TruthAboutHealthCareReform.org

- Will require most US citizens and legal residents to have health insurance
- Through a national Health Benefits Exchange, individuals and small businesses would be able to purchase health coverage, with subsidies available to families/individuals with incomes between 100% and 400% of the federal poverty level (annual income less than or equal to $88,200 for a family of four in 2009)
- It will also require employers to provide coverage to employees or pay an annual fee (with the exception of small employers) and provide certain small employers a credit to offset the cost of providing coverage
- There will also be new regulations on the individual and small group insurance markets
- Medicaid will be expanded to 133% of the poverty level (annual income less than or equal to $29,400 for a family of four)

- Will require all individuals to have health insurance
- Individuals and small businesses would be able to purchase health coverage, with subsidies available to families/individuals with incomes up to 400% of the federal poverty level (annual income less than or equal to $88,200 for a family of four in 2009) from state based American Health Benefit Gateways
- It will also require employers to provide coverage to employees or pay an annual fee (with the exception of small employers) and provide certain small employers a credit to offset the cost of providing coverage
- There will also be new regulations on the individual and small group insurance markets
- Medicaid will be expanded to 150% of the poverty level (annual income less than or equal to $33 075 for a family of four)

- Will require individuals to have "acceptable health coverage"
- Those without coverage pay a penalty of 2.5% of adjusted gross income (up to a maximum of the cost of the average national premium for self-only or family coverage)
- The 2.5% penalty is excepted for those with incomes below the filing threshold (in 2009 the threshold for taxpayers under age 65 is $9,350 for singles and $18,700 for couples), religious objections and financial hardship

- Will require US citizens and legal residents to have health insurance coverage, which will be enforced through a minimum tax penalty of $750 per year
- Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, if the lowest cost plan option exceeds 8% of an individual's income, and if the individual has income below 100% of the poverty level

- Will require employers to offer coverage to their employees (by contributing at least 72.5% of the premium cost for single coverage and 65% of the premium cost for family coverage of the lowest cost plan that meets the essential benefits package requirements)
- Employers with annual payroll of at least $750,000 who do not offer coverage will pay 8% of payroll into the Health Insurance Exchange Trust Fund -- this is known as the pay or play assessment
- Small employers with annual payroll of less than $750,000 will incur a reduced or eliminated pay or play fee, according to the following breakdown:
     - Annual payroll less than $500,000: exempt
     - Annual payroll between $500,000 and $585,000: 2% of payroll
     - Annual payroll between $585,000 and $670,000: 4% of payroll
     - Annual payroll between $670,000 and $750,000: 6% of payroll
- If any individual does not elect coverage under the employer plan or does not opt out of such coverage, the employer will offer coverage to automatically enroll into the employer's lowest cost premium plan
- Will require a government study of the impact of employer responsibility requirements and will recommend to Congress whether an employer hardship exemption is appropriate
[Education & Labor Committee amendment: Provide hardship exemptions for employers that would be negatively affected by job losses as a result of requirement]

- Will require employers (with greater than 50 employees) to offer health coverage to their employees
- Employers with more than 50 employees who do not offer coverage will incur a penalty of $750 for each employee who is not offered coverage
- Employers with 50 or fewer employees are exempt from this penalty

1. Medicaid
- Will expand Medicaid to all individuals under age 65 (children, pregnant women, parents, and adults without dependent children) with incomes up to 150% of the federal poverty level
- Will provide Medicaid coverage for all newborns who lack acceptable coverage
- Will provide optional Medicaid coverage to low-income HIV-infected individuals (with enhanced matching funds) until 2013
- Will provide optional Medicaid coverage to certain low-income women for family planning services
- Will increase Medicaid payment rates for primary care providers to 100% of Medicare rates by 2012
- Will require states to submit a state plan amendment specifying the payment rates to be paid under the state's Medicaid program
- Recognizing the budget challenges in many states, the coverage expansions (except the optional expansions) and the enhanced provider payments will be financed with 100% federal financing through 2014 and 91% federal financing beginning in year 2015
2. Children's Health Insurance Program
- The Children's Health Insurance Program (CHIP) will be repealed
- CHIP enrollees in separate state CHIP programs who have incomes above 150% of the federal poverty level will obtain coverage through the Health Insurance Exchange beginning in 2014
- Children with incomes above 150% of poverty enrolled in Medicaid-expansion CHIP programs will keep Medicaid coverage, and states will receive the enhanced CHIP match rate for these children starting in 2014
- CHIP enrollees with incomes between 100% and 150% of poverty will be transitioned to Medicaid and states will receive the CHIP enhanced match rate for children above current levels and up to 150% of poverty
- Will require a report to Congress with recommendations to ensure that coverage in the Health Insurance Exchange is comparable to coverage under an average CHIP plan, and that there are procedures to transfer CHIP enrollees into the exchange without interrupting coverage or with a written plan of treatment

