President Obama's signature healthcare law will be on the Supreme Court's docket this spring, the court announced Monday. And the most controversial element under review will be the individual mandate, which requires all Americans to purchase health insurance or face a fine, beginning in 2014.
Experts say that if the court strikes the mandate and allows the rest of the Affordable Care Act to stand, most of the law's provisions won't simply unravel. However, the heart and soul of the law, making insurance widely available and affordable, will suffer.
"Health insurance would be more expensive for unhealthy people and might be inaccessible to older and unhealthy people," says Timothy Jost, a professor at Washington & Lee School of Law and author of several books on healthcare. "It will certainly make insurance less affordable for many Americans."
Ilya Shapiro, constitutional expert at the libertarian CATO Institute, agrees. "The main part would indeed be gutted," he says, explaining that without the mandate, the law will no longer be "changing the way that healthcare is provided, who's covered, and what the cost is."
The case the court will take is the one decided by the 11th Circuit Court of Appeals involving a group of 26 states as well as the National Federation of Independent Businesses. The 11th Circuit ruled the individual mandate unconstitutional yet severable, meaning it could be separated from the overall law.
If the high court comes to the same conclusion, the healthcare changes that have already been implemented, and many that are yet to come, will still exist, experts say.
For example, the requirements that many restaurants post nutrition information, that insurance companies cover preventative care, and that children up to age 26 can stay on a parents' health plan would all be likely to stick around.
What could go down with the mandate's ship, however, are three regulations on the insurance industry. The law currently states that insurers will have to insure all applicants, regardless of health status; they will have to accept applicants with pre-existing conditions; and they will not be able to charge anyone a higher premium based on medical history.
Without the mandate, these things likely wouldn't work. "If people are allowed to wait until the last minute to buy health insurance, then they will," explains Ian Millhiser, a constitutional law analyst with the left-leaning Center for American Progress. "Then suddenly they will get diagnosed with an expensive condition," he says, "and then they'll buy insurance at the last minute and take a whole lot of money out of insurance pools they haven't paid into at all."
But these are popular provisions designed to help keep costs down.
Jost, who predicts the court will uphold the mandate anyway, points out that if they don't, subsidies like tax credits for paying insurance premiums would still help people afford healthcare, and other provisions like the state healthcare exchanges would still help to expand care.
Removing the mandate would strike a blow, though. The Affordable Care Act would be "less successful than it would've been had we had the individual mandate," Jost says. "People don't like the individual mandate, but they like the other provisions that it makes possible."
The healthcare law, and the individual mandate in particular, has been a punching bag for GOP 2012 presidential candidates. The fact that the Supreme Court is expected to decide the case by June means that whatever the outcome, the ruling will be a hot political topic, with either side trying to spin the result in their favor.
And though the requirement isn't as unpopular as it once was—a new CNN poll suggests a slight majority (52 percent) of Americans now approve of the individual mandate—some experts, like Thomas Miller, health policy analyst at the center-right American Enterprise Institute, think it's doomed no matter what.