Without further ado, please see my notes on pages 255-304 below.

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SEC. 1146. MEDICARE IMPROVEMENT FUND.

Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 1395iii(b)(1)(A)) is amended to read as follows:

`(A) the period beginning with fiscal year 2011 and ending with fiscal year 2019, $8,000,000,000; and’.

MY NOTE: I looked at this section of the Social Security Act for a long time to make sure I wasn’t getting loopy. There IS no section (A) there at all under (1) for the Act, so it’s not easy to figure out what is intended here.

They may be adding $8 billion to the Medicare Improvement Fund, which runs counter to all of the other budget cuts made to Medicare earlier in the bill, or they could be replacing the $19.9 billion figure listed there currently with $8 billion, which would represent a $12 billion savings.

Since there is a typo, the bill is not clear at all on this point, in my opinion. My sense is that they are trying to cut the improvement fund to a more reasonable level, but this definitely needs to be more clearly written. Here is the section of the Social Security Act as listed on the Social Security Administration website, if you’re interested in seeing it for yourself: http://www.ssa.gov/OP_Home/ssact/title18/1898.htm

SEC. 1147. PAYMENT FOR IMAGING SERVICES.

(a) (C) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT HIGHER PRESUMED UTILIZATION- In computing the number of practice expense relative value units under subsection (c)(2)(C)(ii) with respect to advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)), the Secretary shall adjust such number of units so it reflects a 75 percent (rather than 50 percent) presumed rate of utilization of imaging equipment.’

MY NOTE: This is one of the first places that I have found where actual medical services could be affected adversely, or lead to unnecessary rationing of care. By increasing the utilization rate, the payment for each service is reduced significantly. They were originally seeking to raise the utilization rate from 50% to 95%, but in an apparent concilatory gesture, reduced this to 75% in the bill.

According to EVERY source I read on this topic, this increase in the utilization rate for imaging equipment would amount to a deep and arbitrary reimbursement cut for diagnostic imaging services. If this happens, it could definitely limit access to life-saving services to detect cancer, etc.

I found a letter that was written to the President and Congress urging them not to increase this rate. The thirteen groups that signed the letter are: American Brain Tumor Association; American Pain Foundation; Black Women’s Health Imperative; Brain Injury Association of America; Breast Cancer Network of Strength; Colon Cancer Alliance; Colorectal Cancer Coalition; Kidney Cancer Association; Lung Cancer Alliance; Men’s Health Network; National Ovarian Cancer Coalition; Society for Women’s Health Research; and Us TOO International Prostate Cancer Education & Support Network.

Clearly, this is something that should be debated and studied more. I must admit that I spent over an hour trying to understand the formula and the math behind this problem, but I couldn’t quite get there myself.

SEC. 1152. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS

(d)(2)(C) applying a payment reduction for physicians who treat the patient during the initial admission that results in a readmission

MY NOTE: This is a very long section overall, and it deals with exactly what you would think. Namely, they are looking for ways to adjust payments under Medicare both to hospitals and to physicians when patients are later re-admitted.

It seems as though the assumption is that the facility and/or the doctor didn’t get the job done the first time around. I have mixed emotions about this one. If the doctor did all that was in his/her power to heal the patient, should they be punished if that person gets sick again soon thereafter, necessitating another admission? I don’t know the answer – I just wanted to throw it out there as a point of conversation.

(EDITED: After one of the comments I got on this post from Facebook, I thought it was pertinent to include here – my friend Joy Hilscher remarked, “Wouldn’t doctors want to keep patients in the hospital longer than necessary just to make sure and avoid these fines? Seems to me that it would increase cost.” I must wholeheartedly agree.)

(e) Funding- For purposes of carrying out the provisions of this section, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services for the Center for Medicare & Medicaid Services Program Management Account $25,000,000 for each fiscal year beginning with 2010. Amounts appropriated under this subsection for a fiscal year shall be available until expended.

MY NOTE: As with the assessment of medical codes that I mentioned in my last post, this seems like a lot of money to budget every single year for this function. I can understand a one-time expense, but allotting so much on an ongoing basis seems potentially wasteful. I would prefer to see a mechanism for evaluating this each year. If the money is provided, I have a tough time imagining that it won’t be spent somehow, correct?

SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND BUNDLING PILOT PROGRAM.

MY NOTE: This section charges the Secretary of Health and Human services with developing a program to determine if acute care services can be bundled. It also mentions taking into account gainsharing (doctors and hospitals both profit), anti-referral, anti-kickback, and anti-trust laws. In order to implement this portion of the bill, the Secretary is given $45,000,000 over a three-year period. Yikes!

(2) EXPEDITED DATA COLLECTION- Chapter 35 of title 44, United States Code shall not apply to this section.

MY NOTE: My first question upon reading this line was, “What is Chapter 35 of title 44 of the USC?” Thankfully, it was easy to find the answer.

Here’s a link to the “Purposes” section of title 44 if you want to see it: http://www.law.cornell.edu/uscode/44/usc_sec_44_00003501—-000-.html. As you can see, this code is intended to make reporting for federal agencies more streamlined and more transparent. Why would this portion of the bill be exempt from that code? In fairness, the next section calls for “public reports”, but only “as the Secretary deems necessary”. What if he/she never deems public reports to be necessary?

As you can see, the pages I covered here are all dealing with Medicare in one way or another. During my last post, I was encouraged by some of the ideas to trim costs and waste. This portion, however, seems to involve a lot of spending, unless the aforementioned $8 billion is a reduction from the previously-approved $19.9 billion.

I welcome your input!

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TYPOS/MISTAKES

Please see my note above about Section 1146 – this badly needs to be clarified. As it is currently written, it’s not possible to tell if this is calling for a new $8 billion expenditure, or a $12 billion savings.

