'Let 'em die!' What millions of Americans could lose after the Supreme Court rules.

Remote Area Medical | Jeff Reichert & Farihah Zaman
from Focus Forward Films on Vimeo.

That's three minutes from a new documentary by filmmakers Jeff Reichert and Farihah Zaman, to be released in early 2013, that examines the health care crisis in America through the lens of a Remote Area Medical clinic that took place this past April in the NASCAR speedway in Bristol, Tennessee. That's the status quo that Mitt Romney, Republicans in Congress, and possibly the Supreme Court want to preserve by not only completely repealing the Affordable Care Act, but not replacing it.

The Supreme Court is almost certainly going to strike down at least a part of the law, the mandate that requires those who are uninsured to buy insurance. That's easily the most controversial, and least explained and defended, part of the law, because with it came subsidies and Medicaid expansion to make the mandate affordable. But additionally, with the mandate comes the critical reforms for insurance companies: guaranteed issue and community rating. And if the mandates falls, so do these reforms.

Let's briefly revisit what these reforms are. Guaranteed issue means simply that health insurance companies can't turn you down because of pre-existing health conditions, or because of your age or gender or any other circumstance. Community rating requires that insurers can't gouge certain segments of the population, usually women and seniors, in premiums. They wouldn't, for example, be allowed to charge a woman many times more for the same basic coverage that a man of the same age and in the same location would be charged.

The law immediately put guaranteed issue in place for children, and would bring for the rest of the population in 2014. If the law falls, so possibly does that coverage for minors. As of now, the major health insurers in the country are saying that they will continue to honor at least some of the law's provisions, although possibly not this one.

In its statement, United stopped short of saying it would continue to follow that provision for kids who are ill. While it "recognizes the value of coverage for children," United said, "one company acting alone cannot take that step," adding that it is "committed to working with all other participants in the health care system to sustain that coverage."

That statement alone proves the problem with relying on the insurance companies to keep these reforms alive. One of them can't and won't do it unilaterally. So how long their commitment to these reforms will last is anybody's guess. See, the mandate was a critical factor in the health insurance companies' support for the law: if they had to take on all comers, including the sickest, and were prevented from charging them outrageous premiums, the pool of patients had to be broadened to the whole population to bring in the cheap, healthy people.

The big question, and the question that dominated the oral arguments when the Court heard the case, is whether these reforms'including an expansion of Medicaid'are "severable" from the mandate, whether they can stand if the mandate is struck down. The administration argued that they could not, that trying to maintain them without the mandate would drive up costs and reduce coverage as insurers have to try to provide coverage to all sick comers without having a healthy population to spread out costs to. That would be the opposite of what Congress and the administration were trying to achieve with the law.

So we're left with the likelihood that the woman in the short film, the one who'd never had a chest x-ray and just discovered she has spots on her lung, will never be able to be insured. We're back to the status quo presented in the film. (Note that the Affordable Care Act doesn't address other problems highlighted by the film'dental and vision care' problems that have to be tackled as well. But if the ACA goes down, we're starting at ground zero again with basic medical care being out of reach for tens of millions of Americans.) That's looking ahead at what could be lost, but what about the immediate losses?

Let's explore, over the fold.