Kaiser Health Reform Side by Side Comparison

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Health Reform
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This side-by-side compares the leading comprehensive reform proposals across a number of key characteristics and plan components. Included in this side-by-
side are proposals for moving toward universal coverage that have been put forward by the President and Members of Congress. In an effort to capture the most
important proposals, we have included those that have been formally introduced as legislation as well as those that have been offered as principles or in White
Paper form. This side-by-side will be regularly updated to reflect changes in the proposals and to incorporate major new proposals as they are announced.
The House Tri-Committee summary incorporates the major amendments to the legislation adopted by the three committees of jurisdiction during their mark-ups
of the bill. These amendments are identified using an abbreviation for the House panel that approved it — “E&C” for the Committee on Energy and Commerce;
“E&L” for the Committee on Education and Labor; and “W&M” for the Committee on Ways and Means.
Senate Finance Committee House Tri-Committee

America’s Healthy Future Act Senate HELP Committee America’s Affordable Health President Obama
of 2009 Affordable Health Choices Act Choices Act of 2009 (H.R. 3200) Principles for Health Reform
Date plan announced September 16, 2009 June 9, 2009 June 19, 2009 February 26, 2009
(as amended by Committee (passed by Committee July, 15, 2009)
during mark-up)
Overall approach Require most U.S. citizens and legal Require individuals to have health Require all individuals to have President Obama outlined eight
to expanding access residents to have health insurance. insurance. Create state-based health insurance. Create a Health principles for health care reform
to coverage Create state-based health insurance American Health Benefit Gateways Insurance Exchange through which in his FY 2010 Budget overview.
exchanges through which individuals through which individuals and small individuals and smaller employers The President has indicated that
can purchase coverage, with premium businesses can purchase health can purchase health coverage, with comprehensive health reform should:
and cost-sharing credits available coverage, with subsidies available to premium and cost-sharing credits • Reduce long-term growth of
to individuals/families with income individuals/families with incomes up available to individuals/families health care costs for businesses
between 100-400% of the federal to 400% of the federal poverty level with incomes up to 400% of the and government.
poverty level (the poverty level is (or $73,240 for a family of three in federal poverty level (or $73,240 for
• Protect families from bankruptcy or
$18,310 for a family of three in 2009) 2009). Require employers to provide a family of three in 2009). Require
debt because of health care costs.
and create separate exchanges through coverage to their employees or employers to provide coverage to
• Guarantee choice of doctors and
which small businesses can purchase pay an annual fee, with exceptions employees or pay into a Health
health plans.
coverage. Assess a fee on certain for small employers, and provide Insurance Exchange Trust Fund,
employers that do not offer coverage certain small employers a credit with exceptions for certain small • Invest in prevention and wellness.
for each employee who receives a tax to offset the costs of providing employers, and provide certain • Improve patient safety and quality
credit for health insurance through coverage. Impose new regulations small employers a credit to offset care.
an exchange, with exceptions for on the individual and small group the costs of providing coverage. • Assure affordable, quality health
small employers. Impose new insurance markets. Expand Impose new regulations on plans coverage for all Americans.
regulations on health plans in the Medicaid to all individuals with participating in the Exchange and in • Maintain coverage when you
exchange and in the individual incomes up to 150% of the federal the small group insurance market. change or lose your job.
and small group markets. Expand poverty level. Expand Medicaid to 133% of the • End barriers to coverage for
Medicaid to all individuals with incomes poverty level. people with pre-existing medical
up to 133% of the federal poverty level. conditions.
Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: October 8, 2009
Individual mandate • Require U.S. citizens and legal • Require individuals to have • Require all individuals to have • The plan must put the country
residents to have qualifying health qualifying health coverage. “acceptable health coverage”. on a clear path to cover all
coverage. Enforced through a tax Enforced through a minimum tax Those without coverage pay Americans.
penalty of $750 per adult per year. penalty of $750 per individual a penalty of 2.5% of modified
The penalty will be phased-in per year (maximum penalty per adjusted gross income up to
according to the following schedule: family of 4 times the individual the cost of the average national
$0 in 2013; $200 in 2014; $400 in penalty). Exemptions to the premium for self-only or
2015; $600 in 2016; and $750 in individual mandate will be granted family coverage under a basic
2017. Exemptions will be granted to residents of states that do not plan in the Health Insurance
for financial hardship, religious establish an American Health Exchange. Exceptions granted for
objections, American Indians, and if Benefit Gateway, members of dependents, religious objections,
the lowest cost plan option exceeds Indian tribes, those for whom and financial hardship.
8% of an individual’s income or if affordable coverage is not
the individual has income below available, those without coverage
133% of the poverty level. for fewer than 90 days, and those
with incomes below 150% FPL.
Employer requirements • Assess employers with more than • Require employers to offer health • Require employers to offer Not specified.
50 employees that do not offer coverage to their employees and coverage to their employees and
coverage a fee for each employee contribute at least 60% of the contribute at least 72.5% of the
who receives a tax credit for premium cost or pay $750 for premium cost for single coverage
health insurance through an each uninsured full-time and 65% of the premium cost for
exchange. The penalty is the employee and $375 for each family coverage of the lowest cost
lesser of a flat dollar amount uninsured part-time employee plan that meets the essential
equal to the average national tax who is not offered coverage. For benefits package requirements or
credit for each full-time employee employers subject to the pay 8% of payroll into the Health
receiving a tax credit or $400 assessment, the first 25 workers Insurance Exchange Trust Fund.
times the total number of full- are exempted. [E&L Committee amendment:
time employees in the firm. • Exempt employers with 25 or Provide hardship exemptions
• Exempt employers with 50 or fewer employees from the for employers that would be
fewer employees from the penalty. requirement to provide coverage. negatively affected by job losses
• Require employers with 200 or as a result of requirement.]
more employees to automatically • Eliminate or reduce the pay
enroll employees into health or play assessment for small
insurance plans offered by the employers with annual payroll of
employer. Employees may opt out less than $400,000:
of coverage if they have coverage – Annual payroll less than
from another source. $250,000: exempt
– Annual payroll between
$250,000 and $300,000: 2% of
payroll;
$300,000 and $350,000: 4% of
payroll;
Employer requirements – Annual payroll between

(continued) $350,000 and $400,000: 6% of
payroll.
[E&C Committee amendment:
Extend the reduction in the pay
or play assessment for small
employers with annual payroll of
less than $750,000 and replace
the above schedule with the
following:
– Annual payroll less than
$500,000: exempt
$500,000 and $585,000: 2% of
payroll;
$585,000 and $670,000: 4% of
payroll;
$670,000 and $750,000: 6% of
payroll.]
• Require employers that offer
coverage to automatically enroll
into the employer’s lowest cost
premium plan any individual who
does not elect coverage under the
employer plan or does not opt out
of such coverage.
Expansion of public • Expand Medicaid to all individuals • Expand Medicaid to all individuals • Expand Medicaid to all individuals • As a foundation for health
programs (children, pregnant women, (children, pregnant women, (children, pregnant women, reform, the President signed
parents, and adults without parents, and adults without parents, and adults without the Children’s Health Insurance
dependent children) with dependent children) with incomes dependent children) with incomes Program Reauthorization
incomes up to 133% FPL (to be up to 150% FPL. Individuals up to 133% FPL. Newly eligible, Act (CHIPRA), which provides
implemented in 2014). Adults with eligible for Medicaid will be non-traditional (childless adults) coverage to 11 million children.
incomes between 100-133% FPL covered through state Medicaid Medicaid beneficiaries may
will have the option of obtaining programs and will not be eligible enroll in coverage through the
coverage through Medicaid or for credits to purchase coverage Exchange if they were enrolled in
with federal subsidies through the through American Health Benefit qualified health coverage during
exchange. All newly eligible adults Gateways. the six months before becoming
will be guaranteed a benchmark Medicaid eligible. Provide Medicaid
benefit package that at least coverage for all newborns who lack
meets the minimum creditable acceptable coverage and provide
coverage standards. optional Medicaid coverage to
Expansion of public Require states to provide • Grant individuals eligible for low-income HIV-infected
programs (continued) premium assistance to any the Children’s Health Insurance individuals and for family planning
Medicaid beneficiary with access Program (CHIP) the option of services to certain low-income
to employer-sponsored insurance enrolling in CHIP or enrolling in women. In addition, increase
if it is cost-effective for the state. a qualified health plan through a Medicaid payment rates for
To finance the coverage for the Gateway. primary care providers to 100% of
newly eligible (those who were Medicare rates. [E&C Committee
not previously eligible for a full amendment: Require states to
benchmark benefit package or submit a state plan amendment
who were eligible for a capped specifying the payment rates
program but were not enrolled), to be paid under the state’s
states will receive an increase in Medicaid program.] The coverage
the federal medical assistance expansions (except the optional
percentage (FMAP). Initially, the expansions) and the enhanced
percentage point increase in the provider payments will be fully
FMAP will be 27.3 for states that financed with federal funds. [E&C
already cover adults with incomes Committee amendment: Replace
above 100% FPL and 37.3 for full federal financing for Medicaid
other states. These percentage coverage expansions with 100%
point increases will be adjusted federal financing through 2014
over time so that by 2019, all and 90% federal financing
states will receive an FMAP beginning in year 2015.]
increase of 32.3 percentage points • Require Children’s Health
for the newly eligible. High need Insurance Program (CHIP)
states—those with total Medicaid enrollees to obtain coverage
enrollment that is below the through the Health Insurance
national average for enrollment Exchange (in the first year the
as a percentage of the state Exchange is available) provided
population and unemployment the Health Choices Commissioner
rates of 12% or higher for August determines that the Exchange
2009—will receive full federal has the capacity to cover these
funding for the newly eligible for children and that procedures
five years. are in place to ensure the timely
• Require states to maintain transition of CHIP enrollees
current income eligibility levels into the Exchange without an
for children in Medicaid and the interruption of coverage. [E&C
Children’s Health Insurance Committee amendment: Require
Program (CHIP) until 2019. CHIP that CHIP enrollees not be
benefit package and cost-sharing enrolled in an Exchange plan
rules will continue as under until the Secretary certifies that
current law. Beginning in 2014, coverage is at least comparable
states will receive a 23 percentage to coverage under an average
point increase in the CHIP match CHIP plan in effect in 2011. The
rate up to a cap of 100% and a Secretary must also determine
Expansion of public .15 percentage point increase in that there are procedures to
programs (continued) the Medicaid match rate. CHIP- transfer CHIP enrollees into the
eligible children who are unable exchange without interrupting
to enroll in the program due to coverage or with a written plan of
enrollment caps will be eligible for treatment.]
tax credits in the state exchanges.
Premium subsidies • Provide refundable and • Provide premium credits on a • Provide affordability premium • The plan must protect families’
to individuals advanceable premium credits sliding scale basis to individuals credits to eligible individuals from bankruptcy or debt because
to individuals and families with and families with incomes up to and families with incomes up to of health care costs.
incomes between 133-400% FPL 400% FPL to purchase coverage 400% FPL to purchase insurance • The American Recovery and
in 2013, and including individuals through the Gateway. The through the Health Insurance Reinvestment Act makes coverage
and families with incomes premium credits will be based Exchange. The premium credits more affordable for Americans
between 100-133% FPL in 2014, to on the average cost of the three will be based on the average cost who lose their jobs and their
purchase insurance through the lowest cost qualified health plans of the three lowest cost basic access to employer-based health
health insurance exchanges. The in the area, but will be such that health plans in the area and will coverage by offering a subsidy of
premium credits will be tied to the individuals with incomes less be set on a sliding scale such 65 percent of the premium costs
second lowest-cost silver plan in than 400% FPL pay no more than that the premium contributions for COBRA coverage.
the area and will be provided on 12.5% of income and individuals are limited to the following
a sliding scale basis from 2% of with incomes less than 150% FPL percentages of income for
income for those at 100% FPL to pay 1% of income, with additional specified income tiers:
12% of income for those between limits on cost sharing. 133-150% FPL: 1.5 - 3% of income
300-400% FPL. • Limit availability of premium 150-200% FPL: 3 - 5% of income
• Exclude individuals with incomes credits through the Gateway to 200-250% FPL: 5 - 7% of income
below 100% FPL from eligibility U.S. citizens and lawfully residing 250-300% FPL: 7 - 9% of income
for the premium credits. These immigrants who meet income
300-350% FPL: 9 - 10% of income
individuals will be eligible for limits and are not eligible for
coverage through the Medicaid employer-based coverage that 350-400% FPL: 10 - 11% of income
program. meets minimum qualifying criteria [E&C Committee amendment:
• Provide cost-sharing subsidies to and affordability standards, Replaces the above subsidy
eligible individuals and families Medicare, Medicaid, TRICARE, schedule with the following:
with incomes between 100-200% or the Federal Employee Health 133-150% FPL: 1.5 - 3% of income
FPL. For those with incomes Benefits Program. Individuals 150-200% FPL: 3 – 5.5% of income
between 100-150% FPL, the cost- with access to employer-based 200-250% FPL: 5.5 - 8% of income
sharing subsidies will result in coverage are eligible for the 250-300% FPL: 8 - 10% of income
coverage for 90% of the benefit premium credits if the cost of the
300-350% FPL: 10 - 11% of income
costs of the plan. For those with employee premium exceeds 12.5%
350-400% FPL: 11 - 12% of income]
incomes between 150-200%, the of the individuals’ income.
[E&C Committee amendment:
cost-sharing subsidies will result
Increase the affordability credits
in coverage for 80% of the benefit
annually by the estimated savings
costs of the plan.
achieved through adopting a
• Limit availability of premium
formulary in the public health
credits and cost-sharing subsidies
insurance option, pharmacy
through the exchanges to U.S.
benefit manager transparency
Premium subsidies citizens and legal immigrants who requirements, developing