Without further ado, please see my notes on pages 204-255 below.

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PART 2–PREVENTION OF TAX AVOIDANCE

MY NOTE: There are three sections here that are added to keep (primarily wealthy) people from using tax shelters. Each section modifies and/or adds to the Internal Revenue Code.

SEC. 452. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE.

(1) APPLICATION OF DOCTRINE- In the case of any transaction to which the economic substance doctrine is relevant, such transaction shall be treated as having economic substance only if–

`(A) the transaction changes in a meaningful way (apart from Federal income tax effects) the taxpayer’s economic position, and

`(B) the taxpayer has a substantial purpose (apart from Federal income tax effects) for entering into such transaction.

MY NOTES: The fact that this is included is interesting to me. I researched the “economic substance doctrine”, and it has been hotly debated in Congress for years, since it basically removes many tax shelters that are currently available by making a valid tax shelter one that substantially affects the taxpayer AND requires a “substantial purpose” for entering into a transaction (rather than simply trying to avoid paying tax).

The fact that this is stuck into the health care reform bill is not all that unusual, I guess. It seems that most big pieces of legislation are not “stand alone” bills anymore, because everyone wants to achieve something more than the title of the bill would indicate.

As I see it, this section is included to ensure that they will collect adequate taxes from the wealthiest Americans to pay for this undertaking. The entirety of the following section is to provide penalties for underpayments and erroneous claims arising from “noneconomic substance transactions”. Fun, huh?

DIVISION B–MEDICARE AND MEDICAID IMPROVEMENTS

SEC. 1001. TABLE OF CONTENTS OF DIVISION.

MY NOTE: What follows this is a seven-page list detailing the table of contents for the intended improvements for Medicare and Medicaid.

PART 1–MARKET BASKET UPDATES

MY NOTE: I had to spend some time reading to understand what a “market basket” is. I have a minor in Economics so this material isn’t too tough for me, thankfully. Essentially, a market basket is created by taking the total of all expenses for a specified period of time, then determining how much each category cost as a percentage. Then, a “price proxy” is set by calculating an appropriate price variable. You multiply each category percentage by the price proxy to get the entire market basket. See how easy that is? Just think of this term as the total of all expenses expressed in hard-to-understand language, and you’re there.

SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE.

MY NOTE: I had to read Section 1888 of the Social Security Act to see what this section was proposing. Basically, this would freeze 2010 expenditures at the same level as 2009. After that, it will continue to increase by whatever amount the market basket change does.

According to an article I read from McKnight’s, this relatively small change could save $26 billion over the next ten years, according to the Congressional Budget Office (CBO). Here’s the link if you’re interested: http://www.mcknights.com/CBO-market-basket-freeze-for-skilled-nursing-could-add-up-to-billions-in-savings/article/139823/.

It seems like this is forcing nursing homes to cut costs at least in the short-term. This could be a good thing, depending on what the actual daily outlay is from Medicare for this.

SEC. 1102. INPATIENT REHABILITATION FACILITY PAYMENT UPDATE.

MY NOTE: As with the immediate preceding section, this would freeze any increase in federal payments to an inpatient rehab facility at 0 percent through 2010. As it stands, this was already the case for 2008 and 2009, so the bill seeks to extend this for another year. According to the CBO, this would save another $5 billion in costs.

SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET UPDATES THAT DO NOT ALREADY INCORPORATE SUCH IMPROVEMENTS.

`(II) The productivity adjustment described in this subclause, with respect to an increase or change for a fiscal year or year or cost reporting period, or other annual period, is a productivity offset equal to the percentage change in the 10-year moving average of annual economy-wide private nonfarm business multi-factor productivity (as recently published before the promulgation of such increase for the year or period involved). Except as otherwise provided, any reference to the increase described in this clause shall be a reference to the percentage increase described in subclause (I) minus the percentage change under this subclause.’;

MY NOTE: Yikes! That is some thick language to wade through. Rather than trying to explain every detail here, this section sets up an offset to any automatic increases in funding for places like psychiatric hospitals, acute-care facilities, hospice care, and long-term care facilities.

But how? This formula is based on increases in the 10-year moving average (think of a chart) using a variety of non-farm-based businesses and their productivity. Then, they subtract that from what would have been the normal market basket increase.

What’s the net result here? More than likely, this would provide billions of dollars in federal savings. That being said, it could also be argued that this would result in lower-quality care under Medicare since facilities aren’t getting as much money.

PART 2–OTHER MEDICARE PART A PROVISIONS
SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.
(a) (1) ANALYSIS- The Secretary of Health and Human Services shall conduct, using calendar year 2006 claims data, an initial analysis comparing total payments under title XVIII of the Social Security Act for skilled nursing facility services under the RUG-53 and under the RUG-44 classification systems.

MY NOTE: I can’t imagine why you wouldn’t already be familiar with the RUG-53 and RUG-44 classification systems. Oh, wait…perhaps you are a nursing home administrator. In that case, let me explain briefly. A “RUG” is a Resource Utilization Group. When Medicare Part A and B were enacted, they added nine new groups to the existing hierarchy of 44 groups, to get to 53. This was because there was not a good way to designate payments for people who needed both extensive nursing AND rehab services.

I have no idea why this is based on 2006 data, unless it is just the most recent data available. If that’s true, I am more than a little concerned about the efficiency of record-keeping.

(2) ADJUSTMENT IN RECALIBRATION FACTOR- Based on the initial analysis under paragraph (1), the Secretary shall adjust the case mix indexes under section 1888(e)(4)(G)(i) of the Social Security Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for fiscal year 2010 by the appropriate recalibration factor as proposed in the proposed rule for Medicare skilled nursing facilities issued by such Secretary on May 12, 2009 (74 Federal Register 22214 et seq.).

