Since President Obama's health care law passed in 2010, the federal government, states, insurers, doctors and hospitals have been building a complex scaffolding to extend insurance to 30 million more Americans. The question is: Will the structure be completed, or dismantled?
A Supreme Court decision expected as early as Monday could eliminate a key plank of the law: the mandate that nearly everyone obtain insurance. The court also is weighing whether to strike down other sections of the new insurance marketplaces where 20 million people -- those already with individual policies and those seeking them -- are supposed to find health plans.
Already, 14 states -- including California, Colorado and West Virginia -- have authorized the creation of online "exchanges" where, starting in 2014, those who aren't covered by employers can buy insurance. In addition, doctors, hospitals and insurers have been changing the way they do business as they prepare for an influx of customers and new incentives that reward more coordination between healers, more preventative care and financial penalties on poor performers.
"The train is really well out of the station at this point," says Sara Collins, a vice president at the Commonwealth Fund, a health foundation in New York City.
The justices also will decide whether to block the government from broadening the federal-state Medicaid program to cover 17 million additional people, the program's greatest expansion since it was created a half-century ago.
The court decision could affect millions of Americans, including:
People without insurance. By the year 2021, 39 million Americans would lack health insurance if the justices overturn the mandate to obtain insurance, according to the non-partisan Congressional Budget Office. That would be 16 million more people than if the justices leave the law intact, the CBO says.
People who currently can't get insurance on the open market because they have ailments that make insurers either refuse to cover them or charge them a higher rate than healthy people. The law requires that insurers accept all applicants.
Young adults covered under their parents' policies, as well as very sick people who now have limited coverage that has left them with huge medical expenses. The law has already required that insurers must allow families to keep covering offspring up to age 26, and it banned insurers from placing limits on the maximum amounts they would pay for anyone's care.
Those looking for affordable health coverage in exchanges. RAND Corp., a Santa Monica, Calif., think tank, says premiums would rise 2.4% if the justices nix the mandate but leave the rest of the law in place.
Experts say it's impossible to predict what the court will do, given the range of potential options outlined in court pleadings. The justices could leave the law intact or strike down just the mandate. They might eliminate the rule that limits how much more insurers can charge older people than they do younger folks, or the rule requiring plans to accept customers regardless of health.
Or the justices could strike down larger sections of the law that include financial subsidies, averaging $4,780, that would help lower income people buy coverage in the exchanges. They could get rid of the Medicaid expansion. Finally, they could throw out the entire law.
Experts on both sides of the debate agree the mandate is the most legally vulnerable piece, but disagree about how crucial it is to making the insurance markets work.
Sabrina Corlette, a professor at Georgetown University's Health Policy Institute in Washington who supports the law, says that if the court strikes down the mandate, it "would be quite chaotic and disruptive" because healthy people are less likely to join the health insurance pools. If the court strikes down the broader insurance rules for the exchanges, she says, "then we're back to the status quo of people being denied because they have preexisting conditions, or being told because they have cancer they'll be charged 26 times that of a healthy person."
Joseph Antos of the American Enterprise Institute, who opposes the law, says the mandate's importance has been exaggerated, especially given the weakness of the penalties for people who don't get coverage. Those start at $95 in 2014 and rise to 2.5% of income by 2016, but there are multiple ways people could be exempted, he says. "I just don't see the insurance market collapsing" if the court strikes down the mandate or other parts of the law, Antos says. He predicts insurers would keep some popular provisions that have already begun, such as family coverage for dependents up to age 26.
The law's ultimate future may rest with whichever party wins the White House and Congress in November, says Charlene Frizzera, a health care consultant and former acting administrator of the Centers for Medicare & Medicaid Services.
Republican presidential candidate Mitt Romney has said he would dismantle the law. If Obama is re-elected but the court strikes the insurance mandate, his administration would have a number of ways to write rules that prod people to get insurance, such as charging more to people who wait until they are sick to sign up.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research organization not affiliated with Kaiser Permanente.
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