to individuals (continued) meet income limits. Employees accountable care organization
who are offered coverage by pilot programs in Medicaid, and
an employer are not eligible administrative simplification.]
for premium credits unless the [E&C Committee amendment:
employer plan does not have an Increase the affordability credits
actuarial value of at least 65% annually by the estimated
or if the employee share of the savings achieved through limiting
premium exceeds 10% of income. increases in premiums for plans
• Require verification of both in the Exchange to no more than
income and citizenship status 150% of the annual increase in
in determining eligibility for the medical inflation and by requiring
federal premium credits. the Secretary to negotiate
directly with prescription drug
manufacturers to lower the prices
for Medicare Part D plans.]
• Provide affordability cost-sharing
credits to eligible individuals and
families with incomes up to 400%
FPL. The cost-sharing credits
reduce the cost-sharing amounts
and annual cost-sharing limits
and have the effect of increasing
the actuarial value of the basic
benefit plan to the following
percentages of the full value of the
plan for the specified income tier:
133-150% FPL: 97%
150-200% FPL: 93%
200-250% FPL: 85%
250-300% FPL: 78%
300-350% FPL: 72%
350-400% FPL: 70%
• Limit availability of premium and
cost-sharing credits to US citizens
and lawfully residing immigrants
who meet the income limits and
are not enrolled in qualified or
grandfathered employer or
individual coverage, Medicare,
Medicaid (except those eligible to
enroll in the Exchange), TRICARE,
or VA coverage (with some
Premium subsidies exceptions). Individuals with

to individuals (continued) access to employer-based
coverage are eligible for the
premium and cost-sharing
credits if the cost of the employee
premium exceeds 11% of
the individuals’ income [E&C
Committee amendment: To be
eligible for the premium and cost-
sharing credits, the cost of the
employee premium must exceed
12% of individuals’ income.].
Premium subsidies • Provide small employers with • Provide qualifying small • Provide small employers with Not specified.
to employers fewer than 25 employees and employers with a health options fewer than 25 employees and
average annual wages of less program credit. To qualify for the average wages of less than
than $40,000 that purchase health credit, employers must have fewer $40,000 with a health coverage
insurance for employees with a than 50 full-time employees, pay tax credit. The full credit of 50% of
tax credit. an average wage of less than premium costs paid by employers
Phase I: For tax years 2011 $50,000, and must pay at least is available to employers with 10
and 2012, provide a tax credit 60% of employee health expenses. or fewer employees and average
of up to 35% of the employer’s The credit is equal to $1,000 annual wages of $20,000 or less.
contribution toward the for each employee with single The credit phases-out as firm size
employee’s health insurance coverage and $2,000 for each and average wage increases and
premium if the employer employee with family coverage, is not permitted for employees
contributes at least 50% of the adjusted for firm size (phasing earning more than $80,000 per
total premium cost or 50% of out as firm size increases) and year.
a benchmark premium. The number of months of coverage • Create a temporary reinsurance
full credit will be available to provided. Bonus payments are program for employers providing
employers with 10 or fewer given for each additional 10% health insurance coverage to
employees and average annual of employee health expenses retirees ages 55 to 64. Program
wages of less than $20,000. above 60% paid by the employer. will reimburse employers for 80%
Tax-exempt small businesses Employers may not receive of retiree claims between $15,000
meeting these requirements the credit for more than three and $90,000. Payments from the
are eligible for tax credits of consecutive years. Self-employed reinsurance program will be used
up to 25% of the employer’s individuals who do not receive to lower the costs for enrollees in
contribution toward the premium credits for purchasing the employer plan. Appropriate
employee’s health insurance coverage through the Gateway are $10 billion over ten years for the
premium. eligible for the credit. reinsurance program.
Phase II: For tax years 2013 • Create a temporary reinsurance
and later, for eligible small program for employers providing
businesses that purchase health insurance coverage to
coverage through the state retirees ages 55 to 64. Program
exchange, provide a tax credit will reimburse employers for
Premium subsidies of up to 50% of the employer’s 80% of retiree claims between

to employers (continued) contribution toward the $15,000 and $90,000. Program
employee’s health insurance will end when the state Gateway
premium if the employer is established. Payments from the
contributes at least 50% of the reinsurance program will be used
total premium cost or 50% of to lower the costs for enrollees in
a benchmark premium. The the employer plan.
credit will be available for two
years. The full credit will be
available to employers with
10 or fewer employees and
average annual wages of less
than $20,000. Tax-exempt small
businesses meeting these
requirements are eligible for
tax credits of up to 35% of the
employer’s contribution toward
the employee’s health insurance
premium.
• Create a temporary reinsurance
program for employers providing
health insurance coverage to
retirees ages 55 to 64. Program
will reimburse employers or
insurers for 80% of retiree claims
between $15,000 and $90,000.
Appropriate $5 billion to finance
the program.
Tax changes related • Impose a tax on individuals • Impose a minimum tax on • Impose a tax on individuals Not specified.
to health insurance without qualifying coverage of individuals without qualifying without acceptable health care
$750 per adult per year to be health care coverage of $750 per coverage of 2.5% of modified
phased-in beginning in 2014. individual per year (maximum adjusted gross income.
• Impose an excise tax in 2013 on family penalty of 4 times the
insurers of employer-sponsored individual penalty).
health plans with aggregate
values that exceed $8,000 for
individual coverage and $21,000
for family coverage (these
threshold values will be indexed
to the consumer price index for
urban consumers (CPI-U) plus
1%). The threshold amounts will
be increased for retired individuals
Tax changes related age 55 and up and for employees

to health insurance engaged in high-risk professions
(continued) by $1,850 for individual coverage
and $5,000 for family coverage.
In the 17 states with the highest
health care costs, the threshold
amount is increased by 20%
initially; this premium increase is
subsequently reduced by half each
year until it is phased out in 2015.
The tax is equal to 40% of the
value of the plan that exceeds the
threshold amounts and is imposed
on the issuer of the health
insurance policy, which in the case
of a self-insured plan is the plan
administrator or, in some cases,
the employer. The aggregate
value of the health insurance
plan includes reimbursements
under a flexible spending account
for medical expenses (health
FSA) or health reimbursement
arrangement (HRA), employer
contributions to a health savings
account (HSA), and coverage
for dental, vision, and other
supplementary health insurance
coverage.
• Conform the definition of
medical expenses for purposes
of employer provided health
coverage (including HRAs and
health FSAs), HSAs, and Archer
medical savings accounts to the
definition for purposes of the
itemized deduction for medical
expenses. This change will
exclude the costs for over-the-
counter drugs not prescribed by
a doctor from being reimbursed
through an HRA or health FSA
and from being reimbursed on a
tax-free basis through an HSA or
Archer MSA.
Tax changes related • Increase the tax on distributions

