ROBERT SIEGEL, HOST:

The health insurance industry is trying to prepare for an uncertain future. The Supreme Court is mulling the fate of the federal health overhaul. But whether the health care law is overturned or not, people are still likely to see changes to their insurance plans.

Jeff Cohen from member station WNPR reports.

JEFF COHEN, BYLINE: If you talk to some people in the insurance industry, the worst-case scenario is that the court throws out the heart of the health law; the requirement that everyone have health insurance or pay a penalty.

Karen Ignani says that would mean real problems, at least when it comes to the goal of providing lower premiums to more of the nation's uninsured.

KAREN IGNANI: In every state that tried market reforms without bringing everyone into the system, we saw those markets blow up.

COHEN: Ignani is the CEO of America's Health Insurance Plans, the insurance lobby. And they've been clear from the start. You can't ditch the individual mandate and still make insurers continue to accept all people regardless of the status of their health. The math just doesn't work. Not everyone agrees.

Mila Kofman used to be the superintendent of insurance for the state of Maine. Now, she's a research professor at Georgetown University. She says that should the mandate not survive the legal challenge, the right subsidies could entice people to buy insurance.

MILA KOFMAN: It's not that most people choose to be without coverage because they're buying Porsches; it's that they cannot afford it.

COHEN: David Cordani is the CEO of Cigna, the nation's fourth largest health insurer. He's in his bright, big-windowed corner office just outside Hartford, the city often called the insurance capital of the world. And as the Supreme Court was challenging the Affordable Care Act, Cordani didn't seem phased. Whatever happens with the mandate happens with the mandate.

DAVID CORDANI: Cigna does not have a position relative to the constitutional nature of it. And the broader health care debate is way larger than the individual mandate.

COHEN: Cordani agrees with Kofman that there are other ways to create what he calls a value proposition, to get people to buy insurance should the mandate disappear. But he also says this: The effort to change the way we provide and pay for the nation's health care is bigger than just what happens to the individual mandate. The focus, he says, should be patient health - improving the quality of care and driving down its cost.

CORDANI: Those are exciting opportunities, where you're really moving from sick care to health care, which is a lot of what motivates us.

COHEN: That's happening regardless of what happens with the Affordable Care Act?

CORDANI: Absolutely.

COHEN: It's important to keep in mind that insurers like Cordani are in many cases planning as though the Affordable Care Act is the law of the land because, for now at least, it is. And that means building products for the new insurance marketplace come 2014.

But insurance actuaries, who help insurers quantify risk, are up all night trying to figure out who they're going to be covering next year. Tom Wildsmith is the vice president for health issues at the American Academy of Actuaries.

TOM WILDSMITH: The challenge with health care reform is that it injects some uncertainty in the system that means that even in aggregate, we don't know exactly how things are going to work out.

COHEN: Complicating things is this: Even if all of the rules were set, no one knows just who will be in a particular insurer's risk pool. And the Supreme Court's pending decision only increases that uncertainty. So, for instance, what if a state's new baseline coverage - called its essential benefit package - is just too expensive for consumers?

WILDSMITH: If the essential benefit package means that many of their customers will have to buy up from, you know, a Yugo to a Chevy, they are concerned that they may lose some customers in that buy-up process.

COHEN: It may not be the easiest math in the world, but Mila Kofman says insurers can handle it.

KOFMAN: We're looking at billions of dollars into the pockets of the health insurance industry. So, I'm not worried about the health insurance industry and their financial health at all.

COHEN: In fact, even on the day that the Supreme Court looked like it was ready to toss the individual mandate, Cigna's stock was up 4 percent and other insurers saw similar gains.

For NPR News, I'm Jeff Cohen in Hartford.

SIEGEL: And that story is part of a partnership that includes WNPR, NPR and Kaiser Health News.

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