WASHINGTON - Among the promises of the health reform law -- now in the hands of the Supreme Court -- is affordable insurance for millions of low- and middle-income Americans.
But delivering on that promise won't be free.
The federal government is set to spend more than $1 trillion over the next decade to subsidize coverage and to expand eligibility for Medicaid.
And to pay for it, the law imposes a slew of cuts in federal health care spending, as well as a number of taxes, fees and penalties.
Those taxes will be paid by health sector companies and hospitals; employers and consumers.
Individuals who will help foot the tab -- directly or indirectly -- include very high-income households, those with very generous health benefits at work, those who opt to remain uninsured and those who love a good indoor tan.
Medicare surtax: Starting in 2013, many individuals making more than $200,000 a year ($250,000 if married) will start paying more into Medicare.
The health reform law changes the Medicare tax in two ways: It adds a surtax on wage income above a certain level, and it creates a new Medicare tax on investment income.
Some high-income households will only be subject to one of those changes, and some will be subject to both.
Starting next year, high-income individuals will pay another 0.9 percentage points on their earned income over $200,000 ($250,000 if married). That's on top of the 1.45% they currently pay on all of their wages.
For those with investment income, they also could be subject to a new 3.8% tax on at least a portion of their capital gains and dividends.
New mandate to buy insurance: Starting in 2014, individuals must be insured or pay a penalty.
The amount of the penalty rises annually from 2014 to 2016 and is adjusted for inflation thereafter.
In 2014, the penalty will be no more than $285 per family or 1% of income, whichever is greater. In 2015, the cap rises to $975 or 2% of income. And by 2016, the penalty would be up to $2,085 per family or 2.5% of income, whichever is greater.
The dollar amounts for a single adult would be $95, $325 and then $625 during that same time period.
There are, however, are a number of exemptions. For instance, the penalty will be waived for people with very low incomes who are members of certain religious groups, or who face insurance premiums that would exceed 8% of family income even after including employer contributions and federal subsidies.
For more on how the mandate works, check out this flow chart from the Kaiser Family Foundation.
Many believe that if the Supreme Court strikes down any single provision in the health reform law, it could be the mandate.
New tax on high-cost employer plans: Starting in 2018, insurers of employer-sponsored plans -- or companies that self-insure their own plans -- will be subject to an excise tax if their plan cost tops $10,200 for individual coverage and $27,500 for family coverage. (Thresholds are higher for plans covering retirees and workers in high-risk jobs.)
The theory is that the so-called "Cadillac tax" will encourage companies to choose lower cost plans, and that will free up money to pay workers higher, taxable wages. That, in turn, boosts revenue paid into federal coffers.
Roughly 60% of large employers -- those with more than 500 employees -- believe their plans would trigger the tax unless they take action to avoid it, according to a 2011 survey by Mercer, a human resources consulting firm.
About half of those employers, however, don't think they will be able to get the value of their plan below the threshold.
"While some employers offer high-cost plans because generous benefits are part of their attraction and retention strategy, others have high-cost plans simply because they have an older or less healthy workforce or are located in a high-cost area," Mercer wrote in its survey analysis.
Cap on flexible spending accounts: Starting in 2013, the tax-deductible amount a worker may contribute to a flexible spending plan will be set at $2,500 and adjusted for inflation thereafter.
Currently there is no official limit, but employers set one for each plan.
Money contributed to FSAs may be used to pay for qualified health expenses but generally must be spent during the calendar year.
And in 2011, the law narrowed the list of qualified expenses that an FSA could pay for.
Penalty for misuse of health spending accounts: The health reform law imposed a 20% penalty for the use of a health spending account to pay for non-qualified expenses.
That provision went into effect in 2011.
Money a worker contributes to an HSA is tax deductible, while money his employer contributes to his account is tax-free. Interest and gains earned on the money invested can grow tax-free, and there is no time requirement on when the money must be used. But to qualify for an HSA, a worker must be enrolled in a high-deductible health insurance plan.
Higher threshold on medical deductions: Currently, if your medical expenses exceed 7.5% of your adjusted
gross income, you may deduct the amount above 7.5%. Starting next year, however, you will only be allowed to deduct the amount above 10% of AGI.
That increase, however, is waived for tax years 2013 through 2016 for anyone 65 and older.