Challenges give health care law four possible outcomes

WASHINGTON -- The Supreme Court's decision this month on President Obama's health care law is likely to take one of four basic forms. No matter what the court rules, however, it won't be the last word.

The court can uphold the entire law, strike down the "individual mandate" requiring most Americans to buy insurance, strike down the mandate and related health insurance changes, or kill the entire law.

Still to come: State actions. More lawsuits. The verdict from voters on Nov. 6. And more battles in Congress next year.

"The bottom line here is the Affordable Care Act is moving through a gantlet," says Robert Laszewski, a private health policy consultant. "The first stop in the gantlet was the Supreme Court. The second stop in the gantlet is the election."

The court has some additional issues to decide, including whether the law's Medicaid expansion is unduly "coercive" and whether the law can't be challenged at all until someone pays a penalty to the Internal Revenue Service for not buying insurance.

The major battle, however, is over the constitutionality of the mandate and its relationship to the rest of the law.

Here are four scenarios:

Option 1: Law upheld

A decision upholding the law would unleash a series of political, legislative and legal forces.

As states decide whether to implement the law, such as setting up health care exchanges for millions of Americans to pick insurance plans, "there's going to be political action, there's going to be legislative action, there's going to be lawsuits," says Michael Cannon, health policy director at the Cato Institute, a libertarian think tank. "Opponents … will not go away."

•Republicans in Congress plan to resume legislative attacks. The House of Representatives has voted to weaken or wipe out the law more than a dozen times, including this month's vote to repeal a tax on medical devices.

•Opponents would be galvanized for the fall elections. For Obama, that could mean a more difficult path to re-election, despite his victory in court.

•Lawsuits pending at lower courts will move forward, and new ones could be filed to test other aspects of the law, ranging from its Independent Payment Advisory Board — charged with finding savings in Medicare — to its requirement that most insurance plans pay for contraception coverage.

The pace of litigation could increase as more regulations are issued, because "there's going to be winners and losers all over the place," says Bradley Joondeph, a law professor at Santa Clara University who tracks health care litigation.

Given that upheaval, state governments would face a choice: How fast should they move to implement the law?

"I think most of us are going to wait," Wisconsin Gov. Scott Walker, a Republican, said Thursday.

Bill McCollum, the former Florida attorney general who filed the first lawsuit against the Affordable Care Act on March 23, 2010, agrees. "I don't think it would be an immediate rush to enact the exchanges or conform to the law," he says.

Nevertheless, the Department of Health and Human Services says 34 states have accepted grants to pay for exchanges. They have until November to meet deadlines for exchanges to go into effect in January 2014.