MY NOTE: The “case mix index” mentioned here (CMI) is the number that represents the relative level of care for a RUG. The higher the CMI, the greater the intensity of care and the higher the payment will be.

Later in this section, the Secretary of Health and Human Services is called upon to perform an analysis for ancillary therapy services and to determine how much to pay for them. Thankfully, it also calls for “budget neutrality”, meaning that they cannot spend more than the Social Security Act would have called for.

It also limits “outlier” costs to 2 percent of the budget for this program. An outlier is a statistical term for those items that are outside of the rest of the data. In real estate, we sometimes see houses that are outliers (why did that place sell for so much/little?). As a small aside, Malcolm Gladwell’s book “Outliers” provides an interesting look at people who are outliers in their respective fields.

SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUSTMENTS IN RESPONSE TO COVERAGE EXPANSION.

(a) DSH Report-

(1) IN GENERAL- Not later than January 1, 2016, the Secretary of Health and Human Services shall submit to Congress a report on Medicare DSH taking into account the impact of the health care reforms carried out under division A in reducing the number of uninsured individuals. The report shall include recommendations relating to the following:

(A) The appropriate amount, targeting, and distribution of Medicare DSH to compensate for higher Medicare costs associated with serving low-income beneficiaries (taking into account variations in the empirical justification for Medicare DSH attributable to hospital characteristics, including bed size), consistent with the original intent of Medicare DSH.

(B) The appropriate amount, targeting, and distribution of Medicare DSH to hospitals given their continued uncompensated care costs, to the extent such costs remain.

MY NOTE: DSH stands for “disproportionate share”, and this was originally intended to provide extra funds for hospitals that care for a larger percentage of low-income patients, since they require more staff, supplies, etc. This section of the bill requires the Secretary to evaluate whether these subsidies will still be paid if the rate of uninsurance drops by a significant amount (anything over 8% decrease in the rate of uninsurance).

PART 1–PHYSICIANS’ SERVICES

SEC. 1121. SUSTAINABLE GROWTH RATE REFORM.

MY NOTE: This is one of the longest sections that I have encountered so far. In essence, this references. Here are a couple of glossary terms I learned today:

?Sustainable growth rate (SGR) – Cost containment mechanism intended to restrain the rate of growth in Medicare spending for physician services.
?MEI (Medicare Economic Index) – a measure of inflation faced by physicians with respect to their practice costs and general wage levels.
This section seeks to set different rates of payment and different SGRs for different service categories. Basically, this is another savings plan intended to help fund the public option.

SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.

(ii) IDENTIFICATION OF POTENTIALLY MISVALUED CODES- “…the Secretary shall examine codes for which there has been the fastest growth; codes that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called `Harvard-valued codes’); and such other codes determined to be appropriate by the Secretary.

MY NOTE: This section allows the Secretary to evaluate medical codes established in 1988 by a Harvard study, in order to see if the system is performing as originally intended. My guess is that it’s not, but it’s just a guess.

(1) FUNDING- For purposes of carrying out the provisions of subparagraphs (K) and (L) of 1848(c)(2) of the Social Security Act, as added by subsection (a), in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services for the Center for Medicare & Medicaid Services Program Management Account $20,000,000 for fiscal year 2010 and each subsequent fiscal year. Amounts appropriated under this paragraph for a fiscal year shall be available until expended.

MY NOTE: WHAT?!? Back up a minute here. This is a shocking paragraph, and it will only feed skepticism about government waste. I can understand allocating a good sum of money for this….the first time around. Why is it necessary for this to be a line item in the budget EVERY YEAR? I cannot conceive that medical codes need to be evaluated every single year, or that such re-evaluation would require $20 million each time if it’s that frequent. Where would this money actually go?

(2) ADMINISTRATION- (A) Chapter 35 of title 44, United States Code and the provisions of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to this section or the amendment made by this section.

MY NOTE: Why is this the case? Please take a minute to read this, then think about why this committee would not be required to be governed by the FACA: http://en.wikipedia.org/wiki/Federal_Advisory_Committee_Act

I certainly don’t have the answer to this question – I just think it provides a very interesting point of discussion. It seems that this would allow the committee to operate behind closed doors and for an indeterminate amount of time, neither of which seems very appealing. What do you think?

SUMMARY:
As you can see, the first portion that I covered here is mainly a series of ways to save federal money in order to pay for the public health option. After that, Section 1122 starts out in a pretty innocuous manner, until you realize that the bill calls for $20 million every year to evaluate medical codes for Medicare. I would love to hear anyone explain why this much money is needed, especially when none is being spent on this right now, to the best of my knowledge.

I welcome your input. Thanks so much for reading this. It has taken me two weeks to get this far. I don’t intend to give up now!

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Here are my observations from pages 143 to page 204 of HR 3200:

SEC. 301. INDIVIDUAL RESPONSIBILITY.

For an individual’s responsibility to obtain acceptable coverage, see section 59B of the Internal Revenue Code of 1986 (as added by section 401 of this Act).

MY NOTE: What you see above is the entirety of Section 301, which may be the shortest in the entire bill. As you can see this refers to a new tax that is created on those who don’t have “acceptable” coverage. If the goal of this bill as stated in its primary title is “affordable health choices”, doesn’t it seem counterintuitive to tax those who don’t have coverage?

I sincerely thought that the goal here was to widen the options available, including a public health option. Instead, this bill seeks to punish (tax) those who don’t have acceptable plans. Why? I am certain that the newly appointed Health Commissioner would be the person in charge of determining what constitutes acceptable coverage. I don’t like the idea of the government telling me if my insurance plan is acceptable or not.