to health insurance from a health savings account that
(continued) are not used for qualified medical
expenses to 20% (from 10%) of the
disbursed amount.
• Limit the amount of contributions
to a flexible spending account for
medical expenses to $2,500 per
year.
• Increase the threshold for
the itemized deduction for
unreimbursed medical expenses
from 7.5% of adjusted gross
income to 10% of adjusted gross
income for regular tax purposes.
Individuals age 65 and older
are exempt from the increased
threshold.
• Impose new fees on segments of
the health care sector:
– $2.3 billion annual fee on the
pharmaceutical manufacturing
sector;
– $4 billion annual fee on the
medical device manufacturing
sector; and
– $6.7 billion annual fee on the
health insurance sector.
Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: October 8, 2009 10
Creation of insurance • Provide immediate assistance • Create state-based American • Create a National Health Insurance • The plan should provide portability
pooling mechanisms until the new insurance market Health Benefit Gateways, Exchange, through which individuals of coverage and should offer
rules go into effect for those administered by a governmental and employers (phasing-in eligibility Americans a choice of health
with pre-existing conditions by agency or non-profit organization, for employers starting with smallest plans.
creating a temporary high-risk through which individuals and employers) can purchase qualified
pool. Individuals who have been small employers can purchase insurance, including from private
denied health coverage due to a qualified coverage. States may health plans and the public health
pre-existing medical condition and form regional Gateways or allow insurance option.
who have been uninsured for at more than one Gateway to operate • Restrict access to coverage
least six months will be eligible in a state as long as each Gateway through the Exchange to
to enroll in the high-risk pool and serves a distinct geographic area. individuals who are not enrolled
receive subsidized premiums. The • Restrict access to coverage in qualified or grandfathered
high-risk pool will exist until 2013. through the Gateways to employer or individual coverage,
• Create state-based exchanges individuals who are not Medicare, Medicaid (with some
for the individual market and incarcerated and who are not exceptions), TRICARE, or VA
small business health options eligible for employer-sponsored coverage (with some exceptions).
program (SHOP) exchanges for coverage that meets minimum
the small group market. Allow qualifying criteria and affordability
small businesses with up to 100 standards, Medicare, Medicaid,
employees to purchase coverage TRICARE, or the Federal Employee
through the SHOP exchanges Health Benefits Program.
beginning in 2015 and permit • Create a community health
states to allow businesses with insurance option to be offered
more than 100 employees to through state Gateways that
purchase coverage in the SHOP complies with the requirements of
exchange beginning in 2017. being a qualified health plan and
• Restrict access to coverage meets the same requirements as
through the exchanges to U.S. other plans relating to guarantee
citizens and legal immigrants. issue and renewability, insurance
• Create the Consumer Operated rating rules, quality improvement
and Oriented Plan (CO-OP) and reporting, solvency
program to foster the creation of standards, licensure, and benefit
non-profit, member-run health plan information. Require the
insurance companies in all 50 community health insurance plan
states and District of Columbia. to provide the essential benefits
To be eligible to receive funds, package and offer coverage at
organizations must not be an all cost-sharing tiers. Require
existing organization, substantially that the costs of the community
all of its activities must consist of health insurance plan be financed
the issuance of qualified health through revenues from premiums,
benefit plans in each state in require the plan to negotiate
which it is licensed, governance of payment rates with providers, and
the organization must be subject contract with qualified nonprofit
to a majority vote of its members, entities to administer the plan.
Creation of insurance must operate with a strong Permit the plan to develop [E&C Committee amendment:
pooling mechanisms consumer focus, and any profits innovative payment policies to Permit members of the armed
(continued) must be used to lower premiums, promote quality, efficiency, and forces and those with coverage
improve benefits, or improve the savings to consumers. Require through TRICARE or the VA to
quality of health care delivered to its each State to establish a State enroll in a health benefits plan
members. Require CO-OPs to meet Advisory Council to provide offered through the Exchange.]
the same requirements as private recommendations on policies and • Create a new public health
insurance plans in the exchanges procedures for the community insurance option to be offered
related to solvency, licensure, health insurance option. through the Health Insurance
provider payments, network • Require guarantee issue and Exchange that must meet the same
adequacy, and any applicable state renewability of health insurance requirements as private plans
premium assessments. policies in the individual and regarding benefit levels, provider
• Require all state-licensed insurers small group markets; prohibit networks, consumer protections,
in the individual and small group pre-existing condition exclusions; and cost-sharing. Require the
markets to participate in the prohibit insurers from rescinding public plan to offer basic, enhanced,
exchanges. coverage except in cases of and premium plans, and permit it to
• Require guarantee issue and fraud; and allow rating variation offer premium plus plans. Finance
renewability and allow rating based only on family structure, the costs of the public plan through
variation based only on age geography, the actuarial value of revenues from premiums. For
(limited to 4 to 1 ratio), tobacco the health plan benefit, tobacco the first three years, set provider
use (limited to 1.5. to 1 ratio), use (limited to 1.5 to 1 ratio), and payment rates in the public plan
family composition, and geography age (limited to 2 to 1 ratio). at Medicare rates and allow bonus
in the non-group and the small • Require plans participating in payments of 5% for providers
group market (new rules for small the Gateway to provide coverage that participate in both Medicare
group market will be phased- for at least the essential health and the public plan and for
in over five years). Require risk care benefits, meet network pediatricians and other providers
adjustment in the individual adequacy requirements, and that don’t typically participate in
and small group markets and make information regarding plan Medicare. In subsequent years,
prohibit insurers from rescinding benefits service area, premium permit the Secretary to establish
coverage. and cost sharing, and grievance a process for setting rates. [E&C
• Require the exchanges to and appeal procedures available Committee amendment: Require
develop a standardized format to consumers. the public health insurance option
for presenting insurance • Create three benefit tiers of plans to negotiate rates with providers
options, create a web portal to to be offered through the Gateways so that the rates are not lower
help consumers find insurance, based on the percentage of allowed than Medicare rates and not
maintain a call center for benefit costs covered by the plan: higher than the average rates paid
customer service, and establish – Tier 1: includes the essential by other qualified health benefit
procedures for enrolling health benefits, covers 76% of plan offering entities.] Health care
individuals and businesses and the benefit costs of the plan, providers participating in Medicare
for determining eligibility for and limits out-of-pocket costs are considered participating
tax credits. Permit exchanges to the Health Savings Account providers in the public plan unless
to contract with state Medicaid (HSA) current law limit ($5,950 they opt out.
agencies to determine eligibility for individuals and $11,900 for
for tax credits in the exchanges. families in 2010);
Creation of insurance • Create four benefit categories – Tier 2: includes the essential Permit the public plan to develop
pooling mechanisms of plans plus a separate “young health benefits, covers 84% of innovative payment mechanisms,
(continued) invincible plan” to be offered the benefit costs of the plan, including medical home and other
through the exchange, and in and limits out-of-pocket costs care management payments,
the individual and small group to 50% of the HSA limit ($2,975 value-based purchasing, bundling
markets: for individuals and $5,950 for of services, differential payment
– Bronze plan represents families); and rates, performance based
minimum creditable coverage – Tier 3: includes the essential payments, or partial capitation
and would cover 65% of the health benefits, covers 93% of and modify cost sharing and
benefit costs of the plan, with the benefit costs of the plan, payment rates to encourage use
an out-of-pocket limit equal and limits out-of pocket costs of high-value services. [E&C
to the Health Savings Account to 20% of the HSA limit ($1,190 Committee amendment: Clarify
(HSA) current law limit ($5,950 for individuals and $2,380 for that the public health insurance
for individuals and $11,900 for families). option must meet the same
families in 2010); • Require states to adjust payments requirements as other plans
– Silver plan includes minimum to health plans based on the relating to guarantee issue and
benefits, covers 70% of the actuarial risk of plan enrollees renewability, insurance rating
benefit costs of the plan, with using methods established by the rules, network adequacy, and
the HSA out-of-pocket limits; Secretary. transparency of information.]
– Gold plan includes the minimum • Require the Gateway to certify [E&C Committee amendment:
benefits, covers 80% of the participating health plans, provide Require the public health
benefit costs of the plan, with consumers with information insurance option to adopt a
the HSA out-of-pocket limits; allowing them to choose among prescription drug formulary.]
– Platinum plan includes the plans (including through a • Create four benefit categories of
minimum benefits, covers 90% centralized website), contract with plans to be offered through the
of the benefit costs of the plan, navigators to conduct outreach Exchange:
with the HSA out-of-pocket and enrollment assistance, create – Basic plan includes essential
limits; a single point of entry for enrolling benefits package and covers
– Young Invincible plan available to in coverage through the Gateway 70% of the benefit costs of the
those 25 years old and younger or through Medicaid, CHIP or plan;
and provides catastrophic other federal programs, and assist – Enhanced plan includes
coverage only with the coverage consumers with the purchase essential benefits package,
level set at the HSA current law of long-term care services and reduced cost sharing compared
levels except that prevention supports. to the basic plan, and covers
benefits would be exempt from • Prohibit plans participating in the 85% of benefit costs of the plan;
the deductible. Gateways from discriminating – Premium plan includes essential
• Reduce the out-of-pocket limits against any provider because of benefits package with reduced
for those with incomes up to 400% a willingness or unwillingness to cost sharing compared to the
FPL to the following levels: provide abortions. enhanced plan and covers 95%
– 100-200% FPL: one-third of the of the benefit costs of the plan;
HSA limits ($1,983/individual
and $3,967/family);
Creation of insurance – 200-300% FPL: one-half of the • Following initial federal support, – Premium plus plan is a premium
pooling mechanisms HSA limits ($2,975/individual the Gateway will be funded by plan that provides additional
(continued) and $5,950/family); a surcharge of no more than benefits, such as oral health and
– 300-400% FPL: two-thirds of the 4% of premiums collected by vision care.
HSA limits ($3,987/individual participating health plans. • Require guarantee issue and
and $7,973/family). renewability; allow rating variation
• Permit states the option of based only on age (limited to 2 to
creating a Basic Health Plan 1 ratio), premium rating area, and
for uninsured individuals with family enrollment; and limit the
incomes between 133-200% medical loss ratio to a specified
FPL. States opting to provide percentage.
this coverage will contract with • Require plans participating
multiple private plans to provide in the Exchange to be state
coverage at the level of plans licensed, report data as required,
in the exchanges. They are implement affordability credits,
encouraged to include innovative meet network adequacy
features in the contracts, such as standards, provide culturally and
care coordination and incentives linguistically appropriate services,
for using preventive services contract with essential community
and should seek to contract with providers, and participate in risk
managed care plans that meet pooling. Require participating
specific performance measures. plans to offer one basic plan for
States will receive 85% of the each service area and permit
funds that would have been paid them to offer additional plans.
as federal premium and cost- [E&C Committee amendment:
sharing subsidies for eligible Require plans to provide
individuals in the state with information related to end-of-life
incomes between 133-200% FPL planning to individuals and provide
to establish the Basic Health the option to establish advance
Plan. Individuals with incomes directives and physician’s order
between 133-200% FPL in states for life sustaining treatment.]
creating Basic Health Plans will • Require risk adjustment of
not be eligible for subsidies in the participating Exchange plans.
exchanges. • Provide information to consumers
• Require that at least one plan in to enable them to choose among
the exchanges provide coverage plans in the Exchange, including
for abortions beyond those for establishing a telephone hotline
which federal funds are permitted and maintaining a website and
and require that at least one plan provide information on open
in the exchange does not provide enrollment periods and how to
coverage for abortions beyond enroll.
those for which federal funds are
permitted (in cases of rape or
incest or to save the life of the
Creation of insurance woman). Prohibit plans • [E&C Committee amendment:

pooling mechanisms participating in the exchanges Prohibit plans participating in the
(continued) from discriminating against any Exchange from discriminating
provider because of a willingness against any provider because of
or unwillingness to provide, pay a willingness or unwillingness to
for, provide coverage of, or refer provide abortions.] .
for abortions. • [E&C Committee amendment:
Facilitate the establishment of
non-for-profit, member-run
health insurance cooperatives
to provide insurance through the
Exchange.]
• Allow states to operate state-
based exchanges if they
demonstrate the capacity to
meet the requirements for
administering the Exchange.
Benefit design • Create minimum creditable • Create the essential health care • Create an essential benefits Not specified.
coverage that provides a benefits package that provides a package that provides a
comprehensive set of services, comprehensive array of services comprehensive set of services,
covers 65% of the actuarial value and prohibits inclusion of lifetime covers 70% of the actuarial value
of the covered benefits, limits or annual limits on the dollar of the covered benefits, limits
annual cost-sharing to $5,950/ value of the benefits. The essential annual cost-sharing to $5,000/
individual and $11,900/family, health benefits must be included individual and $10,000/family,
does not impose annual or in all qualified health plans and and does not impose annual or
lifetime limits on coverage, and must be equal to the scope of lifetime limits on coverage. The
is not more extensive than the benefits provided by a typical Health Benefits Advisory Council,
typical employer plan. Require the employer plan. Create a chaired by the Surgeon General,
Secretary to define and annually temporary, independent will make recommendations on
update the benefit package commission to advise the specific services to be covered by
through a transparent and public Secretary in the development of the essential benefits package as
process. (See description of the essential health benefit well as cost-sharing levels. [E&L
benefit categories in Creation of package. Committee amendment: Require
insurance pooling mechanism.) early and periodic screening,
diagnostic, and treatment (EPSDT)
services for children under age
21 be included in the essential
benefits package.]
Benefit design • Prohibit abortion coverage from • Specify the criteria for minimum [E&C Committee amendment:
(continued) being required as part of the qualifying coverage for purposes Prohibit abortion coverage from
minimum benefits package; of meeting the individual mandate being required as part of the
require segregation of public for coverage, and an affordability essential benefits package;
subsidy funds from private standard such that coverage is require segregation of public
premium payments for plans that deemed unaffordable if the subsidy funds from private
choose to cover abortion services premium exceeds 12.5% of an premiums payments for plans that
beyond Hyde—which allows individual’s adjusted gross income. choose to cover abortion services
coverage for abortion services to beyond Hyde—which allows
save the life of the woman and coverage for abortion services to
in cases of rape or incest; and save the life of the woman and
require there be no effect on state in cases of rape or incest; and
or federal laws on abortions. require there be no effect on state
or federal laws on abortions.]
• All qualified health benefits plans,
including those offered through
the Exchange and those offered
outside of the Exchange (except
certain grandfathered individual
and employer-sponsored plans)
must provide at least the essential
benefits package.
Changes to private • Impose the same insurance • Impose the same insurance • Prohibit coverage purchased • The plan must end barriers to
insurance market regulations relating market regulations relating through the individual market from coverage for people with pre-
to guarantee issue, premium to guarantee issue, premium qualifying as acceptable coverage existing medical conditions.
rating, prohibitions on pre- rating, prohibitions on pre- for purposes of the individual
existing condition exclusions, existing condition exclusions, mandate unless it is grandfathered
risk adjustment, and rescissions and prohibitions on insurance coverage. Individuals can purchase
in the individual market, in the plan rescissions in the individual a qualifying health benefit plan
exchange, and in the small group and group markets and in through the Health Insurance
market, phasing in the new rules the American Health Benefit Exchange.
for small group market over five Gateways. (See new rating and • Impose the same insurance
years. (See new rating and market market rules in Creation of market regulations relating to
rules in Creation of insurance insurance pooling mechanism). guarantee issue, premium rating,
pooling mechanism.) • Require health insurers to report and prohibitions on pre-existing
• Require health plans to report the their medical loss ratio. condition exclusions in the insured
proportion of premium dollars • Require health insurers to provide group market and in the Exchange
spent on items other than medical financial incentives to providers (see creation of insurance pooling
care and require plans to compile to better coordinate care through mechanism).
information on coverage in a case management and chronic
standard format. disease management, promote
wellness and health improvement
activities, improve patient safety,
Changes to private • Require all new policies (except reduce medical errors, • Limit health plans’ medical
insurance (continued) stand-alone dental, vision, and and provide culturally and loss ratio to a percentage
long-term care insurance plans) linguistically appropriate care. specified by the Secretary to be
to comply with one of the four • Provide dependent coverage enforced through a rebate back
benefit categories, including those for children up to age 26 for all to consumers. [E&L Committee
offered through the exchanges individual and group policies. amendment: Limit health plans’
and those offered outside of • Require insurers and group plans medical loss ratio to at least 85%.]
the exchanges. Require health to notify enrollees if coverage does • Improve consumer protections by
plans in the individual and small not meet minimum qualifying establishing uniform marketing
group markets to at least offer coverage standards for purposes standards, requiring fair grievance
coverage in the silver and gold of satisfying the individual and appeals mechanisms,
categories. Existing individual and mandate for coverage. and prohibiting insurers from
employer-sponsored plans do • Permit licensed health insurers rescinding health insurance
not have to meet the new benefit to sell health insurance policies coverage except in cases of fraud.
standards. (See description of outside of the Gateway. States • Adopt standards for financial
benefit categories in Creation of will regulate these outside-the- and administrative transactions
insurance pooling mechanism.) Gateway plans. to promote administrative
• Require small employers to simplification.
provide a plan with a deductible • Create the Health Choices
that does not exceed $2,000 Administration to establish
for individuals and $4,000 for the qualifying health benefits
families unless contributions standards, establish the
are offered that offset deductible Exchange, administer the
amounts above these limits. This affordability credits, and
deductible limit will not affect the enforce the requirements for
actuarial value of bronze plans qualified health benefit plan
and does not apply to “young offering entities, including those
invincible” plans. (See description participating in the Exchange or
of benefit categories in Creation of outside the Exchange.
insurance pooling mechanism.)
• Allow states the option of merging
the individual and small group
markets.
• Create a temporary reinsurance
program to help stabilize
premiums during the first
three years of operation of
the exchanges when the risk
of adverse selection due to
enforcement of the new rating
rules and market changes is
greatest. Finance the reinsurance
program through mandatory
contributions by health insurers.
Changes to private • Allow insurers to offer a national

