I am continuing my read-through of the entire proposed health care bill, HR 3200. I also started a new domain over the weekend which will serve as a repository for all of these posts, along with any other pertinent information that I choose to include there:
www.IfCongressWontReadItIWill.com
Here are the first two parts, in case you missed them:
A Layman's View of the Proposed Health Care Bill (HR 3200) - Part Two (Title II, Subtitle A)
My notes on the remainder of Title II are below.
________________________________________
SEC. 222. PREMIUMS AND FINANCING.
(2) CONTINGENCY MARGIN- In establishing premium rates under paragraph (1), the Secretary shall include an appropriate amount for a contingency margin.
MY NOTE: I learned what a "contingency margin" was through a bit of research. It's basically extra money set aside for any potential differences in premiums collected and actual expenses.
(2) START-UP FUNDING- (A) IN GENERAL- In order to provide for the establishment of the public health insurance option there is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $2,000,000,000.
MY NOTE: I guess I find it hard to imagine that we have $2 billion in Treasury funds that are not otherwise appropriated. Also, it struck me as a sad commentary on our government that this figure wasn't shocking to me, based on the staggering amount of spending that has occurred in recent years.
(B) AMORTIZATION OF START-UP FUNDING- The Secretary shall provide for the repayment of the startup funding provided under subparagraph (A) to the Treasury in an amortized manner over the 10-year period beginning with Y1.
MY NOTE: I don't see any way that this public health option could generate enough additional revenue to pay back an average of $200 million annually to the Treasury, largely because of the apparent limits placed on profitability in earlier sections. This is an odd conflict.
SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.
(a)(2)(A) IN GENERAL-"...the Secretary shall base the payment rates under this section for services and providers described in paragraph (1) on the payment rates for similar services and providers under parts A and B of Medicare."
MY NOTE: I wanted to know what Medicare Parts A and B were, so I looked it up. In a nutshell, this is separate insurance provided for those who are eligible for Medicare (over 65, or with certain disabilities, or with renal failure). Part B is more robust than Part A. Since the public health option would be available for a wider variety of enrollees, this section also calls for the Sec. of Health and Human Services to modify rates to allow for things like well child checkups and certain prescriptions not allowed under Medicare.
(f) Limitations on Review- There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.
MY NOTE: Simply put, why is there no process for review or appeal of a payment rate?
SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.
(a) In General- For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.
MY NOTES: I had to look up virtually everything referenced in the above paragraph. Here are some definitions that I found:
"Patient-centered medical home" - This video does a far better job of explaining it than I could: http://www.emmisolutions.com/medicalhome/transformed/. I have to admit that this sounds like a more valuable way to go about treating patients.
"Accountable care organizations" - also known as ACOs, these are 'collaborations that integrate groups of physicians, hospitals, and other providers around the ability to receive shared-savings bonuses by achieving measured quality targets and demonstrating real reductions in overall spending growth for a defined population of patients.' This certainly sounds interesting, at least on the surface.
"Partial capitation" - Doctors would be made partially on a fee-for-service basis and partly as a fixed amount per patient - this is dependent on diagnostic and demographic factors. For example, a 25-year old patient with diabetes would result in a different (probably lower) payment to the doctor than a 65-year old with heart disease. Since the payment would not increase with the number of services provided, it's expected to motivate doctors to give the most efficient care possible.
In my humble opinion, any of these solutions appear to provide interesting alternatives to the status quo. I think partial capitation could eliminate needless medical tests, especially if coupled with solid tort reform policies. Gosh - I can't believe I just wrote that last sentence. I am learning a lot!
Subtitle C--Individual Affordability Credits
SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.
(a) Definition-
(1) IN GENERAL- For purposes of this division, the term `affordable credit eligible individual' means, subject to subsection (b), an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)--
(A) who is enrolled under an Exchange-participating health benefits plan and is not enrolled under such plan as an employee (or dependent of an employee) through an employer qualified health benefits plan that meets the requirements of section 312;
(B) with family income below 400 percent of the Federal poverty level for a family of the size involved; and
(C) who is not a Medicaid eligible individual, other than an individual described in section 202(d)(3) or an individual during a transition period under section 202(d)(4)(B)(ii).
