06/08/2012 05:25 pm ET Updated Aug 08, 2012

Waiting for Godot -- Supreme Court Style

In the play Waiting for Godot by Samuel Beckett, Godot never arrives, but the entire play is consumed with hand-wringing about what might happen if he did appear. In the case of health reform and the Affordable Care Act, there is similar hand-wringing over the Supreme Court decision about the fate of health reform, although we know the answer WILL arrive soon - and certainly by the end of June.

What are the possibilities for a Court decision on health reform and what might the impact be in each case?

1. The most negative prediction is that the Court strikes down the whole Affordable Care Act. Since much of the Act has nothing to do with the most controversial aspect under debate -- the mandate that everyone buy health insurance -- this option is presumed to be fairly unlikely.

2. A more likely outcome is that the individual mandate itself will be struck down, and along with it the guaranteed issue and community rating provisions, leaving the State exchanges, the Medicaid expansion and other features of the law intact.

3. The most optimistic option is that the Court upholds the entire Affordable Care Act.

Bookmakers and law experts are split but give Options 2 and 3 the highest probability.

What's at stake for you?

If the entire Act is declared unconstitutional, you could lose several benefits that have already been implemented:

  1. Free preventive services
  2. Children's access to coverage regardless of pre-existing conditions
  3. Tax credits for small businesses that offer insurance
  4. Coverage for children under 26 who can stay on their parents' plan even if they don't live at home or are employed without insurance
  5. The closure of the prescription drug "donut hole" for Seniors
  6. Training programs to bring additional nurses and doctors into the health care system, particularly in rural areas
  7. The Federal investment in health information technology could be cut back, meaning the chance to access your medical records online or e-mail your doctor for an appointment or a drug refill might be delayed or not happen at all.
  8. Access to high risk insurance pools in your state -- programs that offer insurance to previously uninsurable adults
  9. Ability for low income uninsured to enroll in the Medicaid programs - Medicaid is currently mainly available only to single women with children, the blind and the disabled
  10. Lifetime limits on your health insurance policy could be reinstated, meaning that if you had a truly catastrophic illness, you could end up paying for your very expensive care after your limit is reached. The Affordable Care Act eliminated lifetime limits.

You could also lose the opportunity, once health reform is fully implemented in 2014, to choose a health plan through a state exchange (although some states like California, New York and the State of Washington would likely go ahead with the exchanges anyway) and with that loss, a revival of the high cost of individual insurance plans and the chance of being rejected for coverage.

The law without the mandate

What if only the individual mandate is overturned? There is a lot more to the Affordable Care Act than just the individual mandate. But most economists and business analysts predict that health care costs could increase, because the uninsured would continue to use the system as a last resort, shifting the costs to those of us who are covered. Unless Congress required health plans to accept all applicants, you would once more be in jeopardy of being rejected for coverage if you have ever visited a doctor.

There are, however, a number of ways to get around the overturning of the individual mandate. States could implement their own mandates, like Massachusetts did under Governor Romney; there could be penalties for late enrollment; there could be larger subsidies to entice people to enroll; states could require people to enroll by automatically enrolling them and forcing them to opt out if they don't want insurance.

Whatever way the Court decision goes, the ultimate future of health reform will be dependent on you -- and who wins the Presidency and the Senate in November. Stay tuned.

An earlier version of this blog was posted at