As the U.S. Supreme Court prepares to rule on the Affordable Care Act, Texas officials, insurers and physicians are looking at potential outcomes that could keep health care reform in the spotlight for months to come.

The ruling, which will be delivered by June 28, could uphold the law, uphold parts of it but strike down provisions like the individual mandate or completely overturn the law.

No matter which decision is made, the state will continue to be involved in health care debates, said Attorney General Greg Abbott. If the law is upheld, Abbott said, there will probably be new lawsuits — both at the state and federal levels— concerning its other components. And if the law is completely struck down, both Congress and Texas will look for other legislation to address health care reform.

“Striking down Obamacare doesn’t solve health care problems,” Abbott said.

Uncertainty as to what the court will decide leaves many struggling to determine what changes to prepare for.

If the law is upheld, the state will expand Medicaid, which currently constitutes close to a quarter of its budget. Medicaid, the state health plan for the disabled and very poor, mostly covers children, but under the new law, it would also cover healthy adults — for instance, the parents of children it already covers.

“We would have to move very quickly to put those changes in place,” said Stephanie Goodman, a spokeswoman for the Texas Health and Human Services Commission. But, she stressed, the state would need more federal guidance to do so.

Anne Dunkelberg, associate director of the left-leaning Center for Public Policy Priorities, said that because statewide elected officials did not support the law, Texas did not move efficiently to prepare for implementation of the changes, such as the requirement to set up a state-run health insurance exchange to help Texans choose a health plan. 

“Because we made the choice not to prepare, we will have to start out with a federally facilitated exchange,” Dunkelberg said.

HHSC has begun implementing some changes outlined in the law, though it has not addressed the Medicaid changes. 

Duane Galligher, executive director of the Texas Association of Health Plans, said most insurance companies are basing their actions on the law being upheld, not overturned.

Many companies have implemented some of the changes the law calls for. Of those, he said, some have already been “absorbed by the market.” For example, some of the rebates that have been introduced through the new law will be kept on by insurance companies. Other companies are waiting for the court’s verdict before making major, potentially costlier reforms.

But if the law is upheld, Goodman said, there will still be further changes necessary — in particular, reforming Medicaid as well as expanding it.

Spencer Harris, a health care policy analyst at the Texas Public Policy Foundation, a conservative think tank, noted complications in another potential verdict: striking down just the law’s individual mandate — which requires all citizens to purchase insurance — but leaving other elements intact. 

Such a verdict would change the funding model for insurance, he said. Many healthier people would not purchase insurance, resulting in costlier premiums for most of those who were insured.

Without the individual mandate, there would need to be some kind of incentive for people to purchase health insurance, Dunkelberg said. The mandate as it stands enacts a financial penalty for those who do not purchase insurance.

And if the law is completely struck down, health care reform will remain a concern, said Louis Goodman, CEO and executive vice president of the Texas Medical Association.

“We still have the problem of all the uninsured — nationally but especially in Texas,” he said. “And we certainly will have to redouble our efforts to ensure access for the uninsured.”

Finding the law unconstitutional “brings us back to 2008,” Harris said, a time when, he said, “health care costs were rising faster than businesses could pay for it.”

“Everyone agrees the system needs to be reformed,” he added.

If the law is struck down, Stephanie Goodman said, HHSC would need to work with the federal government to determine which changes should be continued and which discarded.

“Do we reverse those changes? What do we do?” she said.

Until the court issues a ruling, the law’s ambiguous status has left both practitioners and officials uncertain about how to proceed.

“Most of the physicians — individually especially, but even larger groups — are holding back on expansion because one doesn’t know what the future holds,” Louis Goodman said, noting uncertainty about taxes and how doctors will be regulated. “The best thing would be certainty in terms of whether we have the law.”

The undecided status of the case complicates establishing a timeline for HHSC to expand Medicaid, Stephanie Goodman said.

“We don’t want to go out,” Harris said, “and spend hundred of millions of dollars updating an eligibility system if we aren’t going to need it.”

Texas Tribune donors or members may be quoted or mentioned in our stories, or may be the subject of them. For a complete list of contributors, click here.