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Millions of smokers could be priced out of health insurance because of tobacco penalties in President Barack Obama's health care law, according to experts who are just now teasing out the potential impact of a little-noted provision in the massive legislation.

The Affordable Care Act — "Obamacare" to its detractors — allows health insurers to charge smokers buying individual policies up to 50 percent higher premiums starting next Jan. 1.

For a 55-year-old smoker, the penalty could reach nearly $4,250 a year. A 60-year-old could wind up paying nearly $5,100 on top of premiums.

Younger smokers could be charged lower penalties under rules proposed last fall by the Obama administration. But older smokers could face a heavy hit on their household budgets at a time in life when smoking-related illnesses tend to emerge.

Workers covered on the job would be able to avoid tobacco penalties by joining smoking cessation programs, because employer plans operate under different rules. But experts say that option is not guaranteed to smokers trying to purchase coverage individually.

Nearly one of every five U.S. adults smokes. That share is higher among lower-income people, who also are more likely to work in jobs that don't come with health insurance and would therefore depend on the new federal health care law. Smoking increases the risk of developing heart disease, lung problems and cancer, contributing to nearly 450,000 deaths a year.

Insurers won't be allowed to charge more under the overhaul for people who are overweight, or have a health condition like a bad back or a heart that skips beats — but they can charge more if a person smokes.

Starting next Jan. 1, the federal health care law will make it possible for people who can't get coverage now to buy private policies, providing tax credits to keep the premiums affordable. Although the law prohibits insurance companies from turning away the sick, the penalties for smokers could have the same effect in many cases, keeping out potentially costly patients.

"We don't want to create barriers for people to get health care coverage," said California state Assemblyman Richard Pan, who is working on a law in his state that would limit insurers' ability to charge smokers more. The federal law allows states to limit or change the smoking penalty.

"We want people who are smoking to get smoking cessation treatment," added Pan, a pediatrician who represents the Sacramento area.

Obama administration officials declined to be interviewed for this article, but a former consumer protection regulator for the government is raising questions.

"If you are an insurer and there is a group of smokers you don't want in your pool, the ones you really don't want are the ones who have been smoking for 20 or 30 years," said Karen Pollitz, an expert on individual health insurance markets with the nonpartisan Kaiser Family Foundation. "You would have the flexibility to discourage them."

Several provisions in the federal health care law work together to leave older smokers with a bleak set of financial options, said Pollitz, formerly deputy director of the Office of Consumer Support in the federal Health and Human Services Department.

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Confused about the federal budget struggle? So are doctors, hospital administrators and other medical professionals who serve the 100 million Americans covered by Medicare and Medicaid.

Rarely has the government sent so many conflicting signals in so short a time about the bottom line for the health care industry.

Cuts are coming, says Washington, and some could be really big. Yet more government spending is also being promised as President Barack Obama's health care overhaul advances and millions of uninsured people move closer to getting government-subsidized coverage.

"Imagine a person being told they are going to get a raise, but their taxes are also going to go up and they are going to be paying more for gas," said Thornton Kirby, president of the South Carolina Hospital Association. "They don't know if they are going to be taking home more or less. That's the uncertainty when there are so many variables in play."

Real money is at stake for big hospitals and small medical practices alike. Government at all levels pays nearly half the nation's health care tab, with federal funds accounting for most of that.

It's widely assumed that a budget deal will mean cuts for Medicare service providers. But which ones? How much? And will Medicaid and subsidies to help people get coverage under the health care law also be cut?

As House Speaker John Boehner famously said: "God only knows." The Ohio Republican was referring to the overall chances of getting a budget deal, but the same can be said of how health care — one-sixth of the economy — will fare.

"There is no political consensus to do anything significant," said Dan Mendelson, president of Avalere Health, a market analysis firm. "There is a collective walking away from things that matter. All the stuff on the lists of options becomes impossible, because there is no give-and-take."

As if things weren't complicated enough, doctors keep facing their own recurring fiscal cliff, separate from the bigger budget battle but embroiled in it nonetheless.

