If the U.S. Supreme Court pulls the plug on all or part of the federal health care law, hold off on scrawling R.I.P. on reform efforts in Minnesota.

The path might change but the momentum won't die, say some observers and industry leaders.

"There's enough happening on the reform side, you can't roll that one back. You can't stop it," said former U.S. Sen. David Durenberger, who now chairs a health policy institute at the University of St. Thomas. "Health systems are going to be hurt here, no question about that. But it's much less difficult to see us tackling this now than it will be in other parts of the country."

At the core of last week's Supreme Court arguments was the law's requirement that everyone buy insurance. But even without an explicit mandate, Minnesota and other states could move closer to the health care law's underlying goal of universal health coverage.

Lynn Blewett, a professor in the University of Minnesota's School of Public Health, rates Minnesota among the top 10 states that could assemble their own expanded coverage systems should the Supreme Court strike down the Affordable Care Act (ACA).

Minnesota, she said, already has a number of pieces of the national plan in place.

The state has set up a system for online enrollment for insurance coverage. It has worked with "risk adjustment" to make sure good treatment facilities don't get punished because they attract sick people. It has looked at setting premiums based on regional medical care costs instead of pre-existing conditions, individual health histories or age.

"Minnesota could do something like universal coverage," Blewett said. "We've had different attempts in Minnesota to do small employer pools to bring down the price of health insurance."

Many people think overhauling the health care system isn't an appropriate job for the government, whether federal or state.

State Sen. David Hann, R-Eden Prairie, an opponent of the federal law, predicts it will go down. And with it, everything else -- from online exchanges where people can buy insurance to collaborative efforts between insurance plans and providers.

Hann, who is chair of the Senate's Health and Human Services Committee, said he thinks government intervention in the health care system has created more problems than it has solved.

"We ought to figure out how to get legislatures and bureaucracies and government out of the business of managing health care and managing insurance and working on things that'll be economically desirable and encourage those marketplaces to be more efficient."

Years of work

Minnesota has spent more than 20 years working to fix an increasingly costly and broken system, often with a measure of bipartisan agreement and buy-in from the business community and health care industry.

Long before federal officials began crafting rules for "accountable care organizations," the Mayo Clinic was showing that using electronic patient records and a team-based approach to medicine could reduce costs and improve care.

Hospital systems such as Fairview and Allina have joined forces with insurance companies in recent years to mine claims data for ways to keep patients healthier and to upend the traditional model of paying caregivers based on the number of treatments.

Hennepin County began overhauling operations this year to marshal resources from social service agencies and to try to keep some patients with chronic yet manageable diseases from bouncing in and out of the hospital.

Not that these changes have happened without controversy -- from doctors who resent meddling by insurance companies, lawmakers who disagree over how to allocate health care dollars and advocates who believe poor people and working families are falling through the cracks. Meanwhile, the ranks of the uninsured have grown to more than 9 percent.

Yet many components of the ACA -- expanding health care coverage, overhauling financing and restraining insurance profits -- already were underway in Minnesota.

"I don't think you can put the genie back in the bottle," said Larry Jacobs, political and policy analyst at the University of Minnesota. "Most of the major players have already accepted reform and taken some fairly large steps."

If the law is struck down, Minnesota would lose federal dollars that would have gone toward tax subsidies to bring insurance coverage within reach of more people and separately to expand Medicaid. It would also lose the authority to force insurers to provide certain kinds of coverage.

If the mandate gets knocked out but the courts require insurers to cover people with preexisting conditions, it will "raise real serious questions" about how the law proceeds, said Geoff Bartsh, lobbyist for the insurer Medica.

"Everyone knew going in that the requirement to have coverage and the guarantee of coverage had to go hand in hand," he said.

Outlook for exchanges

Some say a ruling against all or parts of the law might not spell the end of the exchanges, state-run marketplaces where, starting in 2014, small businesses and individuals can comparison shop for affordable coverage. Medica and Blue Cross and Blue Shield of Minnesota already have set up private exchanges for businesses.

"We sort of have to wait and see," said Commerce Commissioner Mike Rothman, who chairs an advisory task force and whose department would regulate the exchanges. "In a variety of scenarios, even if it gets struck down entirely, the exchange would continue to be an important piece of health care reform."

The key would be finding ways to entice younger and healthier people to an exchange to spread the costs to care for people who are sicker. Options might include setting up a waiting period to prevent people from buying insurance on the way to the emergency room only to drop it once they're home, or setting up enrollment periods with subsidies or other incentives.

Rep. Steve Gottwalt, R-St. Cloud, has been a champion of creating a Minnesota-made insurance exchange, although not a fan of the current law. He said he worries that the polarizing views about the federal law may have gotten in the way.

"If the [health care act] were done away with tomorrow, we'd still face some tremendous challenges," said Gottwalt, who is chairman of the House and Human Services Reform Committee. "My challenge to those who want to do away with the ACA is, 'That's fine. But what are we going to do?' We still need to answer that question at the end of the day."

Star Tribune staff writer Jim Spencer contributed to this report. Jackie Crosby • 612-673-7335