Senator Max Baucus' much-maligned bill has been debuted, and there's no shortage of criticism on it. I'll be grading his bill, comparing it to the details set out by Obama in his health care speech.
*Do not scrap the current health care system. Examine and revise.
This is done easy enough. Baucus does not propose a major dismantling of the current health care system. Grade: A+
*Those already covered must not be forced to switch coverage or change doctors
It seems like Baucus' bill leaves those satisfied with their insurance or doctors well enough alone. Grade: A+
*Denying coverage due to preexisting conditions must be prohibited by law
The bill expressly prohibits the denial of coverage due to preexisting conditions. Simple enough. Grade: A+
*Coverage may not be dropped or diluted if the policy holder becomes ill
Not sure if there are prohibitions against this in the bill. I wager it is in there somewhere. Grade: Incomplete
*Arbitrary coverage caps for a year or lifetime will not be allowed
It appears that these are prohibited in the bill. Grade: A+
*Out-of-pocket expenses must be limited
It seems like there are limits in place, but they are higher than other plans we see. Grade: C-
*Routine checkups and preventive care must be covered with no additional cost
This seems to be one of the major strengths of the Baucus bill. It makes it far cheaper to receive preventive care and check-ups, and also works to reward healthy lifestyle choices, particularly for Medicare and Medicaid enrollees. But it doesn't do much for those outside those programs. Grade: B+
*Individuals and small businesses may purchase insurance through a market
Yes, there is a market created in the Baucus bill for this purpose. Grade: A+
*Those who cannot afford insurance will be provided with tax credits based upon need
There are subsidies for those who cannot afford insurance, but they are smaller than everything else proposed. While this does keep the overall cost down, it does little good if people still can't buy insurance even with tax credits. Grade: C
*Insurance companies desiring to participate in the aforementioned market have four years to adhere to the outlined regulations above
Yes, the deadline is in 2013. Grade: A+
*Those currently uninsured due to preexisting conditions will be offered low-cost coverage immediately in case of catastrophic illness
There is a catastrophic-only option offered, but only available for the "young invincible" (yes, that is a phrase in the bill). I'm not sure if the plan makes immediate coverage available to those currently uninsured. Grade: C/Incomplete
*Health insurance will be mandatory
Yes, it is mandatory. But the costs for not getting insurance are very high. Combine this with low tax credits, and you may end up with a lot of poor people who still can't buy insurance or afford the four-figure fines associated with that. Grade: C-
*Businesses must offer health care or chip in to cover the costs of health care
This is included in the bill, but there are no regulations of the quality of the care provided. Larger companies could offer expensive programs with low benefits at their leisure, and most workers would be forced to take it. Regulations are necessary. Grade: C+
*There will be a hardship waiver, applicable to 95% of all small businesses
The bill makes it very easy for most small businesses to be waived from their requirements. Grade: A+
*A public option will be made available, running as a not-for profit
There is no public option, instead going for the co-op method. The government will provide start up and solvency funds. Co-ops will be not-for-profit, and any leftover funds they do have will be used to lower premiums or improve benefits. Co-ops will be state-by-state. This is difficult, especially if a state elects not to establish a co-op. It would be far simpler to create a national public option. Grade: B
*This public option will only be available to those who currently do not have insurance
Co-ops are a different beast, but they only seem to be available to those without insurance. Grade: C
*The public option must be self-sufficient
The co-ops will have start-up funds provided, but they are otherwise self-sufficient. Grade: A+
*The overall plan must be deficit neutral
This plan attempts to be deficit neutral, but the way its finances are organized, it's highly doubtful. Grade: C-
*Establish some method of malpractice reform
Since malpractice is mostly covered at the state levels, the bill does not explicitly implement reform. It does, however, call for states to examine their system to seek alternatives to the current litigation system. Whether states do so or not is not mandated. Grade: C+
*The cost must be limited to $900 billion over 10 years
Definitely passes. At $856 billion, it's the lowest figure seen among any of the health care proposals. Grade: A-
*Slow the growth of health care costs by 1/10 of 1% per year
It's hard to see this plan control costs without a public option, and the bill has no regulations to even attempt to control the costs of care. This bill will likely not control costs in any way. Grade: F
*If savings are not up to expectations, create spending cuts
Not sure if this is included. Baucus seems to be trying to put the cart before the horse by keeping the initial cost of his bill low. It would be wiser to start at a higher cost, then reduce it year by year as we know the costs decrease, rather than start low and have to keep increasing because we find that the first year costs are more than expected. Grade: C+
*Meet the following goals:
*Provide security and stability for those with insurance
*Provide insurance for those who currently have none
*Slow the growth of costs
The big grade. Baucus clearly is reaching for compromise in his bill, but the fact that no Republicans have voiced favor for the bill tells me that something isn't quite right. Overall, the bill doesn't really achieve goals 2 or 3 very well, which are the two goals that are the most important. It's very easy to accomplish goal 1; simply create regulations that prohibit the dropping of coverage or care. But Baucus' bill could do more to make insurance available for those without it, and it certainly doesn't slow the growth of costs. Instead, it tries to keep its own costs down, perhaps at the cost of effectiveness. OVERALL GRADE: B/B-
Thursday, September 17, 2009
Thursday, September 10, 2009
The Health Care Speech
Continued posting of the bill is on hiatus. First, a lack of time. Second, the very real possibility that everything may begin to change after last night's speech.
