Richmond, Va. --

The issues being decided in the monumental U.S. Supreme Court review of health care reform hit home for John Rayfield. When the uninsured 64-year-old self-employed carpenter needed heart bypass surgery in December 2010, he had no way to pay for it.

Rayfield, who described himself as a "walking time bomb," was able to have life-saving surgery when Access Now, a privately run program that arranges for low-income, uninsured people to get care from specialists, found a doctor and hospital to take his case and donate their time and costs.

The court's decision could be a game changer for such organizations as Access Now, and the local free clinics, community health centers and private providers that make up a health care safety net, providing health care to patients who otherwise might go without.

"If all the Obamacare goes through and everything's constitutional, and we go ahead, probably 50 to 60 percent of our patients are going to qualify for Medicaid," said Connie Moslow, executive director of the Free Clinic of Powhatan.

"Now, does that mean they are going to take it? It puts the free clinics in kind of a precarious situation also, because our thing is we provide health care to the uninsured," she said. "How do we adjust?"

Soon, the Supreme Court is expected to rule on two controversial provisions of the 2010 health care reform law: Can people be required to buy health insurance, and what the expansion of Medicaid will look like.

The individual mandate of health care reform would require most people to maintain a minimum level of health insurance coverage starting in 2014. There would be federal subsidies and tax credits to help people afford the costs.

Critical to the individual mandate is the creation of health benefit exchanges, state-managed marketplaces where people could shop for affordable health plans without the risk of being turned down because they have medical problems such as heart disease or cancer.

Also, under health care reform, state-run Medicaid programs would have to expand coverage to nearly all people under age 65 with household incomes at or below 133 percent of the federal poverty level beginning in January 2014. For a family of one, that's an annual household income of $14,856 in 2012.

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Health care reform uncertainty has safety-net providers in limbo