WASHINGTON -- To Megan Hildebrandt, President Barack Obama's Affordable Care Act means she can no longer be denied health insurance because of her lymphatic cancer.
There's a big catch: Coverage for the 28-year-old artist and many other Americans without insurance will come at a potentially unaffordable cost.
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Hildebrandt, who relies on hospital charity, will face more than $1,000 in annual premiums, by one estimate, and probably more in out-of-pocket expenses even with new federal subsidies. She and her husband have a combined income of $25,000.
"It's great that I'm not going to have to pay some hugely impossible amount," said Hildebrandt, who lives in Austin, Texas. "Though now I'm in the health-care system and still have to pay money that we can't really afford."
The landmark health-care law, which survived the threats of repeal and a Supreme Court review, now confronts another hurdle: living up to expectations. As the administration spells out the details, many uninsured will be surprised at how much they will have to pay. It may involve "very substantial amounts," and "there still will be a significant number of people who can't afford health coverage," said Ron Pollack, head of Families USA, a consumer group that backs the law.
A family of four earning $75,000 will pay $7,125 in annual premiums and as much as $8,333 in co-pays and deductibles, according to a preliminary estimate by the Kaiser Family Foundation. A single 40-year-old earning $30,000 will pay $2,509 in premiums and as much as $3,125 in cost sharing. For a 60- year-old making $40,000, the amount will be $3,800 in premiums and up to $4,167 in out-of-pocket costs, according to Kaiser.
Those costs will come even as the government spends about $1.16 trillion over the next decade to expand coverage to 30 million uninsured people.
"People are often surprised at how expensive health insurance is once they have to pay for their own," said Karen Pollitz, a senior fellow at Kaiser Family Foundation. "The subsidies will make that better, but they won't make the cost disappear."
The administration recently unveiled regulations to implement the ban on discriminating against those with preexisting conditions. Insurers would be limited to varying premiums by age, family size, geography and tobacco use.
To be sure, the costs will be far less than what many with preexisting conditions would pay in the absence of the overhaul. The law is also designed to reduce expenses for those who already have insurance because hospitals providing charitable care make up those costs by charging others more.
"While we're only dimly aware of it, we all pay," said former Congressional Budget Office Director Robert Reischauer. "There shouldn't be free-riders."
What's more, there are provisions in the law capping the financial burden the requirements will impose on the uninsured. If costs exceed 8 percent of their income, they are exempt from the individual mandate to buy insurance. And people can choose to pay a penalty instead of buying insurance. The fine would be $695, or 2.5 percent of a person's income, whichever is greater.
The law, enacted in March 2010, requires virtually all Americans to have insurance by 2014. It will expand coverage to the uninsured by offering them subsidies to buy policies on newly established health-insurance exchanges and making it easier for lower-income people to qualify for Medicaid, the federal- and state-funded insurance system for the poor.
Consumers' expenses may climb because of a cost-cutting provision inserted in the law that will reduce federal aid to the uninsured if the subsidies exceed a certain threshold -- defined as 0.504 percent of the gross domestic product. The Congressional Budget Office says it expects that will happen.
In 2019, some families could see their premiums climb four times as quickly as the help they receive from the government, according to CBO. That means they will have to bear a larger share of the burden of purchasing coverage.
"That will be a major challenge," said John McDonough, a public-health professor at the Harvard School of Public Health. "It makes the affordability picture far worse."
The subsidies will be offered on a sliding scale, with those earning the least getting the most help. Those at the bottom of the income ladder, earning less than 138 percent of the poverty line -- about $33,000 for a family of four -- will get care through Medicaid. They will face minimal costs because the program has strict limits on co-pays -- if their states decide to opt in to the Medicaid expansion. The Supreme Court ruled in June that the government can't compel states to do so, even as the justices upheld the law.
Those earning up to 400 percent of the poverty line --about $92,000 for a family of four -- will receive tax subsidies to buy private insurance on a sliding scale.
Senator Richard Durbin of Illinois, the chamber's second-ranking Democrat who was instrumental in pushing through the law, said there's "legitimate concern" that care will remain unaffordable for some.
Lawmakers sought to "protect the poorest" yet weren't able to offer as much help to others as they would have liked because of budgetary constraints, said Durbin. "We did all that we could do," he said.
"If we find out that it doesn't reach our goal then we're going to have to sit down and work with it," he said.
He said Republicans have "no response" to the question of how to expand coverage to the uninsured.
A November 2009 analysis by CBO of a draft of the program provides a rough indication of how quickly the subsidies will ramp down. It shows the government covering 77 percent of the premium costs for single persons earning about $20,600, 42 percent for those earning around $32,400 and 13 percent of the premium costs for those making about $44,200.
That means many with modest incomes will be responsible for covering the bulk of their premium costs. About 5 million people required to buy coverage won't receive any help from the government because they earn too much, CBO projects.
"There may not be sufficient management of expectations," said Lynn Quincy, a health-policy analyst at Consumers Union, a Yonkers, N.Y.-based advocacy group. Lawmakers should have been telling the public the law promises "lower-cost" -- not "affordable" -- coverage, she said. "Everybody interprets 'affordable' differently -- it's in the eye of the beholder."
The Obama administration defended the law.
"Independent, nonpartisan experts have said the health- care law will help cover 30 million people who don't have insurance today," White House spokesman Nick Papas said in a statement. "The law takes substantial steps to control costs and will save money for millions of Americans."
Still, the federal subsidies face another danger. While Republicans have given up trying to rescind the law, they're targeting it in budget negotiations over the so-called fiscal cliff, the combination of automatic spending cuts and tax increases scheduled to begin taking effect in January.
Cutting the overhaul's cost could yield savings that most people wouldn't notice because the overhaul doesn't begin in earnest until 2014. Yet it would force the uninsured to shoulder an even greater share of health-care costs.
Republicans are willing to consider tax increases in the form of closing individual breaks, yet House Speaker John Boehner signaled they aren't yielding on cuts to so-called Obamacare.
"The tactics of our repeal efforts will have to change," Boehner wrote last week in the Cincinnati Enquirer. "The law has to stay on the table as both parties discuss ways to solve our nation's massive debt challenge" because "we can't afford to leave it intact."