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.
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