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Who should bear the brunt of the cost of health care reform is a crucial question in the debate.
Published Sep. 21, 2009

Los Angeles Times

WASHINGTON - Imagine the debate over health care legislation on Capitol Hill as a tussle among three friends out for dinner.

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 pays less, the other two get stuck.

That is the dilemma facing President Barack Obama and congressional allies as they try to develop health care legislation that can unite Democrats and make it to the president's desk by the end of 2009.

Think of the three friends as consumers, businesses and government, the three major groups that pay for health care in America. The check is the nation's health care tab, which now tops $2.5 trillion a year.

Consumers, businesses and government are all hurting, battered by the economic downturn.

The government is running record deficits, pushed in part by doubled expenditures on Medicare, Medicaid and other government health programs over the last decade.

Consumers are pinched, too, as their health insurance premiums and medical bills have surged. The average employee will pay more than $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 face even more pressure. Their average contribution to an employee's family health plan ballooned from $4,247 in 1999 to $9,860 in 2009, the survey found.

Obama and his congressional allies working on health care legislation would like to force health care providers to charge less. But few in Washington are comfortable dictating what private hospitals, drugmakers or insurance companies charge.

That has left them with the unpleasant task of divvying up a hefty check.

And 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 percent 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 low-income families.

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 percent of insurance premiums for workers with individual health plans and 65 percent of the premiums for workers with family plans.

Those provisions have made the legislation very unpopular with business groups and with 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.

The alternative was offered this week by Senate Finance Committee chairman Max Baucus, D-Mont., a conservative. 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. It would provide $463 billion to help people buy insurance.

Baucus also would place no requirement on businesses that they 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 work force and for people who have to buy insurance on the individual market."