Regarding last night's speech:
In baseball parlance, I'd give it a triple with bases loaded. Not exactly a grand slam home run, but a very effective play. Included some details, but you have to remember: Obama is clearly a president who believes that Congress should legislate. He'll lay down some ground rules, but will defer to the legislature when the precise terms are written. This is a clear difference from the Bush administration, which had a habit of legislating from the executive's office. So here's the ground rules of health care reform:
*Do not scrap the current health care system. Examine and revise.
*Meet the following goals:
*Provide security and stability for those with insurance
*Provide insurance for those who currently have none
*Slow the growth of costs
*Those already covered must not be forced to switch coverage or change doctors
*Denying coverage due to preexisting conditions must be prohibited by law
*Coverage may not be dropped or diluted if the policy holder becomes ill
*Arbitrary coverage caps for a year or lifetime will not be allowed
*Out-of-pocket expenses must be limited
*Routine checkups and preventive care must be covered with no additional cost
*Individuals and small businesses may purchase insurance through a market
*Those who cannot afford insurance will be provided with tax credits based upon need
*Insurance companies desiring to participate in the aforementioned market have four years to adhere to the outlined regulations above
*Those currently uninsured due to preexisting conditions will be offered low-cost coverage immediately in case of catastrophic illness
*Health insurance will be mandatory
*Businesses must offer health care or chip in to cover the costs of health care
*There will be a hardship waiver, applicable to 95% of all small businesses
*A public option will be made available, running as a not-for profit
*This public option will only be available to those who currently do not have insurance
*The public option must be self-sufficient
*The overall plan must be deficit neutral
*Establish some method of malpractice reform
*The cost must be limited to $900 billion over 10 years
*Slow the growth of health care costs by 1/10 of 1% per year
*If savings are not up to expectations, create spending cuts
Overall, I see a lot of stuff from HR 3200 in here. That may form a foundation for a unified health care bill. Given these parameters, how would you establish a reformed health care system?
Regarding last night's speech:
In baseball parlance, I'd give it a triple with bases loaded. Not exactly a grand slam home run, but a very effective play. Included some details, but you have to remember: Obama is clearly a president who believes that Congress should legislate. He'll lay down some ground rules, but will defer to the legislature when the precise terms are written. This is a clear difference from the Bush administration, which had a habit of legislating from the executive's office. So here's the ground rules of health care reform:
*Do not scrap the current health care system. Examine and revise.
*Meet the following goals:
*Provide security and stability for those with insurance
*Provide insurance for those who currently have none
*Slow the growth of costs
*Those already covered must not be forced to switch coverage or change doctors
*Denying coverage due to preexisting conditions must be prohibited by law
*Coverage may not be dropped or diluted if the policy holder becomes ill
*Arbitrary coverage caps for a year or lifetime will not be allowed
*Out-of-pocket expenses must be limited
*Routine checkups and preventive care must be covered with no additional cost
*Individuals and small businesses may purchase insurance through a market
*Those who cannot afford insurance will be provided with tax credits based upon need
*Insurance companies desiring to participate in the aforementioned market have four years to adhere to the outlined regulations above
*Those currently uninsured due to preexisting conditions will be offered low-cost coverage immediately in case of catastrophic illness
*Health insurance will be mandatory
*Businesses must offer health care or chip in to cover the costs of health care
*There will be a hardship waiver, applicable to 95% of all small businesses
*A public option will be made available, running as a not-for profit
*This public option will only be available to those who currently do not have insurance
*The public option must be self-sufficient
*The overall plan must be deficit neutral
*Establish some method of malpractice reform
*The cost must be limited to $900 billion over 10 years
*Slow the growth of health care costs by 1/10 of 1% per year
*If savings are not up to expectations, create spending cuts
Overall, I see a lot of stuff from HR 3200 in here. That may form a foundation for a unified health care bill. Given these parameters, how would you establish a reformed health care system?
Friday, August 28, 2009
To A Lion
Just a quick break from HR 3200 for a Kennedy memorial. I will not make some long-winded statement, simply because people better suited to the task already have done so. Below, find a timeline of how his work has touched all of us.
1965: Strongly supported and helped pass the Hart-Celler Act, abolishing immigration and ending a ban on immigration from Asia.
1971: Helped establish the Federal Cancer Research Program, and quadrupled funds for cancer research.
1972: Negotiated the creation of Title IX, which requires colleges and universities to equally fund men's and women's athletics.
1974: Passed reform on campaign ethics and election finance, which resulted in the establishment of the FEC.
1983: Pushed Congress to establish Martin Luther King Day as a federal holiday.
1986: Led the override of Reagan's veto of the Comprehensive Anti-Apartheid Act of 1986.
1990: Sponsored the Family and Medical Leave Act, mandating unpaid leave for the birth of a child or medical emergencies.
1996: Let employees keep their health insurance for a set period of time after they leave their jobs and prohibited denial of renewal of care due to preexisting medical conditions through the Kennedy-Kassebaum Act, also called COBRA.
