What if the Supreme Court rejects healthcare reform?

Ruminations on what would happen to healthcare in America if the U.S. Supreme Court disagrees with Congress and the White House and rules all or part of the Affordable Care Act unconstitutional is rather like playing the bracket game. Assuming that the court agrees on the basic premise that they can hear this case prior to any tax surcharge actually being assessed, we have two possible paths for the court to take:  Bracket Number One: The law is constitutional as it stands. End of story. Bracket Number Two: The law has constitutional problems.

If the court chooses the second option, it could then decide to hew closely to the actual challenge regarding the individual mandate that is before them, or they could expand their decision and scuttle the entire law.                               

So, what would actually happen to the healthcare Americans receive, what they pay for it and how (or if ) they can access health insurance if the court chooses to rule that the law is unconstitutional in any way?

"It's a choice between a wrecking operation, which is what you are requesting, or a salvage job," Justice Ruth Bader Ginsburg suggested during the arguments, as the former solicitor general in the George W. Bush administration, Paul Clement, argued that without the mandate, the rest of law could not stand. "And the more conservative approach would be [to] salvage rather than throwing out everything."

If the mandate is struck down - and the rest of the law stands - the Affordable Care Act will definitely not be quite so affordable, either for the federal government or even for people and businesses trying to cope with health insurance premiums. Why? Because insisting that every person in America pay something into the pot in exchange for receiving the basic healthcare every person in the country needs at some point in their lives is the most cost effective way to expand the pool of money needed to provide that care. Minus that pool of revenue, the insurance guarantees in the legislation would send health insurance premiums soaring for everybody else.

That would most likely cause even millions more Americans to become uninsured as small businesses, no longer able to cope with the premiums, drop their coverage. Or, the situation of skyrocketing health insurance premiums could fuel another rise in lay-offs as more jobs get jettisoned and fewer positions are added by the biggest “job creators” in this country: small business.

In an effort to maintain key employees, small employers could opt to have fewer people working full-time, with benefits, and then hire more part-timers or independent contractors  in order to avoid health insurance costs. Either way, the result would be fewer families having health insurance and premiums costing more for those who still do.

So, what about a full repeal?

Some provisions of the Affordable Care Act took effect when it was signed into law in 2010, and a full repeal would eliminate reforms that are already providing widespread relief to some Americans. Others are scheduled to be implemented in a staged process by 2014, when the Affordable Care Act takes full effect.  Here are some consumer benefits that would disappear if the whole law were to be ruled unconstitutional:

Increased coverage of preventive services

Many health insurance plans are now subject to new rules that require them to cover recommended preventive services without charging a co-payment. As a result, consumers pay nothing for services like routine screenings, vaccines, counseling, flu shots and well-baby and well-child visits from birth to age 21.
Birth control coverage

One aspect of the preventive care coverage -- and among the most discussed provisions of the new health care law -- is the requirement that health insurance plans cover contraceptive services. After a widely publicized effort by religious leaders and Republican lawmakers to repeal this measure, the Obama administration blinked and forged a compromise putting the coverage onto the insurance companies instead.

Restrictions on lifetime and annual limits

The Affordable Care Act prohibits insurers from placing lifetime limits on most benefits consumers access, opting for now to allow only yearly limits. But by 2014, annual dollar limits are slated to be phased out entirely.

Coverage for children with pre-existing conditions

Under the new law, insurance companies cannot deny coverage or limit benefits to children under age 19 because of a pre-existing condition or disability. Starting in 2014, people of all ages with pre-existing conditions will be protected.

Pre-Existing Condition Insurance Plan

Adults who have been refused insurance coverage because of pre-existing conditions and who have remained uninsured for at least six months are eligible for the Pre-Existing Condition Insurance Plan. The program covers primary and specialty care, prescription drugs and hospital visits without requesting higher premiums for pre-existing conditions.

No health plan barriers for ob-gyn services

Health plans cannot require women to get a referral from a primary care doctor before seeking ob-gyn services.

Access to out-of-network emergency room services

The Affordable Care Act prohibits a health plan from charging higher co-payments for emergency room visits in hospitals outside of the plan's network. Patients are also exempt from needing a plan's approval before seeking out-of-network emergency care.

Right to appeal health insurance plan decisions

Obama's health care law gives consumers the right to appeal decisions made by their health insurance providers. If an insurance company reviews its decision and still denies a consumer insurance coverage for a treatment, consumers have the right to request an external review and have an independent review organization decide whether to overturn the plan's decision. Some states have Consumer Assistance Programs that help people file appeals and request external reviews.

Consumer Assistance Program

The Affordable Care Act improves the services that some states provide to help people with insurance problems. Grants have allowed states to strengthen and grow programs that assist consumers with enrolling in a health insurance plan and with filing complaints and appeals.

More value for the insurance dollar

A provision of the law called the 80/20 rule requires insurance companies to spend at least 80 percent of their premium dollars on medical care. If they don't, they must provide consumers with refunds starting this summer.

No insurance cancellations for honest mistakes

Insurance companies are not allowed to rescind coverage when patients make honest mistakes on their insurance applications. Before the Affordable Care Act, insurance companies could retroactively cancel patients' policies because of unintentional paperwork errors with little medical bearing.

Expanded Medicare coverage

The law gives elderly adults who face the Medicare coverage gap a 50 percent discount on prescription drugs covered by Medicare Part D. Seniors will receive additional prescription drug savings until the coverage gap is closed in 2020.

Indian Health Care Improvement Act reauthorized

The law reinstates the Indian Health Care Improvement Act, which provides resources to curb the health care disparities faced by American Indians. Originally passed in 1976, and reauthorized in 1992, many of its provisions expired in 2000.

Tanning salon tax

The Affordable Care Act imposes a 10 percent tax on tanning beds, and these proceeds help underwrite other provisions of the law.

Expanded coverage for young adults on their parents’ plans

The law requires insurance plans that offer coverage of dependents to allow children to stay on their parents' plans until age 26. Adult children can be covered on their parents' plans even if they are married, eligible for work or student insurance, living away from home or financially independent.

A decision from the Supreme Court is expected in June. Meanwhile, individual states, like Vermont, are moving ahead with establishing universal healthcare on their own. Other states, like New York, seem stalled as they wrangle over how to create insurance “exchanges” to make affordable health insurance available to a growing class  “independent contractors” whose consulting/contracting jobs provide neither benefits nor enough guaranteed income to access affordable health insurance in the state.