insurance (continued) health plan with a uniform
benefits package in the states in
which they are licensed. National
plans would be required to offer
plans with silver and gold benefit
packages and would be exempt
from state benefit requirements.
Allow states to opt out of the
national plan.
• Permit states to form health
care choice compacts and allow
insurers to sell policies in any
state participating in the compact.
Insurers selling policies through a
compact would only be subject to
the laws and regulations of the state
where the policy is written or issued.
State role • Require states to create • Establish American Health • Require states to enroll newly Not specified.
health insurance exchanges Benefit Gateways meeting eligible Medicaid beneficiaries
for individuals and small federal standards and adopt into the state Medicaid
businesses and require state individual and small group market programs and to implement the
insurance commissioners to regulation changes. specified changes with respect
provide oversight of health • Implement Medicaid eligibility to provider payment rates,
plans with regard to the new expansions and adopt federal benefit enhancements, quality
insurance market regulations, standards and protocols for improvement, and program
consumer protections, rate facilitating enrollment of integrity.
reviews, solvency, reserve fund individuals in federal and state • Require states to maintain
requirements, and premium taxes, health and human services Medicaid and CHIP eligibility
and to define rating areas. programs. standards, methodologies, or
• Require states to enroll newly • Create temporary “RightChoices” procedures that were in place as
eligible Medicaid beneficiaries programs to provide uninsured of June 16, 2009 as a condition of
into state Medicaid programs, individuals with immediate access receiving federal Medicaid or CHIP
coordinate enrollment with the to preventive care and treatment matching payments.
new exchanges, and implement for identified chronic conditions. • Require states to enter into a
other specified changes to the States will receive federal grants Memorandum of Understanding
Medicaid program. Require states to finance these programs. with the Health Insurance
to maintain current Medicaid Exchange to coordinate
and CHIP eligibility levels for enrollment of individuals in
children until 2019. States must Exchange-participating health
also maintain current Medicaid plans and under the state’s
eligibility levels for adults above Medicaid program.
133% FPL until 2013 and until
State role (continued) 2014 for those with incomes at or • May require states to determine
below 133% FPL. A state is exempt eligibility for affordability credits
from the maintenance of effort through the Health Insurance
requirement for non-disabled Exchange.
adults with incomes above 133%
FPL from January 2011 if the state
certifies that it is experiencing a
budget deficit or will experience a
deficit in the following year.
• Require states to establish an
ombudsman office to serve as an
advocate for people with private
coverage in the individual and
small group markets.
• Permit states to obtain a waiver
of certain new health insurance
requirements if the state can
demonstrate that it provides
health coverage to all residents
that is at least as comprehensive
as the coverage required under
an exchange plan and that the
state plan is budget-neutral to
the federal government over
10 years.
Cost containment • Restructure payments to • Establish a Health Care Program • Simplify health insurance • The plan should reduce high
Medicare Advantage plans to Integrity Coordinating Council administration by adopting administrative costs, unnecessary
base payments on plan bids and two new federal department standards for financial and tests and services, waste, and
with bonus payments for quality, positions to oversee policy, administrative transactions, other inefficiencies that consume
performance improvement, and program development, and including timely and transparent money with no added benefit.
care coordination. Grandfather oversight of health care fraud, claims and denial management
the extra benefits in MA plans waste, and abuse in public and processes and use of standard
in areas where plan bids are private coverage. electronic transactions.
at or below 75% of traditional • Simplify health insurance • [E&C Committee amendment:
fee-for-service Medicare (these administration by adopting Limit annual increases in the
plans are required to participate standards for financial and premiums charged under any
in the new competitive bidding administrative transactions, health plans participating in the
process). Provide transitional including timely and transparent Exchange to no more than 150%
extra benefits for MA beneficiaries claims and denial management of the annual percentage increase
in certain areas if they experience processes and use of standard in medical inflation. Provide
a significant reduction in extra electronic transactions. exceptions if this limit would
benefits under competitive bidding. threaten a health plan’s financial
viability.]
Cost containment • Reduce annual market basket • Modify provider payments under
(continued) updates for inpatient hospital, Medicare including:
home health, skilled nursing – Modify market basket updates
facility, hospice and other to account for productivity
Medicare providers, and adjust for improvements for inpatient
productivity. hospital, home health, skilled
• Freeze the threshold for income- nursing facility, and other
related Medicare Part B premiums Medicare providers; and
through 2019, and reduce the – Reduce payments for
Medicare Part D premium subsidy potentially preventable hospital
for those with incomes above readmissions.
$85,000/individual and $170,000/ • Restructure payments to Medicare
couples. Advantage plans, phasing to 100%
• Establish an independent of fee-for-services payments, with
Medicare Commission to submit bonus payments for quality.
proposals for reducing excess • Increase the Medicaid drug
Medicare cost growth by targeted rebate percentage and extend
amounts. Proposals submitted by the prescription drug rebate to
the Commission must be acted Medicaid managed care plans.
on by Congress and if a legislative Require drug manufacturers to
package with the targeted level of provide drug rebates for dual
Medicare savings is not enacted, eligibles enrolled in Part D plans.
the Commission’s proposal will • [E&C Committee amendment:
go into effect automatically. The Require the Secretary to negotiate
Commission would be prohibited directly with pharmaceutical
from submitting proposals that manufacturers to lower drug prices
would ration care, increase for Medicare Part D plans and
revenues or change benefits, Medicare Advantage Part D plans.]
eligibility or Medicare beneficiary
• [E&C Committee amendment:
cost sharing (including Parts
Authorize the Food and Drug
A and B premiums), but would
Administration to approve generic
not be prohibited from making
versions of biologic drugs and
recommendations to reduce
grant biologics manufacturers
premium subsidies for Medicare
12 years of exclusive use before
Advantage or stand-alone Part D
generics can be developed.]
prescription drug plans. Hospitals
and hospices would not be subject • Reduce Medicaid DSH payments
to cost reductions proposed by the by $6 billion in 2019, imposing the
Commission. Beginning January largest percentage reductions in
1, 2019, the growth target for state DSH allotments in states
Medicare spending would be set at with the lowest uninsured rates
GDP per capita plus one percent. and those that do not target DSH
payments.
Cost containment • Reduce Medicare DSH payments • Require hospitals and ambulatory
(continued) by an amount proportional to surgical centers to report on
the percentage point decrease health care-associated infections
in the uninsured for the period to the Centers for Disease Control
evaluated. and Prevention and refuse
• Eliminate the Medicare Medicaid payments for certain
Improvement Fund. health care-associated conditions.
• Allow providers organized as • Reduce waste, fraud, and abuse
accountable care organizations in public programs by allowing
(ACOs) that voluntarily meet provider screening, enhanced
quality thresholds to share in the oversight periods, and enrollment
cost-savings they achieve for the moratoria in areas identified as
Medicare program. To qualify as an being at elevated risk of fraud
ACO, organizations must agree to in all public programs, and by
be accountable for the overall care requiring Medicare and Medicaid
of their Medicare beneficiaries, program providers and suppliers
have adequate participation of to establish compliance programs.
primary care physicians and
specialists, define processes to
promote evidence-based medicine,
report on quality and costs
measure, and coordinate care.
Create a chronic care coordination
pilot program to provide the
highest cost Medicare beneficiaries
with primary care services in their
home and allow participating
teams of health professionals
to share in any savings if they
achieve quality outcomes, patient
satisfaction, and cost savings.
• Create an Innovation Center within
the Centers for Medicare and
Medicaid Services to test, evaluate,
and expand in Medicare, Medicaid,
and CHIP different payment
structures and methodologies
to foster patient-centered care,
improve quality, and slow Medicare
costs growth. Payment reform
models that improve quality and
reduce the rate of costs could be
expanded throughout the Medicare,
Medicaid, and CHIP programs.
Cost containment • Reduce payments for preventable

(continued) hospital readmissions in Medicare:
for hospitals with readmission
rates above a certain threshold
reduce payments by 20% if a
patient is re-hospitalized with a
preventable readmission within
seven days and by 10% if a
patient is re-hospitalized with a
preventable readmission within 15
days, and reduce payments by 1%
to hospitals with the highest rates
of hospital acquired conditions.
• Increase the Medicaid drug rebate
percentage for brand name drugs
to 23.1, increase the Medicaid
rebate for non-innovator, multiple
source drugs to 13% of average
manufacturer price, and extend the
drug rebate to Medicaid managed
care plans.
• Reduce a state’s Medicaid DSH
allotment by 50% (25% for low DSH
states) once the uninsured rate
decreases by at least 50%. DSH
allotments will be further reduced,
not to fall below 35% of the total
allotment in 2012 if states’ uninsured
rates continue to decrease. Exempt
any portion of the DSH allotment
used to expand Medicaid eligibility
through a section 1115 waiver.
• Establish demonstration projects
in Medicaid and CHIP to allow
pediatric medical providers
organized as accountable care
organizations to share in cost-
savings.
• Prohibit federal payments to
states for Medicaid services
related to health care acquired
conditions.
Cost containment • Eliminate fraud, waste, and abuse

