WASHINGTON — For consumers, the health care bills taking final shape in Congress don't rate close to a perfect 10.
The Democratic measures would leave 12 million or more eligible Americans uninsured. Many middle-class families who'd now be required to buy coverage would still find the premiums a stretch, even with government aid. A new federal fund to provide temporary coverage for people with health problems would quickly run out of cash.
For now, these bread-and-butter concerns take a back seat to more pressing issues for Democratic lawmakers trying to deliver on President Barack Obama's signature issue.
Congressional Democrats are trying to resolve differences within their own ranks on abortion, taxes and allowing the government to sell health insurance as a competitor to private companies. Those are all crucial policy questions, and House and Senate Democrats have taken conflicting approaches. But in the end, the concerns lawmakers are focusing on may not match the needs of their constituents.
The House passed its health care bill 220-215 earlier this month. The Senate cleared the way Saturday for debate on legislation unveiled by Majority Leader Harry Reid, D-Nev. The bill, a compromise between two committee-passed versions, could undergo significant changes as senators amend it during weeks of arduous debate ahead.
Both bills would require all Americans to carry health insurance, with government help to make premiums more affordable. They would ban insurance companies from denying coverage or charging more to people with health problems. They would set up new insurance markets for those who now have the hardest time finding and keeping coverage — self-employed people and small businesses. Americans insured through big employer plans would gain new consumer protections but wouldn't face major changes. Seniors would get better prescription coverage.
"For the first time, we're going to allow American consumers to be involved in a buyers' market for health insurance," said Sen. Chris Dodd, D-Conn., one of the authors of the Senate bill. "This Congress is going to pass, and this president is going to sign, a national health care program for all Americans."
Before any signing ceremony, lawmakers must clear some tall hurdles.
On abortion funding, the House adopted strict limitations as the price for getting anti-abortion Democrats to vote for the final bill. Abortion rights supporters are backing Reid's approach in the Senate bill, which tries to preserve coverage for abortion while stipulating that federal dollars may not be used except in cases of rape, incest, or to save the life of the mother.
In the end, Reid may have to bend. Catholic bishops say they can't accept his approach because it would let federally subsidized plans cover abortion. They vow to oppose the health care bill unless, like the House, the Senate enacts stronger language. Democratic senators opposed to abortion are already threatening a battle.
On financing, the House relies mainly on an income tax hike for upper-earners to pay for expanded coverage. The Senate opted for a tax on high-cost insurance plans, a Medicare payroll tax hike on the wealthy and fees on medical industries. In polls, the House approach is more popular. The Obama administration has signaled it likes the Senate's insurance tax.
That leaves the controversy over a creating a government health plan to compete with the insurance industry. It has dominated the debate and remains unresolved.
Both House and Senate bills now provide for a government insurance plan, but Reid's bill would let states opt out. It's not clear that Reid has the votes. He may be able to get a compromise to allow a government plan only if, after a reasonable time, insurance companies fail to deliver lower premiums.
Resolving these policy issues would be a historic accomplishment for Democrats. But the bill could still leave consumers feeling a little cheated.
The main consumer protections and financial help for the uninsured won't kick in for three to four years. The delay was necessary to tamp down costs. Even then, not all Americans would be covered.
The Congressional Budget Office estimates some 12 million eligible Americans would remain uninsured after the House bill is fully phased in, in 2019. Under the Senate bill, roughly 16 million would not have insurance. The bills would provide coverage to more than 30 million now uninsured, but workers would still be more likely to be uninsured than seniors.
Some who remain uninsured might be people who'd rather pay a fine than comply with a mandate to get coverage. But for others, federal subsidies won't go far enough. People with solid middle-class incomes who buy their own insurance are vulnerable, because subsidies are mainly aimed at lower-income households.
For example, a family of four headed by a 45-year-old making $66,000 a year would still have to pay about 10 percent of its income for health insurance, according to the Kaiser Family Foundation. That's after government help of about $4,500 and doesn't count the cost of deductibles and co-payments.
Finally, a temporary safety net for people with health problems has a hole.
Since government subsidies and insurance protections don't start until 2013 under the House bill and 2014 in the Senate version, both bills would set aside $5 billion to provide insurance for people who can't get coverage now because of health problems. But the budget office estimates that the money would be used up before the end of 2011.
"As we get toward a final bill that the public can look at more closely, the adequacy of the underlying coverage is going to emerge as a much bigger issue," said Drew Altman, president of the Kaiser Foundation, a nonpartisan research center. "That is going to put policymakers in an unenviable position."