Come Jan. 1, doctors and certain other medical professionals face a 26.5 percent cut in their Medicare payments, the consequence of a 1990s deficit-reduction law gone awry. Lawmakers failed to repeal or replace that law even after it became obvious that it wasn't working. Instead, Congress usually passes a "doc fix" each year to waive the cuts.

This year, the fix got hung up in larger budget politics. Although a reprieve is expected sooner or later, doctors don't like being told to sit in the congressional waiting room.

"It seems like there is a presumption that physicians and patients can basically tolerate this kind of uncertainty while the Congress goes through whatever political machinations they are going through," said Dr. Jeremy Lazarus, president of the American Medical Association. "Our concern is that physician uncertainty and anxiety about being able to pay the bills will have an impact on taking care of patients."

A recent government survey indicates that Medicare beneficiaries are having more problems when trying to find a new primary care doctor, and Lazarus said that will only get worse.

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Pennsylvania will not set up its own health care exchange under the federal Affordable Care Act, at least not for now, Gov. Tom Corbett said Wednesday, putting the state on a course to join others led by Republicans that will let President Barack Obama's administration run its exchange.

Setting up a state-based exchange would be irresponsible, Corbett said, as he faulted federal authorities for what he called inadequate answers to his questions about cost and other issues.

"Health care reform is too important to be achieved through haphazard planning," Corbett said. "Pennsylvania taxpayers and businesses deserve more. They deserve informed decision making and a strong plan that responsibly uses taxpayer dollars."

The Corbett administration also is rejecting the option of running the exchange as a partnership with the federal government, spokeswoman Christine Cronkright said. But she also noted that the administration has the ability under the law to re-evaluate every year whether to get involved.

Corbett said it "would be irresponsible to put Pennsylvanians on the hook for an unknown amount of money to operate a system under rules that have not been fully written."

The exchanges are to be up and running Jan. 1, 2014.

Many Democratic lawmakers, insurers and hospitals wanted Corbett to set up a state-run system. As Pennsylvania's attorney general in 2010, Corbett joined a federal lawsuit with officials from other states challenging the constitutionality of the landmark federal health care law that was ultimately upheld by the U.S. Supreme Court.

Reaction broke down along partisan lines among Pennsylvania's congressional members and in the state Legislature.

The state Republican Party thanked Corbett for rejecting the exchange. The Washington, D.C.-based group Americans for Prosperity, which was founded by billionaire energy executives Charles and David Koch, had urged Corbett along with other governors to reject it. The group even sent a news release 20 minutes before he released his decision publicly Wednesday, saying they expected Corbett to "bring Christmas early to Pennsylvania" by rejecting an exchange.

State Sen. Daylin Leach, D-Montgomery, said Corbett's reasons for not participating appeared to be more thoughtful than some Republican governors who refused to participate strictly on partisan or ideological grounds. A better test of Corbett's interest in helping the uninsured will come when he decides whether to pursue a federally funded expansion of Medicaid under the law, Leach said.

To that end, Corbett said he will continue to seek guidance from the federal Department of Health and Human Services "on the costs, impacts and flexibility involved in the different options for Medicaid expansion."

Antoinette Kraus, of the Philadelphia-based health care advocacy coalition Pennsylvania Health Access Network, said the Corbett administration could have taken advantage of the opportunity to be innovative in crafting the health care exchange specific to Pennsylvania. But, she said, the most important thing is that people will get help finding coverage through the exchange.

"It's doesn't matter if it's the state or the federal government running it at the end of the day," Kraus said.

So far, 17 states and Washington, D.C., have said they will set up their own exchanges, while 20 other Republican-led states have opted to allow the federal government in. Another seven states have picked the partnership model, and the rest are trying to decide. States that want to run their own exchanges had until Friday to submit plans, and the deadline for partnership applications isn't until February.

The new insurance exchanges will allow households and small businesses to buy a private health plan, and many will get help from the government to pay their premiums. Under the law, states that can't or won't set up exchanges will have theirs run by the federal government.

The partnership option allows states to handle consumer relations and oversight of health plans, while the federal government does the bulk of the work, including handling enrollment and figuring out how much taxpayer-funded help consumers may be entitled to.

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