A provision in President Obama's health care reform plan that requires businesses to offer health insurance to their workers or face a federal tax would cost employers at least $49 billion dollars a year, putting 5.2 million employees at risk of unemployment or underemployment, according to a new study.

"Health care reform is not going to be free," said economist Mark Wilson, who authored the study, which was commissioned by the conservative Heritage Foundation.

Under the provision, known as the play-or-pay mandate, another 10.2 million employees will face stunted wages and the loss of their benefits as employers try to find ways to fund the mandates.

"Those will be a difficult decision for them to make and they're also going to have to decide to the extent they can raise prices and pass the cost onto consumers," Wilson said.

But supporters of Obama's health reform plan say under the current system, thousands already are losing their health coverage or jobs because of the enormous costs employers are bearing.

"What we need to think about in health reform is how to make the system more efficient, how to make sure the system is protecting jobs, and that's exactly what health reform will do," said Peter Harbage, a health policy analyst with the liberal Center for American Progress.

White House spokesman Bill Burton said Thursday that without health reform the entire U.S. economy faces ruin.

"If we don't do something, not only is health care going to be in crisis, but the deficit will -- we just will not be on a fiscally sustainable path as it relates to the deficit," he said.

And as the financial realities of health reform are coming together there are questions about why tort reform isn't part of the package.

At a town hall hosted by Democratic Rep. Jim Moran this week, one person demanded to know why the threat of medical lawsuits couldn't be reduced.

"There's $200 million dollars in savings over 10 years if we had tort reform and nobody loses but the lawyers," the person said before shouting, "Why have we not even considered that?"

Former Democratic National Committee Chairman Howard Dean, a proponent of health reform, responded that tort reform would create more enemies for lawmakers as they try to pass a reform bill.

"Plain and simple truth," he said.

The president of the American Medical Association says without more protections for doctors in the courtroom they will continue to order tests that may be unnecessary and drive up health care costs simply to protect themselves.