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News Analysis

Health Care After the Supreme Court Ruling

LATER this month, the Supreme Court will rule on the Obama administration’s health care law, the Affordable Care Act, deciding whether to uphold or strike down the entire law, or to keep some provisions.

No matter the decision, the political ramifications in this election year will be big. After all, the presidential contenders are President Obama, the top-ranking promoter of the law, and Mitt Romney, the architect of a 2006 health care overhaul in Massachusetts that was, in pivotal ways, the model for the national law.

But experts on health care policy say the practical effect of the court’s decision will probably be less earth-shattering than some people think. If the court takes what many observers believe will be the most likely route and strikes down the individual mandate — the requirement that virtually everyone purchase insurance — many more currently uninsured people are still likely to receive health coverage, they say.

Even if the law is struck down entirely — which could happen if the court decides that the other provisions are too intertwined with the mandate — many experts say that some changes the law has already set in motion will continue, probably more slowly, but possibly at a more urgent pace in reaction to the elimination of the federal law.

“It would have less effect in the short term than most people might think, but it would have much more of a psychological and political effect,” said Gail Wilensky, a health economist who headed Medicare and Medicaid during the administration of the elder President Bush. She suggested that, while the individual mandate seems vulnerable to being ruled unconstitutional, striking down the entire law seems “highly unlikely, and to my way of thinking, highly undesirable, because I think it’s unnecessary.”

And if the law is upheld? More people will get coverage, but significant problems in the health care system will remain. Chief among them is the high cost of medical care. Massachusetts, for example, has only begun to tackle the issue of health care costs, with proposals in the State Legislature that were introduced this year.

Still, nationally, there are now some pilot programs by insurers and hospitals trying to tackle pieces of the cost problem on their own.

“I think much of the transformation of the health care delivery system is moving forward, regardless of the court action,” said Karen Davis, the president of the Commonwealth Fund, a nonpartisan research foundation in New York. “How do we get more efficient? How do we keep people out of hospitals? People are kind of gearing up for this. That’s going to continue. Obviously, it will continue at a faster pace if some of the payments for quality and efficiency in the law continue, but we are already beginning to see a slowdown in hospital costs nationally.”

Most of the major elements of the Affordable Care Act have not taken effect, and would not until 2014. The full law would extend coverage to about 30 million uninsured people — roughly 17 million of those would be covered through an expansion of state Medicaid programs to include everyone earning up to 138 percent of the income established as the federal poverty line. The Medicaid expansion could still take place if the individual mandate were to be struck down, a number of health care experts say.

The individual mandate would require that millions of uninsured people who are not eligible for Medicaid purchase insurance or that their employers provide it. Subsidies would be available through insurance exchanges, and those who could not show a valid reason for not purchasing insurance would pay a penalty on their income taxes.

If the individual mandate is eliminated, but the exchanges remain, significant numbers of uninsured people are likely to purchase insurance anyway, said Amy Lischko, who served in Mr. Romney’s administration when he was governor and helped craft the Massachusetts health care overhaul.

“PEOPLE are still going to purchase the insurance because it’s a better deal than before,” said Dr. Lischko, now an associate professor at the Tufts University School of Medicine. “You’ll get people who have illnesses,” whose health care costs are more expensive, but “you’ll still get people who are reasonably healthy.”

Dr. Lischko and other experts said they were more concerned about two other provisions that could be struck down if the mandate was eliminated: guaranteed issue, in which coverage is offered to people who have pre-existing conditions, and community rating, which requires insurance companies to offer coverage at the same price to people regardless of their health status.

But in some ways these two provisions, the mandate and the subsidies all go together. “States that have tried community rating and guaranteed issue without a mandate and without subsidies saw a ‘death spiral,’ ” Dr. Lischko said, in which more sick people and fewer healthy people enter the insurance pool. “That is because healthy people were rated similar to sick people, and sick people were guaranteed coverage, so people waited until they needed coverage” to obtain insurance.

If all these provisions go, “I still think you get some sick people, but maybe not the sickest because plans don’t have to offer coverage to them,” she said. To draw in healthy people, she said, insurance companies might charge a penalty for people who do not buy insurance when they become eligible, something that Medicare already does.

Still, some warn that the longer-term consequences of striking down the individual mandate could be more significant. Even though some healthy people will voluntarily purchase insurance, “you’ll probably have somewhat older and sicker people in the risk pool, which means it will be more expensive,” said Jean Abraham, a health economist at the University of Minnesota and former senior economist in both the Obama and George W. Bush administrations. Eventually, she said, “people who are lower utilizers of health care won’t find it to be an option and you’ll lose more healthy people over time as premiums go up.”

A health reporter for The New York Times and the author of “Island Practice: Cobblestone Rash, Underground Tom, and Other Adventures of a Nantucket Doctor.”

A version of this article appears in print on  , Section SR, Page 4 of the New York edition with the headline: Health Care After the Supreme Court Ruling. Order Reprints | Today’s Paper | Subscribe

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