With the new framework finally released from the Senate Finance Committee, a compromise will be necessary between the version Senator Baucus released, and the Senate Health, Education, Labor and Pensions Committee (HELP). The bill summary noted that the Committee in July accepted more than 160 Republican amendments during the month-long mark-up. The non-partisan Congressional Budget Office estimates the bill to cost less than $615 billion over 10 years.
Below is a synopsis of the HELP version of The Affordable Health Choices Act.
No denial of health coverage because of a preexisting medical condition. No annual or lifetime limits on coverage, or arbitrary termination to avoid claims.
The bill requires those businesses which do not provide coverage for their workers to contribute to the cost of providing publicly sponsored coverage for those workers. It includes an exception for small businesses. The bill also includes a public option. The Community Health Insurance Option will be available through the American Health Benefit Gateway, a new way for individuals and small employers to find and purchase quality and affordable health insurance in every state.
Insurance rates may only vary within a geographic region by family composition, the value of the benefits package, tobacco use, and age. Rates will not be permitted to vary based on any applicant’s health status, medical condition (including physical and mental illness), claims experience, prior receipt of health care, medical history, genetic information, evidence of insurability (such as being a victim of domestic violence), disability, gender, wages, or class of business.
Guaranteed issue will be required for all insurers operating in the individual and group health insurance markets. All insurance policies must incorporate incentives for high quality and preventive health care services. Dependents will be permitted to stay on parents’ policies until age 26.
Health insurers offering group or individual policies will be required to publicly report the percentage of total premium revenue that is expended on clinical services, quality and all other non-claims costs. Health insurance policies will be required to include financial incentives to reward high quality care.
Essential health care benefits provided include at least ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitative and abilitative services and devices, laboratory services, preventive and wellness services, and pediatric services. Develops a one-time, temporary, and independent commission to advise the Secretary in the development of the essential benefit package.
Low-income and moderate-income Americans who enroll in plans through the Gateways will be eligible for premium credits. The premium credits would be on a sliding scale up to 400% of the poverty line ($88,080 for a family of 4).
Beginning in 2010, employers with 50 or fewer full-time workers who pay 60 percent or more of their employees’ health insurance premiums will be permitted to receive tax credits for subsidizing coverage for up to 3 consecutive years. Self-employed individuals who do not receive credits for purchasing coverage through the Gateway are eligible. Fees will be assessed on employers who do not provide qualifying coverage for full- and part-time employees. Employers with 25 or fewer employees are exempt from penalties. Employers with more than 25 employees who do not offer qualifying coverage or who pay less than 60 percent of their employees’ monthly premiums are subject to a $750 annual fee per uninsured full-time employees and $375 per uninsured part-time employees. For employers subject to the assessment, the first 25 workers will be exempted.
Spending for Federally Qualified Health Centers (FQHCS): FY2010 – $2.9B; FY2011 – $3.8B; FY2012 – $4.9B; FY 2013 – $6.4B; FY2014 – $7.3B; FY2015 – $8.3B.
Funding for National Health Service Corps: FY2010 – $320M; FY2011 – $414M; FY2012 – $535M; FY2013 – $691M; FY2014 – $893M; FY2015 – $1.1B
Community-based mental and behavioral health: $50 million for coordinated and integrated services through the collocation of primary and specialty care.
The Director of the Agency for Health Care Research and Quality (AHRQ) is directed to provide grants to organizations, such as specialty societies, to develop measures in “gap” areas where no quality measures exist, or where existing quality measures need improvement, updating, or expansion.
The bill creates health quality initiatives to reduce medical errors, reduce hospital readmissions, improve patient safety, promote evidence-based medicine and disseminate best care practices. An integrative model of patient-centered care will be supported through the establishment of Community Health Teams.
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Hospitals will be required by the Secretary of HHS to report preventable readmission rates. Hospitals with high re-admission rates will be required to work with local patient safety organizations to improve their care transition practices including the effective use of discharge planning and counseling.
A process will be established for the FDA to evaluate and determine if the use of drug fact boxes in advertising and other forms of communication for prescription medications is warranted.
Establishes the Right Choices Program which would provide chronic disease health risk assessment, a care plan, and referrals to community-based resources for low-income, uninsured adults until universal insurance coverage is made available through the Gateway.
Authorizes a grant program for the operation and development of School-based Health Clinics, which provide comprehensive and accessible preventive and primary health care services to medically underserved children and families.