1996: Helped raise the minimum wage from $4.25 to $5.15.
And that's only a small part of the work he did.
Last, I'm going to include a film that's going around the internet. In 1968, Ted gave a speech on behalf of his brother Bobby in Sitka, Alaska at the Alaska Democratic Convention. It summarizes the philosophy of liberalism, and will perhaps be regarded as one of the best political speeches in American history.
Thanks, Teddy.
1965: Strongly supported and helped pass the Hart-Celler Act, abolishing immigration and ending a ban on immigration from Asia.
1971: Helped establish the Federal Cancer Research Program, and quadrupled funds for cancer research.
1972: Negotiated the creation of Title IX, which requires colleges and universities to equally fund men's and women's athletics.
1974: Passed reform on campaign ethics and election finance, which resulted in the establishment of the FEC.
1983: Pushed Congress to establish Martin Luther King Day as a federal holiday.
1986: Led the override of Reagan's veto of the Comprehensive Anti-Apartheid Act of 1986.
1990: Sponsored the Family and Medical Leave Act, mandating unpaid leave for the birth of a child or medical emergencies.
1996: Let employees keep their health insurance for a set period of time after they leave their jobs and prohibited denial of renewal of care due to preexisting medical conditions through the Kennedy-Kassebaum Act, also called COBRA.
1996: Helped raise the minimum wage from $4.25 to $5.15.
And that's only a small part of the work he did.
Last, I'm going to include a film that's going around the internet. In 1968, Ted gave a speech on behalf of his brother Bobby in Sitka, Alaska at the Alaska Democratic Convention. It summarizes the philosophy of liberalism, and will perhaps be regarded as one of the best political speeches in American history.
Thanks, Teddy.
Sunday, August 23, 2009
H.R. 3200, Part III
Subtitle E - Governance
Sec. 141: Health Choices Administration; Health Choices Commissioner
There will be an independent executive agency called the Health Choices Administration. The head of the agency is the Commissioner, and will be appointed by the president with the advice and consent of Congress. The Health Choices Administration and Commissioner will be compensated in a similar way to Social Security and its administrator.
Sec. 142: Duties and Authority of Commissioner
The Commissioner will enforce the qualified health benefit standards, establish and operate the health insurance exchange, administrate individual affordability credits and determine eligibility for credits, promote accountability from qualified health care providers, perform compliance examinations and audits, and compensate for the costs of those examinations and audits. The Commissioner will also collect data, and remedy violations made by qualified health care providers. These remedies include civil money penalties, suspension of enrollment, suspension of payment of premiums to the offender, and work to prevent further violation.
The Commissioner will also provide definitions for terms used in health insurance coverage, and work to maintain efficiency in the exchange market and affordability credits.
Sec. 143: Consultation and Coordination
The Commissioner will consult with, when necessary, the National Association of Insurance Commissioners, state attorney generals, and state insurance providers over the standards of qualified health care and enforcement of those standards. The Commissioner will also consult with state agencies concerned with affordability credits, other appropriate Federal agencies, Indian tribes and tribal organizations, and the NAIC to form guidelines concerning the enforcement of Subtitles B and D.
The Commissioner will cooperate with federal and state agencies to ensure maximum operation and prevent conflicts of interest and achieve uniform standards to protect consumers and still prevent unreasonable effects on employers and providers.
Sec. 144: Health Insurance Ombudsman
The Commissioner will appoint an ombudsman for qualified health care providers. This ombudsman will have expertise and experience in health care fields and education of individuals. The ombudsman will recieve complaints, grievances, and requests for information, and provide assistance to solve those problems or provide that information. The ombudsman will submit an annual report to the Commissioner and Congress describing their annual activities and making recommendations to improve the administration of the Health Choices Administration. The ombudsman can identify issues and problems in payment and coverage.
Subtitle F - Relation to Other Requirements; Miscellaneous
Sec. 151: Relation to Other Requirements
Health insurance plans not offered through the exchange market or employer-provided plans must at least adhere to the Public Health Service Act, the Employee Retirement Income Security Act, and state law, except when those acts interfere with the explicit requirements mentioned in earlier subtitles, as determined by the Commissioner.
Coverage offered through the exchange market must adhere to title XXVII of the Public Health Service Act or state law, except when those titles and laws interfere with the explicit requirements mentioned in earlier subtitles, as determined by the Commissioner
Sec. 152: Prohibiting Discrimination in Health Care
All health care and related services covered by this act will be provided regardless of personal characteristics unrelated to the provision of quality health care, except for those explicitly permitted in this act or by subesquent regulations as a result of this act. Regulations to prohibit this discrimination will be established no later than 18 months after the enactment of this bill.
Sec. 153: Whistleblower Protection
Employers may not dismiss or discriminate against employees because the employee provided or is about to provide information to the employer, state or federal agencies about a violation of the act or any order or rule established as a result of the act, testified or is about to testify in a proceeding dealing with a violation, or objected to or refused to participate in a task that violates the act.
