WASHINGTON — From the beginning, President Barack Obama and his top advisers have sought to portray health care reform not just as another costly entitlement for the poor, but as part of a larger effort to ease the burden of mounting medical costs for the middle class.
But with Congress now shaping legislation, a thorny political question hangs over the debate: How much will middle-class Americans benefit and will it be enough to win their support?
President Clinton's health-care initiatives collapsed in the early 1990s after the insurance industry used "Harry and Louise" ads to help convince middle America that the plan was a bad deal. Obama has yet to avoid that same pitfall, but recent polls suggest he's already encountering some public discontent with his handling of the health care issue.
"The middle class absolutely is the constituency that will determine" the outcome of the health care debate this year, said Len Nichols, director of the health policy program at the New America Foundation, a Washington think tank. "It will come down to Obama's portrayal of the benefits of the new world" of change versus the status quo of rising premiums and the difficulties of getting individual insurance.
"All this is complicated," Nichols said. "All this is hard to show."
Americans who are going to pay a lot of the bill for covering the uninsured are being asked to believe in a different kind of payoff — one that is appealing but more difficult to quantify than the subsidies needed to help cover poorer people. Look past the price tag of legislation, Obama is saying, to a future of smaller premium increases and guaranteed coverage even if you lose your job or become sick.
The insurance industry has agreed to stop denying coverage because of a medical problem if all Americans are insured. Universal coverage also could help tamp down insurance increases, the administration argues. Today, hospitals and doctors often pass the cost of treating the uninsured to people with insurance by charging them higher rates.
In the current deep recession, these potential benefits are attractive to millions of people, polls show. But many Americans remain doubtful they'll personally benefit from the changes. Some worry that the huge cost of guaranteeing insurance for everyone — the 10-year cost of reform legislation might be $1 trillion or more — will come out of their wallets or harm their coverage.
Nina Hogan, a self-employed Realtor in Mason, Ohio, is one of those who potentially could be helped by the Democrats' proposals. At age 56, she considers herself to be relatively healthy. But an intestinal disorder and a mild case of asthma resulted in a stiff $5,000-a-year premium, a $2,500 annual deductible and annual premium increases in the neighborhood of 13 to 14 percent — all for an individual policy that she doesn't think is very good.
Hogan is among an estimated 25 million Americans whose policies aren't comprehensive or require substantial deductibles and co-payments. These so-called underinsured people include workers whose employers have cut back on benefits, and others who buy skimpier individual policies to save money.
Yet Hogan is skeptical of proposed plans because of the high cost, and she questions how quickly new legislation would produce results directly helping her. "These are all these great suggestions but is it realistic and will it happen in a year? No."
Many experts, including economists at the Congressional Budget Office, caution that the cost-saving fruits of an overhaul might be a decade or more away. There's also concern that Obama's proposal to cut more than $600 billion from Medicare and Medicaid spending over 10 years might help drive up private insurance rates. Under this scenario, hospitals and doctors absorbing cuts in these programs might charge individuals with private coverage more for their health care.
Meanwhile, critics are trying to rip holes in the Democrats' plans and rhetoric.
"I think (Obama's) using all the buzz words he thinks people want to hear," said Sen. John Cornyn, R-Texas, a member of the Finance Committee. "But they don't necessarily string together in any kind of coherent fashion, nor is there any real evidence to support his conclusion that somehow this proposal is going to ultimately bend the cost curve on health care."
Many Americans may balk at the idea of taxing the value of individuals' employer-provided health care benefits, something the Finance Committee is strongly considering. About one in eight U.S. workers who receive health benefits through their jobs — more than nine million workers — could end up paying higher income taxes on those benefits, according to a five-page finance committee document.
"There's no question somebody's taxes will go up," said Nichols of the New America Foundation. "The question for middle class is whether the net increased security, increased quality, lower administrative loads are worth the higher tax bill for some that will come. And in many ways that is the crux of the debate we're about to have."
KHN staff writer Julie Appleby contributed to this article.
(Kaiser Health News is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization that's not affiliated with Kaiser Permanente.)
MORE FROM KAISER HEALTH NEWS
MORE FROM MCCLATCHY