Section 401 needs to be addressed out of order, since that’s the one that creates a new section within the tax code. Here is the portion referenced there if you can figure it out: http://www4.law.cornell.edu/uscode/html/uscode26/usc_sec_26_00006012—-000-.html - I am not a CPA, but it looks like you will be paying a 2.5% tax on the vast majority of your income if you don’t have coverage. So, for anyone who is currently saving money by going without any health insurance, your costs WILL increase under this plan.

You must either pay a premium, or pay a newly-created tax. Period.

SEC. 312. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARDS EMPLOYEE AND DEPENDENT COVERAGE. (a)(3) MINIMUM EMPLOYER CONTRIBUTION FOR EMPLOYEES OTHER THAN FULL-TIME EMPLOYEES In the case of coverage for an employee who is not a full-time employee, the amount of the minimum employer contribution under this subsection shall be a proportion (as determined in accordance with rules of the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable) of the minimum employer contribution under this subsection with respect to a full-time employee that reflects the proportion of–

(A) the average weekly hours of employment of the employee by the employer, to

(B) the minimum weekly hours specified by the Commissioner for an employee to be a full-time employee.

MY NOTE: This comes back to what I said in a previous post about the Commissioner’s level of authority in defining the term “full-time employee”. Is this the type of thing that needs to be left up in the air? If the Commissioner determines that “full-time” is now 20 hours (or 60), that would dramatically affect the cost to employers.

SEC. 313. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.

MY NOTE: This section allows employers to pay 8% of an employee’s wages instead of covering them under a plan. Small employers (defined as employers with total payroll of under $400,000) can pay less. If the total payroll is under $250,000, employers are not required to pay anything at all on behalf of their employees with regard to health coverage.

My reading indicates that all employers must provide coverage, or pay an excise tax. I tried to research this, and I don’t think that this is a current requirement.

SEC. 401. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.
`(a) Tax Imposed- In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of–

`(1) the taxpayer’s modified adjusted gross income for the taxable year, over

`(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer.

MY NOTE: I read the entirety of Section 401 multiple times and very carefully. Basically, if you are not paying a premium, then you will be taxed for an amount not to exceed the national average premium for “self-only” coverage. The assumption here is that the government wants everyone to pay for acceptable coverage. Considering that the alternative is to pay taxes, it would seem like this bill makes it pretty much compulsory.

(5) RELIGIOUS CONSCIENCE EXEMPTION-

`(A) IN GENERAL- Subsection (a) shall not apply to any individual (and any qualifying child residing with such individual) for any period if such individual has in effect an exemption which certifies that such individual is a member of a recognized religious sect or division thereof described in section 1402(g)(1) and an adherent of established tenets or teachings of such sect or division as described in such section.

`(B) EXEMPTION- An application for the exemption described in subparagraph (A) shall be filed with the Secretary at such time and in such form and manner as the Secretary may prescribe. Any such exemption granted by the Secretary shall be effective for such period as the Secretary determines appropriate.

MY NOTE: Who knew? Apparently, under the current tax code, members of certain religious sects can avoid paying taxes for Social Security because their faith doesn’t allow them to collect benefits under those types of programs. The tax code doesn’t name these specifically, but before you decide to start your own religion, it does specify that the sect must have been in existence “at all times since December 31, 1950″. I had no idea!

SEC. 412. RESPONSIBILITIES OF NONELECTING EMPLOYERS.

`(1) IN GENERAL- In addition to other taxes, there is hereby imposed on every nonelecting employer an excise tax, with respect to having individuals in his employ, equal to 8 percent of the wages

MY NOTE: This is a tax created on large employers only, since employers with payrolls under $400,000 don’t have to pay as much (if under $250K, nothing at all). I’m not sure how I feel about this part – I can see the reason behind it, but I’m not sure if taxing companies that decide not to provide coverage is the way to go. I welcome your commentary on this.

SEC. 441. SURCHARGE ON HIGH INCOME INDIVIDUALS.

`(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–

`(1) 1 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $350,000 but does not exceed $500,000,

`(2) 1.5 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $500,000 but does not exceed $1,000,000, and

`(3) 5.4 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $1,000,000.

MY NOTES: This entire section is kind of a bombshell. After this part, it states that the percentages in (1) and (2) above are going to be 2% and 3% respectively, unless the EXCESS FEDERAL HEALTH REFORM SAVINGS is over $150,000,000,000 (yes, that’s billions). The “excess” here is anything over $525,000,000,000. Health reform savings is defined as “the aggregate reductions in Federal expenditures which have been achieved as a result of the provisions of, and amendments made by, division B of the America’s Affordable Health Choices Act of 2009″. If the savings reaches $700 billion, they will not tax the first two groups listed above.

Let me get this straight – you won’t tax rich people IF you manage to save three-quarters of a TRILLION DOLLARS from this program?!? This is the ultimate empty gesture, in my humble opinion. I think it seems even more ludicrous to include this provision, since it seems as though no one has any intention of doing away with this tax at any point. If you make over $1 million, you will pay at least $54,000 for this one tax. I know that most people are probably thinking, “Cry me a river”, but is this equitable?

This reminds me of toll roads and other local taxing entities that are put in place “until the bond is paid off”, but somehow new bonds are always necessary. Does anyone really expect the bookkeeping to reflect a surplus/savings at this level?

SUMMARY: Under these two titles both Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code are modified. New taxes are created in many ways.

If you have actually read all four of these posts, I applaud you, because I think you are ahead of most people, including many of our elected representatives.

TYPOS/MISTAKES

Sec. 312. (c)(1) Should read “such” not “suchs”

SEC. 806. REGULATIONS. There is no part (a) – starts with part (b).

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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, when they were discussing the medical loss ratio. Medical loss ratio is the amount of money paid for actual medical services as a percentage of premiums paid. HR 3200 seeks to make this number as high as possible, and to force companies to refund any overages to their enrollees. Hence, the section above about amortizing the $2 billion startup strikes me as odd and unlikely. conflict.

SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.

(a)(2)(A) IN GENERAL-”…the Secretary shall base the payment rates under this section for services and providers described in paragraph (1) on the payment rates for similar services and providers under parts A and B of Medicare.”

MY NOTE: I wanted to know what Medicare Parts A and B were, so I looked it up. In a nutshell, this is separate insurance provided for those who are eligible for Medicare (over 65, or with certain disabilities, or with renal failure). Part B is more robust than Part A. Since the public health option would be available for a wider variety of enrollees, this section also calls for the Sec. of Health and Human Services to modify rates to allow for things like well child checkups and certain prescriptions not allowed under Medicare.

(f) Limitations on Review- There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.

MY NOTE: Simply put, why is there no process for review or appeal of a payment rate?

SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.

(a) In General- For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.

MY NOTES: I had to look up virtually everything referenced in the above paragraph. Here are some definitions that I found:

“Patient-centered medical home” – This video does a far better job of explaining it than I could: http://www.emmisolutions.com/medicalhome/transformed/. I have to admit that this sounds like a more valuable way to go about treating patients.

“Accountable care organizations” – also known as ACOs, these are ‘collaborations that integrate groups of physicians, hospitals, and other providers around the ability to receive shared-savings bonuses by achieving measured quality targets and demonstrating real reductions in overall spending growth for a defined population of patients.’ This certainly sounds interesting, at least on the surface.

“Partial capitation” – Doctors would be made partially on a fee-for-service basis and partly as a fixed amount per patient – this is dependent on diagnostic and demographic factors. For example, a 25-year old patient with diabetes would result in a different (probably lower) payment to the doctor than a 65-year old with heart disease. Since the payment would not increase with the number of services provided, it’s expected to motivate doctors to give the most efficient care possible.

In my humble opinion, any of these solutions appear to provide interesting alternatives to the status quo. I think partial capitation could eliminate needless medical tests, especially if coupled with solid tort reform policies. Gosh – I can’t believe I just wrote that last sentence. I am learning a lot!

Subtitle C–Individual Affordability Credits

SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.
(a) Definition-
(1) IN GENERAL- For purposes of this division, the term `affordable credit eligible individual’ means, subject to subsection (b), an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)–
(A) who is enrolled under an Exchange-participating health benefits plan and is not enrolled under such plan as an employee (or dependent of an employee) through an employer qualified health benefits plan that meets the requirements of section 312;
(B) with family income below 400 percent of the Federal poverty level for a family of the size involved; and
(C) who is not a Medicaid eligible individual, other than an individual described in section 202(d)(3) or an individual during a transition period under section 202(d)(4)(B)(ii).

MY NOTE: Based on my own family size (6) and the Federal Poverty Level as defined by Health and Human Services, I could make over $118,000/year and still be eligible for an affordability credit under this section. In years when my income has been at or above that level, I haven’t felt strapped financially, so I don’t know if I would need/want to apply for an affordability credit. Then again, if it’s available, why wouldn’t I do so in order to save my own money?

You can also note here that they specifically limit this to those who are “lawfully present in the United States”.

SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.
Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.

MY NOTE: I think this is just there for good measure, since this was addressed a bit earlier in the same subtitle. The section before this provides guidelines for reporting dramatic changes in income, and also provides for penalties for misrepresentation of income.

Thanks very much to those of you who are actually following along as I read through this. This post takes us into page 143 out of 1017 total pages. I recognized that the audience for these posts would likely decrease over time, but I intend to finish regardless.

If you have any comments/questions, I would love to hear them, either in the comments below, or via email (jason@austintexashomes.com) or phone (512-796-7653). Thanks!

Here’s what I am actually trying to do:

I want to form an opinion for myself based exclusively on the facts, rather than listening to so-called experts on either side. I also hope to spur debate and discussion on this massive piece of proposed legislation.

In my opinion, everyone’s ideas are filtered through their experiences and priorities. I have already shared what is important to me in my first post. I have an online network of almost 17,000 people who regularly pay attention to what I say (this comes from my involvement on multiple platforms). I am hoping to have at least a small impact on this critical debate. After all, this is one of the few things that will affect everyone in this country.

The post I wrote a couple of days ago (link above) was forwarded to a U.S. Congressmen, a national TV personality, and a link will be included in a newspaper article set to be published next week in a city up north. Additionally, it was re-posted on many blogs, and it was included in a massive email blast by one reader. If you don’t yet understand how powerful blogging can be, let that sink in for a moment.

This is an even longer post than before, and I am only a little over 10% of the way through the bill. Without further ado, my observations are below.

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SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF DUTIES; DEFINITIONS.

(b) Outline of Duties of Commissioner- In accordance with this subtitle and in coordination with appropriate Federal and State officials as provided under section 143(b), the Commissioner shall–

(1) under section 204 establish standards for, accept bids from, and negotiate and enter into contracts with, QHBP offering entities for the offering of health benefits plans through the Health Insurance Exchange, with different levels of benefits required under section 203, and including with respect to oversight and enforcement.

MY NOTE: This seems to come back to the point I made in my original post. Isn’t the insurance industry already regulated at the state level? I know that we have the Texas Department of Insurance for this stuff. I wonder if this will add another layer of regulation, or if it will shift to the federal level instead. As I mentioned previously, the newly-appointed Commissioner appears to have an amazing amount of responsibility and power.

SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.
(a) Access to Coverage- In accordance with this section, all individuals are eligible to obtain coverage through enrollment in an Exchange-participating health benefits plan offered through the Health Insurance Exchange unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage.

MY NOTE: Does this mean that only people with no insurance coverage at all are eligible, or does it mean that you have to cancel your current coverage if you are accepted into one of the health exchange plans? I think it probably means the latter, but the meaning is certainly not clear at this point. I hope this section is edited later.