An employer who alleges discrimination or was dismissed for these reasons may bring an action goverened by the rules set forth by the Consumer Product Safety Act and section 20109(h) of title 49 of the United States Code.
Sec. 154: Construction Regarding Collective Bargaining
Statutory or other obligations to engage in collective bargaining over the terms and conditions of employment related to health care will not be superseded by this subtitle.
Sec. 155: Severability
If any provision of this act or application of provisions to persons or circumstances is found to be unconsititutional, the remainder of the provisions and application of those provisions will not be affected.
Section G tomorrow.
Sec. 141: Health Choices Administration; Health Choices Commissioner
There will be an independent executive agency called the Health Choices Administration. The head of the agency is the Commissioner, and will be appointed by the president with the advice and consent of Congress. The Health Choices Administration and Commissioner will be compensated in a similar way to Social Security and its administrator.
Sec. 142: Duties and Authority of Commissioner
The Commissioner will enforce the qualified health benefit standards, establish and operate the health insurance exchange, administrate individual affordability credits and determine eligibility for credits, promote accountability from qualified health care providers, perform compliance examinations and audits, and compensate for the costs of those examinations and audits. The Commissioner will also collect data, and remedy violations made by qualified health care providers. These remedies include civil money penalties, suspension of enrollment, suspension of payment of premiums to the offender, and work to prevent further violation.
The Commissioner will also provide definitions for terms used in health insurance coverage, and work to maintain efficiency in the exchange market and affordability credits.
Sec. 143: Consultation and Coordination
The Commissioner will consult with, when necessary, the National Association of Insurance Commissioners, state attorney generals, and state insurance providers over the standards of qualified health care and enforcement of those standards. The Commissioner will also consult with state agencies concerned with affordability credits, other appropriate Federal agencies, Indian tribes and tribal organizations, and the NAIC to form guidelines concerning the enforcement of Subtitles B and D.
The Commissioner will cooperate with federal and state agencies to ensure maximum operation and prevent conflicts of interest and achieve uniform standards to protect consumers and still prevent unreasonable effects on employers and providers.
Sec. 144: Health Insurance Ombudsman
The Commissioner will appoint an ombudsman for qualified health care providers. This ombudsman will have expertise and experience in health care fields and education of individuals. The ombudsman will recieve complaints, grievances, and requests for information, and provide assistance to solve those problems or provide that information. The ombudsman will submit an annual report to the Commissioner and Congress describing their annual activities and making recommendations to improve the administration of the Health Choices Administration. The ombudsman can identify issues and problems in payment and coverage.
Subtitle F - Relation to Other Requirements; Miscellaneous
Sec. 151: Relation to Other Requirements
Health insurance plans not offered through the exchange market or employer-provided plans must at least adhere to the Public Health Service Act, the Employee Retirement Income Security Act, and state law, except when those acts interfere with the explicit requirements mentioned in earlier subtitles, as determined by the Commissioner.
Coverage offered through the exchange market must adhere to title XXVII of the Public Health Service Act or state law, except when those titles and laws interfere with the explicit requirements mentioned in earlier subtitles, as determined by the Commissioner
Sec. 152: Prohibiting Discrimination in Health Care
All health care and related services covered by this act will be provided regardless of personal characteristics unrelated to the provision of quality health care, except for those explicitly permitted in this act or by subesquent regulations as a result of this act. Regulations to prohibit this discrimination will be established no later than 18 months after the enactment of this bill.
Sec. 153: Whistleblower Protection
Employers may not dismiss or discriminate against employees because the employee provided or is about to provide information to the employer, state or federal agencies about a violation of the act or any order or rule established as a result of the act, testified or is about to testify in a proceeding dealing with a violation, or objected to or refused to participate in a task that violates the act.
An employer who alleges discrimination or was dismissed for these reasons may bring an action goverened by the rules set forth by the Consumer Product Safety Act and section 20109(h) of title 49 of the United States Code.
Sec. 154: Construction Regarding Collective Bargaining
Statutory or other obligations to engage in collective bargaining over the terms and conditions of employment related to health care will not be superseded by this subtitle.
Sec. 155: Severability
If any provision of this act or application of provisions to persons or circumstances is found to be unconsititutional, the remainder of the provisions and application of those provisions will not be affected.
Section G tomorrow.
Saturday, August 22, 2009
H.R. 3200, Part II
Subtitle C - Standards Guaranteeing Access to Essential Benefits
Sec. 121: Coverage of Essential Benefits Package
A qualified health plan must meet benefit standards with a certain benefits package for the plan year. If a qualified health plan is not part of the exchange market, it can offer additional benefits beyond the standard benefit package. If a plan is part of the exchange market, it must offer specific levels of benefits, or more if it is a premium-plus plan. These standards do not apply to excepted benefits as long as those are offered as a separate policy. Qualified health benefits may not have restrictions, other than cost-sharing, unrelated to clinical appropriateness regarding health care items and services.
Sec. 122: Essential Benefits Package Defined
Essential benefits means coverage that pays for items and services that meet accepted standards of medical, clinical, or professional practice, limits cost-sharing for such items and services appropriately, offers before-mentioned standards of provider network adequacy, and is equivalent to the average employer-sponsored coverage.
