JOPLIN, Mo. — As battles play out in Congress and the federal courts over national health care reform, patients last week at Access Family Care in Joplin waited and wondered what to make it of it all.

Neosho resident Nathan Zimmerman said he is skeptical of a provision that would mandate that all Americans must buy health insurance. Even with subsidies that would help the poor afford insurance, he said nothing is free.

“They may say it’s free, but they’d just be raising your taxes, so you’d be paying for it one way or other,” said Zimmerman, who was sitting in the Access waiting room with his wife, Elizabeth, and his son, Titus.

“I can afford coming here; if it is was any more expensive, I couldn’t,” he said.

The clinic offers medical care on a sliding scale, based on how much a patient makes. About half of the nearly 44,000 visits made to the three Access clinics in Southwest Missouri last year were made by men and women who did not have insurance.

Elizabeth Zimmerman said one of the ways the family has dealt with the lack of insurance is by not going to a doctor.

“He hasn’t been to a doctor in three years,” she said, gesturing toward Nathan.

Erina Case, Joplin, said she favors mandatory universal health insurance, but worries that many people will not be able to afford their share of the costs.

“So many people can’t afford it,” she added.

Case, who was at Access for treatment for her diabetes and high blood pressure, said she’s now on disability, but she had health insurance when she was working.

“It was high even then and it’s worse now. I don’t know how people do it, especially if they’re raising kids.”

Legal challenges

Patients aren’t the only ones wondering what to make of federal health care reform.

Don McBride, who is CEO of Access, a federally qualified health center, said everything is a moving target, especially after last week’s federal ruling.

“It seems like bits and pieces are being revealed to us. What we are seeing and what we are hearing is more federal funding coming down,” he said. “And then there are the lawsuits.”

The latest of those decisions was handed down last week in Virginia by a federal judge who ruled that a requirement in the legislation that nearly all Americans must purchase health insurance or face penalties is unconstitutional.

The ruling by U.S. District Judge Henry E. Hudson was seen as a “victory” by some who opposed the legislation, including Missouri’s Lt. Gov. Peter Kinder and U.S. Sen.-elect Roy Blunt, R-Mo.

Kinder, a Republican, filed his own lawsuit to challenge the federal health care plan, contending it would actually reduce Missouri residents’ access to affordable health care.

Kinder last week said the judge’s ruling “confirms what many of us believed to be true nearly one year ago — that Congress overstepped its authority in mandating that every American purchase health insurance.”

Similar comments came from U.S. Rep. Lynn Jenkins, R-Kansas, who called the legislation “a  government takeover of health care,” and claimed that requiring citizens to purchase insurance or pay a penalty is a violation of the Constitution’s Commerce Clause.

Blunt said: “The individual mandate in the health care law puts government in the business of forcing individuals to buy a product and taxing you if you chose not to. In my estimation, that’s unconstitutional, and this week, a federal judge agreed. This is good news for families and small businesses.”

Pre-existing

conditions

Hudson, however, also denied Virginia’s request to strike down the health care law in its entirety or block it from being implemented while the ruling is being appealed.

U.S. Sen. Claire McCaskill, D-Missouri, who supported the legislation, noted that other elements of the bill will help Americans get health care coverage, including protections for those who have pre-existing medical conditions. She also predicted more legal challenges.

“The parameters of the health care bill will continue to be sorted out in the courts and in Congress. That is one of the reasons we delayed implementation until 2014,” she said in an e-mail statement to the Globe. “I continue to look for ways to allow people with pre-existing conditions to buy insurance without mandating anyone participate. It is a huge challenge because if you could buy insurance after you are sick, no one would buy it until then, and it would be incredibly expensive for everyone.”

Attorneys general lawsuits

One of those legal challenges also has been filed by more than 20 attorneys general from around the country.

Their attorney told another federal judge last week that the legislation expands government’s powers in dangerous and unintended ways.

The states want U.S. District Judge Roger Vinson to issue a summary judgment throwing out the health care law without a full trial. They argue it violates people’s rights by forcing them to buy health insurance by 2014 or face penalties.

“The act would leave more constitutional damage in its wake than any other statute in our history,” David Rivkin, an attorney for the states, told Vinson.

President Barack Obama’s administration counters that Americans should not be allowed to opt out of the overhaul because everyone requires medical care. Government attorneys also say the states do not have standing to challenge the law and want the case dismissed.

Missouri is not part of that  lawsuit, but Kinder said last week that the state should join it; a statement from Missouri Attorney General Chris Koster’s office only said officials there “are monitoring the various lawsuits related to the health care law.”

Back at Access, McBride isn’t sure what to make of the health care law.

The tough economy and high unemployment, along with those who have jobs but no benefits, are straining their resources. Access also has clinics in Anderson and Cassville, as well as the one on Maiden Lane in Joplin, and has applied for a grant to open a clinic in Lawrence County.

Patient visits to Access Family Care totaled 24,638 in 2007, 32,713 in 2008 and 43,477 in 2009.

“Over two years time we have doubled. The pressure is on. We know the need is out there,” McBride said.

Among Access patients, 50 percent do not have any insurance, 41 to 42 percent rely on Medicaid, and the rest are underinsured.

McBride sees pros and cons to the health care legislation.

“What we are seeing and what we are hearing is more federal funding coming down” for qualified clinics such as Access.

On the downside, he doesn’t think the mandate that every American have insurance or pay penalties is realistic.

“For Missourians that is going to be a problem. There is a large group of Missourians who are going to say ‘No way, You can’t tell us what to do.’ ”

He noted that Missouri voters in August approved a ballot measure designed to block the mandates. Missouri was the first state in the nation to come out shooting at the federal legislation.

That ballot measure, passed by a 71 percent majority, bars imposition of a rule or law that would compel any person or employer to buy health insurance, and prohibits those who do not buy insurance from being penalized.

“We got the notoriety of Missouri being the first state to do this. It is going to be real hard to tell Missourians they have to buy insurance,” McBride added.

The Associated Press contributed to this report.