Poor adults will get Medicaid. Low-income families will get federal subsidies to buy insurance. Small businesses will get tax credits. Children will be able to stay on parents' policies until they turn 26. Seniors will gain additional prescription-drug coverage. People with medical conditions will gain peace of mind because insurers have to cover them. (Emphasis added)

On the other hand, the wealthy will pay higher taxes to help finance the 10-year, roughly $940 billion cost. Businesses with 50 or more workers will have to insure them or pay a penalty. Individuals, too, will have to pay a fine if they don't buy insurance. Premiums could rise for some people. Seniors with Medicare Advantage policies could lose those plans or pay more to keep them.

When congressional leaders said "health care for all," they didn't mean it literally. The Congressional Budget Office projects that millions will remain uninsured by refusing to comply with the new mandate, or because the new federal assistance just isn't enough. [snip] (Emphasis added)

"Because of the way in which this is set up, there's lots of tangible benefits delivered to people, but the pain is very well distributed," says Drew Altman, president of the Kaiser Family Foundation, a health care research group. "While there are some losers, there aren't any big losers." (Emphasis added)

Katie Naranjo, 23, is a winner. She was dropped from her parents' health insurance policy last June after she graduated from the University of Texas. She says she now pays $411 a month for a private policy — more than her rent — and is excited about the possibility of getting back on her parents' policy.

"That monthly cost is a significant portion of my monthly salary," said Naranjo, who runs a small Internet marketing firm in Austin with friends, and campaigned for the health overhaul as president of the College Democrats of America.

Donald Bowles should be a winner, too. The self-employed Oklahoma City man and his wife can't afford insurance on an income that's usually below $30,000 a year, often much lower. They seldom go to a doctor. When they do, it's often a free clinic.

Bowles, 51, doesn't want the government's help. He'd rather take his chances and fend for himself. "I won't take Medicaid, and I will not pay the fine. They'll give me good health benefits in prison, I believe," he quips. "If you can't provide for yourself, why should everyone else provide for you?"

Here's a look at how six groups will be affected:

The uninsured

The Congressional Budget Office projects that 32 million Americans will gain health insurance under the law, beginning in 2014.

The poorest adults — those below 133% of the federal poverty level, or about $29,327 for a family of four — will qualify for Medicaid, the federal-state program for the poor and people with disabilities. Children already qualify at that income level.

Currently, only seven states offer Medicaid to adults without children, says Ron Pollack of Families USA, a consumer advocacy group. The median income eligibility level for that group is 69% of poverty — less than $7,500 for a single person and about $15,200 for a family of four. Many states are significantly lower than that.

Lower-income people who don't qualify for Medicaid will get federal subsidies to help them buy coverage from new state insurance exchanges — organized marketplaces that encourage competition.

Those eligible for the subsidies could have income up to 400% of the poverty level, or $88,200 for a family of four. Those at 133% of poverty will get the most assistance, those at 400% the least, both for premium assistance and benefits.

The premiums will range from 2% to 9.5% of family income, and the poorest families will pay the least. Those families also will have the smallest co-payments — 6%, ranging up to 30% for the top of the income bracket, Pollack says.

"For a lot of people, this bill is going to give them the ability to purchase health insurance, where today they can't afford it," says Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University in Virginia. [snip]

Medicare beneficiaries

There's good news and bad news for seniors. AARP, the nation's largest seniors organization, says most should benefit from a number of provisions.

First is the notorious "doughnut hole" that affects about one in eight Medicare recipients — the coverage gap in the Medicare prescription-drug program created in 2006. Now, seniors whose total drug costs reach $2,830 must pay for all their drugs until they have spent $4,550. The new law will close that gap.

This year, seniors who reach the coverage gap will be eligible for a one-time, $250 rebate. Starting next year, brand-name drug prices will be discounted 50% during the coverage gap period. Every year until 2020, the discount will be increased, until the benefit reaches 75% of the cost.

