Health Care In America: The Republican Alternative

Before I begin the review of the Republican alternative to HR 3962, let me just say one thing.

It was so nice reading a piece of legislation that actually made sense the first time I read it. I didn’t have to cross reference hundreds of different pieces of legislation to figure out what the bill actually said, and I didn’t feel like the text of this amendment was running me in circles.

The Republican alternative to HR 3962 is actually an amendment to the bill. The key being “an amendment in the nature of a substitute”.

Now, before anyone starts stomping their feet and having a hissy fit, I think we all know that Nanny State Nancy will never allow this amendment to come up for a vote, even if she has the votes to defeat it. The last thing she wants is to have this 219 page amendment read on the House floor.

Why? Because it actually makes sense. It isn’t bloated with hundreds of tax hikes, it has no hidden agenda. It simply does (and is) what the title says, “Common Sense Health Care Reform and Affordability Act “. As far as I can tell after reading the bill, it is common sense, it does reform health care, and according to the non-partisan Congressional Budget Office, it does reduce the deficit.

Let’s begin the review.

Division A

Section 101 begins on page 4 and establishes universal access programs for every State and ensures that all Americans, even those in the “high risk” pool have affordable access to health care.

IN GENERAL. – A qualifying State high risk pool described in this subsection means a current section 2745 qualified high risk pool that meets the following requirements:

(A) The pool must provide at least two coverage options, one of which must be a high deductible health plan coupled with a health savings account.

(B) The pool must be funded with a stable funding source.

(C) The pool must eliminate any waiting lists so that all eligible residents who are seek­ing coverage through the pool should be allowed to receive coverage through the pool.

(D) The pool must allow for coverage of individuals who, but for the 24-month disability waiting period under section 226(b) of the Social Security Act, would be eligible for Medicare during the period of such waiting period.

(E) The pool must limit the pool premiums to no more than 150 percent of the average premium for applicable standard risk rates in that State.

(F) The pool must conduct education and outreach initiatives so that residents and brokers understand that the pool is available to eligible residents.

(G) The pool must provide coverage for preventive services and disease management for chronic diseases.

This section concluded within seven pages. I had to read hundreds of pages in Nancy Pelosi’s HR3962 before I could ascertain that the bill specifically allowed waiting lines.

Section 102 eliminates certain requirements for guaranteed availability in individual markets by extending existing HIPAA protections and improving protections for Americans with pre-existing conditions.

Section 103 prohibits any health insurance plan from setting arbitrary annual or lifetime spending caps, which will help those with chronic diseases or some sort of catastrophic medical emergency.

Section 104 prohibits health insurance companies from unlawfully canceling health insurance coverage. HR3692 has no such guarantee. In fact, the only time HR3962 mentions the word cancellation is in reference to loan cancellations.

The remainder of Division A covers topics which will make it easier for consumers to find and compare health insurance plans, make it easier for States to cut health care costs, and to reduce the amount of forms and transactions in health care administration.

Division B

The first few sections of Division B begin by cutting the costs and expanding the access of health insurance for small businesses. Section 201 sets the rules for governing association health plans, Section 202 clarifies single employer arrangements, and sections 203-205 establish the enforcement provisions of those plans and stakes out the cooperation between Federal and State authorities regarding association plans.

Section 211 requires all health care plans to extend coverage of dependents up to age 25, Section 212 allows for automatic enrollment in employer health care plans but it does not require the employee to accept it, and Section 221 is the coup de grace of the Republican alternative. It opens up the health insurance market across state lines.

(1) PRIMARY STATE. – The term ‘primary State’ means, with respect to individual health insur­ance coverage offered by a health insurance issuer, the State designated by the issuer as the State whose covered laws shall govern the health insurance issuer in the sale of such coverage under this part. An issuer, with respect to a particular policy, may only designate one such State as its primary State with respect to all such coverage it offers. Such an issuer may not change the designated primary State with respect to individual health insurance coverage once the policy is issued, except that such a change may be made upon renewal of the policy. With re­spect to such designated State, the issuer is deemed to be doing business in that State.

(2) SECONDARY STATE. – The term ‘secondary State’ means, with respect to individual health insurance coverage offered by a health insurance issuer, any State that is not the primary State. In the case of a health insurance issuer that is selling a policy in, or to a resident of, a secondary State, the issuer is deemed to be doing business in that secondary State.

This section alone will reduce the cost of many health insurance plans across the nation. Before I was laid off in January, my employer was based in Maryland, and because we live here in Georgia our health insurance costs for the employer based plan was extremely inflated. I’m sure this provision alone will save the American public (and their employers) billions of dollars each year.

Section 231 and 232 expand current tax credits for IRAs and 401Ks to Health Savings Accounts (HSAs), and allow for premium payments from those HSAs under certain conditions.

Division C

The sections in Division C deal with medical liability reform by setting a statute of limitations for claims, capping non-economic damages to $250,000, limits punitive damages, and protects States with existing medical liability laws. No provision within this division of the bill limits the economic damages a claimant may receive. In fact, Section 302 makes sure of that.

In any health care lawsuit, nothing in this title shall limit a claimant’s recovery of the full amount of the available economic damages, notwithstanding the limitation in subsection (b).

Subsection B of Section 302 sets the non-economic limit of damages to $250,000. Remember, the largest component of many liability cases are the economic damages.

Division D

This division explicitly prohibits the federal government from intervening with the treatment process.

Section 401 states,

Nothing in this Act shall be construed to interfere with the doctor-patient relationship or the practice of med­icine.

Section 402 repeals section 804 (the Federal Coordinating Council on Comparative Effectiveness Research) of the American Recovery and Reinvestment act to prevent any possibility that the federal government could ration health care based on costs.

Division E

Section 501 provides monetary incentives for prevention and wellness programs. In other words, if employees participated in standards-based wellness programs, employers could offer specific discounts of up to 50% on their health care plan premiums.

