The U.S. Supreme Court building in Washington. (Jan. 25, 2012)

The U.S. Supreme Court building in Washington. (Jan. 25, 2012) Credit: AP

Any day now, the U.S. Supreme Court will issue a decision on the constitutionality of the 2010 Affordable Care Act, a ruling that will affect a sixth of the nation's economy and the presidential race.

At the heart of the ruling will be whether the justices affirm or reject the act's mandate that every citizen obtain health insurance or face a fine.

The individual mandate, the law's backers say, is needed to cover 33 million uninsured people, but it's also a requirement that polls say most Americans want to see thrown out.

If the court strikes down any or all of the complex law passed in 2010 — something many predict the conservative bloc could do on a 5-4 vote — it will be a blow to President Barack Obama and his top legislative achievement.

The court, led by Chief Justice John Roberts, will render its judgment on four separate constitutional issues, but most legal experts predict there are three likely rulings.


Upholding the law

Obama, Democrats and their liberal backers insist the court will uphold the law. If it does, "it's full speed ahead," said Ethan Rome of the Health Care for America Now, a coalition that backs the health plan.

While the law is being put into place, experts said that ruling would clear the way for key elements to take effect in 2014: the mandate, the exchanges for insurance shopping and Medicaid expansion.

Yet presumed GOP presidential nominee Mitt Romney, Republicans and conservative allies said they'll still try to derail the law.

"Unless the court throws out the entire law, the House will vote to repeal whatever is left of 'Obamacare,' " House Speaker John Boehner (R-Ohio) said last week. However the court rules, the political and policy struggle over health care will continue, especially on issues of covering the uninsured, improving the quality of care and curtailing its fast-growing expenses, all in a harshly partisan atmosphere, analysts said.


Strike the mandate

The 26 states and the National Federation of Independent Businesses that sued to overturn the law said they expect the court to throw out the individual mandate.

Experts differ widely on how removing the mandate would affect the rest of the act. Some call it the law's heart; others say it's easily replaced. White House spokesman Jay Carney noted its significance.

"The individual mandate is a hugely important component to the Affordable Care Act because it is what allows for, in many ways, coverage of those with pre-existing conditions and others who might otherwise not be able to get insurance," he said.

About 33 million uninsured people would gain coverage for the first time with a mandate, the Congressional Budget Office said. But studies by the Rand Corporation and other experts estimate that without a mandate, only 8 million to 23.1 million would gain coverage.

American Health Insurance Plans, a trade group, said without a mandate, the country should expect "higher insurance costs and millions of more people without access to affordable care."


Strike entire law

In oral arguments, Justice Antonin Scalia called the individual mandate the "heart" of the health law, and said, "If you take the heart of the statute out, the statute is gone."

In the end, that is what the conservative justices might decide — the whole law is gone.

The impact of that ruling would wipe out the complex insurance exchanges and market reforms, interlocking taxes, tax incentives, grants for pilot programs, funding shifts and Medicaid expansion in the 2,700-page Affordable Care Act.

Striking the entire law would set off another round of Congressional political battles over health care — one of the fastest-growing sectors in the economy and the biggest driver of government debt.

"The court may throw out all of [the law], part of it or none of it," said Bob Graboyes, of the NFIB Research Foundation, the research arm of the business federation, which is one of the plaintiffs against the law. "But no matter which, health care spending will remain the single greatest fiscal threat to the federal government, state governments, businesses and individuals."

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