Division C of the bill, which begins on Page 855, is entitled Public Health and Workforce Development. The first provision gradually increases payments each fiscal year into a "Public Health Investment Fund".
Title I is about Community Health Centers. The first provision increases funding for such centers. It's actually the only provision under this Title.
Title II is about Workforce. Subtitle A deals with Primary Care Workforce. Part 1 is about the National Health Service Corps. The NHSC is appropriated funding out of the above-named Public Health Investment Fund.
Part 2 deals with the promotion of primary care and dentistry (yay dentistry!). Medical students who agree to serve for at least two years as primary care providers in the NHSC in underserved areas are eligible for loan repayments. Provisions also deal with training for general, pediatric, and public health dentists and dental hygienists. The funding for all of these things come from the Public Health Investment Fund.
Subtitle B deals with the Nursing Workforce. Nurses can enter into agreements similar to those for physicians by agreeing to serve at least two years in underserved areas. The funding is through the Public Health Investment Fund.
Subtitle C is about the Public Health Workforce. These "public health professionals" can also agree to serve for at least two years.
Subtitle D entails Adapting Workforce to Evolving Health System Needs. Part 1 deals with Health Professions Training for Diversity. Part 2 deals with Interdisciplinary Training Programs, such as cultural and linguistic competency training. Part 3 establishes an Advisory Committee on Health Workforce Evaluation and Assessment. Part 4 deals with Health Workforce Assessment. Part 5 deals with Authorization of Appropriations.
Title III: Prevention and Wellness begins on Page 930 of HR 3200. Provisions deal with appropriations, setting national priorities, creating a Task Force on Clinical Preventive Services and a Task Force on Community Preventive Services, coordinating research on prevention and wellness, establishing through grants a core public health infrastructure program.
Title IV: Quality and Surveillance begins on Page 964. The provisions deal heavily with the identification and development of "best practices".
Title V: Other Provisions begins on Page 979. Subtitle A deals with Drug Discounts for Rural and Other Hospitals. It's an amendment to an existing program. Subtitle B is about School-Based Health Clinics. The provisions establish through grants health clinics based in schools in certain medically underserved areas. Subtitle C deals with the National Medical Device Registry, establishing such a registry to facilitate analysis of postmarket safety and outcomes data on Class III or some class II devices (the FDA classes devices based on consumer safety; class I is the safest) used on or in patients. Subtitle D establishes Grants for Comprehensive Programs to Provide Education to Nurses and Create a Pipeline to Nursing. Subtitle E deals with States Failing to Adhere to Certain Employment Obligations.
Aaaaaaaaaaaaaaaaaaaand that's a wrap. HR 3200, 1017-page bill, read and analyzed, as my eyes saw it. Obviously the average American does not have time to read through the whole bill to figure out what's in it. I wish there were an official source for summaries of all (not just controversial) provisions. I believe THOMAS (http://thomas.loc.gov) provides summaries with the full text of the bill, but it's not always the easiest sort of thing to understand. Do I dare read the Senate HELP Committee's bill??? Or wait for the Finance Committee's bill?
Wednesday, August 26, 2009
HEALTH CARE REFORM: Chapter 10
Title VII is about Medicaid and CHIP. Subtitle A deals with Medicaid and Health Reform. Because Division A of the bill stated that all eligible Medicaid beneficiaries would be auto-enrolled absent other acceptable health insurance coverage, these provisions are important, establishing the procedure. Other provisions deal with the affordability credits discussed in Division A.
Subtitle B is about Prevention, requiring coverage of certain preventive services in Medicaid. Section 1714 contains a State Eligibility Option for Family Planning Services. States can choose to cover in their Medicaid program " family planning services and supplies...including medical diagnosis and treatment services that are provided pursuant to a family planning service in a family planning setting". Such services are only available to women who are not pregnant, so abortions definitely are not covered here.
Subtitle C deals with Access. Subtitle D deals with Coverage. Subtitle E deals with Financing. Subtitle F deals with Waste, Fraud, and Abuse. Subtitle G deals with Puerto Rico and the Territories. Subtitle H contains Miscellaneous provisions.
Title VIII, which begins on Page 819, is entitled Revenue-Related Provisions.
Title IX begins on Page 835 and contains Miscellaneous Provisions. For example, Section 1905 protects dual eligibles (at times the rules of Medicare and Medicaid can be in conflict with each other). That brings us to Page 854, the end of Division B of the bill.
Subtitle B is about Prevention, requiring coverage of certain preventive services in Medicaid. Section 1714 contains a State Eligibility Option for Family Planning Services. States can choose to cover in their Medicaid program " family planning services and supplies...including medical diagnosis and treatment services that are provided pursuant to a family planning service in a family planning setting". Such services are only available to women who are not pregnant, so abortions definitely are not covered here.
Subtitle C deals with Access. Subtitle D deals with Coverage. Subtitle E deals with Financing. Subtitle F deals with Waste, Fraud, and Abuse. Subtitle G deals with Puerto Rico and the Territories. Subtitle H contains Miscellaneous provisions.
Title VIII, which begins on Page 819, is entitled Revenue-Related Provisions.
Title IX begins on Page 835 and contains Miscellaneous Provisions. For example, Section 1905 protects dual eligibles (at times the rules of Medicare and Medicaid can be in conflict with each other). That brings us to Page 854, the end of Division B of the bill.
HEALTH CARE REFORM: Chapter 9
Title V of this Division is about Medicare Graduate Medical Education, specifically about the redistribution of unused residency positions.
Title VI: Program Integrity starts on Page 685. Subtitle A deals with increased funding to fight waste, fraud, and abuse, appropriating an additional $100 million a year.
Subtitle B enhances the penalties for fraud and abuse. Subtitle C contains enhanced program and provider protections. Subtitle D deals with access to information needed to prevent fraud, waste, and abuse.
Title VI ends on Page 739.
Title VI: Program Integrity starts on Page 685. Subtitle A deals with increased funding to fight waste, fraud, and abuse, appropriating an additional $100 million a year.
Subtitle B enhances the penalties for fraud and abuse. Subtitle C contains enhanced program and provider protections. Subtitle D deals with access to information needed to prevent fraud, waste, and abuse.
Title VI ends on Page 739.
HEALTH CARE REFORM: Chapter 8
Title IV is entitled Quality. Subtitle A is about Comparative Effectiveness Research. The bill calls for a study on the effectiveness of "health care items and services".
Subtitle B deals with Nursing Home Transparency. Skilled nursing facilities would be required to develop compliance and ethics programs. The Department of Health and Human Services would be required to have a comparison feature of nursing homes with the information obtained from the study mandated in this bill on their web site. The bill calls for a standardized formal complaint procedure for all skilled nursing facilities, as well as a complaint resolution process. The bill establishes some minimum and maximum civil penalties based on certain types of violations. This subtitle is very detailed.
Subtitle C deals with Quality Measurements. The bill calls for the establishment of national priorities for performance improvement, such as those that have the greatest potential to decrease morbidity and mortality.
Subtitle D is the Physician Payments Sunshine Provision. The bill calls for financial reports on physicians' financial relationships with the manufacturers and distributors of drugs and other supplies that bill under Medicare.
Subtitle E deals with Public Reporting on Health Care-Associated Infections. Title IV concludes at the end of Page 658.
Subtitle B deals with Nursing Home Transparency. Skilled nursing facilities would be required to develop compliance and ethics programs. The Department of Health and Human Services would be required to have a comparison feature of nursing homes with the information obtained from the study mandated in this bill on their web site. The bill calls for a standardized formal complaint procedure for all skilled nursing facilities, as well as a complaint resolution process. The bill establishes some minimum and maximum civil penalties based on certain types of violations. This subtitle is very detailed.
Subtitle C deals with Quality Measurements. The bill calls for the establishment of national priorities for performance improvement, such as those that have the greatest potential to decrease morbidity and mortality.
Subtitle D is the Physician Payments Sunshine Provision. The bill calls for financial reports on physicians' financial relationships with the manufacturers and distributors of drugs and other supplies that bill under Medicare.
Subtitle E deals with Public Reporting on Health Care-Associated Infections. Title IV concludes at the end of Page 658.