Division F

Section 601 increases funding for the Health and Human Services Office of the Inspector General and the Health Care Fraud and Abuse Control program.

Section 602 explicitly prohibits any federal funding from being used to pay for abortions,

No funds authorized or appropriated by federal law, and none of the funds in any trust fund to which funds are authorized or appropriated by federal law, shall be ex­pended for any abortion.

and it also prohibits funding for health benefits plans that cover abortion.

None of the funds authorized or appropriated by federal law, and none of the funds in any trust fund to which funds are authorized or appropriated by federal law shall be expended for a health benefits plan that includes coverage of abortion.

This section does remove that limitation in a couple of specific cases,

(1) if the pregnancy is the result of an act of rape or incest; or

(2) in the case where a woman suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death unless an abortion is per­formed, including a life-endangering physical condi­tion caused by or arising from the pregnancy itself.

and explicitly allows States to offer a supplemental plan which could cover abortion.

Nothing in this chapter shall be construed as prohibiting any individual, entity, or State or locality from purchasing separate supplemental abortion plan or coverage that includes abortion so long as such plan or cov­erage is paid for entirely using only funds not authorized or appropriated by federal law and such plan or coverage shall not be purchased using matching funds required for a federally subsidized program, including a State’s or locality’s contribution of Medicaid matching funds.

This section also prohibits government discrimination against individual and institutional health care providers.

(a) IN GENERAL. – No funds authorized or appropriated by federal law may be made available to a Federal agency or program, or to a State or local government, if such agency, program, or government subjects any institu­tional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions.

(b) HEALTH CARE ENTITY DEFINED. – For purposes of this section, the term ‘health care entity’ includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.

In other words, if a doctor has a moral or religious objection to providing abortion services, he cannot be discriminated against at the federal, state, local level.

I have one question with this section. Are pharmacists covered as “health care professionals”?

Sections 603 and 604 improve enforcement of Medicare payment provisions and strengthen Medicare provider enrollment standards.

Section 605 establishes an expansion of the Medicare and Medicaid databases to track banned providers across state lines. Many providers, when they get into trouble in one state, simply move to another state to avoid the mess. This would no longer be possible under this provision of the Republican alternative to HR3962.

The Secretary of Health and Human Services shall provide for increased coordination between the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as ”CMS”) and its regional offices to ensure that pro­viders of services and suppliers that have operated in one State and are excluded from participation in the Medicare program are unable to begin operation and participation in the Medicare program in another State.

Division G

The remaining sections of the amendment cover the FDA approval process and expedites the way in which biosimilar drugs will be available on the market when an innovator’s product’s term of patent expires. This will allow quicker access to affordable medications and lower the cost of every health insurance plan that makes them available.

And with that, my review of the 219 page Republican amendment in the nature of a substitution to HR 3962 is complete. It’s short, it’s blunt, and it would do exactly what it says it will do, if it ever got the chance of reaching the House floor.

While many people will be disappointed that this amendment does not raise everyone’s taxes and it doesn’t place their children in a life of servitude to pay the costs of providing health care, this amendment does take some simple, positive steps to true health care reform in our country.

We don’t need a total overhaul of our health system (or our tax system for that matter), but our system does need a few tweaks. The items listed in the Republican amendment tweak our current system by reducing health coverage costs for every American, while reducing the federal deficit by doing so.

You can follow the progress of the Republican amendment (and read some scary reports on HR3962) at the GOP Health Care website.

Finally, we get a real start to the solution for health care reform, and Nancy Pelosi is going to bury it.

HR3962 : Division D

So far, the contents of HR3962 have been absolutely insane. From the transition to the single payer system and federally funded abortions to the tight regulation of neighborhood obesity, restaurant menus, and vending machines, it’s been quite a ride.

This final section, Division D, pertains to Indian Health Care Improvement, but just wait until you see some of the items Nancy Pelosi and the gang feel will improve Indian health.

Section 3101 of HR3962 amends the Indian Health Care Improvement Act. In addition to numerous other sections, it also amends section 301, by stating,

Congress finds the following:

(1) The provision of sanitation facilities is primarily a health consideration and function.

(2) Indian people suffer an inordinately high incidence of disease, injury, and illness directly at attributable to the absence or inadequacy of sanitation facilities.

The bill states “sanitation facilities” several times in this section, and Congress reaffirms the primary responsibility and authority of the Service to provide the necessary sanitation facilities and services, yet they never really state which sanitation systems will be further regulated, and there is no mention about the authority of the local tribes that will be affected by this legislation. What if they have existing standards, infrastructure and systems? Shouldn’t they have some say about how these facilities will be serviced and monitored? Is clean drinking water part of the plan for these “sanitation facilities”?

In the previous post we saw the return of involuntary servitude and discrimination so it only makes sense that “Indian Health Care Improvement” would involve the taking of Indian land… again… right?

Notwithstanding any other provision of law, the Bureau of Indian Affairs and all other agencies and departments of the United States are authorized to transfer, at no cost, land and improvements to the Service for the provision of health care services. The Secretary is authorized to accept such land and improvements for such purposes.

Something tells me this isn’t going to go over well either. Health care services or not, they may take offense to the fact that the Secretary of Health and Human Services now has the right to take any land he/she wants as long as she justifies it in the name of improved health care.

This section continues to erode tribal sovereignty by assigning control of any and all grants and/or contracts between Tries and any health care, education, disease prevention, wild life preservation, land preservation, land purchases, and anything else covered by the Snyder Act.

Under authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), the Secretary, acting through the Service, shall enter into contracts with, or make grants to, urban Indian organizations to assist such organizations in the establishment and administration, within Urban Centers, of programs which meet the requirements set forth in this title. Subject to section 506, the Secretary, acting through the Service, shall include such conditions as the Secretary considers necessary to effect the purpose of this title in any contract into which the Secretary enters with, or in any grant the Secretary makes to, any urban Indian organization pursuant to this title.