1. Medicaid
- Will expand Medicaid to all individuals under 65 (children, pregnant women, parents and adults without dependent children) with incomes up to 133% of the federal poverty level
- States will receive 100% funding from the federal government to finance Medicaid coverage for the newly eligible from 2014 through 2016
2. Children's Health Insurance Program
- Will require states to maintain current income eligibility guidelines for children in CHIP until 2019. CHIP-eligible children who cannot enroll due to enrollment caps will be eligible for tax credits in the Exchange

- Will provide affordability premium credits to eligible individuals and families with incomes up to 400% of the federal poverty level (annual income less than or equal to $88,200 for a family of four in 2009) to purchase insurance through the Health Insurance Exchange
- The credits will be based on the average cost of the three lowest cost basic health plans in the area, and will be set on a sliding scale so that families who earn less will be required to pay a smaller percentage of their income to buy insurance
- Will lower the out-of-pocket spending limits for eligible individuals and families with incomes up to 400% of poverty, so that individuals and families who earn less will have lower limits
- Credits will be available only to US citizens, and to lawfully residing immigrants who meet the income limits and are not enrolled in qualified or grandfathered employer or individual coverage, Medicare, Medicaid (except those eligible to enroll in the Exchange), TRICARE, or VA coverage (with some exceptions)
- Individuals with access to employer-based coverage will be eligible for the credits if the cost of the employee premium exceeds 12% of the individual's income
- Will require verification of both income and citizenship status in determining credit eligibility
- The plan will prohibit credits from being used to purchase a health plan in the Exchange that includes coverage for abortions, except to save the life of the woman or in cases of rape or incest
- Individuals receiving federal credits may purchase supplemental coverage for abortions, but that coverage must be paid for entirely with private funds

- To ensure that those with the lowest incomes receive the most help, the bill will provide premium credits on a sliding scale basis to individuals and families with incomes between 100-400% of the federal poverty level ($88,200 for a family of four) to purchase coverage through the Health Exchange
- The credits will ensure that individuals with incomes at 300-400% FPL pay 9.8% of income and individuals with incomes between 100-133% of the FPL pay 2% of their income
- Premium credits will be limited to individuals who are not eligible for employer-based coverage meeting qualifying criteria and affordability standards, Medicare, Medicaid, TRICARE or the federal Employee Health Benefits Program
- The only individuals with access to employer-based coverage who are eligible for the premium credits are those for whom the cost of the employee premium exceeds 9.8% of the individuals' income

- Will provide small employers (fewer than 25 employees and average wages of less than $40,000) with a health coverage tax credit for up to two years. The full credit of 50% of premium costs paid by employers will be available to employers with 10 or fewer employees and average annual wages of $20,000 or less. The amount of the credit decreases as firm size and average wage increase, and is not permitted for employees earning more than $80,000 per year
- Will create a temporary reinsurance program for employers providing health insurance coverage to retirees ages 55 to 64. Program will reimburse employers for 80% of retiree claims between $15,000 and $90,000. Payments from the reinsurance program will be used to lower the costs for enrollees in the employer plan
- Will appropriate $10 billion over ten years for the reinsurance program

- Will provide employers (with no more than 25 full-time employees and average wages less than $50,000) with a health options program credit
- The credit is equal to 35% of the employer's contribution to each employee's coverage through the year 2013, with up to a 50% credit from year 2014, adjusted for firm size (phasing out as firm size increases) and number of months of coverage provided
- There will also be a temporary reinsurance program for employers providing health insurance coverage to retirees ages 55 to 64, reimbursing employers for 80% of retiree claims between $15,000 and $90,000 (This program will no longer be available once the state Exchange is established)