HEALTH CARE REFORM: Chapter 7
Title III is entitled Promoting Primary Care, Mental Health Services, and Coordinated Care. Its first provision creates an "Accountable Care Organization Pilot Program". The second provision creates a "Medical Home Pilot Program". The third provision creates payment incentives for selected primary care services. The fourth provision increases the reimbursement rate for certified nurse-midwives (although I have to wonder how many Medicare beneficiaries utilize such providers). The fifth provision is about coverage and waiver of cost-sharing for preventive services, such as prostate cancer screenings. The sixth provision waives the deductible for colorectible for colorectal cancer screenings "regardless of coding, subsequent diagnosis, or ancillary tissue removal". The seventh provision excludes clinical social worker services from coverage under the Medicare Skilled Nursing Facility Prospective Payment System and Consolidated Payment. The eighth provision covers marriage and family therapist services and mental health counselor services. I understand that some people have latched onto the idea that the government is going to intervene in their marriage, but they don't have to receive such services and have them covered by Medicare if they don't want to. The ninth provision extends the physician fee schedule mental health add-on. The tenth provision expands access to vaccines. Those 10 brief provisions bring us to Page 501 and the end of Title III.
HEALTH CARE REFORM: Chapter 6
Apparently my numbers for the doughnut hole were low on both ends, but the size and existence of this gap depends on which Medicare Part D a beneficiary is enrolled in.
Now we're looking at Title II: Medicare Beneficiary Improvements. Subtitle A is about improving and simplifying financial assistance for low income Medicare beneficiaries. Although Medicare is generally a MUCH better deal than any private insurance, beneficiaries are still responsible for a certain number of expenses themselves, so low income individuals are eligible for some subsidies. There are the so-called "dual eligibles" who are eligible for both Medicare and Medicaid.
Subtitle B is about reducing health disparities. Provisions include insuring effective communication, such as by providing reimbursements for linguistically and culturally appropriate services.
Subtitle C contains "Miscellaneous Improvements". They do seem pretty miscellaneous. For example, the months of coverage for immuno-suppresive drugs for kidney transplant patients is extended.
That brings us to Section 1233: Advance Care Planning Consultation.
The term "advance care planning consultation" is defined as a "consultation between the individual and a practitioner...regarding advance care planning, if...the individual involved has not had a consultation within the last 5 years. Such consultation shall include the following: (A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to. (B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses. (C) An explanation by the practitioner of the role and responsibilities of a health care proxy. (D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965). (E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title. (F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include-- (I) the reasons why the development of such an order is beneficial to the individual and the individual's family and the reasons why such an order should be updated periodically as the health of the individual changes; (II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and (III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy). (ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State-- (I) in which all legal barriers have beern addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and (II) that has in effect a program for orders for life sustaining treatment described in clause (iii). (iii) A program for orders for life sustaining treatment for a States described in this clause is a program that-- (I) ensures such orders are standardized and uniquely identifiable throughout the State; (II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional's authority under State law) may sign orders for life sustaining treatment; (III) provides traning for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and (IV) is guided by a coalition of stake-holders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association. (2) A practitioner described in this paragraph is-- (A) a physician; and (B) a nurse practitioner or physician's assistant who has the authority under State law to sign orders for life sustaining treatments.".
That's a lot of text, but I think it's very important to look very closely at what the actual text says (and keep in mind the concept of an advance planning care directive was bipartisan until Sarah Palin came out with the death panel nonsense).
In the first place, these consultations are not mandatory. All the language says is that physicians can be reimbursed, no more than once every five years unless there is a serious change in medical condition, by Medicare for such consultations.
In no way is the practitioner or the government dictating end of life care. The provider is to explain the options available. How dare practitioners tell patients they can name a legal surrogate in case they are incapacitated!!!!!!
Frankly, I don't see how this is not a GREAT idea. Seniors have a right to know their rights. If they decide that they want great medical lengths to be taken to preserve their life, so be it. If they would prefer hospice care, they have a right for that preference to be known and honored.
Personally, I almost feel like I should have a living will drawn up soon. I do not want extraordinary measures to be taken to preserve my life, even as a relatively healthy 21-year-old, if its quality will be severely diminished.
Critics of these consultations say that we are "trying to pull the plug on Grandma". End of life care, particularly in hospitals, is expensive, no doubt about that. These costs will continue to go up as health care advances and the Baby Boomers continue to age. But we're not dictating care! And in no way is this euthanasia! All the bill says is that once every five years, a Medicare beneficiary can have a consultation with a physician about their OPTIONS.
Some may OPT to create an "order regarding life sustaining treatment", which is defined as "an actionable medical order relating to the treatment of that individual that-- (i) is signed and dated by a physicial or another health care professional (as specified by the Secretary and who is acting within the scope of the professional's authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care; (ii) effectively communicates the individual's preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual; (iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary)".
How dare we document these preferences, which "may range from an indication for full treatment to an indication to limit some or all specified interventions".
This information would also be published in the "Medicare & You Handbook" distributed to beneficiaries.
Maybe it's me, but I don't detect anything sinister.
At all.
I think it would be a shame for someone who would want to have his preferences known not able to create such an order because he would have to pay his physician out of pocket for it.
There are a few other provisions, but basically that brings us to page 443 and Title III.
Now we're looking at Title II: Medicare Beneficiary Improvements. Subtitle A is about improving and simplifying financial assistance for low income Medicare beneficiaries. Although Medicare is generally a MUCH better deal than any private insurance, beneficiaries are still responsible for a certain number of expenses themselves, so low income individuals are eligible for some subsidies. There are the so-called "dual eligibles" who are eligible for both Medicare and Medicaid.
Subtitle B is about reducing health disparities. Provisions include insuring effective communication, such as by providing reimbursements for linguistically and culturally appropriate services.
Subtitle C contains "Miscellaneous Improvements". They do seem pretty miscellaneous. For example, the months of coverage for immuno-suppresive drugs for kidney transplant patients is extended.
That brings us to Section 1233: Advance Care Planning Consultation.
The term "advance care planning consultation" is defined as a "consultation between the individual and a practitioner...regarding advance care planning, if...the individual involved has not had a consultation within the last 5 years. Such consultation shall include the following: (A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to. (B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses. (C) An explanation by the practitioner of the role and responsibilities of a health care proxy. (D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965). (E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title. (F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include-- (I) the reasons why the development of such an order is beneficial to the individual and the individual's family and the reasons why such an order should be updated periodically as the health of the individual changes; (II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and (III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy). (ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State-- (I) in which all legal barriers have beern addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and (II) that has in effect a program for orders for life sustaining treatment described in clause (iii). (iii) A program for orders for life sustaining treatment for a States described in this clause is a program that-- (I) ensures such orders are standardized and uniquely identifiable throughout the State; (II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional's authority under State law) may sign orders for life sustaining treatment; (III) provides traning for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and (IV) is guided by a coalition of stake-holders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association. (2) A practitioner described in this paragraph is-- (A) a physician; and (B) a nurse practitioner or physician's assistant who has the authority under State law to sign orders for life sustaining treatments.".
That's a lot of text, but I think it's very important to look very closely at what the actual text says (and keep in mind the concept of an advance planning care directive was bipartisan until Sarah Palin came out with the death panel nonsense).
In the first place, these consultations are not mandatory. All the language says is that physicians can be reimbursed, no more than once every five years unless there is a serious change in medical condition, by Medicare for such consultations.
In no way is the practitioner or the government dictating end of life care. The provider is to explain the options available. How dare practitioners tell patients they can name a legal surrogate in case they are incapacitated!!!!!!
Frankly, I don't see how this is not a GREAT idea. Seniors have a right to know their rights. If they decide that they want great medical lengths to be taken to preserve their life, so be it. If they would prefer hospice care, they have a right for that preference to be known and honored.
Personally, I almost feel like I should have a living will drawn up soon. I do not want extraordinary measures to be taken to preserve my life, even as a relatively healthy 21-year-old, if its quality will be severely diminished.
Critics of these consultations say that we are "trying to pull the plug on Grandma". End of life care, particularly in hospitals, is expensive, no doubt about that. These costs will continue to go up as health care advances and the Baby Boomers continue to age. But we're not dictating care! And in no way is this euthanasia! All the bill says is that once every five years, a Medicare beneficiary can have a consultation with a physician about their OPTIONS.