For more information on this blatant encroachment of tribal sovereignty, make sure you read all of the pages from 1805 through 1877.

The bill authorizes the Secretary to decide what constitutes mental illness for the Indian community.

The purposes of this section are as follows:

(1) To authorize and direct the Secretary, acting through the Service, to develop a comprehensive behavioral health prevention and treatment program which emphasizes collaboration among alcohol and substance abuse, social services, and mental health programs.

(2) To provide information, direction, and guidance relating to mental illness and dysfunction and self-destructive behavior, including child abuse and family violence, to those Federal, tribal, State, and local agencies responsible for programs in Indian communities in areas of health care, education, social services, child and family welfare, alcohol and substance abuse, law enforcement, and judicial services.

and also provides for the conversion of existing hospital beds (for medical treatment) to be used in psychiatric wards as needed.

Mental Health Care Need Assessment- Not later than 1 year after the date of enactment of the Indian Health Care Improvement Act Amendments of 2009, the Secretary, acting through the Service, shall make an assessment of the need for inpatient mental health care among Indians and the availability and cost of inpatient mental health facilities which can meet such need. In making such assessment, the Secretary shall consider the possible conversion of existing, underused Service hospital beds into psychiatric units to meet such need.

Why would American Indians need more psychiatric beds anyway? Does the government know something we don’t or are they preparing for something bigger? When it comes to HR3962, it doesn’t get much bigger than this.

The bill makes reference to treatment programs specifically for women,

The Secretary, consistent with section 701, may make grants to Indian Tribes, Tribal Organizations, and urban Indian organizations to develop and implement a comprehensive behavioral health program of prevention, intervention, treatment, and relapse prevention services that specifically addresses the cultural, historical, social, and child care needs of Indian women, regardless of age.

funding for a Fetal Alcohol Disorder Task Force,

The Secretary shall establish a task force to be known as the Fetal Alcohol Disorder Task Force to advise the Secretary in carrying out subsection (b).

and the establishment of a Native American Health and Wellness Foundation.

As soon as practicable after the date of enactment of this title, the Secretary shall establish, under the laws of the District of Columbia and in accordance with this title, the Native American Health and Wellness Foundation.

And with that, I wrap up my quick summary of House Resolution 3962, Affordable Health Care for America Act.

Make sure you read the pertinent parts of this bill. It was a much tougher read than the previous bill, which I think was intentional on the part of Nancy Pelosi and the gang. Almost every provision of HR3962 makes an amendment to some other legislation or act which is already in place, so learning the true intention of many sections was quite painstaking.

I shudder to think what the final Senate version of the bill will look like, if we’re ever allowed to see it, and once the two are merged, it’s going to be completely ridiculous, I am sure.

That’s it for tonight, I’m going to sleep now.

HR3962 : Division C

Once again, I apologize for the brevity of each summary post, but I am hoping I’ll have a little time during the debate on the House floor to discuss some of these provisions in more detail. Here we go with Division C.

Section 2201 establishes the National Health Service Corps, just like HR 3200 did, which will require any member of the Corps to perform “half-time” clinical practice as a contractual obligation under the new scholarship program and/or loan repayment program. There’s nothing like involuntary servitude to make a country stronger.

Not only does HR3962 hail the return of involuntary servitude, but it also opens the door to health care discrimination on a wide-reaching scale in Section 2301.

The term ‘health disparities’ includes health and health care disparities and means population-specific differences in the presence of disease, health outcomes, or access to health care. For purposes of the preceding sentence, a population may be delineated by race, ethnicity, primary language, sex, sexual orientation, gender identity, disability, socioeconomic status, or rural, urban, or other geographic setting, and any other population or subpopulation determined by the Secretary to experience significant gaps in disease, health outcomes, or access to health care.

In other words, the Secretary of Health and Human Services will be permitted to use race, ethnicity, sex, sexual orientation, age, and any other criteria he/she wants while determining your access to health care. Every other government entity is prohibited from discrimination, yet HR3962 doesn’t just open that door, it props it open with a 1,990 page bill.

Section 2502 states,

A hospital described in subparagraph (L), (M), (N), (R), (S), or (T) of paragraph (4) shall not obtain covered outpatient drugs through a group purchasing organization or other group purchasing arrangement.

If hospitals are not permitted to participate outpatient drugs in group purchasing organizations, does this mean they have to do so independently, and if so, why? What is the purpose or motive for disallowing such participation?

Section 2502 also sets the requirements for improvement in the 340B program integrity. The 340B program is the drug pricing program which resulted from enactment of Public Law 102-585, the Veterans Health Care Act of 1992, which is codified as Section 340B of the Public Health Service Act. Section 340B limits the cost of covered outpatient drugs to certain federal grantees, federally-qualified health center look-alikes and qualified disproportionate share hospitals. Significant savings on pharmaceuticals may be seen by those entities that participate in this program.

This section of the bill authorizes the Secretary of Health and Human Services

to verify the accuracy of ceiling prices calculated by manufacturers under subsection (a)(1) and charged to covered entities

Nothing in this section will prohibit the Secretary from abusing their power to make this decision, and nothing in this section provides for any type of oversight to ensure that the Secretary is acting in the best interest of the American taxpayer.

School based health clinics will be established using grants defined in Section 2511.

Funds awarded under a grant under this section–

(1) may be used for–

(A) providing training related to the provision of comprehensive primary health services and additional health services;

(B) the management and operation of SBHC programs, including through subcontracts; and

(C) the payment of salaries for health professionals and other appropriate SBHC personnel; and

(2) may not be used to provide abortions.

While section 2511 clearly prohibits “in school abortions”, it does not prevent or prohibit the distribution of materials regarding abortion or access to information on accessing facilities which provide abortions.

