The battle over reforming the nation's health insurance system might be nearing an end in Congress, but the debate over the historic legislation will continue.
Reaction in the Buffalo Niagara region reflects the divisions and confusion that split the nation in the months-long effort to pass a bill.
The legislation also is so complex that many people still don't understand exactly what it contains or how it will play out.
Like so many others who lack health insurance, Jan Bernas wonders what health reform will mean for her.
The Town of Tonawanda resident lives on a modest fixed income and worries that a mandate to obtain health insurance by 2014 or pay a penalty will force her to buy a policy she can't afford, even with a government subsidy.
"I just don't have the money," she said.
As it happens, Bernas likely will be eligible for expanded Medicaid coverage, another element of the plan that will take effect in 2014.
Still many, especially uninsured people with moderate incomes, continue to worry about the adequacy of the subsidies, which have been beefed up in the final bill, and about the individual requirement to buy insurance.
"If everyone needs to be in the insurance pool to share the risks of getting sick, then the subsidies must be affordable. The job now is to make sure that this will all work," said Ann Monroe, executive director of the Community Health Foundation of Western and Central New York.
The Kaiser Family Foundation developed an interactive tool that illustrates premiums and government assistance under the reform plan for people under age 65 who purchase coverage on their own and are not covered through their employer, Medicare or Medicaid.
It can be found at http://healthreform.kff.org.
Of course, the legislation involves more than subsidies and an expanded Medicaid to cover 32 million people who lack insurance.
Other elements include prohibiting insurance companies from denying coverage because of pre-existing conditions, helping fill the gap in prescription coverage in Medicare Part D, creating an independent Medicare advisory board to set policy, increasing funds for federally qualified community health centers, raising payments to primary care doctors and encouraging Medicare to experiment with alternative reimbursement systems that reward doctors and hospitals for the quality rather than quantity of services.
Is it enough reform? Is it too much? Is it the right kind of reform? Is it the wrong direction to take? Can the country afford the changes?
Different people continue to have different takes on those questions.
Dr. David Holmes, a family physician and vocal advocate in Buffalo of expanding coverage to the uninsured, viewed the legislation as generally good if it fulfills its promise of expanded coverage.
"I saw an uninsured patient with out-of-control diabetes this morning and wouldn't be surprised if the health care system spent at least $1 million on him in the last year. That cost would have been greatly reduced if he had insurance and kept the diabetes under control," Holmes said Monday.
Dr. Edward Cosgrove also supports making health care more accessible to the uninsured. But he wonders how the country can afford to pay for the expanded coverage and whether the implications of the legislation have been fully thought through.
"How do we get to the end of the road of this? How do you expand coverage and control costs in the future? Does all this put us on a slope toward more government control of health care, and is that what we want?" asked Cosgrove, a medical director for Western New York Immediate Care.
The cost of the expanded health reform coverage is pegged at $940 billion over 10 years, or about $94 billion a year.
To put that in perspective, total health care spending in 2014, the year many of the key reform elements start, is projected to be more than $3.2 trillion, according to the federal Centers for Medicare and Medicaid Services.
Cosgrove and Holmes agree on one point.
They both question who will care for the millions of newly insured Americans, in light of the shortage of physicians in the U.S. who provide basic medical services.
Joseph McDonald, chief executive officer of the Catholic Health system, offered a view echoed by others across the U.S.
He characterized the bill Congress passed as the most significant health care legislation since the introduction of Medicare in 1965. But he warned about the "devil in the details," saying how the legislation is translated into federal regulations, and how those regulations interact with state health laws, will be closely monitored by hospitals and other health-related organizations.
"I'm optimistic. We needed an event like this. It allows us to redefine our health system. We can launch initiatives for what health care can become instead of being locked into the status quo," McDonald said.
Among other things, he said the bill includes language that will ignite local efforts nationwide to devise more creative reimbursement policies that offer employers greater certainty about future health costs and improve accountability over quality.
"Long term the legislation also creates a more stable approach to caring for the poor," he said.
"If there is a downside that I worry about," he added, "it's how we manage that gap between the current system and the introduction of new rules and regs. A lot of work will need to be done on how those rules and regs are interpreted."
At Independent Health, one of the region's largest health insurers, Dr. Michael Cropp views the bill as a mixed bag.
He supports expanding coverage to the uninsured and agrees with the insurance industry reforms. But, like many others, wonders if the country first should have dealt with health care costs and quality.
"The [Congressional Budget Office] scoring of the bill does not likely reflect its true costs, so you have to wonder if the money is really there to fulfill a $1 trillion commitment," said Cropp, Independent Health's chief executive officer.
Cropp said a key part of the solution to health reform rests with more creative reimbursement systems tailored to the needs of a community. Such systems reward physicians and hospitals for excellent outcomes and provide funding for team-based care that includes nurses, physician assistants and others led by a physician, he said.
The health care legislation offers a start at encouraging new payment and care models on the local level that improve efficiency and quality, but may not have gone far enough, Cropp said.
"To transform health care we must encourage a culture of restrained spending, preventive care, engagement and transparency, while improving health outcomes," he said. "In short, we need to change how health care is delivered so it is both less expensive and more effective."