The opening remarks at last Friday’s Blue Cross Blue Shield of Western New York-organized forum on the US Supreme Court’s decision on President Obama’s healthcare program provided a telling glimpse of the general situation that produced this reform. The seven panelists were asked by moderator Maryalice Demler, from WGRZ-TV News, to make an opening comment, and one, James R. Kaskie, Kaleida Health president and CEO, responded that America’s healthcare system has been burdened by what he called “an unbridled demand…If you look at emergency rooms, there’s a demand for immediate care.”

In two brief sentences, Kaskie seemed to encapsulate the dangerous, insular indifference of American elites to the often cruelly dysfunctional nature of this country’s health care.

Kaskie seemed to be saying that a major cause of the dysfunction was the excessive demands and unreasonable expectations of the American public, not the withholding of service from the 52 million people who lack insurance, and the millions more who are underinsured. He was oddly and perversely echoing a remark of President George W. Bush, who once told reporters there was no important denial of healthcare in this country because “people can go to the emergency room.” This kind of self-enforced cluelessness manages to ignore the more than 20,000 estimated annual deaths that the National Institute of Medicine attributes to the unavailability of treatment. If Kaskie was trying to call attention to the economic waste and inefficiency of the widespread recourse to hospital emergency rooms in the absence of other options, he dismally failed to make his point.

He was preceded by another, less surprisingly dubious statement. Blue Cross president and CEO Alfonso O’Neil-White welcomed the panelists and audience, telling them his company had been “leading efforts to provide affordable care.” To those who can afford it, he neglected to say.

When O’Neil-White also said that one result of the Supreme Court decision that upheld the Obama administration healthcare reform in the main was that “What seems to be obvious may not be clear,” he was speaking a truth. The panelists’ discussion of the decision’s consequences indicated the new uncertainties that have arisen and the difficulties in assessing the decision’s impacts.

Thomas Rosenthal, M.D., the chair of family medicine at the University at Buffalo, predicted that “once the [American] people understand there’s universal care, they’ll have a sense of freedom.” The public may be in for a long and bumpy ride toward the promised land. Obamacare is unlikely to achieve universal care, no matter how successfully it’s implemented. Former Buffalo-area Congressman John LaFalce struck a more restrained note in harkening back to President Bill Clinton’s 1993 address to Congress, when he held up a prototype of a universal care card as he promoted his care reforms, which were never even voted on by Congress. “Hopefully,” LaFalce said, “someday everyone will have that card.”

But not under Obamacare. Nor did the president intend that they would, as LaFalce was tacitly admitting. Obama’s proposal only covered about 30 million pof the uninsured, relegating many of the rest to the various state Medicaid programs. But the court, by a 7-2 vote, told the president he cannot lawfully coerce those states into expanding their individual programs, pushing the future extent of the expansion into the uncertain column.

Obama only came late to the healthcare reform movement. For all the hoo-ha about his limited mandate, he at first resisted proposals for mandatory coverage, and criticized election-campaign rivals Hillary Clinton and John Edwards for advancing this concept. Only after he was elected, and his administration was casting about for a major legislative accomplishment after the failure of its climate and immigration bills, did he settle on healthcare. And then he proposed insuring substantially fewer Americans than his former campaign rivals. Since then, before and after passage, he has been less than ardent in his championship of his own program. As LaFalce said, “I don’t think the Obama administration has done a good job of trying to explain” its program reforms. Indeed, in this year’s State of the Union Address, the president included only 44 words about this subject, out of over 7,000.

The whole program has had a cobbled-together, Rube Goldberg character. Because Obama limited the applicability of his hotly controversial mandate, he had to assign 17 to 21 million Americans to Medicaid programs. But these asset-test people and force successful applicants to near pauperdom.

Politically, the prospects are even more problematic. Healthcare legal expert and Phillips Lytle LLP partner William P. Keefer cleverly and succinctly described Obamacare near the end of the forum: “patient stabilized, not out of woods.” Keefer pointed out that Republicans are sharpening their procedural knives to kill as much of the program as possible through the use of the Senate’s reconciliation rules, which would only require a filibuster-proof 51 votes to repeal the act. (That’s three more Senate seats, plus a Republican vice-president presiding in the chamber to break a tie.)

The most dismal aspect of all this propagandizing and maneuvering is probably the moral failure. This consideration may seem out-of-sync with the world of political change, but as T. R. Reid wrote in his 2009 book, The Healing of America, health care reform has always been essentially a moral cause. Beyond “the practical reasons,” he wrote, “there’s the basic moral imperative.” What does it say of a nation and its leaders if they don’t recognize this?