The minimum services must be covered; this includes hospitalization, outpatient services, professional services, services, equipment, and supplies necessary for delivery of care, prescription drugs, rehabilitative/habilitative services, mental health/substance abuse disorder services, preventive services, maternity care, and baby/child medical care up to 21 years old.
Cost-sharing is prohibited regarding preventive services. Cost-sharing may not exceed $5,000 per individual per year and $10,000 per family per year. These limits will increase every year by the annual percentage increase determined by the Consumer Price Index. To determine cost-sharing levels for basic, enhanced, and premium plans, co-payments will be used as much as possible. Cost-sharing will provide a level of benefits equal to 70% of the full actuarial value of the essential benefits packaged descibed above.
Sec. 123: Health Benefits Advisory Committee
This will be a private/public committee to recommend covered benefits, and what makes a plan essential, enhanced, or premium. The Surgeon General will chair this committee. Nine members will be non-Federal employees appointed by the President. Nine will be non-Federal employees appointed by the Comptroller General in a method similar to the appointment of members to the Medicare Payment Advisory Commission. Two, four, six, or eight members may be Federal employees and officers appointed by the President.
Each member will serve a three-year term. These terms will be staggered. Membership will reflect providers, consumers, employers, labor, health insurance companies, health care finance and delivery experts, racial/ethnic disparity experts, disabled care experts, relevant government agencies, and at least one practicing physician or health professional and an expert on children's health.
The committee is tasked with recommending and updating benefits standards, the first of which must come before one year after enactment of this bill. The committee will allow for public input as part of making recommendations. An essential plan will have benefits equal to 70% of the actuarial value of the benefits described above. An enhanced plan will have benefits actuarially equal to 85% of the value, and a premium plan will have benefits actuarially equal to 95%.
The committee will recieve coverage for travel expenses and a per diem. They will otherwise not be paid. They will not be considered Federal employees. The committee will adhere to the Federal Advisory Committee Act, and issue an online publication of all its recommendations.
Sec. 124: Process for Adoption of Recommendations; Adoption of Benefit Standards
The Secretary of Health and Human Services will review the committee's recommendations and decide whether or not to adopt those standards within 45 days of receipt. If not accepted, the Secretary must notify the committee of their reasons in writing and provide opportunity for the committee to make changes and resubmit. Standards will be adopted if the Secretary cannot come to a decision within 45 days. Standards will be published in the Federal Register.
The initial set of standards will be adopted no later than 18 months after the enactment of this bill. Adopted standards may not be inconsistent with the guidelines already mentioned in sections 122 and 123.
Section D - Additional Consumer Protections
Sec. 131: Requiring Fair Marketing Practices by Health Insurers
Uniform standards will be established that all entities offering qualified health benefit plans must meet.
Sec. 132: Requiring Fair Grievance and Appeals Mechanisms
Timely grievance and appeals mechanisms will be established. All entities offering qualified health benefit plans must provide an internal claims and appeals process that incorporates the procedures established in the Code of Federal Regulation, as well as any the standards determined by the commission. An external review board will establish a process for expedited review of urgent claims and for a review denied claims. Determinations made by this review board will be binding. All decisions of both internal and external boards are subject to the possibility of judicial review under state law regarding adverse decisions.
Sec. 133: Requiring Information Transparancy and Plan Disclosure
Qualified health benefits providers will disclose plan documents, terms, conditions, claims payment policies and practices, and periodic financial disclosure in an accurate and timely manner. Providers will also disclose data on enrollment and disenrollment, number of claims denials, rating practices, information on cost-sharing and payments regarding out-of-network coverage, and any other information deemed appropriate by the commission. This information will be provided in plain language that even individuals with limited English proficiency can readily understand. It will be clean, concise, and well-organized.
Standards will be established to ensure transparancy regarding reimbursement between a health care plan and provider.
Changes in qualified plans will not be made without reasonable and timely advance notice to enrollees.
Sec. 134: Application to Qualified Health Benefits Plans Not Offered Through the Health Insurance Exchange
Qualified health benefits plans not offered through the exchange will be subject to the same standards previously mentioned to an extent determined by the commission.
Sec. 135: Timely Payment of Claims
Qualified providers will be subject to the same payment rules that Medicare Advantage organizations are required to comply with regarding Medicare Part C, as determined by the Social Security Act.
Sec. 136: Standardized Rules for Coordination and Subrogation of Benefits
The commission will establish standards for coordination and subrogation of benefits and reimbursement of payments in cases involving individuals and multiple plan coverages.
Sec. 137: Application of Administrative Simplification
Qualified providers are subject to electronic financial and administrative transaction standards as defined in the Social Security Act.
Subtitles E and F tomorrow.
Sec. 121: Coverage of Essential Benefits Package
A qualified health plan must meet benefit standards with a certain benefits package for the plan year. If a qualified health plan is not part of the exchange market, it can offer additional benefits beyond the standard benefit package. If a plan is part of the exchange market, it must offer specific levels of benefits, or more if it is a premium-plus plan. These standards do not apply to excepted benefits as long as those are offered as a separate policy. Qualified health benefits may not have restrictions, other than cost-sharing, unrelated to clinical appropriateness regarding health care items and services.
