By Tom Still

MADISON – The passage of the health-care bill in Congress marked the end of one political debate and the start of a different struggle that will play out in the fall elections, in court challenges, in state legislatures and through continuing clashes between the nation’s largest interest groups.

As a result, what this bill means to businesses, individuals and the health-care industry itself is still largely up for grabs, depending on how the bill is enacted over time.

Under the bill, most Americans will be required – beginning in 2013 – to have health insurance or pay a fine. Larger employers will be required to provide coverage or risk financial penalties. Lifetime coverage limits for individuals covered by insurance plans will be banned, and insurers will be barred from denying coverage based on gender or pre-existing conditions.

The bill also allows young people to stay on their parents’ health plans until they are 26, reduces federal support for private Medical Advantage plans but spends more on Medicare prescription drug benefits, and provides small businesses with tax credits if they offer insurance plans. Those are among the provisions that take effect first.

But what worries opponents is the bill’s long-term effect on insurance premiums, the specter of more deficit spending, unintended consequences within the practice of medicine itself and the extension of the federal “nanny state.”

It’s the latter point that is likely to be challenged specifically in court. Attorneys general in about a dozen states have already said they will file lawsuits to test the constitutionality of the bill’s requirement that individuals must purchase insurance. They contend Congress does not have the power to impose such as mandate – or to require states to enact the federal plan.

The fall elections and the campaign for control of Congress is another battleground. Republicans will portray Democrats who voted for the bill as big spenders and advocates of big government; Democrats will paint Republicans as naysayers who failed to come up with a better idea for fixing health care.

The lines are drawn between major interest groups, as well. The president of the United States Chamber of Commerce has pledged to oppose the bill “through all available avenues – regulatory, legislative, legal and political,” and the National Federation of Independent Business has called it “a tax bill wrapped up in health-care paper.”

But other business groups range from muted to supportive. Hospitals, the American Medical Association and trade groups representing the biotechnology and pharmaceutical industries have found reasons to cheer many of the bill’s provisions, which they think will cover more Americans, encourage preventive care over expensive emergency room care, foster more research and make life-saving drugs more available.

For example, the Biotechnology Industry Organization applauded the bill’s creation of a regulatory pathway for the approval of “biosimilars,” which are generic biotech drugs that are substantially similar to the original but not precisely so. The bill helps to protect the intellectual rights of inventors while making such drugs safely available in time.

And while the largest trade group representing health insurance companies strongly opposed the plan, some industry analysts believe those insurance companies that survive may actually prosper under the new model. Why? More people will be covered.

A group to watch in Round 2 of the health-care debate is owners of small businesses, who create a disproportionate amount of the jobs in the United States and whose survival can be threatened by regulations that add costs and force them to think twice about expanding.

In the Tech Leaders Survey released in January, tech company executives across Wisconsin said they were worried that health-care costs will get worse instead of better under a reform bill. Now that the bill is passed, those same executives and others like them across the United States will ask how costs will be controlled – as President Obama and the Democrats contend – and not increase over time.

Passage of one bill, however massive and far-reaching, won’t end the debate over health care quality, cost and access in America. The debate will quickly move from Congress to voters, business owners and others with a direct stake in the long-term results. And in a representative democracy, that’s as it should be.

Still is president of the Wisconsin Technology Council. He is the former associate editor of the Wisconsin State Journal.