Health-care changes coming quickly

WASHINGTON — As Americans delve into the health-care blueprint approved by Congress on Sunday, they will confront a safety net not unlike those offered to earlier generations of Americans — with Social Security and Medicare.

Much as Franklin D. Roosevelt did for old-age assistance and Lyndon B. Johnson for health care for the elderly, President Obama will ask people to accept new costs and government requirements now in exchange for benefits and protections that most will not immediately see, and some may never need at all.

Under the health-care plan Obama will sign into law Tuesday, millions of retirees no longer will have to worry about gaps in Medicare's prescription-drug coverage. Americans who lose their jobs will be able to obtain health insurance. And small-business owners will receive help providing benefits to their workers.

Yet many Americans may not see those new benefits on any given day, especially if they are healthy and work for a company that provides health benefits.

What wealthy taxpayers almost certainly will see is a tax increase. Others, especially the young and healthy, will be pressured to purchase insurance they may not want. And almost everyone will be required to file another form with the Internal Revenue Service certifying that they have health-care coverage.

More complexities

Those trade-offs are critical to make a health-care safety network, according to most health-policy experts.

There is widespread agreement, for instance, that it is necessary to bring everyone into the insurance pool to restrain costs and make it possible to require insurers to cover everyone.

But the trade-offs make the benefits at the heart of the Democratic health-care legislation vastly more complex than the one that Roosevelt made in 1935 or that Johnson struck with the creation of Medicare in 1965.

That complexity also makes this new health-care program potentially much more fragile.

"Politically, Medicare and Social Security are stronger because they include everyone, and therefore everyone has a stake," said Paul Starr, a Princeton University political scientist and health-policy expert. "That does not apply here."

Further complicating Democratic efforts to promote their health-care overhaul is the design of the legislation itself.

Little change at work

Eager to avoid worrying Americans satisfied with the coverage they receive at work, Democrats explicitly designed their bill to do as little as possible to the existing employer-based health-insurance system.

"That was a necessary accommodation,' said Starr, who said the legislation therefore should not be compared to more traditional safety-net programs such as Medicare, Medicaid and Social Security.

The difference means Obama and congressional Democrats often are promoting an array of benefits to different groups of people depending on how old they are, where they work and how much money they make.

Starting this year, for example, insurers no longer will be able to deny coverage to children with pre-existing medical conditions. Adults will have to wait for that protection until 2014.

Single Americans who make less than $14,404 will be able to sign up for the government Medicaid program for the first time.

Americans making more than that who do not receive insurance from their employer will be able to sign up for a commercial plan. And millions of those likely will qualify for subsidies to help them pay their premiums.

"A security policy"

Those benefits should not be underestimated, said Len Nichols, a health-care economist who heads the Center for Health Policy Research and Ethics at George Mason University.

"Every American will now have a security policy built into their insurance contract, so if I am diagnosed with cancer tomorrow, I will no longer have to worry that my family will end up bankrupt," Nichols said.

By September, the health-care legislation will bar insurance companies from imposing lifetime limits on what they will pay for patients' care. "That's a very big deal," Nichols said.

But it may remain an abstraction for many Americans — especially those who never contract a costly chronic illness or do so only in old age, when they are covered by the existing Medicare program.

When Roosevelt signed Social Security into law and Johnson signed Medicare, both presidents insisted that Americans be issued cards to underscore the commitment that the federal government was making to protect their interests.

"Things like Social Security cards and Medicare cards are such powerful symbols," said Brown University political scientist James Morone, who studies health policy.

"Some of the most important things in this bill are things that will not happen. If you have a pre-existing condition, you don't realize that you've just dodged a bullet thanks to this legislation."