Yesterday I spent about 5 hours digging through the senate version of the health care bill. It will probably bear significant resemblance to the bill that is finally passed, and since I am eventually going to need to know what is in the bill, I decided to go ahead and read it. It was not short. In fact, it was incredibly long. Many of the 2074 pages consisted of corrections in wording or lengthy descriptions of the formation of various commissions, which I skimmed. Some points were worded so abstrusely that I just couldn't figure out what they were saying, so I did not address them.
I was generally impressed with the time and thought put into the creation of the bill. I must say, though, that when I finally sit back and evaluate the thing, I think it suffers from its ridiculous length and complexity. It has ended up looking like a wish list written by a monstrous consortium of well informed visionaries. If even a portion of it actually ends up being accomplished it will profoundly change the way our country looks at health and health care. This will probably be a good thing.
I have attempted to distill the bill into a document that a person could reasonably hope to read and maybe understand. I am sure there are inaccuracies due to the fact that apparently there is another dialect of English generally in use by law makers, and it is not my dialect.
Goals of the health care bill fall into 5 categories, and specifics of the bill generally fit into those categories.
Goal 1: Make health care coverage affordable to all Americans
• Create plans which cover minimal essential health care needs to be provided by health insurance companies or coops, payment for which would be subsidized by the government as needed.
• Regulate the insurance companies who provide these plans such that they behave in a way that protects patients from becoming impoverished for care, and in such a way that health is promoted. These regulations include:
o no lifetime limits on coverage
o no unreasonable annual limits
o no policy cancellations
o no co-pay for agreed upon preventive services
o unmarried children will be eligible for coverage on parents' policies up to age 26
o benefits summary must not exceed 4 pages of 12 or greater font and must be understandable to average enrollee
o within 2 years health insurance companies must demonstrate that their practices improve outcomes, decrease hospitalizations and medical errors and promote wellness
o patients will receive rebates if their premiums substantially exceed the services they receive
o no exclusions based on pre-existing conditions
o cost of policies can vary based on age or whether the patient smokes, but within certain limits
• Create an insurance exchange within 90 days of enactment to cover people who have been uninsured and are difficult to insure for various reasons.
• Create an internet site to connect consumers to choices of affordable insurance.
• Government will help reimburse companies for payment of insurance for early retirees (people under age 65 who retire and are not eligible for Medicare).
• Provide loans and grants for creation of health care cooperatives.
• Simplify forms relating to coverage and payments.
• Essential health benefits must include:
o ambulatory services
o emergency care
o hospitalization
o maternity and newborn care
o mental health and substance abuse treatment
o prescription drugs
o rehabilitation
o labs
o preventive and wellness services
o dental and vision coverage for kids
o limitation on deductibles to $2000 for individual and $4000 for other plans
• Each state will establish exchanges for state residents to purchase health insurance, thus fostering competition. One exchange, the American Health Benefit Exchange, will serve individuals and families, and the Small Business Health Options Program (SHOP exchange) will service businesses looking to insure workers.
• Insurance exchanges will be evaluated within 5 years.
• Communities may design their own health insurance options in order to reduce administrative costs.
• States may enact their own plans for covering low income individuals.
• There will be tax credits to help pay for premiums for individuals with incomes up to 4 times the poverty line, and for small businesses.
• Medicaid will be expanded to cover people up to 133% of the poverty line, and there will be increased support of the Children’s Health Insurance Program (CHIP). There will be simplification of the process of applying for these and there will be outreach to at-risk populations.
• Medicaid coverage will be expanded to cover such things as free standing birth centers.
• Individuals will be required to maintain minimal essential coverage for themselves and their dependants, and fines will be phased in for noncompliance. Exceptions will be made for people who are part of a religious based health care ministry or are registered as having a religious basis of objection, people in jail, and those for whom the only available insurance costs more than 8% of their income.
• There will be medication discounts during the “donut hole” gap in Medicare drug coverage (the time after the cap on insurance coverage and before the out of pocket maximum is reached.) The gap will also be reduced.
Goal 2: Improve the quality of health care
• Programs will be supported to provide “health homes” for treatment of chronic conditions, coordinating care through a group of providers.
