If, as many pundits are predicting, the Supreme Court invalidates the individual mandate portion of the Affordable Care Act, the private market will likely be much quicker to implement draconian reactions than will Congress. That's a big problem, because Congress, which doesn't seem to be able to get anything of substance done these days, would be expected to fix the problem of guaranteed issue (that is, no excluding people for pre-existing conditions) coupled with the lack of a mandate.
Among the many cascading effects of such a ruling, the most immediate might be a huge increase in premiums, if insurers choose to remain in the market at all.
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"If you don't [fix that problem], overnight you'll immediately see premiums just go out of sight," says Paul Keckley, executive director of the Deloitte Center for Health Solutions.
That's because the only way the commercial market can accept the terms of the ACA, given the risk, is if there is a strong individual mandate. That is, if you increase the base of the insurance "pyramid" with large numbers of young, mostly healthy people, you can take more risk for people with substantial health problems at the top of the pyramid.
If the rest of the law is upheld, that means insurers can't make increases of more than 10% without federal approval, and can't charge a co-pay or deductible for preventive health. That might be a recipe for bankruptcies and major dislocations in insurance coverage, among other consequences, absent major and quick Congressional changes.
The first of those changes might happen sooner than you may think, and Congress has been anything but fast-moving in recent years.
"[Insurers] will say they can't operate under these terms," says Keckley. "They'll say that unless you let them dramatically increase premiums to cover this new level of risk, they're not in your market."