in Tennessee with a poverty rate of 30 percent and the home to many of the Sewanee clinic visitors. There is only one doctor in the county of 13,000 people, plus five or six nurse practitioners.

Some local providers wonder how much the law will benefit places like this, if people aren’t inclined to seek out regular care. “In the mountains, they come see you when they’re sick, and then they go back up until they’re sick again,” said Dr. Stephen Sommerschield, a primary care physician in Winchester.

Needs will remain

At the Sewanee clinic, the biggest demand, as always, was for dental work. Rows of dental chairs were arrayed inside the gym’s indoor track with no dividers separating them. On a table sat a plastic jar labeled “TEETH” – the harvest was being saved for study by dental students.

Remote Area Medical founder Stan Brock, famous for his role co-starring in the TV show, “Wild Kingdom,” predicts the group will keep seeing demand under the new law – in Tennessee and many other states, Medicaid does not cover most adult dental or vision care, so people will still need help on those fronts.

But it was hard to find visitors to the clinic who would not benefit directly from the law. Barbara Hickey, 54, is a diabetic who lost her insurance five years ago when her husband was injured at his job making fiberglass pipes. She gets discounted diabetic medication from a charity, but came to the clinic to ask a doctor about blood in her urine.

Under the law, she would qualify for Medicaid. Her eyebrows shot up as the law was described to her. “If they put that law into effect, a lot of people won’t need disability,” she said. “A lot of people go onto disability because they can’t afford health insurance.”

Tom Boughan, 58, came to the clinic for glasses and dental work, with a sci-fi novel to pass the time. He’s been without coverage since being laid off from his industrial painting job last year, which means he’s paying $400 every few months for blood work for a thyroid problem.

Boughan knew about the debate over the insurance mandate, which puzzled him. “It’s like when I go get a driver’s license – I have to have auto insurance,” he said. “You got to make sure you get the money in the pool, so that things get covered. I hesitate about mandates, but the ironic thing is, [the idea] came from the Republicans and then they turn around and say this is Obama forcing us to do something, taking away our freedoms.”

Terry Bailey, 38, for years had insurance through his job, at a heavy-equipment manufacturer he commutes to in Georgia. But the company changed hands a few years ago and sharply reduced its health benefits. Bailey, who earns $40,000, decided he could not afford the new $6,240 per-year price tag. (His three children are covered by TennCare.)

It was an ill-fated choice. Bailey started having trouble with his knee, which had been injured in 2004 when he fell asleep at the wheel and crashed into a concrete barrier. One morning, it just locked up and he couldn’t go to work. The MRI cost $1,800, which he borrowed from the bank. He’s experiencing stiffness in his left hand, presumably from all the hours spent holding a paint spray-gun. And both he and his wife have been suffering staph infections. “I take care of it myself – just squeeze it and don’t let it get too bad,” said Kelly Bailey, 31.

Under the law, Bailey could opt out of his employer’s coverage if it costs more than 9.5 percent of his income – which it now does. In that case, he would receive subsidies to buy private coverage on his own and his employer would be assessed a $3,000 penalty. He said he could live with the insurance mandate, given the subsidies, which he hadn’t realized would apply to him before a reporter described the law. “As long as you get help, it ain’t that bad” of an idea, Bailey said. “If you don’t [have a mandate], you’re going to have freeloaders.”

A doctor’s view

After waiting all day with his kids for a dental filling, Bailey let Dr. Matthew Petrilla, the primary care doctor on duty, have a look at his hand and knee. Bailey emerged with two prescriptions – steroids for his knee and a device for his hand to wear while he sleeps — and an invitation for a follow-up appointment at the $20 rate Petrilla charges those without coverage.

Petrilla said he had seen several people at the clinic in such dire condition they were “going to have a heart attack in the next month.” He would ask a local cardiologist if he might see them for free.

A 59-year-old Army veteran, Petrilla has developed a critical view of the country’s health care system after more than two decades of working in southeastern Tennessee. “In this country where we’re supposed to have health care, these people here don’t – they’re walking around on borrowed time,” he said. “No one in this country should not have coverage.”

He thinks he knows why some justices seem ready to overturn the law, regardless of the impact. “It’s because they’re not in the real world,” he said. “They’re up in Washington with their private insurance. They should come down in the sticks and the foxholes, and see what it’s like.”

He acknowledged that some of his colleagues were less than thrilled about the law’s coverage expansion because Medicaid reimbursement rates are low (though the law brings them up slightly for primary care). But he said that doctors in rural Tennessee would have no choice but to see Medicaid patients, since so many patients would have that coverage. “I’m not going to starve to death,” he said. “I don’t know any doctors who’ve starved to death.”

Petrilla also saw Robin Layman, suggesting she try Xanax for her anxiety and cut back on one of her blood-pressure medications. And the chiropractor on duty gave her back a thrust. She emerged from his booth walking straighter than she had going in, with a smile on her face.

“Oh my God,” she said. “That man is an angel.”

This story was produced in partnership with The Tennessean, The New Republic and Kaiser Health News.