Lois M. Collins: Health care reform efforts won't end with Supreme Court decision

SALT LAKE CITY — Regardless of what the U.S. Supreme Court rules on the question of the Affordable Care Act today, health care reform efforts are just getting started, say those who have closely followed the issue.

"This does not mean the end of the health care debate if it is struck down," said Robert F. Bennett, former U.S. Senator from Utah, who is a teacher, researcher and lecturer at the University of Utah's Hinckley Institute of Politics and a Fellow at George Washington University's School of Media and Public Affairs. "However, the Obama (law) itself cannot survive long-term even if it is entirely upheld. The finances don't work and it's unsustainable."

"The way we look at it, this is not the end of the fine-tuning process of the (law)," said Judi Hilman of the Utah Health Policy Project. If the entire law is struck down, she predicts that whoever wins the presidency will find "no turning back on comprehensive reform. Both parties, I think, know that .... What I would like to see if it's all struck down is a serious call for bipartisanship. If you look at health care costs, we are heading toward a train wreck."

The assumption around the Beltway, said Bennett, is that the court will either strike the 2010 Patient Protection and Affordable Care Act, which some call Obamacare, by a 5-4 vote, or it will be upheld 6-3. The rationale is this: Three associate justices are clearly opposed to the law: Clarence Thomas, Antonin Scalia and Samuel Alito. Four — Ruth Bader Ginsburg, Steven Breyer, Sonia Sotomayor and Elena Kagan — support it. The two in the middle, expected to decide the outcome, are Anthony Kennedy and Chief Justice John G. Roberts. It's expected those two will stick together, with Roberts writing the majority opinion however it comes out.

Twenty-six states challenged the act on the basis that individuals can't be forced to buy insurance they may not want or need. The Justice Department has defended the act, maintaining that every American will need medical care sometime, so they don't "choose" to be part of the health care market.

It may not be an all-up or all-down decision. The justices must decide whether the mandate requiring individuals buy insurance is constitutional. If that part of the law is struck down, the next question is one of "severability." As in, can the other parts of the law exist without it or would striking the mandate effectively sink the entire law? That issue took up one of the three days the law was argued before the court in March. There's also a question of whether the law can even be considered by the Supreme Court before it takes effect in 2014.

Different scenarios are getting plenty of discussion, four of them most prominently.

Some are predicting the individual mandate will be struck down and the rest of the act upheld.

Sen. Mike Lee, R-Utah, who clerked for Alito, told the Washington Examiner he thinks the individual mandate will fall as unconstitutional. If this happens, supporters of the mandate worry that those who are healthy will not buy insurance, which would drive up the cost for others. The mandate was enacted as a way of spreading the risk and reducing costs, they say. But critics maintain that it's unfair to force anyone to buy insurance and question whether it's legal to demand it.

An analysis published online at the Urban Institute Health Policy Center predicted overturning the mandate would leave insurers "up in arms" without a mandate for people to buy coverage. "Insurers would end up with a smaller, sicker pool of enrollees than would have occurred with the mandate."

Then again, the law could be upheld, or it could be struck down in its entirety as unconstitutional.