Why exactly do we need school based health clinics anyway? Shouldn’t schools teach children, and medical facilities treat them?

Section 2513 requires “FEDERALLY QUALIFIED BEHAVIORAL HEALTH CENTERS” to offer a wide range of services.

Make available to individuals served by the center, directly, through contract, or through linkages with other programs, each of the following:

(i) Adult and youth peer support and counselor services.

(ii) Family support services for families of children with serious mental disorders.

(iii) Other community or regional services, supports, and providers, including schools, child welfare agencies, juvenile and criminal justice agencies and facilities, housing agencies and programs, employers, and other social services.

(iv) Onsite or offsite access to primary care services.

(v) Enabling services, including outreach, transportation, and translation.

(vi) Health and wellness services, including services for tobacco cessation.

In other words, these newly named “federally qualified behavioral health centers” will be required to offer counseling services, family support for families of children with serious mental disorders, access to schools and a wide range of other public services, as well as access to primary care services and health and wellness services including services for tobacco cessation.

Which health and wellness services would be offered that wouldn’t be covered by a primary care service provider? Is this an implication of some other health service that normally isn’t performed inside hospitals and other medical facilities? And since when is smoking a mental health issue?

Section 2534 allows community organizations to provide services to low-income and uninsured patients and nothing in the section prevents a community-based collaborative care network from providing care to individuals.

Section 2525 establishes the “Community Based Overweight and Obesity Prevention Program which will be administered by eligible entities which will be awarded grants to run the program.

(a) Program- The Secretary shall establish a community-based overweight and obesity prevention program consisting of awarding grants and contracts under subsection (b).

(b) Grants- The Secretary shall award grants to, or enter into contracts with, eligible entities–

(1) to plan evidence-based programs for the prevention of overweight and obesity among children and their families through improved nutrition and increased physical activity; or

(2) to implement such programs.

These grants will be awarded to “representatives of public and private entities that have a history of working within and serving the community. Think ACORN.

As if this bill wasn’t painful enough, Section 2562 actually deals with pain research. Apparently HR3962 establishes an Interagency Pain Research Coordinating Committee. Just thinking of the bureaucracy of this new committee is painful. You may want to read this section to learn how the committee will be comprised, because this committee will be making decisions that could affect your treatment if you have chronic pain.

Just what you need when you’re in pain. A committee deciding if you have had enough medication, whether or not your pain threshold has changed, and whether or not your treatment protocol needs to be changed. You know, for your well-being, since you’re in pain and all.

Believe me, the fun does not stop there. Under Section 2572, the Secretary of Health and Human Services will be regulating every menu in America.

The Secretary shall establish by regulation standards for determining and disclosing the nutrient content for standard menu items that come in different flavors, varieties, or combinations, but which are listed as a single menu item, such as soft drinks, ice cream, pizza, doughnuts, or children’s combination meals, through means determined by the Secretary, including ranges, averages, or other methods.

In addition to menus, vending machines will also be tightly regulated.

In the case of an article of food sold from a vending machine that–

(I) does not permit a prospective purchaser to examine the Nutrition Facts Panel before purchasing the article or does not otherwise provide visible nutrition information at the point of purchase; and

(II) is operated by a person who is engaged in the business of owning or operating 20 or more vending machines,

the vending machine operator shall provide a sign in close proximity to each article of food or the selection button that includes a clear and conspicuous statement disclosing the number of calories contained in the article.

But that’s not all. In addition to deciding which information should be required to appear on menus and next to vending machines, the Secretary of Health and Human Services will also be responsible for the standardization of recipes, methods of preparation, serving size, menu items, space on menus, menu boards, and even human error. Read it if you don’t believe me.

In promulgating regulations, the Secretary shall–

(aa) consider standardization of recipes and methods of preparation, reasonable variation in serving size and formulation of menu items, space on menus and menu boards, inadvertent human error, training of food service workers, variations in ingredients, and other factors, as the Secretary determines; and

(bb) specify the format and manner of the nutrient content disclosure requirements under this subclause.

That Secretary of Health and Human Services must be a talented person. In addition to administering the entire Health and Human Services department of the government, they will also need to know everything there is about health care, pharmaceutical drugs, food, recipes, menus, vending machines, and who knows what else by the time we get done here.

Getting back to health care, yeah I know, it’s such a stretch now isn’t it? Section 2581 amends the Public Health Service Act by requiring the automatic enrollment of employees into a health care plan by the employer, and the inability to disenroll except once per year during an annual enrollment period. If I remember correctly, this same provision appeared in HR 3200.

It’s getting late and my mind is turning to mush, but I’m almost done with this review of HR3962. All that remains is Division D, which will be following this post within the next couple hours. We’ll pick up with Division D, “Indian Health Care Improvement” on page 1635 then.

HR3962 : Division B

So far we have learned that HR 3962 brings the single payer health care system to America along with health care rationing, special end-of-life care, and federally funded abortions. Along with all of those headaches it also brings a dictionary full of new taxes, and all of that was written into Division A. Let’s start a quick review of Division B.

Section 1111 starts off by regulating non-therapy ancillary services. It appears that payment for these services will be based on the patients age, physical and mental status, ability to perform activities of daily living, and other information.

The Secretary of Health and Human Services shall analyze payments for non-therapy ancillary services under a future skilled nursing facility classification system to ensure the accuracy of payment for non-therapy ancillary services. Such analysis shall consider use of appropriate predictors which may include age, physical and mental status, ability to perform activities of daily living, prior nursing home stay, diagnoses, broad RUG category, and a proxy for length of stay.

Why should non-medical staff have the authority to decide what type of non-therapy ancillary service you may require? Shouldn’t your doctor, or at least a health care professional be the one choosing your medical treatment?

Payments for stays in skilled nursing facilities will be based on the aggregate costs during that stay and not on the number of days in that stay.

