In addition, federal subsidies and tax credits for low- and middle-income people to buy insurance in the new marketplaces, or “exchanges” – think Travelocity for health care – will make coverage more affordable.
The real disconnect comes if the Supreme Court strikes down the individual mandate but lets stand the guarantees of coverage for people with preexisting conditions and the “community rating” provision that bars plans from charging more on the basis of gender or health status.
“If just the mandate goes, there’s no question that there are implications in that for how well the law works,” says Larry Levitt, a senior vice president at the Kaiser Family Foundation in Menlo Park, Calif. “There’s a consensus that premiums will go up, though by no means a consensus around how much they’ll go up.”
The CBO has estimated that the Affordable Care Act, minus the mandate, would result in premiums that are 15 to 20 percent higher than if the whole law had gone into effect.
“It’s far from ideal, but it doesn’t mean that the law is a failure or unworkable,” says Mr. Levitt. “People would still be getting benefits; there would still be lots of consumer protections going into effect. I don’t think it cuts out the heart of the law. But it would be a challenge.”
“I don’t think it would create chaos in the insurance system,” he concludes.
Still, all the talk of chaos is for a reason. Some is based on fear of what insurance experts call a “death spiral.” If there's no mandate, but if there are guarantees of coverage, sick people come into the system while many healthy people stay out. Premiums go up; and the more they do, the more people drop out. The result is a system skewed toward people with serious health issues, which is unworkable.