(3) FAR NOT APPLICABLE- The provisions of the Federal Acquisition Regulation shall not apply to contracts between the Commissioner and QHBP offering entities for the offering of Exchange-participating health benefits plans under this title.

MY NOTE: I had to look this up to understand what the Federal Acquisition Regulation (FAR) actually does. Basically, this is in place to regulate the purchase of good and services by the federal government. Why is the Commissioner allowed to enter contracts without the normal safeguards in place for other agencies?

SEC 204 (b)(4) ENROLLMENT- The entity shall accept all enrollments under this subtitle, subject to such exceptions (such as capacity limitations) in accordance with the requirements under title I for a qualified health benefits plan. The entity shall notify the Commissioner if the entity projects or anticipates reaching such a capacity limitation that would result in a limitation in enrollment.

MY NOTE: Could someone explain to me why an insurance company would be limited to a specific number of enrollees? This seems like a bad business plan to me. I am just a real estate broker, but I think I would call this “a good problem to have”, meaning that I would hire the necessary help to handle all of the clients that we have.

I don’t think a provision should be included to allow companies to invoke this “capacity limitation” to avoid covering specific people. It seems like the type of thing that could easily lead to abuse.

SEC. 205. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN.

(b)(2)(B) SPECIAL ENROLLMENT- The Commissioner shall also provide for special enrollment periods to take into account special circumstances of individuals and employers, such as an individual who–

(i) loses acceptable coverage;

(ii) experiences a change in marital or other dependent status;

(iii) moves outside the service area of the Exchange-participating health benefits plan in which the individual is enrolled; or

(iv) experiences a significant change in income

MY NOTE: It’s hard to argue with that section, but I’m sure someone will find a way to do so. Clearly, they are trying to make allowances for the current economic climate., which I can appreciate.

SEC. 205 (c)(2)(D) ensure that the Internet website described in subparagraph (A) and the information described in subparagraph (B) is developed using plain language (as defined in section 133(a)(2)).

MY NOTE: This section is one of several that allude to using “plain language” to describe benefits, etc. to the public. Why is it not possible to do this with the bill itself? I realize that this stuff is written by teams of attorneys, but this is something that will all of us, at least to some degree. I guess it just seems ironic to me.

SEC 205 (d)(1) COVERAGE FOR CERTAIN NEWBORNS

(A) IN GENERAL- In the case of a child born in the United States who at the time of birth is not otherwise covered under acceptable coverage, for the period of time beginning on the date of birth and ending on the date the child otherwise is covered under acceptable coverage (or, if earlier, the end of the month in which the 60-day period, beginning on the date of birth, ends), the child shall be deemed

(i) to be a non-traditional Medicaid eligible individual (as defined in subsection (e)(5)) for purposes of this division and Medicaid; and

(ii) to have elected to enroll in Medicaid through the application of paragraph (3).

2(B) EXTENDED TREATMENT AS TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL- In the case of a child described in subparagraph (A) who at the end of the period referred to in such subparagraph is not otherwise covered under acceptable coverage, the child shall be deemed (until such time as the child obtains such coverage or the State otherwise makes a determination of the child’s eligibility for medical assistance under its Medicaid plan pursuant to section 1943(c)(1) of the Social Security Act) to be a traditional Medicaid eligible individual described in section 1902(l)(1)(B) of such Act

MY NOTE: As I read this last night, I saw a lot of potential for major political disagreement over these paragraphs. Since no distinction is made about the parents of the child born here in the U.S., this section would clearly cover newborns with parents who are here illegally, for at least the first 2 months. As it stands right now, no one can be denied care if they are admitted into an emergency room in the U.S. This is under the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. This section of the bill seems to grant even more benefits, providing for automatic coverage for anyone born on U.S. soil to be eligible for Medicare immediately. Please note that it doesn’t provide this for anyone who already has insurance in place.

As a father of four, I am obviously in favor of taking care of babies, who are utterly helpless. However, I think this section has the potential to cause a huge influx of immigrants who want to take advantage of this loophole, once the word begins to spread. This is bothersome to me, and I hope this is clarified further as the bill progresses into committee discussion.

SEC. 206 (c)(1) (1) ESTABLISHMENT; APPOINTMENT.–There is hereby established the Office of the Special Inspector General for the Health Insurance Exchange, to be headed by a Special Inspector General for the Health Insurance Exchange (in this subsection referred to as the ”Special Inspector General”) to be appointed by the President, by and with the advice and consent of the Senate.

(2) DUTIES- The Special Inspector General shall–

(A) conduct, supervise, and coordinate audits, evaluations and investigations of the Health Insurance Exchange to protect the integrity of the Health Insurance Exchange, as well as the health and welfare of participants in the Exchange;

(B) report both to the Commissioner and to the Congress regarding program and management problems and recommendations to correct them;

(C) have other duties (described in paragraphs (2) and (3) of section 121 of division A of Public Law 110-343) in relation to the duties described in the previous subparagraphs; and

(D) have the authorities provided in section 6 of the Inspector General Act of 1978 in carrying out duties under this paragraph.

MY NOTE: I got excited while reading this section, because I thought it was finally going to provide for some accountability for the Commissioner, too. Unfortunately, this extra position that the bill seeks to create would REPORT to the Commissioner. Darn. This attempt at accountability is also controlled by the Commissioner, it seems.

Furthermore, the Inspector General position terminates completely after five years. And yes, I am sure. It doesn’t say that it’s a five-year term. It states, “(5) TERMINATION- The Office of the Special Inspector General shall terminate five years after the date of the enactment of this Act.” Why is that?

SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.