- Individuals without acceptable health care coverage will incur a penalty tax of 2.5% of adjusted income (up to the cost of the average national premium for self or family coverage)
- Will impose a tax of 5.4% on individuals with adjusted income exceeding $500,000 and families with adjusted income exceeding $1,000,000
- Will permit only prescribed drugs to be reimbursable through a health savings account, Archer medical savings account, health reimbursement arrangement, or flexible spending arrangement for medical expenses
- The tax on health savings account distributions that are not used for qualified medical expenses will increase to 20% of the disbursed amount
- The amount of contributions to a flexible spending arrangement for medical expenses will be limited to $2,500 per year
- Will impose a tax of 2.5% of the price on the first taxable sale of any medical device

A minimum tax of no more than $750 per year will be imposed on individuals without qualifying health care coverage

- Will create a National Health Insurance Exchange, through which individuals and employers (starting with smallest employers) can purchase insurance, including from private health plans and the public health insurance option
- Access to coverage through the Exchange will be restricted to individuals who are not enrolled in employer or individual coverage, Medicare, Medicaid, TRICARE, or VA coverage
- Will create a new public health insurance option to be offered through the Exchange that must meet the same requirements as private plans regarding benefit levels, provider networks, consumer protections, and cost-sharing
- Will require the public plan to offer basic, enhanced, and premium plans, and permit it to offer premium plus plans
- Will prohibit the public plan from providing coverage for abortions beyond those permitted by federal law (to save the life of the woman and in cases of rape and incest).
- Will finance the costs of the public plan through revenues from premiums, and will require the public health insurance option to negotiate rates with providers so that the rates are not lower than Medicare rates and not higher than the average rates paid by other qualified health benefit plan offering entities
- Will create a Consumer Operated and Oriented Program (CO-OP) to facilitate the establishment of non-profit, member-run health insurance cooperatives to provide insurance through the Exchange
- Will provide information to consumers and small employers to enable them to choose among plans in the Exchange, and will provide information on how to enroll
- Federal subsidies may not be used to purchase a plan or supplemental coverage that covers abortions beyond those permitted by federal law. Plans participating in the Exchange will be prohibited from discriminating against any provider because of an unwillingness to provide abortions

- Will create a state-based American Health Benefit Exchange administered by a government agency or non-profit organization, through which individuals and small employers can purchase qualified coverage
- States may form regional Exchanges to operate in a state as long as each Exchange serves a distinct geographic area
- Only US citizens and legal immigrants who are not incarcerated are eligible
- The act will also create non-profit, member-run health insurance companies to offer qualified health plans
- Will create four benefit categories of plans and reduce out-of-pocket limits for those with incomes up to 400% of the federal poverty level
- Will allow states to prohibit plans in the Exchange from providing coverage for abortions

- Will create a benefits package that provides a comprehensive set of services and does not impose annual or lifetime limits on coverage
- Will set limits such that no individual will spend more than $5,000 and no family more than $10,000 per year on health care that falls within the benefit package guidelines.
- Will prohibit abortion coverage from being required as part of the essential benefits package.

- Will create a benefit package that provides a comprehensive array of services and prohibits annual or lifetime limits on coverage
- This benefits package must be included in all qualified health plans
- Will prohibit abortion coverage from being required as part of this package

- Will establish a temporary national high-risk pool to provide health coverage to those who have pre-existing medical conditions, who have been denied coverage or offered unaffordable coverage, or who have been uninsured for at least six months
- Individuals eligible for COBRA continuation coverage will be able to retain COBRA coverage until the Exchange is established or until they obtain acceptable coverage
- Will limit health plans' medical loss ratio, and will enforce this percentage through a rebate back to consumers
- Will prohibit insurers from taking away health insurance coverage except in cases of fraud
- Will provide dependent coverage for children up to age 27 for all individual and group policies
Prohibit reductions to retiree benefits unless reductions also apply to current employees. (Effective upon enactment)
- Individuals may purchase a qualifying health benefit plan only through the Health Insurance Exchange (unless individuals have grandfathered coverage)
- Will improve consumer protections by establishing uniform marketing standards, requiring fair grievance and appeals mechanisms and accurate and timely disclosure of plan information
- Will remove the anti-trust exemption for health insurers and medical malpractice insurers

- Will establish a national high-risk pool to provide coverage to those with pre-existing conditions. Individuals with pre-existing conditions and who have not been insured for at least 6 months will be eligible for the high-risk pool
- Will provide dependent coverage for children up to age 26 for all individual and group policies
- Will develop standards for insurers to use in providing information on benefits and coverage
- Will permit licensed health insurers to sell health insurance policies outside of the Exchange to be regulated by the states