Sec. 122: Essential Benefits Package Defined
Essential benefits means coverage that pays for items and services that meet accepted standards of medical, clinical, or professional practice, limits cost-sharing for such items and services appropriately, offers before-mentioned standards of provider network adequacy, and is equivalent to the average employer-sponsored coverage.
The minimum services must be covered; this includes hospitalization, outpatient services, professional services, services, equipment, and supplies necessary for delivery of care, prescription drugs, rehabilitative/habilitative services, mental health/substance abuse disorder services, preventive services, maternity care, and baby/child medical care up to 21 years old.
Cost-sharing is prohibited regarding preventive services. Cost-sharing may not exceed $5,000 per individual per year and $10,000 per family per year. These limits will increase every year by the annual percentage increase determined by the Consumer Price Index. To determine cost-sharing levels for basic, enhanced, and premium plans, co-payments will be used as much as possible. Cost-sharing will provide a level of benefits equal to 70% of the full actuarial value of the essential benefits packaged descibed above.
Sec. 123: Health Benefits Advisory Committee
This will be a private/public committee to recommend covered benefits, and what makes a plan essential, enhanced, or premium. The Surgeon General will chair this committee. Nine members will be non-Federal employees appointed by the President. Nine will be non-Federal employees appointed by the Comptroller General in a method similar to the appointment of members to the Medicare Payment Advisory Commission. Two, four, six, or eight members may be Federal employees and officers appointed by the President.
Each member will serve a three-year term. These terms will be staggered. Membership will reflect providers, consumers, employers, labor, health insurance companies, health care finance and delivery experts, racial/ethnic disparity experts, disabled care experts, relevant government agencies, and at least one practicing physician or health professional and an expert on children's health.
The committee is tasked with recommending and updating benefits standards, the first of which must come before one year after enactment of this bill. The committee will allow for public input as part of making recommendations. An essential plan will have benefits equal to 70% of the actuarial value of the benefits described above. An enhanced plan will have benefits actuarially equal to 85% of the value, and a premium plan will have benefits actuarially equal to 95%.
The committee will recieve coverage for travel expenses and a per diem. They will otherwise not be paid. They will not be considered Federal employees. The committee will adhere to the Federal Advisory Committee Act, and issue an online publication of all its recommendations.
Sec. 124: Process for Adoption of Recommendations; Adoption of Benefit Standards
The Secretary of Health and Human Services will review the committee's recommendations and decide whether or not to adopt those standards within 45 days of receipt. If not accepted, the Secretary must notify the committee of their reasons in writing and provide opportunity for the committee to make changes and resubmit. Standards will be adopted if the Secretary cannot come to a decision within 45 days. Standards will be published in the Federal Register.
The initial set of standards will be adopted no later than 18 months after the enactment of this bill. Adopted standards may not be inconsistent with the guidelines already mentioned in sections 122 and 123.
Section D - Additional Consumer Protections
Sec. 131: Requiring Fair Marketing Practices by Health Insurers
Uniform standards will be established that all entities offering qualified health benefit plans must meet.
Sec. 132: Requiring Fair Grievance and Appeals Mechanisms
Timely grievance and appeals mechanisms will be established. All entities offering qualified health benefit plans must provide an internal claims and appeals process that incorporates the procedures established in the Code of Federal Regulation, as well as any the standards determined by the commission. An external review board will establish a process for expedited review of urgent claims and for a review denied claims. Determinations made by this review board will be binding. All decisions of both internal and external boards are subject to the possibility of judicial review under state law regarding adverse decisions.
Sec. 133: Requiring Information Transparancy and Plan Disclosure
Qualified health benefits providers will disclose plan documents, terms, conditions, claims payment policies and practices, and periodic financial disclosure in an accurate and timely manner. Providers will also disclose data on enrollment and disenrollment, number of claims denials, rating practices, information on cost-sharing and payments regarding out-of-network coverage, and any other information deemed appropriate by the commission. This information will be provided in plain language that even individuals with limited English proficiency can readily understand. It will be clean, concise, and well-organized.
Standards will be established to ensure transparancy regarding reimbursement between a health care plan and provider.
Changes in qualified plans will not be made without reasonable and timely advance notice to enrollees.
Sec. 134: Application to Qualified Health Benefits Plans Not Offered Through the Health Insurance Exchange
Qualified health benefits plans not offered through the exchange will be subject to the same standards previously mentioned to an extent determined by the commission.
Sec. 135: Timely Payment of Claims
Qualified providers will be subject to the same payment rules that Medicare Advantage organizations are required to comply with regarding Medicare Part C, as determined by the Social Security Act.
Sec. 136: Standardized Rules for Coordination and Subrogation of Benefits
The commission will establish standards for coordination and subrogation of benefits and reimbursement of payments in cases involving individuals and multiple plan coverages.
Sec. 137: Application of Administrative Simplification
Qualified providers are subject to electronic financial and administrative transaction standards as defined in the Social Security Act.
Subtitles E and F tomorrow.