Authorizes the Secretary to award competitive grants to eligible entities for programs that promote individual and community health and prevent the incidence of chronic disease.
The CDC would provide grants to states or large local health departments to conduct pilot programs in the 55-to-64 year old population to evaluate chronic disease risk factors, conduct evidence-based public health interventions, and ensure that individuals identified with chronic disease or at-risk for chronic disease receive clinical treatment to reduce risk.
Authorizes states to purchase adult vaccines under CDC contracts. These contracts for adult vaccines provide savings that range from 23-69 percent compared to the private sector cost.
The bill gives more flexibility under HIPAA and expands the amount that is allowed for employers to reward employees for participating in wellness programs from 20 percent (current law) to 30 percent premium discount. It also increases this reward to 50 percent if deemed appropriate.
Amends current law to ease criteria for schools and students to qualify for loans, shorten payback periods, and ease the non-compliance provision. Grant amounts and updates are increased for nursing schools to establish and maintain student loan funds.
Establishes a loan repayment program for pediatric subspecialists and providers of mental and behavioral health services to children and adolescents who are or will be working in a Health Professional Shortage Area, Medically Underserved Area, or with a Medically Underserved Population. There are also many other areas of the bill establishes for loan repayment programs such as public health professions, and allied health professions.
Strengthens the safety-net and ensures that medically underserved have access to primary care and wellness services by creating a $50 million grant program to support nurse-managed health clinics to be administered by the Health Resources and Services Administration’s Bureau of Primary Health Care.
Provides grants to develop and operate training programs, financial assistance of trainees and faculty, and faculty development in primary care and physician assistant programs. This section provides grants to establish maintain and improve academic units in primary care. Authorization is $125 million.
Authorizes $10 million over three years to establish new training opportunities for direct care workers (CNAs, home health aides and personal/home care aides) already employed in long-term care facilities.
Reinstates dental funding and makes dental programs eligible for grants now only available to medical schools, and authorizes a dental faculty loan repayment. Authorization for $30 million annually is provided.
Authorizes $12 million to geriatric education centers to support training in geriatrics, chronic care management, and long-term care for faculty in health professions schools and family caregivers. Grants are awarded to schools for development, expansion, or enhancement of training programs in social work, graduate psychology, professional training in child and adolescent mental health, and pre-service or in-service training to paraprofessionals in child and adolescent mental health. Awards grants to nursing schools to strengthen nurse education and training programs and to improve nurse retention.
Establishes a federally-funded student loan repayment program for nurses with outstanding debt who pursue careers in nurse education. Nurses agree to teach at an accredited school of nursing for at least 4 years within a 6-year period
The Centers of Excellence program is funded with $50 million to focus on development of a minority applicant pool to enhance recruitment, training, academic performance and other supports for minorities.
Provides scholarships for disadvantaged students who commit to work in medically underserved areas as primary care providers. Funding is increased from $37 to $51 million for 2009 through 2013. This section increases loan repayments for individuals who will serve as members of faculties of eligible institutions from $20,000 to $30,000. (§ 452)
Establishes community-based training and education grants for Area Health Education Centers (AHECs) and Programs. Authorization is for $125 million annually 2009 through 2013.
Creates a Primary Care Extension Program to educate and provide technical assistance to primary care providers about evidence-based therapies, preventive medicine, health promotion, chronic disease management, and mental health.
The Biologics Price Competition and Innovation Act of 2009 require HHS to license a biological product that is shown to be biosimilar to or interchangeable with a licensed biological product, commonly referred to as a reference product. The Act prohibits the approval of an application as either biosimilar or interchangeable until 12 years from the date on which the reference product is first approved.
Expands the drug discount program to cover an entity by free-standing children's hospitals, free-standing cancer hospitals, rural referral centers, sole community hospitals which have a disproportionate share hospital percentage greater than eight percent, and all critical access hospitals;
Expands the program to include a drug used in connection with an inpatient service by enrolled hospitals;
Allows enrolled hospitals to obtain inpatient drugs through a group purchasing agreement or the 340B Prime Vendor Program; and
Requires hospitals enrolled in the 340B program to provide a credit to each state on the estimated annual costs of covered drugs provided to Medicaid recipients for inpatient use.
Requires the Secretary to carry out activities to increase compliance by manufacturers and covered entities with the requirements of the drug discount program; 2) Establishes an administrative process to resolve claims by covered entities and manufacturers of violations of such requirements; and 3) Provides clarifications about the ceiling price used to sell to 340B participants.