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High court ruling on health care act won't be the last word

WASHINGTON -- Some observers are already anticipating that the upcoming Supreme Court ruling on President Obama's health care law will be the "decision of the century."

But the justices are unlikely to have the last word on America's tangled efforts to address health care woes. The problems of high medical costs, widespread waste and tens of millions of people without insurance will require Congress and the president to keep looking for answers, regardless of whether the Affordable Care Act passes the test of constitutionality.

With a decision by the court expected this month, here is a look at potential outcomes:

>Q: What if the Supreme Court upholds the law and finds Congress was within its authority to require most people to have health insurance or pay a penalty?

A: That would settle the legal argument, but not the political battle.

The clear winners if the law is upheld and allowed to take full effect would be uninsured people in the United States, estimated at more than 50 million.

Starting in 2014, most could get coverage through a mix of private insurance and Medicaid. Republican-led states that have resisted creating health insurance markets under the law would face a scramble to comply, but the U.S. would get closer to other economically advanced countries that guarantee medical care for their citizens.

Republicans would keep trying to block the law. They will try to elect their presidential candidate Mitt Romney, backed by a GOP House and Senate, and repeal the law, although their chances of repeal would seem to be diminished by the court's endorsement.

Obama would feel the glow of vindication for his hard-fought health overhaul, but it might not last long even if he's re-elected.

The nation still faces huge problems with health care costs, requiring major changes to Medicare that neither party has explained fully voters. Some backers of Obama's law acknowledge it was only a first installment: Get most people covered, then deal with the harder problem of costs.

>Q: What if the court strikes down the entire law?

A: Many people would applaud, polls suggest.

Taking down the law would kill a costly new federal entitlement before it has a chance to take root and develop a constituency, but that still would leave the problems of high costs, waste and millions uninsured.

Some Republicans in Congress already are talking about passing anew the more popular pieces of the health law.

But the major GOP alternatives to Obama's law would not cover nearly as many uninsured, and it's unclear how much of a dent they would make in costs.

Some liberals say Medicare-for-all, or government-run health insurance, will emerge as the only viable answer if Obama's public-private approach fails.

>Q: What happens if the court strikes down the individual insurance requirement but leaves the rest of the Affordable Care Act in place?

A: Individuals would have no obligation to carry insurance, but insurers would remain bound by the law to accept applicants regardless of medical condition and limit what they charge their oldest and sickest customers.

Studies suggest premiums in the individual health insurance market would jump by 10 percent to 30 percent.

The insurance mandate was primarily a means to an end, a way to create a big pool of customers and allow premiums to remain affordable. Other forms of arm-twisting could be found, including limited enrollment periods and penalties for late sign-up, but such fixes would likely require congressional cooperation.

Without the mandate, millions of uninsured low-income people still would get coverage through the law's Medicaid expansion. The problem would be the 10 million to 15 million middle-class people expected to gain private insurance under the law. They would be eligible for federal subsidies, but premiums would get more expensive.

Taxes, Medicare cuts and penalties on employers not offering coverage would stay in place.

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