( CNN ) -- Suppose the Supreme Court does rule that the health care mandate is unconstitutional ? What happens then ? ( I 'm not saying that they will , but let 's play `` what if ? '' ) The famous individual mandate is just one piece of the new health care law enacted in 2010 . Take away the mandate , and here are two principal elements left behind : . -- A huge expansion of the Medicaid program . The majority of those who 'd gain health coverage under the new health care law , an estimated 18 million people , would gain it from being enrolled in Medicaid , the health care program for the poor . Even before the new health care law , Medicaid was a huge program , covering one in six Americans . It 's on its way to becoming bigger still , whatever happens to the individual mandate . -- Tough new rules on insurance companies . The new health care law forbids insurers to refuse coverage on the basis of `` pre-existing conditions . '' All applicants must be accepted , and they must be covered at the same price as the other members of the insured group . Now let 's war-game what happens post-mandate . 1 . The private insurance market will crash in a spectacular train wreck . Faced with big new costs and deprived of their expected new revenues from the mandate , insurance companies will have to raise prices . Faced with rising prices , employers will cut back coverage . The 2010 law imposes new obligations on employers to provide health insurance but also presents employers with an option to escape those obligations by paying a ( comparatively ) small fine . As insurance costs surge in a post-mandate world , more employers will take advantage of that option . Their employees will join the new market for individual care , the famous health care `` exchanges . '' Minus the mandate , the policies on offer in the exchanges will be unexpectedly expensive . Minus the mandate , many individuals will choose not to buy . The law offers subsidies to buyers who can not afford the full cost of the new policies . Minus the mandate , those subsidies will cost much more than expected . 2 . The Medicaid program will grow . The new health care law dramatically expands eligibility for Medicaid . In a post-mandate world , with employers dropping coverage and the individual market careening into dysfunction , Medicaid will likely grow faster than ever . Costs of the Medicaid program are divided between the federal and state governments . As Medicaid surges , those governments will face an agonizing dilemma : Raise taxes to pay for all those new applicants or reduce coverage , leaving millions of people to clinics and charity . 3 . Meanwhile , the Medicare time bomb will continue to tick . The U.S. already has a single-payer health care system . It 's called Medicare , and even today , it is one of the largest single-payer systems on Earth , enrolling more than 47 million people . As more and more of the baby boomers turn 65 , the program is scheduled to expand rapidly -- to more than 63 million people by 2020 and more than 80 million by 2030 . We are headed , it would seem , to a post-mandate future that looks something like this : . Medicare will provide fairly generous government health coverage to about one-quarter of the population . Medicaid will provide much less generous government coverage to one-quarter of the population . The population outside Medicaid and Medicare will subdivide into two main groups : . The affluent and those whose labor is greatly valuable to their employers will be covered by an ever-more-expensive and ever-shrinking private-insurance market . The people who ca n't pay themselves and whose employers wo n't pay for them will drop out of the private market , and either look for ways to qualify for Medicaid or wait and pray until they qualify for Medicare . Political pressures will induce politicians to open Medicaid to more and more uninsured people . Fiscal pressures will force politicians to make Medicare less generous and more Medicaid-like . If the Supreme Court rules unconstitutional the plan for universal coverage through private insurance , the U.S. will continue to evolve toward a government-led system -- albeit one much more expensive , and much less satisfactory , than the government systems of other advanced democracies . Perhaps after a decade or two of discontent , somebody else will try another reform . But this time , the reform will proceed as an outright government program . There wo n't be any choice , if the Supreme Court of 2012 precludes as unconstitutional the private-sector alternative -- meaning that today 's would-be champions of the free market will have unwittingly brought about the grandest expansion of government control since the 1930s . The opinions expressed in this commentary are solely those of David Frum .
The U.S. Supreme Court may strike down the mandate to buy health insurance . By David Morgan, NBC News contributor Updated at 1:55 p.m. ET -- A federal appeals court on Monday rejected a challenge by President Barack Obama and congressional Democrats that would have allowed Americans who Without private insurance , more people will look to get Medicaid coverage , he says . Frum : The court 's free-market boosters could spark huge government expansion .