(continued) in public programs through more
intensive screening of providers,
the development of the “One PI
database” to capture and share
data across federal and state
programs, increased penalties
for submitting false claims, and
increase funding for anti-fraud
activities.
Improving quality/health • Simplify health insurance • Develop a national strategy to • Support comparative effectiveness • The plan must ensure the
system performance administration by adopting a improve the delivery of health research by establishing a Center implementation of patient safety
single set of operating rules for care services, patient health for Comparative Effectiveness measures and provide incentives
eligibility verification, claims outcomes, and population Research within the Agency for changes in the delivery
status, claims payment, and the health that includes publishing for Healthcare Research and system to reduce unnecessary
electronic transfer of funds. an annual national health care Quality to conduct, support, and variability in patient care. It must
• Establish a non-profit Patient- quality report card. Create an synthesize research on outcomes, support the widespread use of
Centered Outcomes Research inter-agency Working Group on effectiveness, and appropriateness health information technology
Institute to identify research Health Care Quality to coordinate of health care services and and the development of data
priorities and conduct research and streamline federal quality procedures. An independent on the effectiveness of medical
that compares the clinical activities related to the national CER Commission will oversee interventions to improve the
effectiveness of medical quality strategy. the activities of the Center. [E&C quality of care delivered.
treatments. The Institute will be • Develop, through a multi- Committee amendment: Prohibit • To lay the foundation for improving
overseen by an appointed multi- stakeholder process, quality use of comparative effectiveness the health care delivery system
stakeholder Board of Governors measures that allow assessments research findings to deny or and quality of care, the American
and will be assisted by expert of health outcomes; continuity ration care or to make coverage Recovery and Reinvestment
advisory panels. and coordination of care; safety, decisions in Medicare.] Act invests $19 billion in health
• Encourage states to develop effectiveness and timeliness • Strengthen primary care and information technology, including
and test alternatives to the of care; health disparities; care coordination by increasing $17 billion in incentives to
current civil litigation system as and appropriate use of health Medicaid payments for primary providers to encourage their use
a way to improve patient safety, care resources. Require public care providers, providing Medicare of electronic medical records,
reduce medical errors, increase reporting on quality measures bonus payments to primary care and provides $1.1 billion for
the availability of a prompt through a user-friendly website. practitioners (with larger bonuses comparative effectiveness
and fair resolution of disputes, • Create a Center for Health paid to primary care practitioners research.
and improve access to liability Outcomes Research and Evaluation serving in health professional
insurance, while preserving an within the Agency for Healthcare shortage areas).
individual’s right to seek redress Research and Quality to conduct
in court. Recommend that and synthesize research on the
Congress consider establishing effectiveness of health care
a state demonstration project services and procedures to provide
to evaluate alternatives to the providers and patients with
current litigation system. information on the most effective
therapies for preventing and
treating health conditions.
Improving quality/health • Establish a national Medicare pilot • Provide grants for improving health • Conduct Medicare pilot programs
system performance program to develop and evaluate system efficiency, including grants to test payment incentive models
(continued) paying a bundled payment for to establish community health for accountable care organizations
acute, inpatient hospital services teams to support a medical home and bundling of post-acute
and post-acute care services for an model; to implement medication care payments, and conduct
episode of care that begins three management services; to design pilot programs in Medicare and
days prior to a hospitalization and and implement regional emergency Medicaid to assess the feasibility
spans 30 days following discharge. care and trauma systems. of reimbursing qualified patient-
If the pilot program achieves stated • Require hospitals to report centered medical homes. [E&C
goals, develop a plan for making preventable readmission rates; Committee amendment: Adopt
the pilot a permanent part of the hospitals with high re-admission accountable care organization,
Medicare program. rates will be required to work with bundled payment, and medical
• Establish a hospital value-based local patient safety organizations home models on a large scale if
purchasing program in Medicare to to improve their rates. pilot programs prove successful at
pay hospitals based on performance • Create a Patient Safety Research reducing costs.] [E&C Committee
on quality measures and extend the Center charged with identifying, amendment: Conduct accountable
Medicare physician quality reporting evaluating, and disseminating care organization pilot programs
initiative beyond 2010. information on best practices for in Medicaid.]
• Improve care coordination for dual improving health care quality. • [E&C Committee amendment:
eligibles by creating a new office • Create an inter-agency Establish the Center for
within the Centers for Medicare Working Group to coordinate Medicare and Medicaid Payment
and Medicaid services, the Federal and streamline federal quality Innovation Center to test
Coordinated Health Care Office, activities. payment models that address
to align Medicare and Medicaid • Develop interoperable standards populations experiencing poor
benefits, administration, oversight for using HIT to enroll individuals clinical outcomes or avoidable
rules, and policies for dual in public programs and provide expenditures. Evaluate all models
eligibles. grants to states and other and expand those models that
• Develop a national quality governmental entities to adopt improve quality without increasing
improvement strategy that includes and implement enrollment spending or reduce spending
priorities to improve the delivery technology. without reducing quality, or both.]
of health care services, patient • [W&M Committee amendment:
health outcomes, and population Require the Institute of Medicine
health. Create processes for the to conduct a study on geographic
development of quality measures variation in health care spending
involving input from multiple and recommend strategies for
stakeholders and for selecting addressing this variation by
quality measures to be used in promoting high-value care.]
reporting to and payment under • Improve coordination of care
federal health programs. Establish for dual eligibles by creating a
the Medicaid Quality Measurement new office or program within
Program to establish priorities for the Centers for Medicare and
the development and advancement Medicaid Services.
of quality measures for adults in
Medicaid.
Improving quality/health • Require enhanced collection • Establish the Center for Quality
system performance and reporting of data on race, Improvement to identify, develop,
(continued) ethnicity, and primary language. evaluate, disseminate, and
Also require collection of access implement best practices in the
and treatment data for people with delivery of health care services.
disabilities. Develop national priorities for
performance improvement and
quality measures for the delivery
of health care services.
• Require disclosure of financial
relationships between health entities,
including physicians, hospitals,
pharmacists, and other providers,
and manufacturers and distributors
of covered drugs, devices, biologicals,
and medical supplies.
• Reduce racial and ethnic
disparities by conducting a study
on the feasibility of developing
Medicare payment systems for
language services, providing
Medicare demonstration grants
to reimburse culturally and
linguistically appropriate services
and developing standards for
the collection of data on race,
ethnicity, and primary language.
• [E&C Committee amendment:
Conduct a national public education
campaign to raise awareness about
the importance of planning for care
near the end of life.]
Prevention/wellness • Provide Medicare beneficiaries • Develop a national prevention and • Develop a national strategy to • The plan must invest in public
access to a comprehensive health health promotion strategy that improve the nation’s health health measures proven to reduce
risk assessment and creation of sets specific goals for improving through evidenced-based clinical cost drivers in our system, such as
a personalized prevention plan, health. Create a prevention and and community-based prevention obesity, sedentary lifestyles, and
eliminate cost-sharing for certain public health investment fund and wellness activities. Create smoking, as well as guarantee
preventive services in Medicare. to expand and sustain funding task forces on Clinical Preventive access to proven preventive
Cover only proven preventive for prevention and public health Services and Community Preventive treatments. The American
services in Medicare and Medicaid programs. Services to develop, update, and Recovery and Reinvestment Act
and provide incentives to Medicare • Award competitive grants to disseminate evidenced-based provides $1 billion for prevention
and Medicaid beneficiaries to state and local governments and recommendations on the use of and wellness.
complete behavior modification community-based organizations clinical and community prevention
programs. to implement and evaluate services.
Prevention/wellness • Require Medicaid coverage proven community preventive • Improve prevention by covering
(continued) for tobacco cessation services health activities to reduce chronic only proven preventive services in
for pregnant women, and for disease rates and address health Medicare and Medicaid. Eliminate
states that provide coverage for disparities. any cost-sharing for preventive
and remove cost-sharing for • Permit insurers to create services in Medicare and increase
preventive services recommended incentives for health promotion Medicare payments for certain
by the US Preventive Services and disease prevention practices. preventive services to 100% of
Task Force and recommended • Encourage employers to provide actual charges or fee schedule
immunizations, provide a one wellness programs by conducting rates.
percentage point increase in the targeted educational campaigns
FMAP for these services and for to raise awareness of the value of
the tobacco cessation services. these programs and by increasing
• Create a new Medicaid state the allowable premium discount
plan option to permit Medicaid for employees who participate in
enrollees with at least two chronic these programs from 20 percent
conditions, one condition and risk to 30 percent.
of developing another, or at least • Create a temporary Right Choices
one serious and persistent mental Program to provide uninsured
health condition to designate a adults with access to preventive
provider as a health home. Provide services.
states taking up the option with
90% FMAP for two years.
• Prohibit insurance plans (except
existing grandfathered plans and
those that use a value-based
insurance design) from charging
cost-sharing for preventive services.
• Allow insurers to vary premium
rates based on tobacco use. Any
insurer that rates based on
tobacco use must provide
coverage for comprehensive
tobacco cessation programs,
including counseling and
pharmacotherapy.
• Provide grants to small
businesses to establish
comprehensive, evidence-based
workplace wellness programs.
• Permit employers to offer
employees rewards of up to 30%
of the cost of coverage for
participating in a wellness
program. Rewards may be in the
Prevention/wellness form of premium discounts, waivers

(continued) of cost-sharing requirements, or
benefits that would otherwise not be
provided. Rewards may be increased
to 50% of the cost of coverage if a
report finds the increase
appropriate. Establish 10-state pilot
programs in 2014 to permit
participating states to apply similar
rewards for participating in wellness
programs in the individual market.
Long-term care • Extend the Medicaid Money • Establish a national, voluntary • [E&C Committee amendment: Not specified.
Follows the Person Rebalancing insurance program for purchasing Establish a national, voluntary
Demonstration program through community living assistance insurance program for purchasing
September 2016 and allocate $10 services and supports (CLASS community living assistance
million per year for five years to program). The program will services and supports (CLASS
continue the Aging and Disability provide individuals with functional program). The program will
Resource Center initiatives. limitations a cash benefit to provide individuals with functional
• Provide states that undertake purchase non-medical services limitations a cash benefit to
reforms to increase nursing home and supports necessary to purchase non-medical services
diversions and access to home maintain community residence. and supports necessary to
and community-based services The program is financed through maintain community residence.
in their Medicaid programs with voluntary payroll deductions: The program is financed through
a targeted increase in the federal all working adults will be voluntary payroll deductions:
matching rate for five years. automatically enrolled in the all working adults will be
• Establish the Community First program, unless they choose to automatically enrolled in the
Choice Option in Medicaid to opt-out. program, unless they choose to
provide community-based opt-out.]
attendant supports and services • Improve transparency of
to individuals with disabilities information about skilled nursing
who require an institutional level facilities and nursing facilities.
of care. Provide states with an
enhanced federal matching rate
of an additional six percentage
points for reimbursable expenses
in the program. Sunset the option
after five years.
• Improve transparency of
information about skilled nursing
facilities (SNF) and nursing
homes, enforcement of SNF and
nursing home standards and
rules, and training of SNF and
nursing home staff.
Other investments • Make improvements to the • Establish a National Health • Make improvements to the • As an initial investment in
Medicare program: Care Workforce Commission to Medicare program: strengthening the health care
– Provide a 50% discount on make recommendations and – Reform the sustainable growth workforce, the American Recovery
brand-name prescriptions disseminate information on health rate for physicians, with and Reinvestment Act provides
filled in the Medicare Part D workforce priorities, goals, and incentive payments for primary $500 million to train the next
coverage gap for enrollees, policies including education and care services, and for services in generation of doctors and nurses.
other than those who receive training, workforce supply and efficient areas;
low-income subsidies and those demand, and retention practices. – Eliminate the Medicare Part D
with incomes above $85,000/ • Reform Graduate Medical coverage gap (phased in over
individual and $170,000/couples; Education to increase the supply, 15 years) and require drug
– Make Part D cost-sharing education, and training of doctors, manufacturers to provide a
for full-benefit dual eligible nurses, and other health care 50% discount on brand-name
beneficiaries receiving home workers, especially in pediatric, prescriptions filled in the
and community-based care geriatric, and primary care. coverage gap;
services equal to the cost- • Improve access to care by – Increase the asset test for
sharing for those who receive providing additional funding Medicare Savings Program and
institutional care; and to increase the number of Part D Low-Income Subsidies to
– Provide a one-year increase community health centers and $17,000/$34,000; and
in physician payments under school-based health centers. – Eliminate any cost-sharing for
Medicare to prevent a reduction preventive services in Medicare
in fees that would otherwise and increase Medicare payments
take effect, with 10% bonus for certain preventive services
payments for primary care. to 100% of actual charges or fee
Provide general surgeons schedule rates.
and primary care physicians • Reform Graduate Medical
practicing in health professional Education to increase training
shortage areas with a 10% of primary care providers
Medicare bonus. by redistributing residency
• Establish a multi-stakeholder positions and promote training in
Workforce Advisory Committee outpatient settings and support
to develop a national workforce the development of primary care
strategy for recruiting, training, training programs.
and retaining a health care • Support training of health
workforce that meets current and professionals, including advanced
projected health care needs. education nurses, who will practice
• Increase the number of Graduate in underserved areas; establish
Medical Education (GME) training a public health workforce corps;
positions by redistributing and promote training of a diverse
currently unused slots, with workforce and provide cultural
priorities given to primary care competence training for health
and general surgery and to care professionals.
states with the lowest resident
physician-to-population ratios,
and increase flexibility in laws and
Other investments regulations that govern GME [E&C Committee amendment:

