As the country awaits and debates the Supreme Court's pending decision on health care reform, about the only thing insurers, providers and patients can agree on is the need for clarity.
The court's decision, expected within the month and perhaps as soon as today, could give direction to a health care system that has been in a holding pattern since challenges to the law's constitutionality were heard in March.
Some aspects of the Affordable Care Act that passed in 2010 have already launched, such as extended coverage for young adults on their parents' insurance. Others, like the more controversial requirement for all Americans to buy insurance, would take effect in 2014. Most states are waiting on the court's move to start organizing insurance markets as called for by next year.
"Everybody is ready for this decision to come down," said Ryan Barker, director of health policy for the Missouri Foundation for Health. "Regardless of what the decision is, we need to move forward."
The ruling is certain to produce a torrent of reaction and election-year posturing no matter what the decision. Both political parties have been preparing for the possible outcomes, distributing talking points and laying contingency plans for piecemeal legislation if all or part of the law is struck down.
Some experts believe that the potential of a split decision — striking down the individual insurance mandate while leaving other portions of the law intact — would trigger an especially chaotic political situation.
"It would be a colossal mess, even if we assume good faith on the part of our elected officials," remarked Gregory Magarian, a law professor at Washington University. "As a practical matter, it would be almost the worst of all political worlds."
Insurance companies have rushed to ease fears about the more popular aspects of the law. Several of the industry's major players have vowed to continue covering dependents until age 26 and free preventive care such as immunizations, regardless of the court's decision.
"Health plans' top priorities are providing peace of mind and continuity of coverage to their beneficiaries," said Karen Ignagni, president of America's Health Insurance Plans, in a statement. "No matter what the Supreme Court decides, individuals and families should rest assured that their current coverage will remain in effect."
What's less clear is how much the cost of insurance premiums will change if any or all of the law is tossed out.
Insurance companies have lobbied to keep the individual mandate, arguing that the only way to fund other aspects of the law — no more dropping people who get sick, rejecting people with pre-existing conditions or imposing lifetime bans on coverage — is to make sure everyone jumps in the risk pool.
"The individual mandate is kind of the backbone of what makes the law work, so that it's not just sick people getting insurance," said Elisabeth Askin, a third-year medical student at Washington University and co-author of "The Health Care Handbook: A Clear and Concise Guide to the U.S. Health Care System."
Askin lays out five possible actions the court could take:
• Postpone a decision until 2014 when the individual mandate takes effect.
• Uphold the entire law.
• Strike down the individual mandate.
• Decide that an expansion of Medicaid to cover more low-income people violates states' rights.
• Strike down the entire law.
Most legal scholars are expecting at least some parts of the law to be thrown out, with the individual insurance mandate the most likely. In that event, House Republicans already have signaled that they would immediately seek repeal of portions of the law that remain, although a repeal stands little chance of passing the Democratic-run Senate.
Meanwhile, both parties would face pressure from the insurance industry to fix the glaring problem of being forced to write risky policies without the certainty of a flood of new policyholders under a mandate.
"The insurance industry gives money to both sides. They'd be saying, 'Look, you guys may hate each other, but you've got to get something done here,' " said Donald Taylor, of Duke University, an associate professor of public policy who blogs on health care and other topics.
Sen. Roy Blunt, R-Mo., said recently that he anticipates the political parties would work together to continue to allow young adults to stay on their parents' health policies.
A report from the Commonwealth Fund estimated that 6.6 million young adults have taken advantage of the benefit, while a new Gallup survey showed the uninsured rate for people ages 18-25 continues to decline, down to 23 percent from 28 percent when the law took effect.
In the House, Majority Leader Eric Cantor, R-Va., said recently that his party would proceed after the repeal vote on separate proposals such as bolstering health savings accounts and allowing the purchase of insurance across state lines.
Meanwhile, the White House has sought to project confidence that the court will uphold President Barack Obama's defining accomplishment. That could give Obama an election-year boost and blunt an argument being used against Missouri Sen. Claire McCaskill and other Democrats on the November ballot.
If the law is struck down, Democrats see a silver lining: the ability to go on the attack against Republicans after being bludgeoned themselves since 2010 for engineering a law that is unpopular in its entirety.
In the pocket cards distributed to House Democrats, a column that reads Numbers to Know recommends talking about how 86 million people have received free preventive care services under the Affordable Care Act and 17 million children with pre-existing conditions can no longer be denied coverage.
No matter what the court does, there is a consensus that Congress and whoever occupies the White House next year will need to act given the increasing burdens of health care costs, which the Affordable Care Act does little to address.
Before then, as Duke's Taylor suggested, the chance of anything substantial out of the Congress could be remote.
"It seems to me that both sides think they can win one more election by saying we're not as bad as the other side," he said.
The Associated Press contributed to this report.