Outlier adjustments or additional payments described in subparagraph (A) shall be based on aggregate costs during a stay in a skilled nursing facility and not on the number of days in such stay.

but

The Secretary shall reduce estimated payments that would otherwise be made under the prospective payment system under this subsection with respect to a fiscal year by 2 percent. The total amount of the additional payments or payment adjustments for outliers made under this paragraph with respect to a fiscal year may not exceed 2 percent of the total payments projected or estimated to be made based on the prospective payment system under this subsection for the fiscal year.

So rather than base the payment on the number of days a patient stays in the facility, the payments will now be based on aggregate costs minus 2 percent. In other words, facilities will not even be paid for their actual costs for providing treatment.

Section 1112 establishes the standard by which Medicare DSH payments will be reduced to hospitals and service providers based on the “significant” decrease in the numbers of those who are uninsured. A significant decrease will be measured only if there is an 8% decrease in the number of those uninsured. I thought the purpose of this bill was to insure all of the uninsured people in America. Isn’t setting a target goal of only 8% rather lame?

There is a lot more to this bill than I am covering, but like I said when I started, I am trying to cover some of the more important sections of the bill before the debate on the bill begins. You can be sure of one thing. If you followed my review of HR 3200, which was much more in-depth, almost every provision of that bill also exists in this bill.

Section 1156 prohibits the expansion of hospitals without the approval of the Secretary of Health and Human Services. The expansion of facility capacity is completely prohibited.

PROHIBITION ON EXPANSION OF FACILITY CAPACITY- Except as provided in paragraph (2), the number of operating rooms, procedure rooms, or beds of the hospital at any time on or after the date of the enactment of this subsection are no greater than the number of operating rooms, procedure rooms, or beds, respectively, as of such date.

But the Secretary can determine the process in which those facilities can apply for an exception and be allowed to expand.

The Secretary shall establish and implement a process under which a hospital may apply for an exception from the requirement under paragraph (1)(C).

While these exceptions may be approved and facilities will be allowed to expand, they won’t be allowed to expand to a size which is double the size they were when the bill takes affect.

PERMITTED INCREASE-

(i) IN GENERAL- Subject to clause (ii) and subparagraph (D), a hospital granted an exception under the process described in subparagraph (A) may increase the number of operating rooms, procedure rooms, or beds of the hospital above the baseline number of operating rooms, procedure rooms, or beds, respectively, of the hospital (or, if the hospital has been granted a previous exception under this paragraph, above the number of operating rooms, procedure rooms, or beds, respectively, of the hospital after the application of the most recent increase under such an exception).

(ii) 100 PERCENT INCREASE LIMITATION- The Secretary shall not permit an increase in the number of operating rooms, procedure rooms, or beds of a hospital under clause (i) to the extent such increase would result in the number of operating rooms, procedure rooms, or beds of the hospital exceeding 200 percent of the baseline number of operating rooms, procedure rooms, or beds of the hospital.

(iii) BASELINE NUMBER OF OPERATING ROOMS, PROCEDURE ROOMS, OR BEDS- In this paragraph, the term ‘baseline number of operating rooms, procedure rooms, or beds’ means the number of operating rooms, procedure rooms, or beds of a hospital as of the date of enactment of this subsection.

Expansions will be limited only to those hospitals and facilities which have experienced population increases, increased patient admissions in their respective counties, and a higher bed occupancy rate within their state.

In other words, Section 1156 will hasten the end of quality medical care in rural America. If the population isn’t there, it won’t be cost effective to expand (or even build) medical facilities.

Section 1161 gives the Secretary authority to cut payments and even make the determination if Medicare Advantage Plans are qualified health plans.

AUTHORITY TO DISQUALIFY DEFICIENT PLANS- The Secretary may determine that a Medicare Advantage plan is not a qualifying plan if the Secretary has identified deficiencies in the plan’s compliance with rules for Medicare Advantage plans under this part.

The entire section is much longer, but in essence, $150 billion could be cut from Medicare Advantage Plans, which would reduce or eliminate the coverage for millions of senior citizens.

If it wasn’t enough to put their health coverage plans in jeopardy, Section 1236 authorizes the Secretary of Health and Human Services, acting through the Center for Medicare and Medicaid Innovation established under section 1115A of the Social Security Act, to establish a decision making program under the Medicare program using patient decision aids to meet the objective of improving the understanding of medical treatment options in a “shared decision making” process using those patient decision aids.

This section will also waive requirements of the Social Security Act Titles XI and XVIII, seniors will be required to meet attend counseling on Medicare services, and compensation will be granted to providers who generate less cost for care.

Read that last paragraph again people. Compensation if you generate less cost for care. Exactly how do you generate less cost for care with a “patient decision aid”? What decision could a senior citizen possibly make that would reduce the cost for their care? You get the point.

Section 1401 creates the “Center for Comparative Effectiveness Research”. The what? Comparative effectiveness?

The Center shall–

(A) conduct, support, and synthesize research relevant to the comparative effectiveness of the full spectrum of health care items, services and systems, including pharmaceuticals, medical devices, medical and surgical procedures, and other medical interventions;

(B) conduct and support systematic reviews of clinical research, including original research conducted subsequent to the date of the enactment of this section;

(C) continuously develop rigorous scientific methodologies for conducting comparative effectiveness studies, and use such methodologies appropriately;

(D) submit to the Comparative Effectiveness Research Commission, the Secretary, and Congress appropriate relevant reports described in subsection (d)(2);

(E) not later than one year after the date of the enactment of this section, enter into an arrangement under which the Institute of Medicine of the National Academy of Sciences shall conduct an evaluation and report on standards of evidence for highly credible research;

(F) encourage, as appropriate, the development and use of clinical registries and the development of clinical effectiveness research data networks from electronic health records, post marketing drug and medical device surveillance efforts, and other forms of electronic health data; and

(G) appoint clinical perspective advisory panels for research priorities under this section, which shall consult with patients and other stakeholders and advise the Center on research questions, methods, and evidence gaps in terms of clinical outcomes for the specific research inquiry to be examined with respect to such priority to ensure that the information produced from such research is clinically relevant to decisions made by clinicians and patients at the point of care.

