Jennifer B. Danielson, the new president of one of Utah's largest insurers, Regence BlueCross BlueShield, awaits the pending Supreme Court ruling on federal health reform as keenly as anyone else.
She doesn't offer odds on the decision, expected later this month. Her only hope, she says, is "for clarity" and her charge: "Making sure we are open to the one constant in our industry, which is change."
No matter where the ruling lands, industry consultants agree the Affordable Care Act's future is uncertain, pivoting on politics, the economy and 2012 election. But the stakes the fate of a trillion-dollar industry, and massive public programs such as Medicaid and Medicare are too high for prognosticators to ignore.
Some, like Utah's own Leavitt Partners, have made a game of it. The advisory group built by former governor and Health and Human Services Secretary Mike Leavitt has a "Health Reform Bracketology" widget that pairs competing "if-then" scenarios into NCAA Tournament-style brackets, which trace to one of several possible outcomes.
Users of the online tool start by choosing assumptions, such as whether the law, or parts of it, will be upheld or overturned, and whether a Democrat or a Republican will occupy the White House and which party will dominate Congress.
The tool then serves up a prediction or analysis based on those assumptions.
"Lots of people have opinions on what's going to happen, but we've tried to make it as prescient as possible, to look around the corner of health care and see what some of the trends will be," said David Merritt, a senior adviser at Leavitt Partners.
"If the law is upheld and Obama is re-elected, we could see it permanently ensconced," he said. "If things go the other way, we could see it this time next year almost a shell of what it was in 2010."
If those are the two extremes, Merritt forecasts something in between.
"My best guess is they'll overturn the mandate [to buy health coverage] and leave it at that, and pitch the clean-up back to Congress. It remains to be seen who they'll pitch it back to," he said, pegging the odds of a clean Republican sweep versus Obama retaining the presidency at about 50/50.
Merritt insists the brackets are free of political bias even though Leavitt still has a foot in party politics and was recently tapped to lead Republican presidential candidate Mitt Romney's transition team. Merritt himself has served as an adviser to presidential campaigns, most recently for Newt Gingrich.
Few of the brackets paint a rosy future for health reform.
Assuming Merritt's best guess holds true, Republicans will still hold a majority in Congress and fight to repeal the law, likely with some success, Leavitt Partners predicts.
Popular provisions such as guaranteed coverage for kids will go, health exchanges to buy insurance will be privatized and premium subsidies will be gutted and reserved for the poorest citizens.
And budget pressures will force the White House to concede to a smaller expansion of Medicaid than the law calls for now.
"There are more scenarios where the law is in jeopardy," admits Merritt. "But we're talking about where health care is likely to be, not where it should be."
With the economy on a slow path to improvement, the tenor of oral arguments before the high court and gridlock in Congress, health insurance professionals expect much the same.
"The industry seems to be in quicksand right now. We are waiting on [a ruling], but even after that I don't see a resolution," said Salt Lake City insurance broker Ernie Sweat.
"If [the law is] upheld it adds even more venom to this year's election...," he said. "If it's thrown out altogether we would have at this point almost three years of new mandated benefits the public likes possibly being removed, and a scrambling Congress trying to get something passed to keep them in order to avoid political fallout."
He adds: "It's very interesting, historic, probably can even be called fascinating. I just wish I was more of an observer."