Though efforts to set up a health insurance exchange in Missouri have failed so far, the concept is regarded nationally as one of the many measures connected to the Affordable Care Act that will take root and thrive no matter what the Supreme Court says about the overall law. The court will soon decide whether Congress went too far in mandating that most people buy health insurance or pay a penalty, and in expanding Medicaid to cover more of the uninsured.

A health insurance exchange is a state regulated health-care plan from which residents can purchase health insurance eligible for federal subsidies. It's part of the Obama administration's efforts to make insurance more affordable to more citizens.

Among those betting on the survival of some form of insurance exchange is Christopher Condeluci, who was tax counsel for the Senate Finance Committee during the period when the health legislation was crafted. He's now an attorney at the law firm Venable LLP in Washington.

"Some of the more liberal states, California and Maryland, are really moving ahead in setting up an exchange mechanism under the new health-care law" he says. "Even if the law goes away, I think they will continue on their current trajectory and set up an exchange under their own auspices."

He also notes that Massachusetts has what amounts to a robust exchange-like system and that four other states -- New York, Utah, Connecticut and Florida -- already have in place bits and pieces of what might be regarded as insurance exchange provisions.

"Those four states will build on the exchange structure they currently have in place," he said in an interview, suggesting that even a dozen or more states might press ahead on exchange programs.

Some states might change their minds if the court scraps ACA, but for now the Kaiser Foundation's State Health Facts website, found that 15 states were in the process of setting up exchanges, three were planning to establish them, and 19 were studying that option. The site says no significant activity on exchanges was taking place in the dozen or so remaining states, including Missouri, which has received more than $21 million for planning and setting up its program.  State Senate leaders have decided to put everything on hold until after the Supreme Court's ruling.

Many benefits will survive

Another ACA benefit that might survive in some form, Condeluci predicts, is the provision allowing young adults to remain on the insurance plans of their parents until age 26. He says Congress would be spurred to save that provision, no matter what happens, because it's popular among voters.

Many provisions relating to hospital care, cost and quality that predated ACA have been folded into the law and are likely to remain in effect regardless of the outcome of the court decision, says Dave Dillon, vice president of media relations for the Missouri Hospital Association. He says the Affordable Care Act has given added momentum to "what we're already doing." The ongoing focus on quality, he says, "has fundamentally shifted the culture of patient safety and reporting.  It's been ground-breaking in terms of transparency and health-care quality. These types of activities will continue and the scope of reporting will expand."

An example, he says, is  attention to hospital-acquired infections. Nearly two weeks ago, data distributed by the Centers for Disease Control and Prevention showed a 25 percent reduction in the spread of infections to patients at some Missouri hospitals. While the state health department praised the reduction, the CDC noted that the results didn't tell the whole story.

For one thing, only 13 of the state's 156 acute-care hospitals were reporting their data to the CDC. State officials say the rest do report data to the Missouri Health Department. The CDC study for 2010 said Missouri wasn't among the 21 states having the most significant decreases in central line associated bloodstream infections. The federal government has now raised the bar, making it mandatory for more than 70 Missouri hospitals to submit their data to the CDC.  It says the broder sample should give the public a fuller picture of the prevalence of hospital-acquired infections.

Federal health officials also are expected to stay focused on several other patient improvements whatever the Supreme Court decides. These include values-based purchasing under which hospitals are paid based on performance on certain quality measures. They also face a loss of 1 percent of their payments, starting this fall for having to readmit an excessive number of patients because the care wasn't done properly the first time around.

"If you think in terms of 10 years ago, and there was an error in care, if someone had bedsores, for example, Medicare or Medicaid or a private insurer would pay for the condition" which is regarded in federal jargon as "a never event," Dillon says.

Other quality measures include the federal government's website on hospital comparisons, which allows the public to track how well hospitals are performing in relation to one another on several quality measures.

Also expected to remain on track are new quality-care measures that ACA mandates for doctors who treat Medicare patients. Physicians in Missouri, Iowa, Kansas and Nebraska have received a sample report showing that the federal government hopes to impose a "payment modifier" under which doctors would receive higher fees for delivering quality care at a lower cost and less for care that costs more but doesn't improve medical results.

Like many other changes, this one is likely to be reinstated if it's somehow voided by the court decision since the modifier is an attempt to wring some of the needless cost from a health system consuming in excess of $2.5 trillion a year.

Electronic medical records have 'tons of potential'

Dillon notes that the electronic health records program is indirectly part of ACA, though the program was funded by stimulus money. He says the program certainly is expected to survive because it has "tons of potential to change the way health care is delivered." Among other things, the electronic system makes access to medical records easier and quicker, helps to cut out redundant medical tests and to provide more accurate diagnoses and effective treatment.

Beyond the question of what happens if the law is voided, Dillon says, are the issues of how society will care for the uninsured and whether lawmakers would put back the old method of hospital spending. For example, the reform law calls for a $155 billion reduction over 10 years in government payments to hospitals. The assumption under ACA was that health costs would be reduced through improved and better coordinated care, and that more of the uninsured would get help through the Medicaid safety net. It would be expanded to cover individuals earning up to 133 percent of the federal poverty level, which is more than $14,000 in yearly income for an individual.

"If ACA would disappear, there is very little chance that legislators and Congress would put that money back in," Dillon says. "This isn't necessarily about the uninsured but about how health care will be funded. We have to look at a better model of funding. What will happen in the future. That's the big question mark."