Americans will feel the pain before the gain from the health care overhaul Democrats are close to pushing through Congress.
Proposed taxes and fees on upper-income earners, insurers, even tanning parlors, take effect quickly. So would Medicare cuts.
Benefits, such as subsidies for lower middle-income households, consumer protections for all, eliminating the prescription coverage gap for seniors, come gradually.
"There's going to be an expectations gap, no question about that," said Drew Altman, president of the nonpartisan Kaiser Family Foundation. "People are going to see their premiums and out-of-pocket costs go up before the tangible benefits kick in."
Most of the 30 million uninsured helped by the bill won't get coverage until 2013 at the earliest, well after the next presidential election.
More than two-thirds of Americans get their coverage through large employer plans and their premiums won't go up because of the legislation, according to number crunchers at the nonpartisan Congressional Budget Office.
But Congress can't abolish medical inflation, so don't hold your breath waiting for premiums to drop.
For people who buy their own insurance policies — about one of every six Americans — premiums will go up. But that's for better benefits prescribed under the legislation. And about half of them would get tax credits to substantially lower their costs.
As Senate Democrats cleared the second of three 60-vote procedural hurdles, over unanimous GOP opposition Tuesday, it looked like the White House was already celebrating. "Health care reform is not a matter of if, health care reform now is a matter of when, and I think the president is enormously encouraged by that," declared spokesman Robert Gibbs.
Republicans cry foul on deals
Republicans, bolstered by opinion polls that show a majority of Americans opposed to the legislation, aimed their fire at dozens of deals Democratic leaders cut to line up the 60 votes needed in the Senate. "Senator so-and-so may have gotten his deal," said GOP Leader Mitch McConnell of Kentucky. "But the American people haven't signed off."
If the Senate passes the bill Thursday, as now seems likely, the pressure will be on Democrats to quickly sort out House and Senate differences and get final legislation to Obama's desk. That would end a divisive debate that has soured the public mood.
But there are significant differences between the bills, including stricter abortion language in the House version as well as a government-run insurance plan that is missing from the Senate package. The Senate plan also embraces a tax on high-value insurance plans, something strongly opposed by unions and many House Democrats.
One thing that won't emerge in the end is a government takeover of health care. The government-run insurance plan some liberals were hoping would be a step to Medicare-for-all lacks support in the Senate. If negotiators put it back, moderate Democrats in the Senate say they'll oppose the final bill. And Majority Leader Harry Reid, D-Nev., needs every one of his party's 60 votes.
Instead, the final package could end up looking like the Medicare prescription drug benefit, delivered through private insurance companies, but subsidized and regulated by the government.
Just like seniors now pick their drug coverage from a range of private plans, Americans who were previously uninsured would select brand-name coverage through a new kind of insurance supermarket called an exchange. Like seniors today, they would have to pay part of the cost themselves. Most people with employer coverage wouldn't need to go to the exchange.
The exchanges could be national, regional, or state-based. They'd be up and running in 2013 under the House bill, a year later in the Senate version. Around that same time, other major changes would snap into place:
- Health insurance companies would be prohibited from denying coverage to people with health problems, or charging them more.
- For the first time, Americans would be required to carry health insurance, either through an employer, Medicare or Medicaid, or by buying it themselves. Refusal would bring fines, except in cases of financial hardship.
- Federal subsidies would start flowing to individuals and small businesses buying coverage in the exchange, helping them afford the premiums.
- Most employers would be required to offer coverage or pay a tax, under the House bill. In the Senate version, employers would get a bill if any of their workers got subsidized coverage in the exchange.
- Medicaid coverage would be expanded to pick up millions more living near the poverty line.
Debated since President Harry Truman's administration, health care overhaul would finally be in place. An estimated 94-96 percent of Americans, not counting illegal immigrants, would have coverage.
But there's a catch.
Cost is the Achilles heel of the whole complicated undertaking. To keep the cost of the bill at around $1 trillion over 10 years, lawmakers had to limit subsidies for people seeking coverage through the exchange.
The aid tapers off dramatically for households with solid middle-class incomes. A family of four making $66,000 a year would still have to spend about 10 percent of its income on premiums — less than a mortgage but more than a car payment. And that's without counting copayments and deductible. Several million otherwise eligible Americans could still be priced out.
Altman, the Kaiser Foundation expert, thinks Democrats won't be able to resist the temptation to keep tinkering with the legislation to improve or speed up coverage. "The legislation is going to be out there, and politics can change," he said. "There's a potential for modification and amendment."
Health care overhaul could be back for an encore.