New Business October 22, 2009, 5:00PM EST

Who Picks Up the Tab for Health Reform

Insurers and taxpayers are likely to pay big chunks of the $900 billion bill to overhaul the nation's health-care system. Doctors will feel the least pain

Browse Issues

Story Tools

The odds are shifting in favor of health-care reform legislation making it through Congress this year, to the point where bookies could put money on the ultimate winners and losers. Many details have yet to be determined, as congressional leaders try to merge two Senate and three House proposals, all of them more than 1,000 pages long. And beyond the contentious battle over the public insurance option, there's a huge fight over another question: Who will pay to cover the uninsured? It's safe to say doctors will give up the least, pharmaceutical and medical device makers will fall somewhere in the middle, and insurers will be the big losers.

Then there's the taxpayer. Senate Democrats want to levy a 40% excise tax on so-called Cadillac plans, policies that cost more than $21,000 a year. Backers say the tax would bring in $215 billion, but unions are determined to block it, arguing that middle-income workers will get hit with the tax as well. A fierce battle will erupt over the levy when the Senate and the House begin to work on the final bill. Meanwhile, the 85% of citizens with insurance of any kind, Cadillac or Hyundai, should probably assume that most costs levied on other parties to health reform will be passed along to them through higher premiums.

Most Washington observers now think the final bill will closely resemble the Senate Finance Committee proposal because it has a smidgen of bipartisan support, thanks to Senator Olympia Snowe (R-Me.). It also meets President Barack Obama's demands that a reform package cannot add to the federal deficit and the tab should come in at around $900 billion over 10 years. With billions in potential profits or lost benefits at stake, lobbyists are scrambling to make sure that someone else—anyone else—foots the bill. "Figuring out how to pay for this package remains the hardest thing," warns Andy Laperriere, a Washington policy analyst with institutional broker ISI Group. Nevertheless, it is possible to envision which groups will have to pony up:

HEALTH INSURERS

The insurance industry has been actively involved in efforts to craft a health-care bill ever since President Obama took office. Insurers have already agreed to several concessions on the assumption that they will gain 30 million or so new customers from the ranks of the uninsured. Those efforts haven't paid off the way they'd hoped. "The bill has certainly taken a turn for the worse for the [insurers]," says Rick Weissenstein, an analyst with Washington Research Group.

Lawmakers have proposed that the industry pay the government flat fees worth $67 billion over the next decade—an idea that's likely to get backing from House Speaker Nancy Pelosi (D.-Calif.). Throw in the $100 billion-plus that both chambers aim to get by cutting subsidies for Medicare Advantage plans, and the industry may have to give up more than $200 billion. "It's totally disproportionate to our share of the health-care expenditures," says Karen Ignagni, president of America's Health Insurance Plans, the industry lobby.

She argues that the industry will have no choice but to raise customers' premiums to fund the new fees. Moreover, a mandate requiring everyone to buy insurance or pay a fine has been so watered down that insurers won't gain enough new customers—the basis for their reform support in the first place.

On top of that, the House Judiciary Committee voted on Oct. 21 to end the industry's 60-year-old exemption from federal antitrust laws. "The insurance companies are obviously turning into the villain here," says Laperriere. "The chances are more likely that their costs will go up, not down."

DRUG AND MEDICAL-DEVICE MAKERS

There were hopes that covering the uninsured would mean a lot more customers for these companies as well. Consequently, drugmakers cut a deal with the White House in May to absorb $80 billion in cuts to Medicare reimbursements and fees over 10 years—a fraction of the industry's total revenues of more than $600 billion a year. The device makers never came to the table, and that could haunt them.