Friday, August 21, 2009
H.R. 3200, Part I
There's a lot of bitching these days about health care. Most of it is the idiotic rambling of morons who couldn't pour piss out of a boot if the instructions were written on the heel. Some of it actually addresses concerns over cost, feasibility, and how such a program would operate. While the Senate continues to write their bill, the House already has one on hand, H.R. 3200. Many people are complaining that their Representatives haven't read the bill (ignore anyone claiming their Senator hasn't read H.R. 3200, they are a member of the group of above-mentioned morons), but many laypeople have not read the bill either. Well, for your convenience and education, I will be summarizing the ~1,040 page bill, in parts.
A BILL To provide affordable, quality health care for all Americans, and reduce the growth in health care spending, and for other purposes.
DIVISION A: Affordable Health Care Choices, Title I - Protections and Standards for Qualified Health Benefits Plans
Subtitle A - General Standards
Sec. 101: Requirement Reforming Health Insurance Marketplace
Upon the enforcment of the bill, in order for a plan to be a qualified it must meet requirements relating to affordability, essential benefits, and consumer protection. A person is enrolled in an employment-based plan if that person benefits or participates in a plan as defined by the Employee Retirement Income Security Act of 1974. Individual health insurance coverage and group health insurance coverage is defined by the Public Heath Service Act.
Sec. 102: Protecting the Choice to Keep Current Coverage
Insurance will be grandfathered in if the first day of coverage is not after this bill is enforced. Dependents may enroll into the grandfathered insurance plan after enforcement. The provider must not change any terms or conditions, and may not alter premiums unless such a change is made for all policy-holders in the same risk group at the same rate.
Employment-based plans in effect before enforcement have a five-year grace period to meet the requirements relating to affordability, essential benefits, and consumer protection. During the grace period, those plans will be considered acceptable. Exceptions to this include plans that adhere to section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009, excepted benefits in section 733(c) of the Employee Retirement Income Security Act of 1974, and other limited benefits as determined by a commission. However, any coverage that extends only to those exceptions will be regarded as unacceptable.
Individual coverage offered after enforcement may only be offered through the exchange-market program. Excepted benefits are not included in the definition of health care coverage, and need only be available in the exchange and offered at a separate price from insurance coverage.
Subtitle B - Standards Guaranteeing Access to Affordable Coverage
Sec. 111: Prohibiting Pre-Existing Condition Exclusions
Qualified plans may not impose any pre-existing condition exclusion. Limitation of coverage based on health-related factors is prohibited.
Sec. 112: Guaranteed Issue and Renewal for Insured Plans
Employers and individuals will be guaranteed availability and renewal of their plans unless payment of premiums have not been received. In that case, the issuer must notify the holder of lapsed payment and provide a grace period for the holder to make such payments. Coverage may not be cut off except in cases of fraud.
Sec. 113: Insurance Rating Rules
Premium rates for a qualified plan may not vary except in consideration of age, area, and family enrollment.
Health and Human Services and Labor will conduct a study of large-group insurance and self-insured employer markets. This study will examine what types of employers self-insure or use group insurance, the similarities and differences between those plans, how solvent those self-insured employers are, the risk of self-insured employers not being able to pay obligations, and the effect of rating rules in determining choice of insurance plan. This report will make recommendations to prevent adverse selection in insurance plans to the detriment of employees.
Sec. 114: Nondiscrimination in Benefits; Parity in Mental Health and Substance Abuse Disorder Benefits
Qualified plans may not discriminate in health benefit or benefit structures. Benefits dealing with mental illness or substance abuse disorders shall not be discriminated against either in the individual or large group market.
Sec. 115: Ensuring Adequacy of Provider Networks
Qualified plans using a provider network will meet standards to provide access to items and services and provide transparancy in the cost difference between in-network and out-of-network coverage.
Sec. 116: Ensuring Value and Lower Premiums
Qualified plans must meet a medical loss ratio as determined by the commission. Plans that do not meet set ratio in a year must offer rebates to their enrollees to meet that ratio. This ratio will be based on definitions and methodologies determined by HHS.
More later.
A BILL To provide affordable, quality health care for all Americans, and reduce the growth in health care spending, and for other purposes.
DIVISION A: Affordable Health Care Choices, Title I - Protections and Standards for Qualified Health Benefits Plans
Subtitle A - General Standards
Sec. 101: Requirement Reforming Health Insurance Marketplace
Upon the enforcment of the bill, in order for a plan to be a qualified it must meet requirements relating to affordability, essential benefits, and consumer protection. A person is enrolled in an employment-based plan if that person benefits or participates in a plan as defined by the Employee Retirement Income Security Act of 1974. Individual health insurance coverage and group health insurance coverage is defined by the Public Heath Service Act.
Sec. 102: Protecting the Choice to Keep Current Coverage
Insurance will be grandfathered in if the first day of coverage is not after this bill is enforced. Dependents may enroll into the grandfathered insurance plan after enforcement. The provider must not change any terms or conditions, and may not alter premiums unless such a change is made for all policy-holders in the same risk group at the same rate.
Employment-based plans in effect before enforcement have a five-year grace period to meet the requirements relating to affordability, essential benefits, and consumer protection. During the grace period, those plans will be considered acceptable. Exceptions to this include plans that adhere to section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009, excepted benefits in section 733(c) of the Employee Retirement Income Security Act of 1974, and other limited benefits as determined by a commission. However, any coverage that extends only to those exceptions will be regarded as unacceptable.