MY NOTE: Based on my own family size (6) and the Federal Poverty Level as defined by Health and Human Services, I could make over $118,000/year and still be eligible for an affordability credit under this section. In years when my income has been at or above that level, I haven't felt strapped financially, so I don't know if I would need/want to apply for an affordability credit. Then again, if it's available, why wouldn't I do so in order to save my own money?
You can also note here that they specifically limit this to those who are "lawfully present in the United States".
SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.
Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.
MY NOTE: I think this is just there for good measure, since this was addressed a bit earlier in the same subtitle. The section before this provides guidelines for reporting dramatic changes in income, and also provides for penalties for misrepresentation of income.
Thanks very much to those of you who are actually following along as I read through this. This post takes us into page 143 out of 1017 total pages. I recognized that the audience for these posts would likely decrease over time, but I intend to finish regardless.
If you have any comments/questions, I would love to hear them, either in the comments below, or via email (jason@austintexashomes.com) or phone (512-796-7653). Thanks!
If you enjoyed this post, why not connect with me elsewhere or subscribe via email?
If you're looking for a home in the Austin area, you can also visit my primary Austin real estate website at www.austintexashomes.com. If you're interested in social media training, visit 210 Consulting. Thanks!
Anyone who has the desire, ability and determination to read through this Bill ought to run for President. I'd vote for you, Jason. :)
Wow Jason What an accomplishment to decipher all that. I agree with Lina. We need you for president. This Bill is so complicated ..Thanks so much for sharing. I too have an interest. My daughter who is having a baby due Dec 26 has diabetes that sometimes affects pregnant mothers and disappears after birth. She was telling me it cost her $ 40. per month to take the test. I ask if her insurance covered the cost and she said yes that is what it is after the insurance kicks in..It would cost her
$ 400 a month instead of $ 40...unbelievable isn't it. Something need done and implemented.
My thought is thanks for sharing your finding. At least you explain the bill. Our elected people do not seem to care that much.
The more complex and difficult this is to understand, the more likely that unscrupulous people will find ways to abuse the system as they have in the past. I have little confidence in the current administration's ability to "fix" health care, even if they did have the public's good in mind (which is questionable). But I appreciate your efforts to understand it and try to
Thank you for doing this....and for sharing your thoughts! I'm hoping that this is going to die and go away. The outrageous costs...like June mentioned...is only going to get worst with one-payor..and I'm tired of paying for everything.
Lina - I think that you are the 8th person to mention this. I guess I have at 10-15 votes. :)
June - Agreed. Costs have spiraled out of control. I'm not surprised to hear that the test for gestational diabetes is so high. We paid almost $30,000 to have our last two children, and my wife didn't have any drugs!
Frank - Well, you're welcome!
Colleen - I think it is needlessly complex, but I do want to understand the basics, hence this series of posts. I think there are several missing items that could actually help, but we'll see.
Karen - I find it interesting that so many people think that this is a version of socialized medicine, when I haven't found any evidence that it will be free. Premiums are mentioned throughout the bill. I don't know if it will go away altogether, but I do hope it is heavily modified.
Jason.
Count me in on a vote for you for the Presidency! It is amazing the time and energy you are spending on reading this to formulate your own opinion. If you can complete the review I'm here to read your findings!
Dorie - Thanks for saying that! I appreciate the supportive words. I will continue!
Evening Jason, And to think you gave up part of your Labor Day weekend to read this ! Have you read enough that you would offer an informed opinion on which parts deserve to be in whatever the final version is ?
It is certainly good that someone is reading this stuff -- heaven knows the congress seems not to be.