Some may OPT to create an "order regarding life sustaining treatment", which is defined as "an actionable medical order relating to the treatment of that individual that-- (i) is signed and dated by a physicial or another health care professional (as specified by the Secretary and who is acting within the scope of the professional's authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care; (ii) effectively communicates the individual's preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual; (iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary)".
How dare we document these preferences, which "may range from an indication for full treatment to an indication to limit some or all specified interventions".
This information would also be published in the "Medicare & You Handbook" distributed to beneficiaries.
Maybe it's me, but I don't detect anything sinister.
At all.
I think it would be a shame for someone who would want to have his preferences known not able to create such an order because he would have to pay his physician out of pocket for it.
There are a few other provisions, but basically that brings us to page 443 and Title III.
Tuesday, August 25, 2009
Edward M. Kennedy, 1932-2009
Obviously we must take a minute to remember the Senator who championed health care reform. Say what you will about Ted's personal life, but the Lion of the Senate was a very dedicated lawmaker, working tirelessly towards the passage of such hallmarks as the American with Disabilities Act and SCHIP. My thoughts are with the Kennedy family.
Sadly, I'm not sure what Ted's death will mean for health care reform. Many believe that if he had not been so ill, much more progress would have been made already in terms of formulating a bipartisan compromise, his forte despite being an extremely liberal senator. His death presents a banner for the health care reform reform movement, as he truly did champion health care reform his entire 47-year Senate career. Unfortunately, the vacancy will probably not be filled quickly, and Senator Robert Byrd's health is very unwell, so the 60 votes will be tricky to find.
RIP, Ted.
Sadly, I'm not sure what Ted's death will mean for health care reform. Many believe that if he had not been so ill, much more progress would have been made already in terms of formulating a bipartisan compromise, his forte despite being an extremely liberal senator. His death presents a banner for the health care reform reform movement, as he truly did champion health care reform his entire 47-year Senate career. Unfortunately, the vacancy will probably not be filled quickly, and Senator Robert Byrd's health is very unwell, so the 60 votes will be tricky to find.
RIP, Ted.
HEALTH CARE REFORM: Chapter 5
Division B deals with Medicare and Medicaid improvements. It really is the bulk of the bill.
Title I is entitled Improving Health Care Value. Subtitle A contains the provisions related to Medicare Part A, which is the hospital insurance aspect of Medicare. Part 1 of this subtitle deals with "market basket updates". Market baskets are a measure of inflation, so here reimbursements seem to be updated to keep up with inflation.
Part 2 of the subtitle is "Other Medicare Part A Provisions". For example, here we find a change in the "recalibration factor" for skilled nursing facility reimbursement. Another provision is a study of Medicare DSH payments (disproportionate share, extra payments to hospitals who treat a lot of Medicare and low-income patients) in light of more low-income patients being insured through Division A of the bill.
Subtitle B contains provisions related to Part B, which is the medical insurance Medicare component. The first provision here deals with sustainable growth reform. The next section singles out some potentially misvalued codes under the physician fee schedule. The third section is about incentive payments for efficient areas. The fourth section modifies the Physician Quality Reporting Initiative (PQRI). The fifth section adjusts the Medicare payment localities.
Part 2 of Subtitle B is about market basket updates. Part 3 is about other provisions, such as modifications to Medicare's involvement in the rental and purchase of power-driven wheelchairs. Another important provision calls for a study evaluating the difference between the costs incurred by cancer hospitals and the costs incurred by other hospitals when treating Medicare patients with cancer.
Subtitle C is provisions related to Medicare Parts A and B (tricksters, I was expecting Part C).
The first provision is about reducing potentially preventable hospital readmissions. I think this idea is somewhat controversial in that it seems to penalize hospitals when their patients are readmitted. However, from my understanding of the language, hospitals are paid a certain amount when their Medicare patients are discharged, and these discharge payments would be reduced. These payments will be reduced taking into account the hospital's "excess readmission ratio". Certain readmission cases for certain conditions are excluded from counting. The idea is to create an incentive to prevent, when possible, readmissions. Targeted hospitals would receive additional payments to be used for transitional care activities to address the patient noncompliance issues that result in higher than normal readmission rates.
Another provision deals with self-referrals and hospital ownership interests held by physicians. There is a prohibition on self-referrals under Medicare. There are exceptions to this exception for rural providers and in certain situations of hospital ownership.
Subtitle D is Medicare Advantage (Medicare Part C, basically private plans, often with prescription drug coverage, offered to Medicare beneficiaries) reforms. Each Medicare Advantage plan will receive a quality performance score. Improvement will also be tracked. Plans that do not provide performance data will automatically be ranked as the worst plans.
Subtitle E contains improvements to Medicare Part D (private prescription drug plans offered to Medicare beneficiaries; some Medicare Advantage plans contain a Part D component). The first provision sets out a schedule for gradually eliminating the coverage gap (known as the doughnut hole where beneficiaries have to pay out of pocket 100% of prescription drug costs once their total drug costs are over $2400 until they reach $3850; not all plans have this gap in coverage).
Subtitle F contains Medicare Rural Access Protections. The first provision is about telehealth expansion. Telehealth already seems to be utilized, especially in rural areas, and the bill creates a Telehealth Advisory Committee to establish what services are appropriate to be delivered in this manner.
This subtitle brings us to page 385 and the end of Title I of Division B. I haven't gone in to a lot of details on these provisions, largely because they all seem to be pretty non-radical (no death panels, that's coming up) amendments to Medicare that will probably get passed even if the health care reform bill dies. But I really want the government to stay away from my Medicare! That would be awful!!
Title I is entitled Improving Health Care Value. Subtitle A contains the provisions related to Medicare Part A, which is the hospital insurance aspect of Medicare. Part 1 of this subtitle deals with "market basket updates". Market baskets are a measure of inflation, so here reimbursements seem to be updated to keep up with inflation.
Part 2 of the subtitle is "Other Medicare Part A Provisions". For example, here we find a change in the "recalibration factor" for skilled nursing facility reimbursement. Another provision is a study of Medicare DSH payments (disproportionate share, extra payments to hospitals who treat a lot of Medicare and low-income patients) in light of more low-income patients being insured through Division A of the bill.
Subtitle B contains provisions related to Part B, which is the medical insurance Medicare component. The first provision here deals with sustainable growth reform. The next section singles out some potentially misvalued codes under the physician fee schedule. The third section is about incentive payments for efficient areas. The fourth section modifies the Physician Quality Reporting Initiative (PQRI). The fifth section adjusts the Medicare payment localities.
Part 2 of Subtitle B is about market basket updates. Part 3 is about other provisions, such as modifications to Medicare's involvement in the rental and purchase of power-driven wheelchairs. Another important provision calls for a study evaluating the difference between the costs incurred by cancer hospitals and the costs incurred by other hospitals when treating Medicare patients with cancer.
Subtitle C is provisions related to Medicare Parts A and B (tricksters, I was expecting Part C).
The first provision is about reducing potentially preventable hospital readmissions. I think this idea is somewhat controversial in that it seems to penalize hospitals when their patients are readmitted. However, from my understanding of the language, hospitals are paid a certain amount when their Medicare patients are discharged, and these discharge payments would be reduced. These payments will be reduced taking into account the hospital's "excess readmission ratio". Certain readmission cases for certain conditions are excluded from counting. The idea is to create an incentive to prevent, when possible, readmissions. Targeted hospitals would receive additional payments to be used for transitional care activities to address the patient noncompliance issues that result in higher than normal readmission rates.
Another provision deals with self-referrals and hospital ownership interests held by physicians. There is a prohibition on self-referrals under Medicare. There are exceptions to this exception for rural providers and in certain situations of hospital ownership.
Subtitle D is Medicare Advantage (Medicare Part C, basically private plans, often with prescription drug coverage, offered to Medicare beneficiaries) reforms. Each Medicare Advantage plan will receive a quality performance score. Improvement will also be tracked. Plans that do not provide performance data will automatically be ranked as the worst plans.