• Provide money to pay for maternal, infant and early childhood home visits
• Increase hospital payments based on performance for several diagnoses (pneumonia, heart attacks, congestive heart failure and surgeries.)
• Increase provider reimbursement based on quality indicators.
• Establish a center for Medicare and Medicaid innovation.
• Pilot program for bundling payment for episodes requiring hospitalization.
• Pilot program for evaluation of home based care by physicians and nurses.
• Improve payments to critical access hospitals (rural hospitals in underserved areas) for participation in delivery system reforms.
• Pilot program to look at cost effectiveness of providing hospice services along with certain Medicare services.
• Improve formularies for Medicare D so more medications are covered by insurance.
• Fund health care delivery quality research addressing best practices and patient safety.
• Fund creation of practice teams for Patient Centered Medical Homes.
• Fund medication management services.
• Provide funding for systems that improve emergency services including trauma care, public health.
• Develop a program to facilitate shared decision making between doctors and patients in choices of care.
• Establish a Women's Health office of the Department of Health and Human Services.
• Patient centered outcomes research: provide more money to evaluate which treatments work and to compare cost effectiveness.
• Increase funding for protection from elder abuse.
• Fund research into pain treatment.
Goal 3: Reduce costs
• Medicare will not pay for costs associated with health care acquired conditions.
• Adjust payments for home health care to more accurately represent value and expense of care, including hospice.
• Re-evaluate billing codes, especially codes used multiple times for a single visit, codes that have the fastest growth and codes for new technology, and re-calculate the relative value scale which is used to determine Medicare payments for various billing codes.
• Reduce payment for the technical component of imaging multiple body parts.
• Oversee Medicare Advantage programs.
• Reduce part D subsidies for high income patients.
• Reduce waste in drugs dispensed in nursing homes associated with 30 day refills.
• Hospitals will be required to publish standard charges.
• Reduce overall Medicare reimbursement increased to hospitals and nursing homes based on productivity.
• Establish a board to decrease per capita growth in Medicare spending.
• Increase transparency of costs and payments related to physician ownership of hospitals and nursing homes.
• Increase surveillance for fraud and fines for fraud in Medicare.
• States are encouraged to develop and test alternatives to the present civil litigation system.
• Excise taxes will be levied on high cost employer sponsored health care (employee will be charged 40% of excess benefit) and 5% excise tax on cost of cosmetic medical procedures.
• Increase oversight of drug sampling and payments for brand name drugs.
• The senate notes that 3 elderly or disabled individuals can be cared for in home and community based services for the cost of 1 cared for in a nursing home. Voluntary insurance for community based services will be established.
Goal 4: Improve availability of care
• Establish a commission to improve and increase the health care work force.
• Enhance student loan programs.
• Repay loans for certain primary care and public health students.
• Increase funding to the National Health Service Corps significantly (1 billion by 2015).
• Fund certain nurse practitioner managed clinics.
• Increase training programs in family practice, general internal medicine, physician’s assistant programs, pediatrics, including needs based fellowships, support public health dentistry and training for nursing home care providers.
• Support primary care dentistry including hygienist clinics.
• Provide training grants for mental health providers, advanced care nurses.
• Increase payment for primary care services by 10%.
• Increase payment for general surgery in shortage areas.
• Provide money to start clinics in underserved areas.
• Adjust Medicare payments based on geographical differences in cost of living.
• Pilot program to increase payment to Medicare dependant urban hospitals, along the lines of critical access hospitals in rural areas.
• Improve Medicare payments to low volume hospitals to preserve access.
Goal 5: Promote health
• Create an advisory group to set specific goals for Americans and a national strategy for achieving those goals.
• Support the work of a preventive services task force to evaluate the effectiveness of preventive services, and introduce community preventive services task forces.
• Fund school based health centers.
• Medicare will pay for annual preventive visits with personalized prevention plans.
• Medicaid will pay for smoking cessation services for pregnant women.
• Fund community transformation grants to create healthier communities (including improvement of food at schools, programs to increase activity, work based wellness services, reduction in ethnic disparities.)