(b) Payments From Trust Fund- The Commissioner shall pay from time to time from the Trust Fund such amounts as the Commissioner determines are necessary to make payments to operate the Health Insurance Exchange, including payments under subtitle C (relating to affordability credits).

MY NOTE: Again, this appears to give one person carte blanche to determine how much money is needed to run the exchange.

(c) Transfers to Trust Fund-

(1) DEDICATED PAYMENTS- There is hereby appropriated to the Trust Fund amounts equivalent to the following:

(A) TAXES ON INDIVIDUALS NOT OBTAINING ACCEPTABLE COVERAGE- The amounts received in the Treasury under section 59B of the Internal Revenue Code of 1986 (relating to requirement of health insurance coverage for individuals).

(B) EMPLOYMENT TAXES ON EMPLOYERS NOT PROVIDING ACCEPTABLE COVERAGE- The amounts received in the Treasury under section 3111(c) of the Internal Revenue Code of 1986 (relating to employers electing to not provide health benefits).

(C) EXCISE TAX ON FAILURES TO MEET CERTAIN HEALTH COVERAGE REQUIREMENTS- The amounts received in the Treasury under section 4980H(b) (relating to excise tax with respect to failure to meet health coverage participation requirements).

MY NOTES: Where do I start with this one? In a nutshell, each subparagraph here appears to refer to something that is either repealed or that they are hoping to create with the bill itself. Frankly, this seems to be lifted from a previous document, since some of the reference points are outdated.

Under section (A), it refers to amounts received under section 59B on the Internal Revenue Code of 1986. Because of the intriguing title of that subparagraph, I wanted to see what the Code actually says in that section. Based on my research today, it appears as though this section of the tax code was repealed on December 13, 1989. How is it possible to collect funds under a law that no longer exists?

Here’s a link to one place that I found this, on the Cornell University Law School website:

http://www.law.cornell.edu/uscode/search/display.html?terms=59b&url=/uscode/html/uscode26/usc_sec_26_00000059—B000-.html

Under section (B), it refers to 3111 (c) of the same tax code. This bill appears to create that section as part of the federal tax code(i.e. did not exist before).

As for section (C), it seems as though this would also create a new section within the tax code. I found 4980G, but not H.

SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES.

(b) Requirements for Approval -

(5) Such other requirements as the Commissioner may specify.

(2) TERMINATION; HEALTH INSURANCE EXCHANGE RESUMPTION OF FUNCTIONS- The Commissioner may terminate the approval (for some or all functions) of a State-based Health Insurance Exchange under this section if the Commissioner determines that such Exchange no longer meets the requirements of subsection (b) or is no longer capable of carrying out such functions in accordance with the requirements of this subtitle. In lieu of terminating such approval, the Commissioner may temporarily assume some or all functions of the State-based Health Insurance Exchange until such time as the Commissioner determines the State-based Health Insurance Exchange meets such requirements of subsection (b) and is capable of carrying out such functions in accordance with the requirements of this subtitle.

MY NOTE: I think I am detecting a theme here. What do you think? This basically says that the Health Commissioner can dictate whatever requirements he/she feels are necessary for a state-based health insurance exchange to operate. Then, it goes on in section (2) to state that the Commissioner can terminate an exchange with the same amount of unilateral power. Basically, if this bill is passed, states will only be allowed to operate programs if the Health Commissioner approves the program.

I have read through 115 pages as of today. I will return sometime soon with more of my input. Thanks for reading!

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TYPOS/MISTAKES I FOUND:

Sec. 207 (c)(1)(C) Presumably, the words, “of the Internal Revenue Code of 1986″ need to be added, in order to make this section consistent.

I have never been one to allow others to form my opinions for me, and I have a feeling that this particular topic is one that will be discussed for some time. I want to be able to speak knowledgably about this issue. There is no better place to garner this information than directly from the source itself.

My guess is that it will take me a few weeks to work my way through the bill, since it is essentially 1100 pages of legalese. That being said, I am committed to finishing this quest. I do know that this is not the final version, as it must progress through committees before getting to any vote. That being said, there is so much discussion about this that I wanted to learn as much as I could.

I am presently neither in favor of this bill nor am I fully opposed to it, although that will probably change as I read further. I intend to do my best to present the facts in a neutral manner.

A LITTLE ABOUT ME: Before I start, I thought it would be a good idea to give you some background information about myself. I am a Christian homeschooling father of four, and I am generally conservative in my political beliefs. That being said, I am also one of the many millions of people with a pre-existing condition that makes it impossible for me to get normal individual insurance coverage. Hence, we pay about $1300/month for insurance, since I am self-employed. Additionally, my wife and I paid approximately $30,000 to give birth to our last two children, and those were natural childbirths (i.e. no epidural, etc.). Clearly, I am in favor of anything that will reduce our health care costs, as long as it makes sense. As you can see, my opinions probably don’t line up with either side at this point. I am not an attorney – I’m just a regular guy who is interested in seeing what is proposed.

I can’t really apologize for the fact that this post is over 2,000 words long – the source document is huge, after all.

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I finished reading the first large section (Title I) a few days ago. Here are my notes and observations for that portion:

MOST POTENTIALLY CONTROVERSIAL TABLE OF CONTENTS SECTIONS:
My reading of the table of contents revealed the following sections that seem ripe for political disagreements. We will return to review these as I work my way through the bill.

Sec. 246. No Federal payment for undocumented aliens.

Sec. 441. Surcharge on high income individuals.

SOMETHING I LEARNED

I learned via my research that an insurance company’s “medical loss ratio” is the percentage of premiums actually used to pay for medical services. The Act calls for the highest-possible ratio. If plans don’t meet this, they must rebate any overage to their enrollees. While I suppose it seems appealing to get a dividend of sorts from my insurance company, this feature also seems to inhibit companies from being profitable.

