Washington ? Sixty years is how long Democrats say they’ve been pushing for legislation that provides health care access for all Americans. They’ll have to wait another three if President Barack Obama gets a bill to sign this year.

Under the Democratic bills, federal tax credits to help make health insurance affordable for millions of low- and middle-income households won’t start flowing until 2013 — after the next presidential election. But Medicare cuts and a sizable chunk of the tax increases to pay for the overhaul kick in immediately.

The eat-your-vegetables-first approach is causing heartburn for some Democrats. Three years is a long time to wait for dessert, and opponents could capitalize on misgivings about the complex legislation to undo what would be a signature achievement for Obama.

“The real danger is that health reform could be vulnerable to what we see with the stimulus package,” said Democratic health policy consultant Peter Harbage, referring to criticism that Obama’s $787 billion economic plan hasn’t stemmed rising unemployment. “There needs to be more focus on what can you do quickly so that real people will start seeing change sooner, rather than later.”

Said Judy Feder, a senior health official in President Bill Clinton’s administration: “Just as we are fending off ideological attacks to get the bill passed, we will be fending them off as we implement the law.”

Obama administration officials and Democratic lawmakers say the reason for the three-year wait is the time it’s going to take to set up insurance marketplaces, write consumer protection rules and reconfigure the bureaucracy to carry out the legislation. It took President George W. Bush’s administration two years to phase in the Medicare prescription benefit, a more modest undertaking.

“It’s very important to get the execution right,” White House budget director Peter Orszag told The Associated Press in a recent interview.

There’s another reason, less talked about: to make the costs of the plan seem more manageable under congressional budgeting rules.

Lawmakers use a 10-year accounting window to assess new programs. Starting the Medicare cuts and some of the taxes in the early years — and pushing the bulk of new spending into the latter years — helps keep the cost of the health care overhaul within Obama’s $900 billion limit. Bush used the same kind of maneuver to push the Medicare benefit through Congress.

“It means that the full cost of the program is underestimated in the 10-year window that you are looking at,” said Gail Wilensky, who ran Medicare for former President George H.W. Bush. “It’s not like we’ve never seen this before, but people need to understand what’s going on.”

Congressional Democrats are defensive about their slow-motion rollout.

Senate Finance Committee Chairman Max Baucus, D-Mont., addressed the concerns in a recent news release captioned: “What You Get Right Away.”

Among the major short-term improvements in his bill would be a benefit for people on Medicare, who already have insurance coverage. Starting in 2010, those who fall into the Medicare prescription plan’s coverage gap would get a 50 percent discount off the price of brand-name drugs.

If there’s a silver lining in the wait, it’s that it will give individuals and families time to prepare for a new federal requirement to carry health insurance, starting in 2013.