• Fund grants to enhance wellness in seniors.
• Increase spending for public health programs such as personal responsibility education.
• Require nutritional labeling of menus at restaurants.
• Allow reasonable break times for nursing mothers.
I was generally impressed with the time and thought put into the creation of the bill. I must say, though, that when I finally sit back and evaluate the thing, I think it suffers from its ridiculous length and complexity. It has ended up looking like a wish list written by a monstrous consortium of well informed visionaries. If even a portion of it actually ends up being accomplished it will profoundly change the way our country looks at health and health care. This will probably be a good thing.
I have attempted to distill the bill into a document that a person could reasonably hope to read and maybe understand. I am sure there are inaccuracies due to the fact that apparently there is another dialect of English generally in use by law makers, and it is not my dialect.
Goals of the health care bill fall into 5 categories, and specifics of the bill generally fit into those categories.
Goal 1: Make health care coverage affordable to all Americans
• Create plans which cover minimal essential health care needs to be provided by health insurance companies or coops, payment for which would be subsidized by the government as needed.
• Regulate the insurance companies who provide these plans such that they behave in a way that protects patients from becoming impoverished for care, and in such a way that health is promoted. These regulations include:
o no lifetime limits on coverage
o no unreasonable annual limits
o no policy cancellations
o no co-pay for agreed upon preventive services
o unmarried children will be eligible for coverage on parents' policies up to age 26
o benefits summary must not exceed 4 pages of 12 or greater font and must be understandable to average enrollee
o within 2 years health insurance companies must demonstrate that their practices improve outcomes, decrease hospitalizations and medical errors and promote wellness
o patients will receive rebates if their premiums substantially exceed the services they receive
o no exclusions based on pre-existing conditions
o cost of policies can vary based on age or whether the patient smokes, but within certain limits
• Create an insurance exchange within 90 days of enactment to cover people who have been uninsured and are difficult to insure for various reasons.
• Create an internet site to connect consumers to choices of affordable insurance.
• Government will help reimburse companies for payment of insurance for early retirees (people under age 65 who retire and are not eligible for Medicare).
• Provide loans and grants for creation of health care cooperatives.
• Simplify forms relating to coverage and payments.
• Essential health benefits must include:
o ambulatory services
o emergency care
o hospitalization
o maternity and newborn care
o mental health and substance abuse treatment
o prescription drugs
o rehabilitation
o labs
o preventive and wellness services
o dental and vision coverage for kids
o limitation on deductibles to $2000 for individual and $4000 for other plans
• Each state will establish exchanges for state residents to purchase health insurance, thus fostering competition. One exchange, the American Health Benefit Exchange, will serve individuals and families, and the Small Business Health Options Program (SHOP exchange) will service businesses looking to insure workers.
• Insurance exchanges will be evaluated within 5 years.
• Communities may design their own health insurance options in order to reduce administrative costs.
• States may enact their own plans for covering low income individuals.
• There will be tax credits to help pay for premiums for individuals with incomes up to 4 times the poverty line, and for small businesses.
• Medicaid will be expanded to cover people up to 133% of the poverty line, and there will be increased support of the Children’s Health Insurance Program (CHIP). There will be simplification of the process of applying for these and there will be outreach to at-risk populations.
• Medicaid coverage will be expanded to cover such things as free standing birth centers.
• Individuals will be required to maintain minimal essential coverage for themselves and their dependants, and fines will be phased in for noncompliance. Exceptions will be made for people who are part of a religious based health care ministry or are registered as having a religious basis of objection, people in jail, and those for whom the only available insurance costs more than 8% of their income.
• There will be medication discounts during the “donut hole” gap in Medicare drug coverage (the time after the cap on insurance coverage and before the out of pocket maximum is reached.) The gap will also be reduced.
Goal 2: Improve the quality of health care
• Programs will be supported to provide “health homes” for treatment of chronic conditions, coordinating care through a group of providers.
• Provide money to pay for maternal, infant and early childhood home visits
• Increase hospital payments based on performance for several diagnoses (pneumonia, heart attacks, congestive heart failure and surgeries.)