(continued) funding to promote training Support the development of
in outpatient settings, and interdisciplinary mental and
ensure the availability of behavioral health training
residency programs in rural and programs.] [E&C Committee
underserved areas. Establish amendment: Establish a
Teaching Health Centers, defined training program for oral health
as community-based, ambulatory professionals.]
patient care centers, including • Provide grants to each state health
federally qualified health centers department to address core public
and other federally-funded health infrastructure needs.
health centers, that are eligible • Conduct a study of the feasibility of
for Medicare payments for adjusting the federal poverty level
the expenses associated with to reflect variations in the cost of
operating primary care residency living across different areas.
programs. • [E&L Committee amendment:
• Establish a graduate nurse Grant waivers to requirements
education demonstration related to the Employee
program to provide Medicare Retirement Income Security Act
reimbursement to hospitals for of 1974 (ERISA) to states seeking
costs associated with training to establish a state single payer
advance practice nurses. system.]
• Impose additional requirements
on non-profit hospitals to conduct
a community needs assessment
every three years and adopt
an implementation strategy to
meet the identified needs, adopt
and widely publicize a financial
assistance policy that indicates
whether free or discounted
care is available and how to
apply for the assistance, limit
charges to patients who qualify
for financial assistance to the
amount generally billed to insured
patients, and make reasonable
attempts to inform patients about
the financial assistance policy
before undertaking extraordinary
collection actions.
Financing CBO estimates the cost of the The Congressional Budget Office The Congressional Budget Office President Obama dedicated $630
coverage components of the estimates this proposal will cost estimates the net cost of the proposal billion over ten years toward a
Chairman’s Mark, as amended during $645 billion over 10 years. Because (less payments from employers and Health Reform Reserve Fund in his
mark-up, to be $829 billion over the Senate HELP Committee does uninsured individuals) to be $1.042 budget outline released in February
ten years. These costs are financed not have jurisdiction over the trillion over ten years. Approximately 2009 to partially offset the cost of
through a combination of savings Medicare and Medicaid programs half of the cost of the plan is financed health reform.
from Medicare and Medicaid and new or revenue raising authority, through savings from Medicare and
taxes and fees. The net savings from mechanisms for financing the Medicaid, including incorporating
Medicare and Medicaid are estimated proposal will be developed in productivity improvements into
to be $404 billion over ten years and conjunction with the Senate Finance Medicare market basket updates,
the primary sources of these savings Committee. reducing payments to Medicare
include incorporating productivity Advantage plans, changing drug
improvements into Medicare market rebate provisions, reducing potentially
basket updates, reducing payments to preventable hospital readmissions,
Medicare Advantage plans, creating and cutting Medicaid DSH payments.
the Medicare Commission charged The remaining costs are financed
with finding savings in the program, through a surcharge imposed on
changing the Medicaid drug rebate families with incomes above $350,000
provisions, and cutting Medicaid and individuals with incomes above
and Medicare DSH payments. $280,000. The surcharge is equal to
(See descriptions of cost savings 1% for families with modified adjusted
provisions in Cost containment.) The gross income between $350,000
largest source of new revenue will and $500,000; 1.5% for families with
come from an excise tax on high cost modified adjusted gross income
insurance, which CBO estimates will between $500,000 and $1,000,000;
raise $201 billion over ten years. and 5.4% for families with modified
Additional revenue provisions will adjusted gross income greater
generate $196 billion over the same than $1,000,000. These surcharge
time period. (See Tax changes related percentages may be adjusted if
to health insurance.) CBO estimates federal health reform achieves
the proposal will reduce the deficit by greater than expected savings.
$81 billion over ten years.
Sources of information http://www.finance.senate.gov/ http://help.senate.gov/ Ways and Means Committee: http://www.whitehouse.gov/omb/
sitepages/baucus.htm http://waysandmeans.house.gov/ budget/
MoreInfo.asp?section=52 http://www.HealthReform.gov
Energy and Commerce Committee:
http://energycommerce.house.
gov/index.php?option=com_content
&view=article&id=1687&catid=156&
Itemid=55
Education and Labor Committee:
http://edlabor.house.gov/
newsroom/2009/07/ed-labor-
approves-historic-hea.shtml
Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes Rep. John Conyers Rep. John Dingell
Patients’ Choice Act of 2009 U.S. National Health Care Act National Health Insurance Act
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)
Date plan announced May 20, 2009 January 26, 2009 January 6, 2009
(Has introduced similar legislation in each
Congressional session since 1957)
Overall approach Create state-based health insurance exchanges Create a public health insurance program for Create a national health insurance program for
to expanding access through which private plans offer coverage all U.S. residents. Replace employer coverage individuals meeting eligibility requirements.
to coverage meeting certain benefit and other standards. and eliminate the Medicare, Medicaid and CHIP Require states to administer the program
Employers can continue to provide coverage programs. Individuals are not required to pay and provide for equivalent care for “needy”
to their employees, but the current tax premiums or cost-sharing. Require conversion individuals who do not meet eligibility
preference for employer-sponsored insurance to a non-profit health care system. Provide requirements. A National Health Insurance
will be replaced with a tax credit of $2,290 for for global budgets for hospitals and negotiate Board determines allotments for the classes of
individuals and $5,710 for families to provide annual reimbursement rates with physicians covered services. Financed by a value-added tax
incentives for insurance coverage. Maintain and other non-institutional providers. Finance imposed on certain transactions.
Medicaid coverage for low-income people with program by redirecting current federal and state
disabilities, but integrate low-income families health care spending, impose an employer/
currently eligible for Medicaid into private employee payroll tax, and leverage additional
insurance. taxes.
Individual mandate • No requirement for individuals to have • All individuals residing in the US are covered • Individuals meeting certain requirements are
coverage. Permit states to establish procedures under the United States National Health Care entitled to benefits under the National Health
to automatically enroll individuals into low- Act (USNHC). Insurance Program.
cost, high-deductible coverage through the
exchange and to provide incentives to individuals
to maintain coverage from year to year.
Employer requirements No provision. No provision. No provision.
Expansion of public • Restructure the Medicaid program to provide • Create a new public plan, the USNHC program, • Create a new public plan, covering medical,
programs acute care only to low-income people with that provides coverage for a comprehensive set dental, podiatric, home-nursing, hospital, and
disabilities, children in foster care, low-income of benefits, including long-term care services, auxiliary services. A National Health Insurance
women with breast or cervical cancer, and to all US residents. Board, in consultation with a National Advisory
certain TB-infected individuals. Integrate • Eliminate the Medicare, Medicaid, and CHIP Medical Council determines the scope of
low-income families into private insurance programs as beneficiaries of these programs benefits consistent with the statute.
by providing them with a tax credit plus other are eligible for the USNHC program. • Continue Medicare, but enrollees may be
financial support. Eliminate the entitlement • VA health programs will remain independent transferred into the new program in the future.
for long-term care services under Medicaid for 10 years after which they will either remain Medicare beneficiaries are covered under the
and replace it with a block grant to states for independent or be integrated into the USNHC new program for services that are not covered
long-term care services for eligible elderly and program. The Indian Health Service will remain by Medicare.
disabled individuals. independent for 5 years after which it will be • Require states to provide equivalent services to
• Allow private facilities to compete with integrated into the USNHC program. those not eligible under the new plan. Current
Veteran’s Administration facilities to provide federal Medicaid funds and other federal funds
care to veterans. provided to states under the Social Security Act
• Allow eligible American Indians to access are available for this purpose.
medical care outside of Indian Health Service
facilities.
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)
Premium subsidies • Provide a qualified health insurance credit of • Individuals are not required to pay premiums • Individuals are not required to pay premiums to
to individuals $2,290 for individuals and $5,710 for families to obtain coverage nor are they charged obtain coverage.
to be used to purchase health insurance. copayments or coinsurance for covered
Individuals enrolled in Medicare or military benefits.
coverage and people with disabilities enrolled
in Medicaid are not eligible for the tax credit.
Any tax credit amount exceeding the cost
of a health insurance plan purchased by an
individual or family will be deposited into a
medical savings account.
• Provide a supplemental debit card to families
with incomes below 200% FPL to be used to
pay for private health insurance costs. The
amounts available on the debit cards range
from $5,000 for families with incomes below
100% FPL to $2,000 for families with incomes
between 180 and 200% FPL. Additional
amounts provided for pregnancy ($1,000) and
infants under age 1 ($500).
Premium subsidies No provision. No provision. No provision.
to employers
Tax changes related • Reform the tax code to eliminate the exclusion No provision. No provision.
to health insurance of the value of health insurance plans offered
by employers from workers’ taxable income.
• Allow individuals and families purchasing
high-deductible health plans that are less than
the value of the tax credit to deposit the excess
amount into a medical savings account.
• Change health savings account (HSA)
requirements by allowing health insurance
premiums for high-deductible health plans to
be paid tax-free from an HSA, increasing the
allowable contribution amounts for people
with chronic conditions, and permitting high-
deductible health plans to cover preventive
services, maintenance costs of chronic
diseases, and concierge-style primary care
services.
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)
Creation of insurance • Provide states with the option of creating State No provision other than pooling achieved through No provision other than pooling achieved through
pooling mechanisms Health Insurance Exchanges through which USNHC. new public program.
individuals can purchase qualified private
insurance. To encourage the establishment of
exchanges, states may be eligible for grants
to develop and implement exchanges and
may also receive a 1% increase in federal
Medicaid payments. States may form regional
exchanges.
• Require plans participating in the Exchanges
to provide coverage on a guarantee issue basis
and prohibit discrimination based on pre-
existing conditions.
• Require plans to provide coverage similar to
that provided to Members of Congress.
• Require establishment of a mechanism to
prevent insurers from charging excessive
premiums. Such mechanism may include
risk-adjustment among insurance plans
participating in the Exchange, health security
pools for high-risk individuals, or reinsurance
for high-risk individuals.
Benefit design • Provide coverage that meets the same • Provide coverage for all medically necessary • Provide the following classes of personal
statutory requirements used for the services, including primary care and health services:
health benefits for Members of Congress. prevention; inpatient care; outpatient care; – Medical services including primary and
Qualifying health insurance for purposes emergency care; prescription drugs; durable specialty care;
of obtaining premium credits includes medical equipment; long-term care; palliative – Dental services;
coverage for inpatient and outpatient care, care; mental health services; dental services; – Podiatric services;
emergency benefits, and physician care and chiropractic services; basic vision correction;
– Home-nursing services;
has responsible annual and lifetime benefit hearing services; and podiatric care.
maximums. – Hospital services, for a maximum of 60 days
in a benefit year;
– Auxiliary services including diagnostic
laboratory services, X-ray and related
therapy, physiotherapy, optometry services,
prescription drugs, and eyeglasses.
Changes to private No provision. • Prohibit insurers from duplicating USNHC No provision.
insurance benefits but they may offer coverage for
benefits not covered by the USNHC program.
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)
State role • Create, at state option, state health insurance No provision. • Assume responsibility for administration of the
exchanges that meet federal standards. program. States must submit a state plan of
• Form voluntary compacts (at state option) with operations that designates a state agency for
other state exchanges to diversify pooling, administering the program benefits; creates,
ease administrative burdens, and increase the among other things, an advisory committee;
availability of innovative insurance products. establishes local health service areas to
further decentralize program administration;
and provides a plan for ensuring that benefits
will be provided efficiently and to all areas of
the state.
Cost containment • Encourage adoption and use of health • Establish annual budgets for health care • Require the National Health Insurance
information technology by providing incentives professional staffing, capital expenditures, Board to establish allotments for each of five
to hospitals and individual providers. Create reimbursement for providers, and health classes of services to be provided under the
personal health records maintained by an professional education. program (medical services, dental services,
independent health record bank and available • Pay institutional providers, including hospitals, home-nursing services, hospital services,
to the individual through a card, much like an nursing homes, community or migrant health and auxiliary services). Allotments are made
ATM card. centers, home care agencies, and other to the states based on population, medical
• Allow providers to form accountable care institutional and prepaid group practices, professionals and facilities, and cost of
organizations and receive bonuses in Medicare a monthly lump sum to cover operating services.
if they improve quality and satisfaction while expenses. • Require a study of cost control mechanisms,
also lowering costs. • Pay physicians and other non-institutional including an analysis of the impact on medical
• Adopt competitive bidding for Medicare providers based on a simplified fee scheduled malpractice claims and liability insurance on
Advantage plans and set the benchmark bid to or as a salaried employee in an institution health care costs.
106% of Medicare fee-for-service payments. receiving a global budget or in a group practice
• Require Medicare beneficiaries making or HMO receiving capitation payments.
more than $170,000 per year (for couples) • Establish a uniform electronic billing system
to pay more for Medicare Part B and Part D and create an electronic patient record system.
premiums. • Allow only public or not-for-profit institutions
to participate in USNHC. Private physicians,
clinics, and other participating providers may
not be investor owned.
• Require USNHC program to negotiate annually
prices for drugs, medical supplies, and
assistive equipment.
• Establish a prescription drug formulary that
encourages best practices in prescribing and
promotes use of generics and other lower cost
alternatives.
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)
Cost containment • Enhance efforts to detect and eliminate