Subtitle E contains improvements to Medicare Part D (private prescription drug plans offered to Medicare beneficiaries; some Medicare Advantage plans contain a Part D component). The first provision sets out a schedule for gradually eliminating the coverage gap (known as the doughnut hole where beneficiaries have to pay out of pocket 100% of prescription drug costs once their total drug costs are over $2400 until they reach $3850; not all plans have this gap in coverage).
Subtitle F contains Medicare Rural Access Protections. The first provision is about telehealth expansion. Telehealth already seems to be utilized, especially in rural areas, and the bill creates a Telehealth Advisory Committee to establish what services are appropriate to be delivered in this manner.
This subtitle brings us to page 385 and the end of Title I of Division B. I haven't gone in to a lot of details on these provisions, largely because they all seem to be pretty non-radical (no death panels, that's coming up) amendments to Medicare that will probably get passed even if the health care reform bill dies. But I really want the government to stay away from my Medicare! That would be awful!!
Monday, August 24, 2009
HEALTH CARE REFORM: Chapter 4
Title IV is amendments to the Internal Revenue Code of 1986, starting with Subtitle A: Shared Responsibility.
Section 401 establishes a tax on individuals without acceptable health care coverage. The tax is 2.5% of the taxpayer's modified adjusted gross income for the taxable year, over the amount of gross income to be established later. The tax imposed cannot exceed the applicable national average premium for the year. The tax can be prorated for part of the year. There are exemptions for individuals living outside of the U.S. and individuals living in possessions of the U.S. There's even a religious conscience exemption.
Section 411 gets into the employer's responsibulity. These items are the same as in Title III.
Section 421 is about a credit for small business employee health coverage expenses. Section 431 is about disclosure of return information for health insurance exchange subsidies. I read that some opponents were concerned about the Health Choices Administration having access about tax return information, but the solution is simple. If you are eligible but don't want them to see your tax return, don't opt to apply for an affordability credit. The provision provides for sufficient restrictions when handling personal information.
Section 441 calls for a "surcharge" on high income individuals. The provision establishes new tax of 1% of an individual's modified gross income exceeding $350,000 but not exceeding $500,000; 1.5% of income exceeding $500,000 but not $1,000,000; 5.4% of income exceeding $1,000,000. In December 2012, if the excess Federal health reform savings is more than $150,000,000,000 but not more than $175,000,000,000 (not likely, folks) 2% will be substituted for 1% and 3% will be substituted for 1.5%. If excess federal health reform savings are more than $175,000,000,000 as of December 2012, the 1% and 1.5% taxes will be eliminated completely!
Translation: upper income folks, your taxes are going up.
There are a few other Internal Revenue Code amendments, but they really didn't seem like they were making big changes.
In summary: you can be taxed if you do not have health insurance; your employer must offer coverage or pay contributions to the Health Insurance Exchange; taxes are going up at least 1% on annual incomes over $350,000.
We're on Page 215, and already next up is Division B: Medicare and Medicaid Improvements.
Section 401 establishes a tax on individuals without acceptable health care coverage. The tax is 2.5% of the taxpayer's modified adjusted gross income for the taxable year, over the amount of gross income to be established later. The tax imposed cannot exceed the applicable national average premium for the year. The tax can be prorated for part of the year. There are exemptions for individuals living outside of the U.S. and individuals living in possessions of the U.S. There's even a religious conscience exemption.
Section 411 gets into the employer's responsibulity. These items are the same as in Title III.
Section 421 is about a credit for small business employee health coverage expenses. Section 431 is about disclosure of return information for health insurance exchange subsidies. I read that some opponents were concerned about the Health Choices Administration having access about tax return information, but the solution is simple. If you are eligible but don't want them to see your tax return, don't opt to apply for an affordability credit. The provision provides for sufficient restrictions when handling personal information.
Section 441 calls for a "surcharge" on high income individuals. The provision establishes new tax of 1% of an individual's modified gross income exceeding $350,000 but not exceeding $500,000; 1.5% of income exceeding $500,000 but not $1,000,000; 5.4% of income exceeding $1,000,000. In December 2012, if the excess Federal health reform savings is more than $150,000,000,000 but not more than $175,000,000,000 (not likely, folks) 2% will be substituted for 1% and 3% will be substituted for 1.5%. If excess federal health reform savings are more than $175,000,000,000 as of December 2012, the 1% and 1.5% taxes will be eliminated completely!
Translation: upper income folks, your taxes are going up.
There are a few other Internal Revenue Code amendments, but they really didn't seem like they were making big changes.
In summary: you can be taxed if you do not have health insurance; your employer must offer coverage or pay contributions to the Health Insurance Exchange; taxes are going up at least 1% on annual incomes over $350,000.
We're on Page 215, and already next up is Division B: Medicare and Medicaid Improvements.
HEALTH CARE REFORM: Chapter 3
Title III of this bill is Shared Responsibility. Subtitle A is about individual responsibility.
Section 301 states that individuals will have a responsibility to obtain coverage. Details to come later in Section 401 as an Internal Revenue Code Amendment.
Then we get right into Subtitle B, employer responsibility. Section 311 establishes that employers must offer each employee individual and family coverage under a QHBP.
Section 312 establishes the required employer contribution. The employer's required contribution towards a part-time employee is a proportion of the required contribution towards a full-time employee. Keep in mind that a proportion can be 0. Employer contributions cannot come as salary reductions.
Section 313 establishes the possibility of employer contributions in lieu of coverage. The contribution must equal 8% of the average wages paid by the employer during the period of enrollment. The money will be paid into the Health Insurance Exchange Trust Fund and will not be applied against the employee's premium. "Small employers" contribute less, if anything. If the annual payroll of such employer for the preceding calendar year exceeds $350,000, but does not exceed $400,000, the contribution is 6%. If the payroll exceeds $300,000, but does not exceed $350,000, the contribution is 4%. If the payroll exceeds $250,000, but does not exceed $300,000, the contribution is 2%. If the payroll does not exceed $250,000, no contribution is required.
Section 321 amends ERISA, the Employee Retirement Income Security Act of 1974. Section 323 amends the Public Health Service Act. These items bring us to page 167 and the beginning of Title IV.
Title III is not long. Its substance is that employers would be required to offer health insurance coverage to their employers, or pay a contribution to the Health Insurance Exchange Trust Fund. The idea is to get all employers to offer coverage, exempting the smallest businesses. Since this reform is working within the employment-based insurance model, it seems logical to mandate that individuals get coverage as well as encourage all employers to offer coverage.
Section 301 states that individuals will have a responsibility to obtain coverage. Details to come later in Section 401 as an Internal Revenue Code Amendment.
Then we get right into Subtitle B, employer responsibility. Section 311 establishes that employers must offer each employee individual and family coverage under a QHBP.
Section 312 establishes the required employer contribution. The employer's required contribution towards a part-time employee is a proportion of the required contribution towards a full-time employee. Keep in mind that a proportion can be 0. Employer contributions cannot come as salary reductions.
Section 313 establishes the possibility of employer contributions in lieu of coverage. The contribution must equal 8% of the average wages paid by the employer during the period of enrollment. The money will be paid into the Health Insurance Exchange Trust Fund and will not be applied against the employee's premium. "Small employers" contribute less, if anything. If the annual payroll of such employer for the preceding calendar year exceeds $350,000, but does not exceed $400,000, the contribution is 6%. If the payroll exceeds $300,000, but does not exceed $350,000, the contribution is 4%. If the payroll exceeds $250,000, but does not exceed $300,000, the contribution is 2%. If the payroll does not exceed $250,000, no contribution is required.
Section 321 amends ERISA, the Employee Retirement Income Security Act of 1974. Section 323 amends the Public Health Service Act. These items bring us to page 167 and the beginning of Title IV.
Title III is not long. Its substance is that employers would be required to offer health insurance coverage to their employers, or pay a contribution to the Health Insurance Exchange Trust Fund. The idea is to get all employers to offer coverage, exempting the smallest businesses. Since this reform is working within the employment-based insurance model, it seems logical to mandate that individuals get coverage as well as encourage all employers to offer coverage.