The measure includes other benefits for seniors, including free preventive services such as cancer screenings and funding for states to improve community services for people with disabilities.

Yet seniors who use Medicare Advantage plans — private plans combining hospital, physician and drug coverage — could see their premiums increased or benefits reduced. That's because the law reduces Medicare payments to those plans. About 23% of Medicare beneficiaries are in those plans.

The law extracts about $500 billion over 10 years from the future growth rate of Medicare, bringing it down from 6.6% to about 6%, says John Rother of AARP. In doing so, it extends the life of the program for nine years, which relieves some pressure to cut benefits or increase premiums.

Upper-income taxpayers

If a law costs nearly $100 billion a year, someone has to pay. In this case, that mostly means the wealthy.

If the Senate passes the package of changes, the biggest tax increases will come in Medicare payroll taxes. Those take two forms, both starting in 2013:

• Single people earning more than $200,000 and couples starting at $250,000 will pay 0.9 percentage points more on their wages and self-employment income.

• For people at those income levels, all their investment earnings will be taxed 3.8%, marking the first time the hospital insurance tax has hit non-wage income.

The other major tax increase hits the most generous health plans. Those don't apply just to upper-income people. State employees and other union workers have won excellent health coverage in recent years rather than big pay increases.

Starting in 2018, family insurance plans valued at more than $27,500 will pay a 40% tax above that level.

The goal is for employers to reduce the "Cadillac" benefits, rather than pay the tax.

Young adults

Young adults will be among the early beneficiaries of the law, which requires insurers to extend parental coverage to children until they turn 26.

About 30% of the uninsured are between the ages of 19 and 29, the highest rate of any age group, says Tanya Schwartz, a policy analyst with the Kaiser Family Foundation.

[snip]

Beginning in 2014, young adults will be required to purchase insurance or face tax penalties. Those will be phased in, reaching $695 per year by 2016 for an individual or 2.5% of household income, whichever is larger. Young adults will be eligible for subsidies, though, if they meet income.

People with health problems

Beginning later this year, insurers will no longer be able to refuse to insure children with pre-existing medical conditions, such as asthma, heart defects or cancer. The provision that allows young adults to stay on their parents' policies longer also helps those with chronic health problems, says Rob Schneider, deputy director of Consumers Union's health care campaign.

Protections for adults with pre-existing conditions won't take effect until 2014, but the legislation calls on federal health officials to create a national high-risk insurance pool program that they can buy from this year. Unlike some existing state high-risk pool programs, which can be expensive, the new program is supposed to keep rates closer to standard premiums paid by healthy people, Pollitz says.

The legislation also prohibits insurance companies from canceling coverage for people who develop costly health problems. It eliminates lifetime caps on covered medical expenses in six months.

"For us, this is life-changing," said Beth Sufian, a 44-year-old attorney who has cystic fibrosis and directs a legal hotline for those with disease.

Every week, dozens of people call for advice because they were denied insurance coverage on the private market for their chronic lung disease, which can cost $80,000 a year to treat. "This reform bill is just going to free people up to have the choices people without chronic illnesses have," she says.

People with employer-sponsored insurance

People who have good health coverage through their employer can keep it, Schwartz says. Many employer plans already meet minimum federal coverage requirements.

They also will get additional protections such as the end of lifetime coverage limits.

For employees who lose their jobs, beginning in 2014 they can buy affordable insurance through the health care exchanges. The insurance will have to meet minimum coverage standards.

The law will require a percentage of health care premiums go for care and improving quality, rather than toward marketing or administrative overhead. For large group insurance plans, at least 85% of premiums must go for care or quality improvement; otherwise, money will get rebated to policyholders, according to Families USA.

Although the legislation provides the framework, many of the details still must be hashed out in the coming months and years as federal health officials write the rules needed to carry out the changes.

"It's going to be a huge challenge," Secretary of Health and Human Services Kathleen Sebelius says.

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