WASHINGTON — Imagine the debate over healthcare legislation on Capitol Hill as a tussle among three friends out for dinner.
All three have been struggling to pay their bills lately. When the check arrives, they try to figure out how to divide it. The problem is no one can really afford the meal. And if one manages to pay less, the other two will go home even deeper in the hole.
That is the dilemma facing President Obama and his congressional allies as they try to develop healthcare legislation that can unite liberal and conservative Democrats and make it to the president's desk by the end of the year.
"It is all a question of balancing," said Ken Thorpe, a healthcare economist at Emory University who has advised congressional Democrats working on healthcare bills.
Think of our three friends as consumers, businesses and government, the three major groups that pay for healthcare in America.
The check is the nation's healthcare tab, which now tops $2.5 trillion a year.
Consumers, businesses and government are all hurting, battered by arguably the worst economic downturn since the Great Depression and years of living beyond their means.
The government is running record deficits, pushed there in part by skyrocketing healthcare costs that have doubled expenditures on Medicare, Medicaid and other government health programs over the last decade.
Consumers are being pinched too as their health insurance premiums and medical bills have surged. The average employee will pay $3,515 for a family health plan that he or she gets through work this year, more than double the cost in 1999, according to a survey by the nonprofit Kaiser Family Foundation and the Health Research and Educational Trust.
Businesses are facing even more pressure. Their average contribution to an employee's family health plan ballooned to $9,860 this year from $4,247 in 1999, the survey found.
Obama and his congressional allies working on healthcare legislation would like to relieve some of the pressure on everyone's wallets by forcing healthcare providers to charge less.
But few in Washington are comfortable dictating what private hospitals, drug makers or insurance companies can charge.
That has left them with the unpleasant task of divvying up a hefty check.
And now, because Democrats are pushing to expand coverage to millions more Americans who don't have insurance, the bill is getting a lot bigger.
Liberal Democrats believe the tab should be picked up largely by government and business.
In the legislation developed by Democratic leaders in the House, the federal government would spend more than $1.1 trillion over the next decade to help expand coverage to 97% of Americans, according to estimates by the nonpartisan Congressional Budget Office.
That includes $438 billion for Medicaid and the Children's Health Insurance Program, the joint federal-state government insurance programs for the poor.
And it would include $773 billion in new subsidies to help people making less than four times the federal poverty level -- or $43,320 for an individual -- buy insurance on their own.
The House bill also places major new burdens on businesses by requiring that medium and large employers not only provide insurance, but also pay most of the cost of their employees' premiums.
The legislation mandates that businesses cover 72.5% of insurance premiums for workers with individual health plans and 65% of the premiums for workers with family plans.
Those provisions have made the legislation very unpopular with business groups and fiscal conservatives, who worry that the big expansion of government aid threatens the budget and will require new taxes.
One of the most controversial provisions of the House bill would impose a surtax on individual taxpayers making more than $280,000 a year and couples making more than $350,000 a year.
An alternative was offered this week by Senate Finance Committee Chairman Max Baucus, a conservative Democrat from Montana.
In his proposal, government and business are stuck with much less of the tab.
The Baucus legislation would commit the federal government to paying $287 billion to expand Medicaid and the Children's Health Insurance Program. And it would provide just $463 billion to help people buy insurance.
Baucus also would place no requirement on businesses to cover a percentage of their employees' premiums.
That pleased many business groups.
"This improves the House bill by leaps and bounds," said Amanda Austin, a lobbyist for the National Federation of Independent Business, a historically conservative group that represents small businesses.
But with fewer demands on business and government, consumers could face much higher insurance premiums than they would in the House bill, a prospect that has consumer groups and many liberal Democrats demanding change.
"It's a disaster," said Richard Kirsch, national campaign manager of Health Care for America Now, a leading liberal grass-roots coalition. "The Baucus bill will make insurance less affordable for people in the workforce and for people who have to buy insurance on the individual market."