How long until the “Center for Comparative Effectiveness Research” begins to deny access to necessary, life saving treatments because the comparative costs of providing them no longer shows effectiveness in reviews by the center staff?

Again, there is a lot more in this bill. I feel like I haven’t even scratched the surface yet. It’s not that I feel I am missing information, I just don’t feel the need to regurgitate all of the text from HR 3200 that still exists in this bill.

Section 1416 with authorize the all powerful Secretary of Health and Human Services to maintain specific information on all direct care staffing at each and every medical facility in the country.

SUBMISSION OF STAFFING INFORMATION BASED ON PAYROLL DATA IN A UNIFORM FORMAT

On and after the first day of the first calendar quarter beginning after the date that is 2 years after the date of enactment of this subparagraph, and after consulting with State long-term care ombudsman programs, consumer advocacy groups, provider stakeholder groups, employees and their representatives, and other parties the Secretary deems appropriate, the Secretary shall require a skilled nursing facility to electronically submit to the Secretary direct care staffing information (including information with respect to agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format (according to specifications established by the Secretary in consultation with such programs, groups, and parties). Such specifications shall require that the information submitted under the preceding sentence–

(i) specify the category of work a certified employee performs (such as whether the employee is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other medical personnel);

(ii) include resident census data and information on resident case mix;

(iii) include a regular reporting schedule; and

(iv) include information on employee turnover and tenure and on the hours of care provided by each category of certified employees referenced in clause (i) per resident per day.

Nothing in this subparagraph shall be construed as preventing the Secretary from requiring submission of such information with respect to specific categories, such as nursing staff, before other categories of certified employees. Information under this subparagraph with respect to agency and contract staff shall be kept separate from information on employee staffing.’.

What purpose would the government have for keeping track of every member of the direct care staff, unless they’re just preparing for the new single payer system where every member of the medical community works for the federal government anyway?

Section 1802 establishes the funding for the aforementioned “Center for Comparative Effectiveness Research”, which will be funded by taxes on certain insurance policies. Yes. In addition to the bakers dozen of new taxes already mentioned, Nancy Pelosi intends to tax some specific health care plans in order to fund their comparative effectiveness research.

Back on July 9th, 2009, Speaker of the House Nancy Pelosi pledged that the House would not leave for the August recess without passing a health care overhaul bill, and she promised that any bill from the House would not tax health benefits.

Pelosi said that any bill the House passes will not tax employee health care benefits and will include a robust public insurance option.

We will not be taxing benefits in any bill that passes the House,” she said.

She lied. Section 1802 of HR3962, the bill she herself helped craft and announced last Thursday, clearly states otherwise. So much for the promises of the Speaker of the House. The same can be said for President Obama. He promised not to raise taxes on any family making less than $250,000. Section 1802 breaks that promise as well. I wonder if HR3962 contains a provision for comparative mental health treatment for dilusional politicians who lack effectiveness?

That’s it for Division B. Tonight, I will tackle the remainder of HR 3962, “Affordable Health Care for America Act”. For those of you keeping track, we’ll pick up on page 1209.

HR3962 : Division A : Part Two

Before I begin tonight, I need to backtrack a bit and remind you that HR3962 establishes the new Health Choices Administration, the Health Choices Commissioner, and the Health Insurance Exchange just like HR 3200 contained. The Secretary of Health and Human Services, as well as this new Commissioner will dictate every aspect of the new government controlled “exchange plans”.

The Health Choices Commissioner will have the authority to audit every qualified health benefits plan to see if the plan meets all government criteria and whether or not that plan has violated any government regulation. As written in this bill (like HR 3200) there is no limit to this authority and leaves the door wide open for abuse by the HCC.

I still have 12 pages of notes on my desk to get through, and somehow I skipped that interesting tidbit in my review last night. In this post I will pick up right where we left off, with additional taxes and “credits” in Section 521 on page 318.

In previous sections we learned that a small business owner could potentially pay almost $28,500 in taxes (as penalties) when he/she makes just $100,000 per year. Section 521 gives that small business owner an “employer health coverage tax credit”.

The default amount for that credit is 50% of what that small business owner pays in health care costs based on the employee, if they have 10 employees or less.

In the case of an employer whose average annual employee compensation for the taxable year exceeds $20,000, the percentage specified in paragraph (1) shall be reduced by a number of percentage points which bears the same ratio to 50 as such excess bears to $20,000.

On page 319 we learn that there will be no credit for the employer if the employee makes $80,000 or more. I don’t know about you, but I foresee a big reduction in salaries as a way for employers to receive a larger credit from the government. Oh, and HR3962 makes sure that credit is not permanent. It only applies for two taxable years. Generous huh?

Section 531 changes the way you’ll be able to use your Health Savings Account, Flexible Spending Accounts, or Health Reimbursement Arrangements. Thanks to this section you will no longer be allowed to use those accounts to purchase non-prescription medications which will in turn raise the amount of taxes you pay on your income because you’ll no longer be able to use non-taxed money to make those purchases.

Flexible Spending Accounts help American’s budget their medical and health needs throughout the year, and thus far have been uncapped. Section 532 changes this by capping FSA’s at $2,500 per year. Section 533 increases the penalty for nonqualified distributions (like purchasing non-prescription medication) from 10 percent to 20 percent. Yes, you read that correctly. HR3962 will cut the number of qualified items and services you can purchase with your FSA while doubling the penalty for those non-qualified purchases.

Section 534 eliminates the current tax deduction for employer based health plans which coordinate with Medicare Part D, which will make private health insurance participation in Medicare non existent (while that private health insurance exists anyway).

