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:
Here are the first two parts, in case you missed them:
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.
(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 (firstname.lastname@example.org) or phone (512-796-7653). Thanks!