Jason, this Bill hits very close to home for me. I am a single mother raising an autistic child who just turned 11. I have never received child support. I had the same insurance carrier for 10 years. I dropped them earlier this year because they did not cover my son's medical needs. For the past 5 years, they did pay $240 per year for my son's doctor visits, but after our last office visit my insurance carrier denied the claim stating they do not cover "pychosis." My son is not psychotic, he's autistic. Not only did they deny that claim, they went back the previous 5 years and demanded a refund of all the claims they paid to that physician. I spend $600 in medications, and $400 in therapy each month....then there are the usual and customary costs of raising a child. During the boom years, it didn't bother me to pay $500 a month in insurance for me and my son, plus the cost of his care. But now....every dime counts. Since I am getting the least bang for my buck with the insurance, they were the first to go. I have made less than $500 in claims in the last 10 years, and my son hasn't even had a runny nose since he was 2. That's a savings of $6,000 a year. I realize I am rolling the dice here, but I feel like I have paid my dues and received nothing in return.
Quite frankly, if the government would force the insurance carriers to cover my son's diagnosis, I would not have cancelled it. Alternatively, fix the economy and I'll buy my own.
If you find a solution in that Bill somewhere for someone like me, please let me know.
Oh, and by the way, I'll personally head up your campaign for President. :) CROUCH IN 2012!!!!
Jason - Like you and Lina, this is a big deal for me and my family. My children were born very premature and have had numerous issues as a result. Fortuneately, I had excellent insurance at the time and Medicaid provided some assistance. In total, the bill just to get them out of the hospital was over $4,000,000. My out-of-pocket expenses easily break the 5-digit mark every year and monthly medical bills occasionally surpass my mortgage. We are fortunate to be able to provide the therapy and care our children need so that they have the opportunity to one day lead somewhat normal lives. I know many others who do not have this luxury. The system is broken. I don't know if this is the solution, but I am joining you in reading the bill to find out.
Jason, I congratulate you for continuing to persue this and help sort it out. One of my questions is that Medicare Part A AND B still do not cover many necessary things for good health care so a supplimental policy is needed as well as a prescription plan.
Even then, if you exceed a certain amount in medications, you fall into a donut hole out of which I believe you pay $5,000 out of pocket before Medicare picks up again. Seems to me, Medicare Part B, a supplimental policy and prescription policy still cost a LOT of money every month and people who are eligible may not be able to afford it either.
It also concerns me that you cannot appeal a decision.
Jason,
There seems to be many incentives to reduce cost and withhold care and no benefit for providing even good care let alone excellentcare as seen from the patience's point of view. But, then ccongress and the president have their own coverage.
Bill
Wow, Thanks for blogging this proposal,we all need to take a good look at it,it is a bit overwhelming.
Kudos for your diligence! I enjoyed getting your feedback on the bill thus far. It will be interesting to see how this administration plays out. Our founding fathers would be shocked at the state of the nation today.
Another piece of the puzzle they call Health Care Reform Jason, Thanks for the breakdown!
That's why they call it Tuesday,
Paul
Thanks for doing this J. As I stated earlier, I started this task, but have all but given up on it. Perhaps I'll dig in again, but I get good cliff notes from you. Seriously...thanks.
Jason _ I agree with Bill on this one. Who's going to want to become a doctor if this thing passes? You might make more money working at walmart.
But then again, it will reduce helath care expense if you don't have any doctors.
It's so nice to know that you're reading this...I'm pretty sure no one on the Hill has! Thanks for all of your hard work!
oi. I'm trying to follow along, but there's lots of big words in there! Thanks for taking the time to do this!
I'm also worried about no way to appeal a claim. That's my problem now! I have an autistic child who was also born with a birth defect that we got surgically corrected. Despite the proper referrals and all being good before he went under the knife, they then turned around and denied our claim, saying that yes we had the referral but the HOSPITAL didn't pre-authorize. Still appealing this $25,000 bill.
Yet another time they denied coverage for am ambulance ride and hospital visit for my son, who had a seizure and started turning blue. Why? Because I didn't call in to pre-authorize his ER trip!! Excuse me, my son's not breathing, do you mind if we go to the ER now? nevermind that by the time i'd get through hold, he'd have been dead. Geez.
Anywho. :) Long story short - what we have now sucks. Hopefully when you're done, you'll be able to tell us if this looks any better. That or you'll have had a week's worth of really good sleep, cuz that's what reading it does for me!
You should forward these posts to Obama - maybe they'll hire you as a layman analyst and bill editor :-) seriously...