- Will require states to implement Medicaid eligibility expansions and specified changes with respect to provider payment rates, benefit enhancements, quality improvement, and program integrity
- Will require states to maintain Medicaid and CHIP eligibility standards, methodologies, or procedures that were in place as of June 16, 2009 as a condition of receiving federal Medicaid matching payments.
- Will maintain eligibility requirement for children in Medicaid expansion CHIP programs with incomes above 150% of poverty, and will require CHIP maintenance of eligibility through December 31, 2013
- Will require states to enter into a Memorandum of Understanding with the Health Insurance Exchange to coordinate enrollment of individuals in Exchange-participating health plans and under the state's Medicaid program
- May require states to determine eligibility for affordability credits through the Health Insurance Exchange

- Will require states to establish an American Health Benefit Exchange meeting federal standards and adopt individual and small group market regulation changes
- Will require states to implement Medicaid eligibility expansions and adopt federal standards and protocols for facilitating enrollment of individuals in federal and state health and human service programs
- Will allow states to create a Basic Health Plan for uninsured individuals with incomes between 133-200% of the federal poverty level

- Will simplify health insurance administration, for example by adopting timely and transparent claims and denial management processes, and the use of standard electronic transactions
- Will restructure payments to Medicare Advantage plans, phasing to 100% of fee-for-services payments, with bonus payments for quality
- Will reduce Medicare Disproportionate Share Hospital (DSH) allotments by $10 billion, imposing the largest percentage reductions in state DSH allotments in states with the lowest uninsured rates and those that do not target DSH payments
- Will reduce Medicare payments for potentially preventable hospital readmissions
- Will require drug manufacturers to provide drug rebates for dual eligibles enrolled in Part D plans
- Will authorize the Food and Drug Administration to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed
- Will enhance competition in the pharmaceutical market by stopping agreements between brand name and generic drug manufacturers that limit, delay, or otherwise prevent competition from generic drugs
- Reduce waste, fraud, and abuse in public programs by allowing provider screening, enhanced oversight periods, and enrollment moratoria in areas identified as being at elevated risk of fraud in all public programs, and by requiring Medicare and Medicaid program providers and suppliers to establish compliance programs

- Will simplify health insurance administration, for example by adopting timely and transparent claims and denial management processes, and the use of standard electronic transactions
- Will work to expand different payment structures in Medicare, Medicaid and CHIP in order to reduce program expenditures and maintain or improve quality of care
- Will authorize the FDA to approve generic versions of drugs, and to grant biologics manufacturers 12 years of exclusive use before generics can be developed

- Will establish a Center for Comparative Effectiveness Research to conduct, support, and synthesize research on outcomes, effectiveness, and appropriateness of health care services and procedures
- Will provide incentive payments to states with alternative medical liability laws that make the liability system more reliable through the prevention or resolution of disputes, encourage the disclosure of health care errors, and maintain access to affordable liability insurance
- Will strengthen primary care and care coordination by increasing Medicaid payments for primary care providers, and providing Medicare bonus payments to primary care practitioners (with larger bonuses paid to primary care practitioners serving in health professional shortage areas)
- Will expand the role of the Medicaid and CHIP Payment and Access Commission (MACPAC) to include all individuals, and will require reports on the implementation of health reform that relate to Medicaid and CHIP, including the effect of implementation on access
- Will establish the Center for Quality Improvement to identify, develop, evaluate, disseminate, and implement best practices in the delivery of health care services. Will develop national priorities for performance improvement and quality measures for the delivery of health care services
- Will require disclosure of financial relationships between health entities, including physicians, hospitals, pharmacists, and other providers, and manufacturers and distributors of covered drugs, devices, biologicals, and medical supplies
- Will reduce racial and ethnic disparities by conducting a study on the feasibility of developing Medicare payment systems for language services, providing Medicare demonstration grants to reimburse culturally and linguistically appropriate services, and developing standards for the collection of data on race, ethnicity, and primary language

- Will establish a non-profit research institute to conduct research on the clinical effectiveness of medical treatments
- Develop a national strategy to improve the delivery of health care services, patient health outcomes and population health including an annual national health care quality report card
- Will also develop certain quality measures to allow for health outcome assessment, coordination, safety, effectiveness and timeliness of care and appropriate usage of resources. There would also be a public reporting component through a website
- There would also be grants available for improving efficiency, to establish community health teams, to establish medication management services and to design and implement regional emergency care and trauma systems
- Will require collection and reporting of data on race, ethnicity, sex, primary language, disability status, etc.

