Possible outcomes in pending health care law case

WASHINGTON — Some people already are anticipating the Supreme Court’s ruling on President Barack Obama’s health care law as the “decision of the century.” But the justices are unlikely to have the last word on America’s tangled efforts to address health care woes.

The problems of high medical costs, widespread waste, and tens of millions of people without insurance will require Congress and the president to keep looking for answers, whether or not the Affordable Care Act passes the test of constitutionality.

With a decision by the court expected this week, here is a look at potential outcomes:

Q: What if the Supreme Court upholds the law and finds Congress was within its authority to require most people to have health insurance or pay a penalty?

A: That would settle the legal argument, but not the political battle.

The clear winners if the law is upheld and allowed to take full effect would be uninsured people in the United States, estimated at more than 50 million.

Starting in 2014, most could get coverage through a mix of private insurance and Medicaid, a safety-net program. Republican-led states that have resisted creating health insurance markets under the law, including South Carolina, would face a scramble to comply, but the U.S. would get closer to other economically advanced countries that guarantee medical care for their citizens.

Republicans would keep trying to block the law. They will try to elect presidential candidate Mitt Romney, backed by a GOP House and Senate, and repeal the law, although their chances of repeal would seem to be diminished by the court’s endorsement.

Q: On the other hand, what if the court strikes down the entire law?

A: Many people would applaud, polls suggest.

Taking down the law would kill a costly federal entitlement before it has a chance to take root and develop a clamoring constituency, but that still would leave the problems of high costs, waste and millions uninsured. Some Republicans in Congress already are talking about passing anew the more popular pieces of the health law.

Q: What happens if the court strikes down the individual insurance requirement, but leaves the rest of the Affordable Care Act in place?

A: Individuals would have no obligation to carry insurance, but insurers would remain bound by the law to accept applicants regardless of medical condition and limit what they charge their oldest and sickest customers.

Studies suggest that premiums in the individual health insurance market would jump by 10 percent to 30 percent.

Experts debate whether that would trigger the collapse of the market for individuals and small businesses, or just make coverage even harder to afford than it is now. In any event, there would be risks to the health care system. Fewer people would sign up for coverage.

Q: What if the court strikes down the mandate and also invalidates the parts of the law that require insurance companies to cover people regardless of medical problems and that limit what they can charge older people?

A: Many fewer people would get covered, but the health insurance industry would avoid a dire financial hit.

Insurers could continue screening out people with a history of medical problems, diabetes patients or cancer survivors, for example.

That would prevent a sudden jump in premiums. But it would leave consumers with no assurance that they can get health insurance when they need it, which is a major problem that the law was intended to fix.

Q: What happens if the court throws out only the expansion of the Medicaid program?

A: That severely would limit the law’s impact, because roughly half of the more than 30 million people expected to gain insurance under the law would get it through the expansion of Medicaid, the federal-state health insurance program for low-income people.

But a potentially sizable number of those low-income people still might be eligible for government-subsidized private insurance under other provisions. Private coverage is more expensive to subsidize than Medicaid.

States suing to overturn the federal law argue that the Medicaid expansion comes with so many strings attached that it amounts to an unconstitutional power grab by Washington. The administration said the federal government will pay virtually all the cost, and that the expansion is no different from ones that states have accepted in the past.

Q: What happens if the court decides that the constitutional challenge is premature?

A: The wild card, and least conclusive outcome in the case, probably also is the most unlikely, based on what justices said during the arguments. No justice seemed inclined to take this path, which involves the court’s consideration of a technical issue.