• Increase provider reimbursement based on quality indicators.
• Establish a center for Medicare and Medicaid innovation.
• Pilot program for bundling payment for episodes requiring hospitalization.
• Pilot program for evaluation of home based care by physicians and nurses.
• Improve payments to critical access hospitals (rural hospitals in underserved areas) for participation in delivery system reforms.
• Pilot program to look at cost effectiveness of providing hospice services along with certain Medicare services.
• Improve formularies for Medicare D so more medications are covered by insurance.
• Fund health care delivery quality research addressing best practices and patient safety.
• Fund creation of practice teams for Patient Centered Medical Homes.
• Fund medication management services.
• Provide funding for systems that improve emergency services including trauma care, public health.
• Develop a program to facilitate shared decision making between doctors and patients in choices of care.
• Establish a Women's Health office of the Department of Health and Human Services.
• Patient centered outcomes research: provide more money to evaluate which treatments work and to compare cost effectiveness.
• Increase funding for protection from elder abuse.
• Fund research into pain treatment.
Goal 3: Reduce costs
• Medicare will not pay for costs associated with health care acquired conditions.
• Adjust payments for home health care to more accurately represent value and expense of care, including hospice.
• Re-evaluate billing codes, especially codes used multiple times for a single visit, codes that have the fastest growth and codes for new technology, and re-calculate the relative value scale which is used to determine Medicare payments for various billing codes.
• Reduce payment for the technical component of imaging multiple body parts.
• Oversee Medicare Advantage programs.
• Reduce part D subsidies for high income patients.
• Reduce waste in drugs dispensed in nursing homes associated with 30 day refills.
• Hospitals will be required to publish standard charges.
• Reduce overall Medicare reimbursement increased to hospitals and nursing homes based on productivity.
• Establish a board to decrease per capita growth in Medicare spending.
• Increase transparency of costs and payments related to physician ownership of hospitals and nursing homes.
• Increase surveillance for fraud and fines for fraud in Medicare.
• States are encouraged to develop and test alternatives to the present civil litigation system.
• Excise taxes will be levied on high cost employer sponsored health care (employee will be charged 40% of excess benefit) and 5% excise tax on cost of cosmetic medical procedures.
• Increase oversight of drug sampling and payments for brand name drugs.
• The senate notes that 3 elderly or disabled individuals can be cared for in home and community based services for the cost of 1 cared for in a nursing home. Voluntary insurance for community based services will be established.
Goal 4: Improve availability of care
• Establish a commission to improve and increase the health care work force.
• Enhance student loan programs.
• Repay loans for certain primary care and public health students.
• Increase funding to the National Health Service Corps significantly (1 billion by 2015).
• Fund certain nurse practitioner managed clinics.
• Increase training programs in family practice, general internal medicine, physician’s assistant programs, pediatrics, including needs based fellowships, support public health dentistry and training for nursing home care providers.
• Support primary care dentistry including hygienist clinics.
• Provide training grants for mental health providers, advanced care nurses.
• Increase payment for primary care services by 10%.
• Increase payment for general surgery in shortage areas.
• Provide money to start clinics in underserved areas.
• Adjust Medicare payments based on geographical differences in cost of living.
• Pilot program to increase payment to Medicare dependant urban hospitals, along the lines of critical access hospitals in rural areas.
• Improve Medicare payments to low volume hospitals to preserve access.
Goal 5: Promote health
• Create an advisory group to set specific goals for Americans and a national strategy for achieving those goals.
• Support the work of a preventive services task force to evaluate the effectiveness of preventive services, and introduce community preventive services task forces.
• Fund school based health centers.
• Medicare will pay for annual preventive visits with personalized prevention plans.
• Medicaid will pay for smoking cessation services for pregnant women.
• Fund community transformation grants to create healthier communities (including improvement of food at schools, programs to increase activity, work based wellness services, reduction in ethnic disparities.)
• Fund grants to enhance wellness in seniors.
• Increase spending for public health programs such as personal responsibility education.
• Require nutritional labeling of menus at restaurants.
• Allow reasonable break times for nursing mothers.
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