WASHINGTON — It seems as if the entire nation is holding its
breath for the Supreme Court’s health care ruling – the presidential
candidates, governors of virtually every state, insurers with billions
at stake, companies large and small and countless millions of Americans
concerned about their own medical care and how they’ll pay for it.

Still, Thursday’s expected ruling almost certainly will not be the last
word on the nation’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 President Barack Obama’s Affordable
Care Act passes the test of constitutionality.

A look at potential outcomes:

Q: What if the Supreme Court, despite justices’ blunt questions during
public arguments, 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 would have
to scramble to comply, but the U.S. would get closer to other
economically advanced countries that guarantee medical care for their

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

Obama would feel the glow of vindication for his hard-fought health
overhaul, but it might not last long even if he’s re-elected.

The nation still faces huge problems with health care costs, requiring
major changes to Medicare that neither party has explained squarely to
voters. Some backers of Obama’s law acknowledge it was only a first
installment: Get most people covered, then deal with the harder problem
of costs.

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 new 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 of
uninsured people.

Some Republicans in Congress already are talking about passing anew the
more popular pieces of the law if it’s thrown out. But the major GOP
alternatives to Obama’s law would not cover nearly as many uninsured,
and it’s unclear how much of a dent they would make in costs. Some
liberals say Medicare-for-all, or government-run health insurance, will
emerge as the only viable answer if Obama’s public-private approach fails.

People who already have health insurance could lose some ground as well.
Employers and insurance companies would have no obligation to keep
providing popular new benefits such as preventive care with no
copayments and coverage for young adults until age 26 on a parent’s
plan. Medicare recipients with high prescription drug costs could lose
discounts averaging about $600.

Q: What happens if the court strikes down the requirement that everyone
must have insurance, but leaves the rest of the Affordable Care Act in

A: People 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 premiums in the individual health insurance market would
jump by 10 percent to 30 percent.

Experts debate whether or not 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.

The insurance mandate was primarily a means to an end, a way to create a
big pool of customers and allow premiums to remain affordable. Other
forms of arm-twisting could be found, including limited enrollment
periods and penalties for late sign-up, but such approaches probably
would require congressional cooperation.

Unless there’s a political deal to fix it, the complicated legislation
would get more difficult to carry out. Congressional Republicans say
they will keep pushing for repeal.

Without the mandate, millions of uninsured low-income people still would
get coverage through the law’s Medicaid expansion. The problem would be
the 10 million to 15 million middle class people expected to gain
private insurance under the law. They would be eligible for federal
subsidies, but premiums would get more expensive.

Taxes, Medicare cuts and penalties on employers not offering coverage
would stay in place.

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 people can be charged.

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 could get health insurance when
they need it, which is a major problem the law was intended to fix.

Obama administration lawyers say the insurance requirement goes hand in
hand with the coverage guarantee and cap on premiums, and they have
asked the court to get rid of both if it finds the mandate to be

One scenario sends shivers through the health care industry: The Supreme
Court strikes down the mandate only, and delegates other courts to
determine what else stays or goes.

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

A: That would limit the law’s impact severely 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 it amounts to an
unconstitutional power grab by Washington. The administration says the
federal government will pay virtually all the cost and says the
expansion is no different from ones that states have accepted in the past.

Q: What happens if the court simply punts, deciding it’s too early for a
constitutional challenge?

A: The wild card, and least conclusive outcome in the case, probably
also is the least likely, based on what justices said during oral arguments.

No justice seemed inclined to take this path, which involves the court’s
consideration of a technical issue.

The federal appeals court in Richmond, Va., held that the challenge to
the insurance requirement has to wait until people start paying the
penalty for not purchasing insurance. The appeals court said it was
bound by the federal Anti-Injunction Act, which says federal courts may
not hear challenges to taxes, or anything that looks like a tax, until
after the taxes are paid.

So if the justices have trouble coming together on any of the other
options they could simply put the whole thing off.

The administration says it doesn’t want this result. Yet such a decision
would allow it to continue putting the law in place, postponing any
challenge until more of the benefits are being received. On the other
hand, it might give Republicans more ammunition to press for repeal in
the meantime.