HEALTH CARE REFORM: Chapter 2
Welcome back. Today's order of business is Title II: Health Insurance Exchange and Related Provisions of HR 3200, the health care reform bill under consideration by the House of Representatives.
The first Section 201 establishes a Health Insurance Exchange "in order to facilitate access of individuals and employers, through a transparent process, to a variety of choices of affordable, quality health insurance coverage, including a public health insurance option". It seems the Administration has all but backed off the public option (although that will play out interestingly if the liberal members keep their promise to vote against any legislation without the public option), but I'll consider the text of the bill as it is now.
A big fear out there seems to be that you will be required to participate in whatever program the government comes up with. However, the bill defines "Exchange-participating health benefits plan" as a QHBP "that is offered through the Health Insurance Exchange", which right there in the definition makes it sound as though all plans will be part of this Exchange.
Section 202 states that all individuals are eligible to obtain coverage through the Exchange "unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage". Again, the Exchange will not be the only option. The bill further defines "acceptable coverage", which includes grandfathered health insurance coverage, aka coverage under a current group health plan, Medicare (we're not abolishing Medicare, Grandma, don't worry), Medicaid, military coverage, and the VA, among other acceptable forms of coverage.
At first, individuals and small employers would be eligible to participate in the exchange, and by the third year of the program larger employers would begin to be eligible to participate. The language states that employers may offer the Exchange to their employees, and those employees may choose this coverage. Choice is heavily emphasized.
Section 202 ends with, what else, a survey to study the Exchange.
Section 203 is about benefit package levels. The first provision is that "The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year".
For example, in each "service area", there can only be one basic Exchange-participating health benefits plan offered by an entity under contract with the Commissioner. That entity also has the option of offering an enhanced, premium, or premium-plus plan in that service area if it wishes. The Commissioner will establish standards for the benefit levels of these categories. The Commissioner will also establish the permissible range of variation in cost-sharing for the various types of plans.
Section 204 is about contracts to offer Exchange-participating plans. The only potentially controversial requirement is for "culturally and linguistically appropriate services and communications", as apparently to some people that sets of an ILLEGAL ALIENS siren. Actually, cultural and linguistic sensitivity is becoming a more and more important part of medical training, as you're more likely to trust your doctor if you feel they understand you and where you come from. Thus, it makes sense that insurers could be required to provide such services and communications should they choose to participate in the exchange.
The Commissioner will evaluate the adequacy of any provider networks used by the entities offering plans through the Exchange.
Section 205 deals with outreach and enrollment of eligible individuals and employers. Outreach would be needed to advise people of their eligibility to participate in the Exchange. Vulnerable populations cited as needing specific outreach are children, individuals with disabilities, individuals with mental illness, and individuals with other cognitive impairments.
The open enrollment period for Exchange-participating plans will be September through November of each year. Under special circumstances, such as loss of other coverage or change in marital/dependent status, special enrollment will be possible at other times.
An important provision calls for the establishment of a process through which Exchange-eligible individuals are automatically "enrolled under an appropriate Exchange-participating health benefits plan". However, as you may recall, you are not an Exchange-eligible individual if you have other coverage. But, yes the idea is that there is an insurance mandate. But, if you think about it, we mandate auto insurance, and I doubt that anyone would suggest we end that policy. It's scary enough to have some people illegally driving around uninsured. And if anyone takes issue with the idea that we have a problem with too many Americans being uninsured or underinsured, well then we would need to have a conversation that doesn't even have anything to do with the bill.
There seems to be agreement that we have a problem.
Some individuals would be eligible for affordability credits.
Any premiums will be paid directly, not through the Commissioner or the Health Insurance Exchange. This provision makes sense to me, seeming to prevent absolutely unnecessary additional bureaucracy.
Medicaid-eligible individuals who do not elect to enroll in an Exchange-participating plan will be automatically enrolled in Medicaid. Again, auto-enrollment provisions seem to be sticky issues, but if people are eligible for Medicaid and don't have other insurance, they will be enrolled in Medicaid.
The bill establishes an Office of the Special Inspector General for the Health Insurance Exchange, headed by a Special Inspector General, whose duties include conducting, supervising, and coordinating audits, evaluations and investigations of the Exchange, to protect the integrity of the Exchange and more importantly the health and welfare of participants in the Exchange.
Section 207 creates a Health Insurance Exchange Trust Fund. Payments to this Fund will come from taxes on individuals not obtaining acceptable coverage, taxes on employers not providing acceptable coverage, and excise taxes on failures to meet certain health coverage requirements.
Section 208 gives the states/groups of states the option, once certain requirements are met, of establishing state-based Health Insurance Exchanges. Only one Health Insurance Exchange can operate in any one state.
This brings us to Subtitle B of Title II. Public Health Insurance Option time!!!!!!!!
Section 221 establishes within the Exchange a public health insurance option. This public option would ensure "choice, competition, and stability of affordable, high quality coverage throughout the United States...In designing the option, the Secretary's primary responsibility is to create a low-cost plan without compromising quality or access to care". This first definition doesn't seem to contain anything too sinister, including choice, competition, affordability and quality.
The public option will include basic, enhanced, and premium plans. It may include premium-plus plans.
An office of the ombudsman for the public health insurance option is established, using as its model the existing Medicare Beneficiary Ombudsman.
The premium rates for the public option will comply with the same rules for all Exchange-participating plans.
For start-up funding, the bill appropriates $2,000,000,000 out of unappropriated Treasury funds. That's a lot of zeros, but $2 billion in start-up costs is far from unreasonable.
The public option is intended to have competitive rates. Its initial "provider network" will be any Medicare provider who does not otherwise opt-out, although the bill cites pediatricians as providers who do not traditionally participate in Medicare who would be encouraged to participate.
Section 224 is about modernized payment initiatives and delivery system reform. For example, one provision states: "To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost sharing and payment rates to encourage the use of services that promote health and value".
Section 225 is about provider participation. It establishes two classes of participating physicians: preferred physicians, for whom the agreed payment rate is payment in full, and participating, non-preferred physicians, who agree not to impose charges above a ratio established in the Social Security Act. Health care providers other than physicians can participate only if the payment shall be accepted as payment in full.
We've now arrived at Subtitle C of Title II: Individual Affordability Credits. Section 241 states that individuals eligible for affordability credits will have such credits either applied against their premiums or as a reduction in cost-sharing. Such eligibility would be determined on an application basis.
You are not eligible for the affordability credit if you are a full-time employee enrolled through your employer. Your family income would have to be below 400 percent of the Federal poverty level for a family of that size, and you cannot receive an affordability credit if you are eligible for Medicaid.
Section 243 is about the affordable premium credit, establishing limits on premiums based on income tiers. Section 244 is about the affordability cost-sharing credit, similarly reducing cost-sharing amounts based on income tiers. Section 245 establishes the procedures for determining income and thus eligibility for affordability credits.
I will reproduce Section 246 in full: "Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States". We are now on Page 143 of the bill, and at the end of Title II.
What I've analyzed here is really THE controversial part of the bill (again, there are no death panels...), and it's only about 70 pages long. To my untrained eye, it doesn't seem unreasonable. Especially if you do consider its content without the public option.
What we hear is that the public option is "not fair" to the insurance industry. Well, in the first place, why do we need to be "fair" to the insurance industry? Supposedly, the public option will completely eliminate all other participants in the exchange and eventually the entire market. People are attached to the coverage they have and wary of it getting worse.
But the system we have isn't great. People end up attached to their jobs because they don't want to lose their health insurance coverage. Providing insurance is destroying small businesses. Trying to find individual coverage? Have a pre-existing condition? Good luck to you.
Certainly the costs of establishing the Exchange, public option or not, will probably exceed the $2 billion appropriated for start-up costs in getting the public option off the ground. Still involved in Iraq and Afghanistan and heavily in debt, it seems we can't afford to get involved in such a massively expensive undertaking. Unfortunately, we also can't afford not to do something DRASTIC. If this bill (and we still have almost 900 pages to go) gets gutted to a few paltry savings here and there, Congress and the Obama Administration will have done this country an extreme disservice, even if the public opinion seemed to be clamoring for that disservice. Am I actually nostalgic for Cheney and friends in the Bush Administration who did whatever they pleased, public opinion be damned???