Section 551 imposes a surtax on anyone who finds success and earns a high income because of that success. According to this section, those individuals who make more than $500,000 (modified adjusted gross income) will pay an additional surtax (yes, this is another reference to another newly defined tax) of 5.4%.

(a) General Rule- In the case of a taxpayer other than a corporation, there is hereby imposed (in addition to any other tax imposed by this subtitle) a tax equal to 5.4 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $1,000,000.

(b) Taxpayers Not Making a Joint Return- In the case of any taxpayer other than a taxpayer making a joint return under section 6013 or a surviving spouse (as defined in section 2(a)), subsection (a) shall be applied by substituting ‘$500,000’ for ‘$1,000,000’.

This new surtax will raise the top tax rate of 39.6% to 45%. Yes. If you make $500,000 per year you will pay 45% income tax. It seems that the lawmakers who wrote this bill are a bit jealous of those who find success and this is their way of sending a message that they would prefer them not to be successful.

Think about it. If you make $500,000, you’ll be paying an additional $27,000 simply for being successful. In total, if you sit at the highest tax rate and you make $500,000, you’ll end up paying $225,000 in taxes and end up with a net total of $275,000. Your counterpart, however, who makes $499,000 will pay $197,604 and end up with a net total of $301,396. In other words, if you make $1,000 more than your counterpart, your counterpart will take home $26,396 more than you will.

Those Democrats sure have a great way of congratulating you for your success, don’t they? Hang in there. At this point you still have some income left and we still have at least five new taxes to discuss here.

Section 552 implements a new excise tax of 2.5% on the manufacture of medical devices, Section 553 requires the reporting the “exchanges of property” in addition to income on 1099-MISC forms as well as requiring corporations to report payments to other corporations, not just individuals, Section 554 delays corporate tax relief from the American Jobs Creation Act for nine years, and Section 561 places limitations on tax treaty benefits for certain deductible payments, which will allow for double taxation on some earnings.

I’ll take a moment to pause right here and reflect on the fact that a delay in tax relief is basically the same as imposing a new tax. I’ll wait another moment too, so those who got lost because we moved so quickly through that last paragraph can have a chance to catch up with the rest of us.

Section 562 gives the Internal Revenue Service a new unbridled power under the title “Economic Substance Doctrine”, where the IRS will be permitted to disallow legitimate tax deductions

ECONOMIC SUBSTANCE DOCTRINE- The term ‘economic substance doctrine’ means the common law doctrine under which tax benefits under subtitle A with respect to a transaction are not allowable if the transaction does not have economic substance or lacks a business purpose.

If the IRS believes the motive for the deduction was not primarily business related, the IRS, in it’s own determination will decide whether or not the deduction is allowed. This section does not define the appeal process, if there is any, regarding the new ‘economic substance doctrine’.

Too bad our own government isn’t required to follow some sort of economic substance doctrine.

According to Section 563, partnerships and corporations that make more than $100,000,000 (100 million dollars) are “more likely than not’ to make underpayments on their taxes and HR 3962 aims to hold them “more likely than not” accountable.

In the case of any specified person, paragraph (1) shall apply to the portion of an underpayment which is attributable to any item only if such person has a reasonable belief that the tax treatment of such item by such person is more likely than not the proper tax treatment of such item.

With that, we have finished Division A. I’ll have another post this afternoon beginning with Division B on page 366.

HR3962 : Division A : Part One

As you know by now, Nancy Pelosi announced the release of HR 3962 : Affordable Health Care for America Act on Thursday of last week.

I took a quick glance at it that afternoon, and mentioned that I would be looking at the bill over the weekend. You will be happy to know that I have spent the better part of my weekend reading through the bill and making notes.

The summary of this bill won’t be quite as detailed as the one I did for HR 3200, but I will cover as much as I can before tomorrow night. I’ve heard rumors that the House will begin debate on the bill this week, and I want to get through as much of the bill as I can so you know what to talk about when you call your Representatives about HR 3962.

While the word rationing does not appear in the text of the bill, Title I, Section 101, authorizes the Secretary of Health and Human Services to monitor the costs of covering the “high-risk pool” of citizens, and to adjust benefits, premiums and such to offset the expenses of treating them. It even goes so far as to establish waiting lists for those in this “pool”.

If the Secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high-risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit, including reducing benefits, increasing premiums, or establishing waiting lists.

Twenty-five pages into the bill and they’ve already established the authorization for rationing your health care. Remember my review of HR 3200 and my examples, including those who are elderly with cancer, those who have AIDS/HIV, or those who have lifelong diseases like Parkinsons? It’s only a matter of time before their coverage dries up completely now.

At this point, I thought it might be a good idea to take some Tylenol, while I still have access to it. Based on these first pages, this is going to be an interesting read.

Title II, Section 202 will phase out private health insurance coverage by 2013. This section states,

Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan.

Can you say hello single payer health care? Seriously. At first I thought this bill was a “Punk’d” prank played by Nancy Pelosi on the House Republicans, but as I read more, I realized this really is our nightmare and if we don’t do something about it, it will come true.

Things get very controversial, and sad, Subtitle C, Section 222 authorizes the use of federal funding for abortions. Yes, the bill actually mentions the word abortion, and they make it blatantly clear that this public health care bill (in it’s current form) will remove all roadblocks of federally funded abortions.

(3) COVERAGE UNDER PUBLIC HEALTH INSURANCE OPTION- The public health insurance option shall provide coverage for services described in paragraph (4)(B). Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in paragraph (4)(A).

(4) ABORTION SERVICES-

(A) ABORTIONS FOR WHICH PUBLIC FUNDING IS PROHIBITED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved.

(B) ABORTIONS FOR WHICH PUBLIC FUNDING IS ALLOWED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved.

Subtitle C, Section 223, establishes the Health Benefits Advisory Committee, much like HR 3200. The HBAC will be authorized to recommend covered benefits and essential, enhanced, and premium plans.

