President Obama, with Vice President Joe Biden, makes a statement to the… (Pablo Martinez Monsivais…)
Reporting from Washington — As Americans delve into the healthcare blueprint approved by the House of Representatives on Sunday, they will confront a bargain not unlike those earlier generations of Americans faced with Social Security and Medicare.
As Franklin D. Roosevelt did for old age assistance and Lyndon B. Johnson for healthcare 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 healthcare plan Obama will sign into law Tuesday, millions of retirees will no longer have to worry about gaps in Medicare's prescription drug coverage. Americans who lose their jobs will be able to get health insurance. And small-business owners will get help providing benefits to their workers.
But on any given day, many Americans may not see those new benefits, especially if they are healthy and work for a company that already provides them with a health plan.
What wealthy taxpayers will almost certainly see is a tax hike. Others, especially the young and healthy, will be required to buy insurance they may not want. And almost everyone will have to file another form with the Internal Revenue Service certifying that they have coverage.
Those trade-offs are crucial to a healthcare safety network, according to most health policy experts.
There is widespread agreement, for instance, that it is necessary to dramatically broaden the insurance pool to curb costs and make it possible to require insurers to extend coverage. But the trade-offs are more complex than the ones Roosevelt made in 1935 or that Johnson struck with the creation of Medicare in 1965. That complexity makes this new healthcare bargain potentially 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 healthcare overhaul is the design of the legislation itself.
Eager to avoid worrying Americans satisfied with the coverage they get 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 should therefore not be compared to traditional safety net programs such as Medicare, Medicaid and Social Security.
The difference means that Obama and congressional Democrats often are promoting an array of different 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 will no longer be able to deny coverage to children with preexisting medical conditions. Adults will have to wait for that protection until 2014.
Single Americans who make less than $14,404 will for the first time be able to sign up for the government Medicaid program.
Americans who earn more than that but who do not get insurance from their employer will be able to sign up for a commercial plan. Millions of them will probably qualify for subsidies to help them pay their premiums.
Those benefits should not be underestimated, said Len Nichols, a healthcare 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 healthcare 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 them.
"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," he said. "If you have a preexisting condition, you don't realize that you've just dodged a bullet thanks to this legislation."