OTHER NOTES FROM TITLE I

SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS. This is the first section that I liked, at least in principle. In a nutshell, this section states that “A qualified health benefits plan may not impose any pre-existing condition exclusion…”. Clearly, I like this, since I haven’t been able to get “real” insurance since 1993.

Sec. 113, (a) (1) – Limited age variation permitted – no more than a 2:1 ratio. This means that they can’t charge anyone more than double what the lowest rates are. Admittedly, this seems more fair than the present rules would indicate, although I am pretty sure that the Texas Health Insurance Risk Pool (my insurance) has the same limit in place.

SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

(c) No Restrictions on Coverage Unrelated to Clinical Appropriateness- A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services.

MY NOTE: Since this would tend to indicate that the public health option cannot restrict care unless there is a medical reason to do so (and I welcome other interpretations here), it seems to me that this particular section could cause a lot of problems and arguments. Why? Well, simply put, most abortions would be covered, if I am reading this correctly. I am personally pro-life, but I have discussed this with a couple of pro-choice friends. Frankly, it seems that none of us want to fund abortions via our tax dollars.

SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.

Under part (a):

(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services;

MY NOTE: This seems reasonable to me. I know people who have run up against their limit from ONE big illness/hospitalization. I doubt that the average insurance shopper knows to look at this limit in their current policy. To me, having a limit in place for health care is like saying that your home’s hazard insurance will cover you as long as nothing really bad happens, like a fire.

(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.

MY NOTE: Again, this seems very reasonable.

Under part (b):

Minimum Services To Be Covered- The items and services described in this subsection are the following:

(1) Hospitalization.

(2) Outpatient hospital and outpatient clinic services, including emergency department services.

(3) Professional services of physicians and other health professionals.

(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.

(5) Prescription drugs.

(6) Rehabilitative and habilitative services.

(7) Mental health and substance use disorder services.

(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.

(9) Maternity care.

(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.

MY NOTE: I was pleasantly surprised to see maternity care covered under the essential plan. In my own family, this item would have saved us countless thousands of dollars. My wife pointed out that the list didn’t include birth control pills, which I suppose could result in a new baby boom.

SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.

This will automatically includes Surgeon General, and up to 17 people appointed by the President, along with 9 people appointed by the Comptroller General.

MY NOTE: Why is the President (no matter which party) given this much control over this committee? If the President is able to appoint 17 of the 27 members, it seems like an inordinate amount of control. Perhaps this should be spread out a bit more.

SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.
(a) In General- There is hereby established, as an independent agency in the executive branch of the Government, a Health Choices Administration (in this division referred to as the `Administration’).

NOTE: Is it really necessary to set up an entirely new agency? This seems like the type of thing that could be maintained and subsumed under another department that already exists, such as Health and Human Services, in my opinion.

(2) FLEXIBILITY IN PLAN ENROLLMENT AUTHORIZED- Beginning with Y3, the Commissioner shall establish a process to allow an affordability credit to be used for enrollees in enhanced or premium plans. In the case of an affordable credit eligible individual who enrolls in an enhanced or premium plan, the individual shall be responsible for any difference between the premium for such plan and the affordable credit amount otherwise applicable if the individual had enrolled in a basic plan.

NOTE: I understand the principle at play here, but I don’t understand why the affordability credits can be used to defray the cost of “premium” plans. It would seem more fair to simply provide the basic plan to those who can’t afford it, rather than allowing them to choose the most expensive plan and pay very little for this.

(B) FOR UNAFFORDABLE EMPLOYER COVERAGE- Beginning in Y2, in the case of full-time employees for which the cost of the employee premium for coverage under a group health plan would exceed 11 percent of current family income (determined by the Commissioner on the basis of verifiable documentation and without regard to section 245), paragraph (1) shall not apply.

NOTE: I certainly hope the costs are supremely low if this is the definition that they intend to use. I would love for my own insurance cost to be under 11% of my income. The section also refers to modified adjusted gross income, which would make it an even lower figure. This seems like a low threshold for what constitutes “unaffordable”, but I must admit that this would benefit me directly.

Sec. 1137A. (D) enable the real-time (or near real-time) determination of an individual’s financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card.

NOTE: This section is actually modifying the Social Security Act, which is why the numbering is different. This could result in some interesting debates with regard to individual privacy. Does this information go to the newly-created Health Choices Administration, or is it simply meant to make payment and approvals faster?

SEC. 164. REINSURANCE PROGRAM FOR RETIREES. (d) Retiree Reserve Trust Fund- (B) FUNDING- There are hereby appropriated to the Trust Fund, out of any moneys in the Treasury not otherwise appropriated, an amount requested by the Secretary as necessary to carry out this section, except that the total of all such amounts requested shall not exceed $10,000,000,000.

NOTE: This section is intended to provide reimbursement for employers who provide health care for their retirees. This particular figure ($10 Billion) seems to have been thrown out without a lot of supporting research for setting the limit there. I would love to see some reference to a study or any documentation on this figure.

Overall, it seems as though the Health Choices Commissioner (new position created by the Act if it is passed) is given a LOT of power to determine things under this bill. This will be a Presidential appointee. In one section, it states that the duties include “ADDITIONAL FUNCTIONS- Such additional functions as may be specified in this division.” Later, the bill gives the Commissioner the power to provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms. This seems like an exceptional amount of power to me to vest in one person.

If you have any questions or want to disagree with me, I welcome that. Just make sure that you bring your documentation. I brought mine, after all.
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TYPOS/MISTAKES

I realize that this version hasn’t been finalized in any way, but I did find a few errors, for what it’s worth. I suppose I included these items just to prove that I am reading every word of this thing:

Sec. 154 – SHOULD SAY “or” instead of “of”.