So basically, the Surgeon General, nine Presidential appointees, nine people appointed by the Comptroller General and up to eight Federal employees will be deciding which benefits will be offered, which benefits are essential, and which benefits will be offered with which plans.

Say hello to the RATION BOARD.

We were told early on in the public discussion about HR 3200 that the bill did not include anything to do with end-of-life care, death panels, or any mention of assisted suicide. Then someone decided they would remove that section. You know, the section they say was never there (even though we have copies of it in HR 3200). Well, guess what? It’s back.

While they make several references stating that the section does not promote suicide, assisted suicide, euthanasia, or mercy killing. They also go to great lengths to state that the section shall not presume the withdrawal of treatment. Yet, Subtitle D, Section 240 states,

Nothing in this section shall be construed –

(1) to require an individual to complete an advanced directive or a physician’s order for life sustaining treatment or other end-of-life planning document;

(2) to require an individual to consent to restrictions on the amount, duration, or scope of medical benefits otherwise covered under a qualified health benefits plan

In other words, even though nothing in that section will promote suicide, assisted suicide, euthanasia, or mercy killing, we as individuals will not be required to complete an advanced directive, our physicians won’t be required to fulfill an order for life sustaining treatment or end-of-life planning, and we’ll have no say when they begin restricting the amount of medicine and treatment we receive in our “end of life” stage.

Subtitle F, Section 258 brings up the topic of abortion again. At the top of page 147 we learn,

IN GENERAL- Nothing in this Act shall be construed to have any effect on Federal laws regarding

(A) conscience protection;

(B) willingness or refusal to provide abortion; and

(C) discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion.

Read that highlighted part again. Doesn’t this potentially open the door for federally funding organizations such as Planned Parenthood and others which promote (and offer) abortion services?

This section makes sure that nothing in the act shall be construed to have any effect on current laws, and does not explicitly ban funding, it in effect authorizes the federal funding of abortion under the soon to be debated public option.

Subtitle B, Section 321 establishes the “Public Health Insurance Option”. Nanny State Nancy Pelosi spent the better part of last week trying to re-brand the public option into the “consumer option” but the only way to genuinely describe this plan is to call it the “government option”.

For years beginning with Y1, the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the ‘public health insurance option’) that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.

Remember now, the Secretary of Health and Human Services primary responsibility will be to create a low-cost plan without compromising quality or access to care, but we learned on page 25 that the same Secretary will also be authorized to cut services (compromise quality) and create waiting lists (cut off access to care), anytime he/she feels it is appropriate. Do you feel like we are running in circles here?

Section 330 permits members of Congress to enroll in the new public option. Like any sane member of Congress is going to turn away from their existing plan to take this option. If they are going to support this thing, they should be required, not permitted, to be covered by the same plan we are.

In Subtitle C, Section 345 we welcome back the income verification section which is quite similar to what we saw in HR 3200, and again, there is no mention of how an individuals information will be verified, only their income. 250 pages into the bill and we still haven’t addressed the coverage for millions of illegal immigrants.

Program Integrity; Income Verification Procedures-

(1) PROGRAM INTEGRITY- The Commissioner shall take such steps as may be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle.

(2) INCOME VERIFICATION-

(A) IN GENERAL- Upon an initial application of an individual for an affordability credit under this subtitle (or in applying section 342(b)) or upon an application for a change in the affordability credit based upon a significant change in modified adjusted gross income described in subsection (c)

(1)–

(i) the Commissioner shall request from the Secretary of the Treasury the disclosure to the Commissioner of such information as may be permitted to verify the information contained in such application; and

(ii) the Commissioner shall use the information so disclosed to verify such information.

(B) ALTERNATIVE PROCEDURES- The Commissioner shall establish procedures for the verification of income for purposes of this subtitle if no income tax return is available for the most recent completed tax year.

As I mentioned after my first glance at the bill, Title IV, Subtitle B, Section 413 imposes a mandatory tax on employers who do not meet the “minimum employer contribution”, by charging them up to 8% of the employee’s average wages paid by the employer.

Title V, Subtitle A, Section 501 makes amendments to the Internal Revenue Code of 1986, by implementing the 2.5% tax (yes, they reference this penalty as a tax) on those who do not possess “acceptable health care coverage” and Section 511 adds an additional $100 per day fee (per employee) for employers who fail to satisfy the health coverage participation requirements.

Let’s say you make $100,000 per year. If you do not have insurance through your employer, your employer will be paying as much as $8,000 per year as a penalty for not offering you insurance. If this continues for 100 days, they will pay an additional $10,000. Then, on top of that you will be paying an additional $2,500 per year for not possessing acceptable health care coverage. Remember, these are just the penalties, not the actual cost of health care coverage for you. One individual. Hold on though, it doesn’t stop there.

Section 512 goes on to add yet another “tax” on firms who elect not to offer, or cannot afford to offer, coverage. This Employer Excise Tax (yes, again they define this penalty as another tax) will amount to another 8% of the employee’s average wages.

So, if you, the person I just mentioned above, work for a small firm, or you own your own small firm, you will be paying an additional $8,000 “excise tax”. At this point, as a self-employed individual, you will have paid $28,500 out of pocket in additional taxes thanks to HR 3962.

So in review, under HR 3962, if you make $100,000 per year in wages, you could be paying an additional $28,500 in taxes before you even begin to calculate your income taxes, self-employment taxes, or any other taxes and fees that will be thrown at you.

According to what we’ve covered so far, that $28,500 will buy you the right to have your health care rationed, the transformation to a single payer health care system, special end-of-life care, and even more taxes which I’ll discuss in my next post. Your contribution will also help cover the health care costs of millions of illegal immigrants and women who choose to obtain abortions.

For those of you keeping track and reading along (cough) this brings us to page 316.

More to follow…