In any case, I hope that this actual Title of the bill gets debated, not the rumors that are flying around.
The first Section 201 establishes a Health Insurance Exchange "in order to facilitate access of individuals and employers, through a transparent process, to a variety of choices of affordable, quality health insurance coverage, including a public health insurance option". It seems the Administration has all but backed off the public option (although that will play out interestingly if the liberal members keep their promise to vote against any legislation without the public option), but I'll consider the text of the bill as it is now.
A big fear out there seems to be that you will be required to participate in whatever program the government comes up with. However, the bill defines "Exchange-participating health benefits plan" as a QHBP "that is offered through the Health Insurance Exchange", which right there in the definition makes it sound as though all plans will be part of this Exchange.
Section 202 states that all individuals are eligible to obtain coverage through the Exchange "unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage". Again, the Exchange will not be the only option. The bill further defines "acceptable coverage", which includes grandfathered health insurance coverage, aka coverage under a current group health plan, Medicare (we're not abolishing Medicare, Grandma, don't worry), Medicaid, military coverage, and the VA, among other acceptable forms of coverage.
At first, individuals and small employers would be eligible to participate in the exchange, and by the third year of the program larger employers would begin to be eligible to participate. The language states that employers may offer the Exchange to their employees, and those employees may choose this coverage. Choice is heavily emphasized.
Section 202 ends with, what else, a survey to study the Exchange.
Section 203 is about benefit package levels. The first provision is that "The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year".
For example, in each "service area", there can only be one basic Exchange-participating health benefits plan offered by an entity under contract with the Commissioner. That entity also has the option of offering an enhanced, premium, or premium-plus plan in that service area if it wishes. The Commissioner will establish standards for the benefit levels of these categories. The Commissioner will also establish the permissible range of variation in cost-sharing for the various types of plans.
Section 204 is about contracts to offer Exchange-participating plans. The only potentially controversial requirement is for "culturally and linguistically appropriate services and communications", as apparently to some people that sets of an ILLEGAL ALIENS siren. Actually, cultural and linguistic sensitivity is becoming a more and more important part of medical training, as you're more likely to trust your doctor if you feel they understand you and where you come from. Thus, it makes sense that insurers could be required to provide such services and communications should they choose to participate in the exchange.
The Commissioner will evaluate the adequacy of any provider networks used by the entities offering plans through the Exchange.
Section 205 deals with outreach and enrollment of eligible individuals and employers. Outreach would be needed to advise people of their eligibility to participate in the Exchange. Vulnerable populations cited as needing specific outreach are children, individuals with disabilities, individuals with mental illness, and individuals with other cognitive impairments.
The open enrollment period for Exchange-participating plans will be September through November of each year. Under special circumstances, such as loss of other coverage or change in marital/dependent status, special enrollment will be possible at other times.
An important provision calls for the establishment of a process through which Exchange-eligible individuals are automatically "enrolled under an appropriate Exchange-participating health benefits plan". However, as you may recall, you are not an Exchange-eligible individual if you have other coverage. But, yes the idea is that there is an insurance mandate. But, if you think about it, we mandate auto insurance, and I doubt that anyone would suggest we end that policy. It's scary enough to have some people illegally driving around uninsured. And if anyone takes issue with the idea that we have a problem with too many Americans being uninsured or underinsured, well then we would need to have a conversation that doesn't even have anything to do with the bill.
There seems to be agreement that we have a problem.
Some individuals would be eligible for affordability credits.
Any premiums will be paid directly, not through the Commissioner or the Health Insurance Exchange. This provision makes sense to me, seeming to prevent absolutely unnecessary additional bureaucracy.
Medicaid-eligible individuals who do not elect to enroll in an Exchange-participating plan will be automatically enrolled in Medicaid. Again, auto-enrollment provisions seem to be sticky issues, but if people are eligible for Medicaid and don't have other insurance, they will be enrolled in Medicaid.
The bill establishes an Office of the Special Inspector General for the Health Insurance Exchange, headed by a Special Inspector General, whose duties include conducting, supervising, and coordinating audits, evaluations and investigations of the Exchange, to protect the integrity of the Exchange and more importantly the health and welfare of participants in the Exchange.
Section 207 creates a Health Insurance Exchange Trust Fund. Payments to this Fund will come from taxes on individuals not obtaining acceptable coverage, taxes on employers not providing acceptable coverage, and excise taxes on failures to meet certain health coverage requirements.
Section 208 gives the states/groups of states the option, once certain requirements are met, of establishing state-based Health Insurance Exchanges. Only one Health Insurance Exchange can operate in any one state.
This brings us to Subtitle B of Title II. Public Health Insurance Option time!!!!!!!!
Section 221 establishes within the Exchange a public health insurance option. This public option would ensure "choice, competition, and stability of affordable, high quality coverage throughout the United States...In designing the option, the Secretary's primary responsibility is to create a low-cost plan without compromising quality or access to care". This first definition doesn't seem to contain anything too sinister, including choice, competition, affordability and quality.
The public option will include basic, enhanced, and premium plans. It may include premium-plus plans.
An office of the ombudsman for the public health insurance option is established, using as its model the existing Medicare Beneficiary Ombudsman.
The premium rates for the public option will comply with the same rules for all Exchange-participating plans.
For start-up funding, the bill appropriates $2,000,000,000 out of unappropriated Treasury funds. That's a lot of zeros, but $2 billion in start-up costs is far from unreasonable.
The public option is intended to have competitive rates. Its initial "provider network" will be any Medicare provider who does not otherwise opt-out, although the bill cites pediatricians as providers who do not traditionally participate in Medicare who would be encouraged to participate.
Section 224 is about modernized payment initiatives and delivery system reform. For example, one provision states: "To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost sharing and payment rates to encourage the use of services that promote health and value".
Section 225 is about provider participation. It establishes two classes of participating physicians: preferred physicians, for whom the agreed payment rate is payment in full, and participating, non-preferred physicians, who agree not to impose charges above a ratio established in the Social Security Act. Health care providers other than physicians can participate only if the payment shall be accepted as payment in full.
We've now arrived at Subtitle C of Title II: Individual Affordability Credits. Section 241 states that individuals eligible for affordability credits will have such credits either applied against their premiums or as a reduction in cost-sharing. Such eligibility would be determined on an application basis.
You are not eligible for the affordability credit if you are a full-time employee enrolled through your employer. Your family income would have to be below 400 percent of the Federal poverty level for a family of that size, and you cannot receive an affordability credit if you are eligible for Medicaid.
Section 243 is about the affordable premium credit, establishing limits on premiums based on income tiers. Section 244 is about the affordability cost-sharing credit, similarly reducing cost-sharing amounts based on income tiers. Section 245 establishes the procedures for determining income and thus eligibility for affordability credits.
I will reproduce Section 246 in full: "Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States". We are now on Page 143 of the bill, and at the end of Title II.
What I've analyzed here is really THE controversial part of the bill (again, there are no death panels...), and it's only about 70 pages long. To my untrained eye, it doesn't seem unreasonable. Especially if you do consider its content without the public option.
What we hear is that the public option is "not fair" to the insurance industry. Well, in the first place, why do we need to be "fair" to the insurance industry? Supposedly, the public option will completely eliminate all other participants in the exchange and eventually the entire market. People are attached to the coverage they have and wary of it getting worse.
But the system we have isn't great. People end up attached to their jobs because they don't want to lose their health insurance coverage. Providing insurance is destroying small businesses. Trying to find individual coverage? Have a pre-existing condition? Good luck to you.
Certainly the costs of establishing the Exchange, public option or not, will probably exceed the $2 billion appropriated for start-up costs in getting the public option off the ground. Still involved in Iraq and Afghanistan and heavily in debt, it seems we can't afford to get involved in such a massively expensive undertaking. Unfortunately, we also can't afford not to do something DRASTIC. If this bill (and we still have almost 900 pages to go) gets gutted to a few paltry savings here and there, Congress and the Obama Administration will have done this country an extreme disservice, even if the public opinion seemed to be clamoring for that disservice. Am I actually nostalgic for Cheney and friends in the Bush Administration who did whatever they pleased, public opinion be damned???
