To the surprise of nearly everyone, the Supreme Court has upheld the individual mandate and saved the skin of the Patient Protection and Affordable Care Act (PPACA), the national health insurance reform that President Obama and his congressional allies crafted and passed in 2009. It is a creaky, complicated contraption that could have collapsed had the supporting structure of the individual mandate been pulled out, but somehow it passed muster with the conservative-dominated Supreme Court, perhaps in recognition that it was an idea originally generated by the Heritage Foundation to protect and preserve the role of private insurers in health reform and to nix the logical alternative of a single-payer system. What happens now? Is it full steam ahead or will there continue to be difficult passages? We posit five distinct possibilities below.