- Will develop a national strategy to improve the nation's health through evidenced-based clinical and community-based prevention and wellness activities
- Will create task forces on Clinical Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services
- Will improve prevention by covering only proven preventive services and eliminating cost-sharing for preventive services in Medicare and Medicaid
- Will increase Medicare payments for certain preventive services to 100% of charges or rates
- Will provide wellness grants (maximum 3 years) to small employers for up to 50% of the costs for a qualified wellness program
- Will require chain restaurants and vending-machine food to disclose the nutritional content of each item

- Will include a national prevention and health promotion strategy setting specific goals for health improvement by expanding funding for prevention and public health programs (ie. awarding grants to local governments and organizations to implement programs proven to reduce chronic disease rates).
- Will also allow insurers to create incentives for health promotion and disease prevention practices and encourage employers to provide wellness programs by conducting educational campaigns

- Will establish a national, voluntary insurance program for purchasing community living assistance services and supports (CLASS program). The program will provide individuals with functional limitations a cash benefit to purchase non-medical services and supports necessary to maintain community residence. The program will be financed through voluntary payroll deductions: all working adults will be automatically enrolled in the program, unless they choose to opt-out
- Will improve transparency of information about skilled nursing facilities and nursing facilities

This act would establish a national, voluntary insurance program for purchasing community living assistance services and supports (CLASS) programs which will provide individuals with functional limitation a cash benefit for purchase of non-medical services and supports necessary to maintain community residence. This program will be financed through voluntary payroll deductions.

- Will improve the Medicare program:
     a) Eventually eliminate the Medicare Part D coverage gap by 2019
     b) Require drug manufacturers to provide a 50% discount on brand-name prescriptions filled in the coverage gap
     c) Increase the asset test threshold for Medicare Savings Program and Part D Low-Income Subsidies to $17,000/individual and $34,000/couple
     d) Eliminate any cost-sharing for preventive services in Medicare, and finance these costs with up to 100% federal funding
- Will improve workforce training and development:
     a) Reform Graduate Medical Education to increase training of primary care providers by redistributing residency positions and promote training in outpatient settings
     b) Support training of health professionals through scholarships and loans; establish a primary care training and capacity building program; establish a loan repayment program for professionals who work in health professions needs areas; establish a public health workforce corps; promote training of a diverse workforce; and provide cultural competence training for health care professionals
     c) Support the development of interdisciplinary mental and behavioral health training programs and establish a training program for oral health professionals. (Funds appropriated beginning FY 2011)
     d) Increase the capacity for nurse education, support training programs, provide loan repayment and retention grants, and create a career ladder to nursing - Will establish the Public Health Investment Fund for financing designated public health provisions
- Will establish trauma center program to strengthen emergency department and trauma center capacity, and to establish new trauma centers in urban areas with substantial trauma related to violent crimes
- Will improve access to care by increasing funding by $12 billion over five years for community health centers, and by establishing new programs to support school-based and nurse-managed health centers
- Will provide grants to each state health department to address core public health infrastructure needs
- Reauthorize and amend the Indian Health Care Improvement Act

- Will make significant improvements to Medicare, including Part D coverage limits and cost sharing
- Will establish a National Health Care Workforce commission to make recommendations and disseminate information on health workforce priorities, goals and policies including education and training
- There would also be significant reform to graduate medical education to increase the supply, education and training of doctors, nurses and other health care workers, especially in pediatric, geriatric and primary care
- Will also improve access to care by providing additional funding to increase the number of community and school-based health centers

- Estimated cost: $894 billion over ten years
- Financed through a combination of savings from Medicare and Medicaid ($426 billion over ten years)
- Remaining costs will be financed through a 5.4% surcharge imposed on families with incomes above $1,000,000 and individuals with incomes above $500,000 (projected to raise $461 billion)
- Additional revenue provisions will generate $97 billion over the same time period.
- Deficit will be reduced by $104 billion over ten years

- The Congressional Budget Office (CBO) estimates the proposal will cost $871 billion over the course of 10 years
- These costs will be financed through a combination of Medicare/Medicaid savings ($438 billion) and new taxes/fees
- CBO estimates this proposal will reduce the deficit by $132 billion over ten years