In any case, I hope that this actual Title of the bill gets debated, not the rumors that are flying around.
Wednesday, August 19, 2009
HEALTH CARE REFORM: Chapter 1
First of all, I would like to the point out the title of this blog. What I post here is my personal opinion.
My personal opinion is that there has been a lot of serious misinformation going around regarding health care reform. That irritates me. If we're going to make a lot of noise, let's make noise about the facts. There are debatable things up for discussion. But there are also heinous lies being irresponsibly fed to people. And people believe them.
I am not a health care provider. I am not an insurance agent. I am not even a policy wonk. I am a 21 year old intern and student. But I have enough time to read these health care bills (something not a lot of people have done) and analyze them. I am not an expert. But I have an opinion, and hopefully it is somewhat informed.
For today, I present the first 71 pages (less, really, considering the table of contents) of one bill. HR 3200: America's Affordable Health Choices Act of 2009 is the House bill, and it's over 1,000 pages long.
Division A of the bill is titled "Affordable Health Care Choices."
Today, I'm analyzing Title I: "Protections and Standards for Qualified Health Benefits Plans."
I would like to start out by saying that I never found a clear and satisfying definition of "qualified health benefit plan," or QHBP as it is referred to, although that is probably because it will refer to whatever ends up in the final bill.
In Section 102, we find the language, "grandfathered health insurance coverage." Meaning: the current coverage you have, you can keep. The argument of course is that the public option (which we haven't come to and will probably NOT be in the final bill) would run other insurance companies out of business with an unfair advantage. But let the record show that the bill does not say that you MUST abandon your current coverage (if you are so lucky to have adequate coverage).
Section 111 is one that contains a lot I hope we can agree on: the so-called QHBPs will not have exclusions for pre-existing conditions.
Section 122 establishes what will be in an essential benefits package, i.e. the minimum coverage. It limits cost-sharing, which prompted me to ask, what is the difference between "cost-sharing," "copay" and "coinsurance"? I did not look into these definitions, but I plan to do so at some point.
Section 123 establishes a "Health Benefits Advisory Committee" to recommend benefit standards. The Committee is ADVISORY and will make RECOMMENDATIONS.
Section 132 calls for a fair grievance and appeals mechanism, which I think is necessary.
Section 141 expands government, creating an independent agency in the executive branch, the Health Choices Administration, which will be headed by a Health Choices Commissioner. Section 142 establishes the duties of the Commissioner: QHBP standards, the Health Insurance Exchange, and affordability credits, with a focus on accountability.
Section 144 calls for a QHBP Ombudsman.
Section 152 prohibits discrimination in health care.
Section 162 ends insurance recission abuse. Your coverage, under the language of this bill, could only be rescinded by the insurance company upon clear and convincing evidence of fraud.
Secion 163 deals with administrative simplification, with such goals as enabling the real time or near real time determination of an individual's financial responsibility at point of service and near real time adjudication of claims, requiring timely and transparent claim and denial management processes, including tracking adjudications and appeal processing.
Section 164 is about reinsurance for retirees, which entails employment-based plans for retirees 55 or older not yet eligible for Social Security.
And that's Title I. I can't promise a thorough and complete analysis, but nothing too earth-shattering.
Up next is Title II: "Health Insurance Exchange and Related Provisions." That's where all of the new, really controversial ideas are, so I'm really looking forward to reading through that. Maybe a career in health policy could be in the cards for me?
My personal opinion is that there has been a lot of serious misinformation going around regarding health care reform. That irritates me. If we're going to make a lot of noise, let's make noise about the facts. There are debatable things up for discussion. But there are also heinous lies being irresponsibly fed to people. And people believe them.
I am not a health care provider. I am not an insurance agent. I am not even a policy wonk. I am a 21 year old intern and student. But I have enough time to read these health care bills (something not a lot of people have done) and analyze them. I am not an expert. But I have an opinion, and hopefully it is somewhat informed.
For today, I present the first 71 pages (less, really, considering the table of contents) of one bill. HR 3200: America's Affordable Health Choices Act of 2009 is the House bill, and it's over 1,000 pages long.
Division A of the bill is titled "Affordable Health Care Choices."
Today, I'm analyzing Title I: "Protections and Standards for Qualified Health Benefits Plans."
I would like to start out by saying that I never found a clear and satisfying definition of "qualified health benefit plan," or QHBP as it is referred to, although that is probably because it will refer to whatever ends up in the final bill.
In Section 102, we find the language, "grandfathered health insurance coverage." Meaning: the current coverage you have, you can keep. The argument of course is that the public option (which we haven't come to and will probably NOT be in the final bill) would run other insurance companies out of business with an unfair advantage. But let the record show that the bill does not say that you MUST abandon your current coverage (if you are so lucky to have adequate coverage).
Section 111 is one that contains a lot I hope we can agree on: the so-called QHBPs will not have exclusions for pre-existing conditions.
Section 122 establishes what will be in an essential benefits package, i.e. the minimum coverage. It limits cost-sharing, which prompted me to ask, what is the difference between "cost-sharing," "copay" and "coinsurance"? I did not look into these definitions, but I plan to do so at some point.
Section 123 establishes a "Health Benefits Advisory Committee" to recommend benefit standards. The Committee is ADVISORY and will make RECOMMENDATIONS.
Section 132 calls for a fair grievance and appeals mechanism, which I think is necessary.
Section 141 expands government, creating an independent agency in the executive branch, the Health Choices Administration, which will be headed by a Health Choices Commissioner. Section 142 establishes the duties of the Commissioner: QHBP standards, the Health Insurance Exchange, and affordability credits, with a focus on accountability.
Section 144 calls for a QHBP Ombudsman.
Section 152 prohibits discrimination in health care.
Section 162 ends insurance recission abuse. Your coverage, under the language of this bill, could only be rescinded by the insurance company upon clear and convincing evidence of fraud.
Secion 163 deals with administrative simplification, with such goals as enabling the real time or near real time determination of an individual's financial responsibility at point of service and near real time adjudication of claims, requiring timely and transparent claim and denial management processes, including tracking adjudications and appeal processing.
Section 164 is about reinsurance for retirees, which entails employment-based plans for retirees 55 or older not yet eligible for Social Security.
And that's Title I. I can't promise a thorough and complete analysis, but nothing too earth-shattering.
Up next is Title II: "Health Insurance Exchange and Related Provisions." That's where all of the new, really controversial ideas are, so I'm really looking forward to reading through that. Maybe a career in health policy could be in the cards for me?
Monday, August 17, 2009
Tell all the Truth but tell it slant
by Emily Dickinson
Tell all the Truth but tell it slant --
Success in Circuit lies
Too bright for our infirm Delight
The Truth's superb surprise
As Lightning to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind --
Tell all the Truth but tell it slant --
Success in Circuit lies
Too bright for our infirm Delight
The Truth's superb surprise
As Lightning to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind --
Frigid air
I'm no fan of extreme temperatures at either end. I'm always cold, except when I'm hot. I've always been amazed at those people who show up to the first day of school in August in jeans and a sweater and then claim in January that a North Face fleece shell is outerwear. Sweaters are a must for me, but I am constantly taking it on and off.
Given the choice of a cold, cold winter and a hot, hot summer, I'd choose winter in a heartbeat. Why? AIR CONDITIONING.
In theory, air conditioning is pretty cool. And I've grown up with it my entire life. What's not to like about being able to control the indoor environment?
Well, picture this: me, on an average summer day, heading to my internship, probably in pants and a short sleeved blouse. And then putting on two sweaters when I get inside. And sitting on my hands to keep warm.
I can't even wear skirts really. With tights even, that would be pushing it. So much for the fun sundresses I bought in Spain.
There's really no need to control the indoor environment so that snow seems feasible indoors.
Here in Chicago, the summer has been quite cool. Record-setting in fact. However, it seems buildings just have one setting: SUMMER AIR CONDITIONING BLAST. Not good for the sneezing intern, shivering her way through spreadsheets. Not good for the environment (global warming, man). And certainly not good for the bottom line. We are in a recession, you know!
