Hayes, too, said she voted against the referendum to opt out of the federal law. She supports Obama “whole heartedly, but I knew he was not liberal.”

While at the clinic I stopped by to talk to Thania Fitzgerald, a Brazilian by birth, who came to Missouri as an exchange student and stayed. She is now a research specialist at the university and starting a new program at the clinic to screen patients for substance abuse. Fitzgerald, who is thirty-one, had worked two years as a therapist and saw patients struggling to get health insurance. She isn’t keen on the U.S. system. “Honestly, I wish there was socialized medicine like in other countries.” She said that while the health system in Brazil is not perfect, “nobody dies because they can’t go to a hospital. Everyone in her family is a doctor, she told me, so she knows the system in her native country. “I feel in Brazil people won’t die because of lack of care.”

She has insurance through the university, and, like Paxton and Smale, her health benefits will eventually be cut. She didn’t seem to know about that. She sees some value in the reform law, but adds “I don’t like the mandate. I don’t see how it’s going to work. Everyone has a right to health care but it shouldn’t be forced.” Her solution: allow the state or the federal government to give people the choice of opting into Medicaid. Medicaid is good insurance, she explained. That would, of course, put the system on a path to a national health insurance system, an approach the pols and the stakeholders rejected last year.

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.