(continued) fraud and abuse in the Medicare program
by establishing procedures to identify and
investigate unusual billing, investigating
providers and suppliers using identification of
ineligible beneficiaries, and imposing penalties
on facilities employing physicians or other
employees convicted of Medicare or Medicaid
fraud.
• Adopt medical malpractice reforms that create
independent expert panels or state “health
courts” or both to review cases and render
decisions. Parties will still have access to state
courts if not satisfied with decisions.
Improving quality/health • Create a new Health Care Services • Require participating providers to meet state • Require state and local administration to:
system performance Commission to establish uniform measures quality and licensing guidelines. – Promote coordination among providers,
for reporting price and quality information. The • Create a National Board of Universal Quality between providers and public health centers
HSC, managed by five commissioners from the and Access to address issues, such as access and educational and research institutions.
private sector appointed by the President, will to care, quality improvement, administrative – Emphasize prevention of disease, disability,
issue a report containing guidelines regulating efficiency, budget adequacy, reimbursement and premature death.
the publication and dissemination of health levels, capital needs, long term care, and – Insure the provision of efficient, high quality
care information and will be authorized to staffing levels. services.
enforce these standards. • Establish a universal standard of care relating
to appropriate staffing levels; appropriate
medical technology; scope of work in the
workplace; best practices; salary levels for
medical professional and support staff.
Prevention/wellness • Emphasize prevention by developing a No provision. • Emphasize prevention of disease, disability,
national strategic prevention plan, creating and premature death.
a web-based prevention tool capable of
producing personalized prevention plans, and
implementing national science-based media
campaigns on health promotion and disease
prevention.
• Reward seniors who adopt healthier behaviors
with lower Medicare premiums.
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)
Long-term care • Make changes to Medicaid long-term care • Provide coverage for long-term care services No provision.
services to provide sates with a defined through the USNHC program and establish
allotment for Medicaid long-term care services regional budgets to cover these long-term care
in exchange for having the Medicare program services.
assume responsibility for the premiums, • Encourage long-term care to be provided
cost-sharing, and deductibles for low-income in home and community-based settings, as
Medicare beneficiaries and ensure choice opposed to in institutions.
between institutionalized and home-based
long-term care services.
Other investments No provision. • Establish a USNHC Employment Transition • Provide grants for training and education of
Fund to assist people who lose their jobs as professional and technical personnel needed to
a result of the transition to the new national provide or administer benefits. Makes available
system. $5 million in 2010 and 2011; and up to one half
• Create a mechanism to facilitate the conversion of one percent of benefit payments annually
of for-profit providers of care to not-for-profit thereafter.
status and provide compensation for the
financial losses associated with the conversion.
Financing Financing will come from the specified cost- The USNHC program will be funded through Program will be financed through a National
containment provisions, converting Medicaid the USNHC Trust Fund. Funding for the Trust Health Care Trust Fund. The trust fund will
acute care services from defined benefits to Fund will come from redirecting existing federal be funded with a value-added tax of 5 percent
defined contributions, block granting Medicaid payments for health care; increasing the imposed on certain transactions.
long-term care services, and eliminating the tax income tax for the top 5% of earners, instituting
exclusion for employer-sponsored insurance. a modest and progressive payroll tax, and
To ensure revenue-neutrality of the reform imposing a tax on stock and bond transactions.
proposal, the qualified health insurance credits
in any year are limited to savings generated
through entitlement reform and repeal of the tax
exclusion for employer-sponsored insurance.
Sources of information http://coburn.senate.gov/public/index. http://conyers.house.gov/index. http://www.house.gov/dingell/issue_healthcare.
cfm?FuseAction=HealthCareReform. cfm?FuseAction=Issues.Home&Issue_ shtml
Home&ContentRecord_id=5e3b30a4-802a-23ad- id=063b74a4-19b9-b4b1-126b-f67f60e05f8c
4b44-14f0219114c6
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)
Date plan announced July 30, 2009 March 25, 2009 January 6, 2009
Overall approach Allow people who purchase coverage in the Create a state-based public health insurance Create a new public plan, modeled on Medicare,
to expanding access individual market to deduct the cost of premiums program for all U.S. residents. Replace employer as default coverage for all Americans. Individuals
to coverage from their income taxes. Provide refundable tax coverage and eliminate the Medicare, Medicaid in a qualified group plan or Medicare may opt
credits to individuals and families with incomes and CHIP programs. Individuals are not required out of AmeriCare. Require employers and
below 300% FPL to purchase insurance in the to pay premiums or cost-sharing. Provide for individuals to contribute toward the cost of the
individual market. Establish Association Health global budgets for hospitals and negotiate plan, with federal premium subsidies available
Plans and Individual Membership Associations annual reimbursement rates with physicians for individuals below 300% FPL. Use Medicare’s
through which employers and individuals can and other non-institutional providers. Finance administrative structure to govern the plan.
purchase coverage. Implement state high- program by redirecting current federal and state Financed by premium contributions from
risk pools or reinsurance programs to provide health care spending, impose an employer/ employers and individuals, state maintenance of
coverage for people with pre-existing health employee payroll tax, and leverage a new health effort payments, and from general revenue.
conditions. Require states to provide coverage to care income tax.
90% of children with family incomes below 200%
FPL as a condition for expanding child eligibility
to 300% FPL, and require states to provide
vouchers to children eligible for Medicaid and
CHIP, to be used to purchase private insurance.
Individual mandate • No requirement for individuals to have • All individuals residing in the US are entitled • All U.S. residents are entitled to coverage
coverage. Permit employers to automatically to coverage under the American Health under AmeriCare. Individuals may choose not
enroll individuals in the lowest cost group Security Act. to enroll in the AmeriCare plan if they have
health plan as long as they can opt out of coverage under a group health plan.
coverage.
Employer requirements • Permit employers to offer employees a • Prohibit employers from offering health • Require employers to contribute at least 80%
defined contribution for the purchase of health benefits that duplicate those provided by State of the AmeriCare premiums for employees
insurance in the individual market. health security programs. or at least 80% of the cost of the group plan
• Require employers to disclose to employees if the employer provides qualifying employee
the total amount the employer spends on the coverage. Employers with fewer than 100
employee’s health insurance premium. employees will be given an additional three
years to come into compliance with this
provision. A surcharge may be imposed on
employers to prevent adverse selection.
(H.R. 3400) (S. 703) (H.R. 193)
Expansion of public • Require states to achieve coverage for 90% of • Create a new state-based American Health • Create a new public plan, modeled on
programs children with family incomes below 200% FPL Security Program that provides coverage for Medicare, as default coverage for all
who are eligible for public coverage before a comprehensive set of benefits to all U.S. Americans.
they can expand CHIP for children with family residents. • AmeriCare plan enrollees are subject to
incomes between 200% FPL and 300% FPL. • Eliminate the Medicare, Medicaid, and CHIP deductibles ($350 individual/$500 family) and
Require states to provide premium assistance programs as beneficiaries of these programs coinsurance of 20% until limits on out-of-
for Medicaid and CHIP enrollees with access to are eligible for State Health Security Programs. pocket (OOP) expenses are met. The OOP limits
employer-sponsored insurance. Require states • Veteran’s Affairs and Indian Health Service are $2,500 per individual and $4,000 per family.
to offer vouchers to individuals who would programs remain independent. Deductibles and limits are indexed to inflation.
otherwise be eligible for Medicaid and CHIP • Prohibit coverage under state Medicaid
for the purchase of alternative private health and CHIP programs for benefits covered by
insurance. AmeriCare plans.
Subsidies to individuals • Provide a refundable tax credit of $2,000 for • Individuals are not required to pay premiums • Low-income individuals (family income <200%
individuals and $5,000 for a family of four with to obtain coverage nor are they charged FPL) are not required to pay premiums and are
incomes up to 200% FPL for the purchase of copayments or coinsurance for covered not subject to deductibles and co-insurance.
health insurance in the individual market. benefits. • Provide premium subsidies and reduced
Phase down the credit for individuals and deductibles for individuals with family incomes
families with incomes between 200% FPL between 200% and 300% FPL.
and 300% FPL. Citizens and legal permanent • Limit OOP costs for deductibles and
residents of the United States are eligible for coinsurance to 5% of income for those between
the tax credit. 200 and 300% FPL, and 7.5% of income for
• Permit individuals eligible for other health those between 300 and 500% FPL.
benefit programs, including Medicare, • No deductibles and coinsurance for pregnancy-
Medicaid, CHIP, TRICARE, Veterans’ Affairs, the related services and covered benefits provided
Federal Employee Health Benefits Program, to children (up to age 24).
and subsidized group coverage to receive a
tax credit instead of coverage through the
program.
Subsidies to employers • Provide small employers (50 and fewer No provision. No provision.
employees) with a temporary tax credit to adopt
auto-enrollment procedures and to contribute
toward coverage for employees who choose
to purchase private coverage in the individual
market.
(H.R. 3400) (S. 703) (H.R. 193)
Tax changes related • Reform the tax code to permit individuals • Impose a new health care income tax on • Individual premium payments for AmeriCare
to health insurance and families to deduct the amount paid for individuals of 2.2% of taxable income. coverage are considered a tax and subject to
premiums purchased in the individual market withholding.
from taxable income. Cap the deduction at the
value of the national exclusion for employer-
sponsored insurance.
• Provide tax credits to individuals and families
with incomes below 300% FPL to purchase
health insurance in the individual market.
• Allow physicians to deduct costs related to
providing uncompensated care required under
Emergency Medical Treatment and Active
Labor Act (EMTALA). Limit the deduction
amount to the Medicare payment amount for
the services provided.
Creation of insurance • Encourage states to implement a high- No provision other than pooling achieved through No provision other than pooling achieved through
pooling mechanisms risk pool, a reinsurance pool, or other risk state health security programs. AmeriCare.
adjustment mechanism to subsidize the
purchase of private health insurance for
a high-risk population. Current high-risk
pools may qualify if they only cover high-risk
populations. New high-risk pools are required
to offer at least one high-deductible plan
option with a health savings account, multiple
competing plan options, and may only cover
high-risk populations. Provide a Federal block
grant to states to operate qualified high-risk
pools and reinsurance pools.
• Establish certified Association Health Plans
through which member employers can purchase
health coverage for their employees. Permit
association health plans to determine what
benefits will be covered under the plans they
offer and allow the same variations in premiums
as is permitted in the small group market.
• Permit individuals to purchase health coverage
through Individual Membership Associations
(IMAs) that operate under the direction of an
association. Require IMAs to provide coverage
through contracts with licensed health insurers
that meet state standards relating to consumer
protections. Exempt IMAs from state laws
relating to benefit mandates. Permit more than
one IMA to operate in a geographic area.
(H.R. 3400) (S. 703) (H.R. 193)
Benefit design • Allow tax credit and employer defined • Provide coverage for services including hospital • Provide the same benefits available through
contribution to be used for all HIPAA eligible and professional services; community-based Medicare, with the addition of benefits, such as
coverage, except certain limited or disease- primary health care; preventive care; long- well-child visits, early and periodic screening,
specific plans. term acute and chronic care services, including diagnostic, and treatment (EPSDT) services
• Prohibit use of federal funds to be used to home and community-based services; for children, prenatal and obstetric care, and
provide coverage for abortions, except to save prescription drugs; dental services; mental family planning services to reflect the needs of
the life of the woman or in cases of rape or health and substance abuse; diagnostics a younger population.
incest. tests; outpatient therapy; durable medical
equipment; and other services as specified by
the American Health Security Standards Board.
Changes to private • Permit insurers to sell insurance policies • Prohibit insurers from duplicating State health • Allow AmeriCare supplemental policies to be
insurance across state lines. Insurers must designate security program but they may offer coverage offered that meet minimum federal standards,
one state as its primary state and the laws for benefits not covered by the health security including standardized benefits, limitations on
and regulations in the primary state apply to program. sales commissions, and the following:
coverage offered in that state and in other – Require insurers that offer AmeriCare
states. Allow individuals whose premiums for supplemental policies to do so on a
individual health insurance exceed the national guarantee issue and renewability basis
average premium by 10 percent or more to and prohibit them from charging higher
purchase coverage in another state. premiums based on health status.
• Require insurance companies to disclose the – Require insurers offering AmeriCare
true health insurance plan costs to employers. supplemental policies to meet minimum
medical loss ratios (85% for group policies;
75% for individual policies).
State role • Encourage states to implement a high-risk • Create a state health security program to • Require states to make maintenance of effort
pool, reinsurance pool, or other risk adjusted provide health care services to state residents. payments in the amount of the state share
mechanism. States must have a high-risk May join with one or more neighboring states to of Medicaid and CHIP spending for benefits
pool, reinsurance pool, or other risk adjusted form a regional health security program. State replaced by the AmeriCare plan.
mechanism in place in order for state residents programs must designate a single state agency • Allow states to impose more stringent
to be eligible to receive tax credits to purchase to administer the program; establish state requirements on entities offering AmeriCare
insurance. health security budgets; establish provider supplemental policies than specified by the
• Allow states to establish a Health Plan and payment methodologies; license and regulate Secretary.
Provider Portal website to provide information health providers and facilities; establish a
on all health plans and health care providers in quality review system; create an independent
the state. ombudsman program to resolve consumer
complaints and disputes; publish an annual
report on the operation of the state program;
and create a fraud and abuse prevention and
control unit.
(H.R. 3400) (S. 703) (H.R. 193)
Cost containment • Adopt medical malpractice reforms that limit • Establish annual budgets for operating • Generally apply Medicare payment
lawsuit rewards and create state health care expenditures, administrative costs, health mechanisms, adjusted to reflect the AmeriCare
tribunals to review cases and render decisions. professional education, and quality assessment population.
Parties will still have access to state courts if activities. • Limit payments to private plans offered
not satisfied with decisions. • Require states to pay institutional providers, through AmeriCare (similar to Medicare
• Reduce Medicaid and Medicare Disproportionate including hospitals and nursing facilities, Advantage) to average per capita costs under
Hospital Share (DSH) funds if there is a decrease through an annual prospective global budget AmeriCare.
in the national uninsurance rate of 8% or more. and develop payment methodologies for • Require AmeriCare to develop a fee schedule
• Enhance efforts to detect and eliminate independent health practitioners that include for outpatient drugs and biologics, to negotiate
fraud and abuse in Medicare and Medicaid by incentives to encourage practitioners to choose directly with drug companies for the purchase
providing funding for the Office of the Inspector primary care medicine. price of those drugs and biologics, and to
General of the Department of Health and • Limit national health security spending growth encourage greater use of generics and lower
Human Services. Identify instances where to the average annual percentage increase in cost alternatives.
Medicare should be, but is not, acting as a the gross domestic product. • Require AmeriCare contractors to submit
secondary payer to an individual’s private • Establish individual and state capitation electronic claims.
coverage. amounts and risk adjustment methodologies • Apply Medicare provisions relating to fraud
• Reinstate the Medicare Trigger, which requires to be used for developing state and national and abuse and administrative simplification to
the President to submit a plan to contain global budgets. AmeriCare plans.
Medicare costs if 45% or more of the program’s • Limit state administrative costs to 3% of total
funding comes from general tax revenues for expenditures.
two consecutive years. • Create state fraud and abuse prevention and
control units to investigate and prosecute
violations of state law.
• Develop provider payment methodologies
that include global fees for related services
furnished to individuals over time.
• Establish prices for approved prescription
drugs, devices, and equipment.
Improving quality/health • Prohibit comparative effectiveness research • Create an American Health Security Quality • Apply Medicare provisions relating to outcomes
system performance from being used to deny coverage of a health Council to review and evaluate practice research and quality to AmeriCare.
care service under a Federal health care guidelines and performance measures; adopt
program and require the Federal Coordinating methodologies for profiling practice patterns
Council for Comparative Effectiveness and identifying outliers; and develop guidelines
Research to present research findings to for medical procedures to be performed at
relevant specialty organizations before publicly centers of excellence.
releasing them. • Improve access to care through grants to
• Create a process to develop performance- support the development of primary care
based quality measures that could be applied centers to serve medically underserved
to physician services under Medicare. populations in urban and rural areas and the
expansion of school health service sites.
(H.R. 3400) (S. 703) (H.R. 193)
Improving quality/health • Create a health plan and provider portal

