Nearly two-thirds of Americans say the health care overhaul signed into law last week costs too much and expands the government’s role in health care too far, a USA TODAY/Gallup Poll finds, underscoring an uphill selling job ahead for President Obama and congressional Democrats.

Those surveyed are inclined to fear that the massive legislation will increase their costs and hurt the quality of health care their families receive, although they are more positive about its impact on the nation’s health care system overall.

Supporters “are not only going to have to focus on implementing this kind of major reform,” says Robert Blendon, a professor of health policy and political analysis at Harvard. “They’re going to have to spend substantial time convincing people of the concrete benefits of this legislation.”

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Under the health care overhaul, young adults who buy their own insurance will carry a heavier burden of the medical costs of older Americans”” a shift expected to raise insurance premiums for young people when the plan takes full effect.

Beginning in 2014, most Americans will be required to buy insurance or pay a tax penalty. That’s when premiums for young adults seeking coverage on the individual market would likely climb by 17% on average, or roughly $42 a month, according to an analysis of the plan conducted for The Associated Press. The analysis did not factor in tax credits to help offset the increase.

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“It’s the context of people’s lives that determines their health,” said a World Health Organization report on health disparities. “So blaming individuals for poor health or crediting them for good health is inappropriate.”

I must admit I often feel like my colleagues who grouse about spending all day treating patients who do not seem to care about their health and then demand a quick fix. I do not relish paying more taxes to treat patients who engage in unhealthy habits. But then I remind myself that we all engage in socially irresponsible behavior that others pay for. I try to eat right and get enough exercise. But then I also sometimes send text messages when I drive.

The whole point of insurance is to reduce risk. When people inveigh against the lack of personal responsibility in health care, they are really demanding a different model, one based on actual risk, not just on spreading costs evenly through society. Sick people, they are really saying, should pay more. Which model we eventually adopt in this country will say a lot about the kind of society we want to live in.

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During the period when the Patient Protection and Affordable Care Act (PPACA) was being considered, arguments were made by both supporters and detractors that the Private Health Insurance Markets would be changed drastically by Reform. Those on the left indicated that the Bill was unfair, because it passed a mandate that forced Americans to purchase health insurance and left private coverage as the only option, thus putting American’s at the mercy of “Greedy, villainous Health Insurance Executives (Nancy Pelosi, August 2009 House Testimony). In addition, the Progressive Coalition in the House of Representatives, 71 members strong, signed a statement that said that without a “public option” (a private insurance entity run by the federal government as an alternative to for-profit or private not-for-profit coverage) the Senate Bill was a boon for insurance companies, offering up 46 million new customers with federal subsidies to boot.

On the right, and in alliance with the Health Insurance Companies, detractors said the bill would impose so many new government regulations on Health Insurance Companies that insurance pools would be destabilized and runaway premium costs would result. Thus in the end, the federal government would be ordered to step in anyway, thus creating a Single Payer, or Federally Controlled Health Insurance plan that would interpose itself between patient and doctor and eventually ration the care Americans received through that entity.

Both arguments are compelling and both outcomes undesirable. In this article I would like to examine the realities from a “boots on the ground” perspective as a Chief Forecaster and Senior Healthcare Policy/Intelligence Analyst in the health insurance business. To be clear, I am not an attorney, accountant, or actuary. I am not qualified to comment on regulatory issues as to their specific effects on employer groups. What I am called upon daily to do, is to coordinate the projections for all the moving parts of the PPACA Bill and its changes and to forecast its effects on the Plan that employs me (The not-for-profit Blue Cross and Blue Shield of Louisiana) and communicate these changes and potential effects in a meaningful way to a whole bunch of smart, experienced stakeholders in the healthcare industry so they can incorporate my projections and background fact and data into their decision making going forward.

Let’s examine the arguments one at a time.

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Because of the new health care law, Arizona lawmakers must now find a way to maintain insurance coverage for 350,000 children and adults that they slashed just last week to help close a $2.6 billion budget deficit.

Louisiana officials say a reduction in federal money to hospitals that treat the uninsured under the bill could be a death knell for their state-run charity hospital system.

In California, policymakers estimate they will have to come up with an additional $500 million a year to make necessary increases in payments to Medicaid providers.

Across the country, state officials are wading through the minutiae of the health care overhaul to understand just how their governments will be affected. Even with much still to be digested, it is clear the law may be as much of a burden to some state budgets as it is a boon to uninsured consumers.

States with the largest uninsured populations, like Texas and California, might be considered by its backers the biggest winners to emerge from the law, because so many additional residents will have access to health insurance. But because those states are being required to significantly expand their Medicaid programs, they are precisely the ones that will face the biggest financial strains, in many cases magnified by existing budget shortfalls.

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