I'm not sure if this cool Chicago summer is worse than last summer in DC. Built on a swamp, our nation's capital is famous for it's humidity. So, this freezing intern experienced quite a shock every day at 4:30 upon being exposed to sunlight and an environment in which it was too hot to even touch a jacket.
I realize that not everyone is quite as sensitive to temperature as I am (last summer someone called a technician to the room where my desk was to test the temperature after hearing me suffer. No difference in temp from the rest of the office), but can't we find middle ground? Turn the thermostat up 2 degrees and give yourself a raise!
In Spain, you really don't find air conditioning many places. Hotels where American tourists stay. Some stores and museums. And I suppose more and more office buildings as they modernize. The humidity is low, so the nighttime temperature drops off blessedly after dark. Even in June, the weather is pretty miserable, and in August the entire city of Madrid is on vacation somewhere near a beach. But, you know what? We were all suffering together! We may have been a little sweaty after we ran to catch that Metro, but we all made it.
Not everywhere in America has air conditioning, either. August 9, for example, was the hottest day on record for the summer. I was in my brother's piano teacher's unairconditioned home for a concert, with minimal fan action. I was ready to go the SECOND the regularly scheduled musical program was over.
You see, I'm not advocating an OVERTHROW of air conditioning. There's nothing quite like it on that hottest day of the year when you wouldn't dream of going outside and the grid is stretched to the max but doing its job.
But PLEASE I will not stop until office buildings can adjust the thermostat. We can't be stuck with the same temperature all summer whether it's a scorcher or barely a summer at all. And, even when the temperatures are outrageously hot, let's not keep it cold enough to need a parka indoors. After all, we've only got three months for our summer wardrobe!
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Thanks for putting up with that. I really needed a forum.
I deleted all but the first line of the poem at the top. The layout looked terrible.
Coming up: Health Care Reform. I've now at least skimmed the first 500 or so pages of H.R. 3200. Surprisingly little of the 1,000+ manuscript is about the so-called public option and the health care exchange, which together are probably the most revolutionary pieces. The public option is probably off the table at this point. That leaves us with a lot of cleaning up things like Medicare (OMG death panels killing Grandma and Palins with a vengeance!). We'll see what happens.
Given the choice of a cold, cold winter and a hot, hot summer, I'd choose winter in a heartbeat. Why? AIR CONDITIONING.
In theory, air conditioning is pretty cool. And I've grown up with it my entire life. What's not to like about being able to control the indoor environment?
Well, picture this: me, on an average summer day, heading to my internship, probably in pants and a short sleeved blouse. And then putting on two sweaters when I get inside. And sitting on my hands to keep warm.
I can't even wear skirts really. With tights even, that would be pushing it. So much for the fun sundresses I bought in Spain.
There's really no need to control the indoor environment so that snow seems feasible indoors.
Here in Chicago, the summer has been quite cool. Record-setting in fact. However, it seems buildings just have one setting: SUMMER AIR CONDITIONING BLAST. Not good for the sneezing intern, shivering her way through spreadsheets. Not good for the environment (global warming, man). And certainly not good for the bottom line. We are in a recession, you know!
I'm not sure if this cool Chicago summer is worse than last summer in DC. Built on a swamp, our nation's capital is famous for it's humidity. So, this freezing intern experienced quite a shock every day at 4:30 upon being exposed to sunlight and an environment in which it was too hot to even touch a jacket.
I realize that not everyone is quite as sensitive to temperature as I am (last summer someone called a technician to the room where my desk was to test the temperature after hearing me suffer. No difference in temp from the rest of the office), but can't we find middle ground? Turn the thermostat up 2 degrees and give yourself a raise!
In Spain, you really don't find air conditioning many places. Hotels where American tourists stay. Some stores and museums. And I suppose more and more office buildings as they modernize. The humidity is low, so the nighttime temperature drops off blessedly after dark. Even in June, the weather is pretty miserable, and in August the entire city of Madrid is on vacation somewhere near a beach. But, you know what? We were all suffering together! We may have been a little sweaty after we ran to catch that Metro, but we all made it.
Not everywhere in America has air conditioning, either. August 9, for example, was the hottest day on record for the summer. I was in my brother's piano teacher's unairconditioned home for a concert, with minimal fan action. I was ready to go the SECOND the regularly scheduled musical program was over.
You see, I'm not advocating an OVERTHROW of air conditioning. There's nothing quite like it on that hottest day of the year when you wouldn't dream of going outside and the grid is stretched to the max but doing its job.
But PLEASE I will not stop until office buildings can adjust the thermostat. We can't be stuck with the same temperature all summer whether it's a scorcher or barely a summer at all. And, even when the temperatures are outrageously hot, let's not keep it cold enough to need a parka indoors. After all, we've only got three months for our summer wardrobe!
----------------------
Thanks for putting up with that. I really needed a forum.
I deleted all but the first line of the poem at the top. The layout looked terrible.
Coming up: Health Care Reform. I've now at least skimmed the first 500 or so pages of H.R. 3200. Surprisingly little of the 1,000+ manuscript is about the so-called public option and the health care exchange, which together are probably the most revolutionary pieces. The public option is probably off the table at this point. That leaves us with a lot of cleaning up things like Medicare (OMG death panels killing Grandma and Palins with a vengeance!). We'll see what happens.
Wednesday, August 12, 2009
A new vision...
Apparently it's really hard to customize a blog on Blogger! As far as I can tell, you are required to use one of their templates, and there really aren't many of those available. It also seems like it's very hard to customize the elements of those templates. For example, the subheading of this newly fashioned blog is an eight-line poem. I made the text giant so at least the first line could be on its own. The rest kind of just flows together, but luckily it's Emily Dickinson, so that almost makes sense.
Although I will soon be leaving the ORD for DCA (I'm actually flying MDW to IAD because Southwest has the cheapest one-way fares. I've never been to Dulles before. Adventure!), the ORD DCA MAD concept is a bit old, as my life is no longer quite as exciting. I suppose there is some inherent excitement in being a senior at Georgetown University, but not the same jet-setting excitement that necessitates a breathless narrative account of my every move.
But I've still got to write, don't I?
Therefore, my new angle is "The Slant." Every blog has its own slant, derived from the blogger, and I'm embracing my own, inspired by Emily Dickinson's poem, which I first discovered in Barbara Kingsolver's fantastic novel, The Poisonwood Bible. Read it. Seriously. The poem and the book.
What can you expect to see on my new blog? My first post will likely be about how I can't stand overdone air conditioning. I expect I'll also digest political news and goings on, and throw in a bit of funny/awkward events from my life. As I get closer to graduation, which keeps getting closer and closer and therefore much more intimidating, you'll probably get some self discovery. And desperation.
As a final note to anyone who may be reading this:
MY LIFE GOAL IS TO HAVE RICK STEVES' JOB. IF YOU CAN MAKE THAT HAPPEN...
P.S. I just listened to Shakira's new single, She Wolf, 20 times. It's a pretty fantastic track, and the video is...edgy. Check it out!
Although I will soon be leaving the ORD for DCA (I'm actually flying MDW to IAD because Southwest has the cheapest one-way fares. I've never been to Dulles before. Adventure!), the ORD DCA MAD concept is a bit old, as my life is no longer quite as exciting. I suppose there is some inherent excitement in being a senior at Georgetown University, but not the same jet-setting excitement that necessitates a breathless narrative account of my every move.
But I've still got to write, don't I?
Therefore, my new angle is "The Slant." Every blog has its own slant, derived from the blogger, and I'm embracing my own, inspired by Emily Dickinson's poem, which I first discovered in Barbara Kingsolver's fantastic novel, The Poisonwood Bible. Read it. Seriously. The poem and the book.
What can you expect to see on my new blog? My first post will likely be about how I can't stand overdone air conditioning. I expect I'll also digest political news and goings on, and throw in a bit of funny/awkward events from my life. As I get closer to graduation, which keeps getting closer and closer and therefore much more intimidating, you'll probably get some self discovery. And desperation.
As a final note to anyone who may be reading this:
MY LIFE GOAL IS TO HAVE RICK STEVES' JOB. IF YOU CAN MAKE THAT HAPPEN...
P.S. I just listened to Shakira's new single, She Wolf, 20 times. It's a pretty fantastic track, and the video is...edgy. Check it out!
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