Individual coverage offered after enforcement may only be offered through the exchange-market program. Excepted benefits are not included in the definition of health care coverage, and need only be available in the exchange and offered at a separate price from insurance coverage.
Subtitle B - Standards Guaranteeing Access to Affordable Coverage
Sec. 111: Prohibiting Pre-Existing Condition Exclusions
Qualified plans may not impose any pre-existing condition exclusion. Limitation of coverage based on health-related factors is prohibited.
Sec. 112: Guaranteed Issue and Renewal for Insured Plans
Employers and individuals will be guaranteed availability and renewal of their plans unless payment of premiums have not been received. In that case, the issuer must notify the holder of lapsed payment and provide a grace period for the holder to make such payments. Coverage may not be cut off except in cases of fraud.
Sec. 113: Insurance Rating Rules
Premium rates for a qualified plan may not vary except in consideration of age, area, and family enrollment.
Health and Human Services and Labor will conduct a study of large-group insurance and self-insured employer markets. This study will examine what types of employers self-insure or use group insurance, the similarities and differences between those plans, how solvent those self-insured employers are, the risk of self-insured employers not being able to pay obligations, and the effect of rating rules in determining choice of insurance plan. This report will make recommendations to prevent adverse selection in insurance plans to the detriment of employees.
Sec. 114: Nondiscrimination in Benefits; Parity in Mental Health and Substance Abuse Disorder Benefits
Qualified plans may not discriminate in health benefit or benefit structures. Benefits dealing with mental illness or substance abuse disorders shall not be discriminated against either in the individual or large group market.
Sec. 115: Ensuring Adequacy of Provider Networks
Qualified plans using a provider network will meet standards to provide access to items and services and provide transparancy in the cost difference between in-network and out-of-network coverage.
Sec. 116: Ensuring Value and Lower Premiums
Qualified plans must meet a medical loss ratio as determined by the commission. Plans that do not meet set ratio in a year must offer rebates to their enrollees to meet that ratio. This ratio will be based on definitions and methodologies determined by HHS.
More later.
Thursday, August 20, 2009
Cost of Convicts
Excellent op-ed in the NYT today regarding the high costs of our incarceration system.
Essentially, prisons are very expensive, and our high national incarceration rate is a major money hole. Reformation of our prison system can drastically reduce costs, which can be spent on better things, like..say, education or health care. Costs are tremendous. California spends $49,000 per inmate annually, $216,000 on each juvenile inmate. Compare this to $8,000 on each student in the Oakland school system.
According to a 2001 DOJ report (because it was the only one I could find...why is it so hard to get these numbers?), Wisconsin spent $709,202,000 on its prison system. That's a cost of roughly $132 per Wisconsin resident, and that $28,622 per inmate.
The causes of these high costs are documented in the article. Harsh sentences for drug-related offenses, programs like the "three-strike rule", and incarceration for many non-violent crimes (82% of all inmates are in prison for non-violent crimes). Kristof offers some possible solutions to reducing costs, which got me thinking.
One solution is to expand the use of the death penalty. But statistics show that harsher penalties have little effect on offenders, and the appeals system will actually keep prisoners incarcerated longer, not to mention the trial costs. But here's a better idea: If a prisoner can pay for their own stay, they should. Drug dealers, white-collar criminals, anyone who makes money illegally should pay for their stay. Would anyone have a problem if we said that Bernie Madoff would have to spend his own money to cover the costs of keeping him in prison? I, in fact, would find it more fitting. The government, in this situation, actually makes money off the offender rather than losing it.
Just an idea. Prison reform merits examination.
Essentially, prisons are very expensive, and our high national incarceration rate is a major money hole. Reformation of our prison system can drastically reduce costs, which can be spent on better things, like..say, education or health care. Costs are tremendous. California spends $49,000 per inmate annually, $216,000 on each juvenile inmate. Compare this to $8,000 on each student in the Oakland school system.
According to a 2001 DOJ report (because it was the only one I could find...why is it so hard to get these numbers?), Wisconsin spent $709,202,000 on its prison system. That's a cost of roughly $132 per Wisconsin resident, and that $28,622 per inmate.
The causes of these high costs are documented in the article. Harsh sentences for drug-related offenses, programs like the "three-strike rule", and incarceration for many non-violent crimes (82% of all inmates are in prison for non-violent crimes). Kristof offers some possible solutions to reducing costs, which got me thinking.
One solution is to expand the use of the death penalty. But statistics show that harsher penalties have little effect on offenders, and the appeals system will actually keep prisoners incarcerated longer, not to mention the trial costs. But here's a better idea: If a prisoner can pay for their own stay, they should. Drug dealers, white-collar criminals, anyone who makes money illegally should pay for their stay. Would anyone have a problem if we said that Bernie Madoff would have to spend his own money to cover the costs of keeping him in prison? I, in fact, would find it more fitting. The government, in this situation, actually makes money off the offender rather than losing it.
Just an idea. Prison reform merits examination.
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