system performance website to provide standardized information
(continued) on health insurance plans and provider price
and quality data. Provide states with funding to
implement the standardized health plan and
provider portal website.
Prevention/wellness • Allow insurers that offer health coverage • Create an Office of Primary Care and No provision.
through Individual Membership Associations Prevention Research to identify research
and the individual market to establish premium related to primary care and prevention
discounts/rebates for individuals for adherence for children and adults and to establish a
to health promotion and disease prevention system for collecting, storing, analyzing, and
programs. disseminating information related to primary
• Allow employers to vary premiums and cost- care and prevention research.
sharing up to 50 percent of the value of benefits
under the plan, based on participation in a
wellness program.
Long-term care Not specified. • Provide coverage for acute and chronic long- No provision.
term care services through the State American
Health Security Programs.
• Limit spending on home and community-based
care to no more than 65% (or an established
alternative ratio) of the average amount that
would have been spent if all of the home-
based long-term care beneficiaries had been
residents of nursing facilities in the same area.
Other investments • Establish a student loan fund with public or • Redesign health professional education No provision.
non-profit schools of medicine or osteopathic programs to promote primary care so that
medicine to provide loans for medical students, within five years at least 50% of residents in
including for those who enter training medical resident education programs are
programs in fields other than primary care. primary care residents and the number of
• Provide up to $50,000 of loan forgiveness for mid-level primary care practitioners and
primary care providers who serve for at least dentists meets certain targets.
5 years or 3 years in a medically underserved • Provide funding to the Public Health Service
area. to support the National Health Service Corps,
• Reform the sustainable growth rate for health professions education, and nursing
physicians in the Medicare program. education.
• Provide grants to states to support core public
health functions, including data collection and
analysis, investigation and control of adverse
health events, health promotion and disease
prevention activities, research on cost-effective
public health practices, and integration and
coordination of prevention programs and services.
(H.R. 3400) (S. 703) (H.R. 193)
Financing Financing for the proposal will come from The American Health Security Act will be funded Plan will be financed through an AmeriCare
limiting malpractice lawsuits, cutting through the American Health Security Act Trust Trust Fund. The trust fund will be financed with
government payments to hospitals that serve a Fund. Funding for the Trust Fund will come employer and individual premium payments,
disproportionate number of uninsured, capping from redirecting existing federal payments state maintenance of effort payments, and
non-defense discretionary spending, and for health care; imposing a payroll tax of 8.7% general revenue for premium subsidies.
increased detection and elimination of waste, on employers and employees; and imposing a
fraud and abuse in government programs. health care income tax of 2.2%.
Sources of information http://rsc.tomprice.house.gov/Solutions/ http://www.sanders.senate.gov/news/record. http://www.stark.house.gov/index.
EmpoweringPatientsFirstAct.htm cfm?id=313855 php?option=com_content&task=view&id=1081&
Itemid=103
http://www.stark.house.gov/index.
php?option=com_content&task=view&id=1238&
Itemid=84
Sens. Ron Wyden and Bob Bennett Former Majority Leaders:
Healthy Americans Act Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391) Crossing Our Lines: Working Together to Reform the U.S. Health System
Date plan announced February 5, 2009 June 17, 2009

Overall approach Require most Americans to purchase private coverage (called Healthy Require all Americans and legal residents to have health insurance. Create
to expanding access Americans Private Insurance or HAPI) meeting certain standards, with state-based health insurance exchanges through which individuals and
to coverage federal subsidies available for individuals/families up to 400% of the employers can purchase health coverage, with premium credits available
federal poverty level. State-based Health Help Agencies administer the to individuals/families with incomes up to 400% of the federal poverty level.
offering of HAPI plans, which have to meet federal benefit and other Require employers to provide coverage to employees or pay a fee based on
standards. Employers can continue to sponsor health plans but many are annual payroll, with exceptions for certain small employers, and provide
unlikely to do so because the favorable tax treatment for individuals of certain small employers a credit to offset the costs of providing coverage.
employer-paid and insurance is eliminated. Impose new regulations on plans participating in the exchanges and in the
individual and small group insurance markets. Expand Medicaid to 100% of
the poverty level.
Individual mandate • Require all citizens over age 19 to have insurance along with dependent • Require all Americans and legal residents to have health insurance that
children. Those without coverage are subject to a financial penalty based meets minimum creditable coverage standards. Enforcement options
on the number of uncovered months and the weighted average include: default enrollment in basic coverage through an employer or
of HAPI premiums. the exchange when starting a job, tax penalties including loss of federal
deductions or exemptions, and a “fair share” fee added to income tax
liability to reflect the cost of uncompensated care. Exceptions granted for
religious objections and financial hardship.
Employer requirements • Require employers to contribute an amount equal to a percentage of • Require employers to offer coverage to their employees or pay a fee
the average premium of their workforce times the number of workers. based on the percentage of payroll. The fees would range from 1% of
Percentage of the average premium varies for large and small employers payroll for firms with annual payrolls between $1 million and $2 million
from 2% to 25%. and 3% of payroll for firms with annual payrolls above $3 million.
• For the first two years, permit employers previously providing health • Exempt small businesses with payrolls less than $1 million.
insurance to increase their workers’ wages by the amount of the health
insurance premium in lieu of the employer shared responsibility payment
described above.
• Employers who continue to sponsor health plans must provide
information on HAPI plans to employees.
• Require employers to deduct individual and family premiums from
workers’ payroll.
Expansion of public • Eliminate Medicaid and CHIP as comprehensive coverage programs and • Expand Medicaid to all individuals with incomes up to 100% FPL.
programs instead provide supplemental, wrap-around coverage for low-income Initially, all individuals eligible for Medicaid and CHIP will obtain or
beneficiaries. Provides for a modified Medicaid long-term care services retain coverage through state Medicaid programs. After five years, the
program. HHS Secretary will be authorized to permit Medicaid and CHIP eligible
individuals to enroll in the exchange provided such coverage does not
result in increased cost sharing or loss of benefits.
• Allow states to create a state plan option to provide another choice of
coverage in the exchange. The state plan may be modeled after state
self-insured plan, co-op plans with consumer boards, or other designs.
The state plan must be actuarially sound; cannot be managed by the
same entity that regulates the state’s insurance markets; cannot
leverage participation in public programs as a means of developing
provider networks; cannot be provided special advantages with respect
to risk adjustment, premium rating, reserve rules, marketing, and
automatic enrollment; and must be self-sustaining. If, after five years,
HHS determines that affordability and coverage goals have not been met,
a proposal for a federal or a state plan to be offered in the exchanges will
be considered by Congress under an expedited procedure.
Subsidies to individuals • Provide premium subsidies for individuals and families with incomes • Provide tax credits on a sliding scale basis to individuals and families
between 100 and 400% FPL; those with incomes below 100% FPL would with incomes up to 400% FPL to purchase insurance through the Health
not pay premiums. Insurance Exchanges and families with incomes below 100% FPL will
• Provide a health care standard tax deduction for individuals and families be enrolled in Medicaid and pay no premiums. Within the exchange,
with incomes above 100% FPL; would phase-out at higher income levels. those with incomes between 100 and 150% FPL will pay 2% of income;
those with incomes between 150 and 250% FPL will pay 5% of income;
those with incomes between 250 and 350% FPL will pay 10% of income;
those between 350 and 400% FPL will pay 12.5%. The tax credits will be
refundable and advanceable.
• Limit premiums for individuals and families with incomes above 400%
FPL to no more than 15 percent of their income.
Subsidies to employers No provision. • Provide small employers with fewer than 25 employees who are mostly
low-wage with tax credits to help offer coverage to their workers.
Tax changes related • Reform the tax code to eliminate the exclusion of the value of health • Cap the income tax exclusion for employer-sponsored insurance at
to health insurance insurance plans offered by employers from workers’ taxable income the value of the FEHBP standard option and index that amount by
(with exceptions, such as for employer-paid retiree health coverage and medical inflation over time. Exempt retirees and individuals covered by
coverage through collectively bargained agreements until those agreements expire.
a collectively bargained plan).
• Provide a new health care standard deduction that phases out for higher
income taxpayers.
Creation of insurance • Create new state-based purchasing pools (Health Help Agencies) that • Create state or regional Health Insurance Exchanges through which
pooling mechanisms would offer a choice of HAPI plans. all individuals and small employers with 50 or fewer employees can
• Everyone, except people enrolled in Medicare, retiree benefit plans, purchase qualified insurance. Implement a federal fallback if states or
or military-related coverage, are required to enroll in plans through regions do not create exchanges in a timely manner.
the Health Help Agencies. (Note: employers can still sponsor health • Require plans to offer benefits that are at least actuarially equivalent to
insurance but would have to inform employees of HAPI plans available four established federal standards. The four standard plan levels are:
through Health Help Agency.) high (similar to the FEHBP Blue Cross Blue Shield Standard Option),
• Participating plans provide coverage similar medium (similar to a typical small group market plan), standard (similar
to that available through FEHBP. to a typical individual market plan), and basic (equivalent to the federal
• Require insurers to offer HAPI coverage on a guaranteed issue basis and minimum creditable coverage standard). Plans have flexibility to vary
use adjusted community rating principles in setting premiums. cost sharing in each of the standard plan levels.
• Require guarantee issue and renewability; allow rating variation based
only on age (limited to 5 to 1 ratio), geographic region, and family
enrollment. States can opt to impose tighter consumer protections.
• Require risk adjustment of participating Exchange plans.
• Require exchanges to make available educational resources and
consumer support tools and to adopt strategies to improve plan choice.
Benefit design • Provide benefits through HAPI plans that are actuarially equivalent or • Create minimum creditable coverage standards for insurance plans
greater in value than the benefits offered under the Blue Cross/Blue offered in all markets. Creditable coverage will include: catastrophic
Shield Standard Plan provided under the Federal Employees Health protections, coverage for a comprehensive ranges of health care
Benefit Program (FEHBP). services, and coverage of preventive care and prescription drugs before
• Additionally provide benefits for wellness programs and incentives to the deductible. Creditable coverage must be at least as generous as a
promote the use of these programs, coverage for catastrophic medical federal high-deductible plan. Permit states to increase the minimum
events for an individual or family if lifetime limits are exhausted, and full standards provided that it does not increase federal costs.
parity for mental health benefits.
• Create the Healthy America Advisory Committee to issue annual reports
recommending modifications to the benefits, items, and services covered
by HAPI plans.
Changes to private • Require insurers to offer coverage on a guaranteed issue basis and use • Require guarantee issue and renewability and allow rating variation
insurance adjusted community rating principles in setting premiums; prohibit based only on age (limited to a 5 to 1 ratio with state option to reduce
discrimination based on health status. the ratio), geographic region, and family enrollment in the individual and
• Require insurers to meet established medical loss ratios. small group markets and the Exchange. Prohibit imposition of any pre-
• Require insurers to create an electronic medical record for each covered existing condition exclusions. Allow existing plans in the individual and
individual. small group markets to be grandfathered for five years before coming
into compliance with new insurance market reforms.
• Standardize health care claims processing to promote administrative
simplification of payment systems and collect and publish data on
medical loss ratios of plans participating in the individual and small
group markets.
State role • Create Health Help Agencies and ensure that participating insurers meet • Require states to establish, operate, and regulate state or regional
requirements related to solvency and financial standards, consumer exchanges and to report annually on the number of plans offered through
protections, and establishment of wellness programs. the exchange, the range of premiums, and the number of individuals
• Implement mechanisms, such as automatic enrollment, to ensure covered through the exchange.
maximum enrollment
of individuals into private insurance.
Cost containment • Adopt payment policies that reward providers for achieving quality and • Invest in meaningful and effective use of HIT and ensure that HIT bonus
cost efficiency in prevention, early detection of disease, and chronic care payments to providers are coordinated with new payments to achieve
management. better care.
• Require insurers to create and implement electronic medical records for • Reform provider payments in federal health programs to pay for high-
each covered individual. value care.
• Require insurers to adopt uniform billing and claims forms. – Move from pay-for-reporting to pay-for-performance based on
• Encourage more rigorous study of new drugs and devices by granting measures reflecting overall quality and coordination of care;
additional exclusivity and patent protections to those subjected – Implement medical home payments that hold providers accountable
to comparative effectiveness reviews. Disallow tax deductions for for patient results over time;
pharmaceutical manufacturers for direct to consumer advertising for – Expand the use of bundled payments for episodes of care and link to an
most new drugs. expanded “Centers of Excellence” program in Medicare;
• Require insurers and providers to publicly report data on medical – Limit public program payments for unnecessary or inappropriate care,
outcomes, health care quality and costs. such as for hospital-acquired conditions or hospital readmissions; and
• Provide bonuses to states that enact medical malpractice reforms. – Establish accountable care organizations (ACOs) in Medicare and
permit ACOs that meet quality care benchmarks and reduce overall
costs to share in the savings achieved.
• Adjust Medicare market basket updates to reflect savings from delivery
system reforms, such as bundled payments, and reduce Medicare
payments to home health and skilled nursing facilities.
• Restructure payments to Medicare Advantage plans to align more closely
with fee-for-services payments and adopt incentives for quality reporting
and performance improvement.
• Reform prescription drug payments in Medicaid by increasing the drug
rebate rate while eliminating the “best price” provision.
• Adjust Medicare and Medicaid Disproportionate Share Hospital funding to
reflect reductions in uncompensated care. Payments should be reduced
by one-third over 10 years.
• Create a regulatory pathway for the approval of biosimilar and biogeneric
products.
• Restructure Medicare and Medigap cost sharing and reallocate Medicare and
Medicaid improvement funds.
Improving quality/health • Encourage chronic care programs • Support comparative effectiveness research that compares the risks,
system performance • Require hospitals to demonstrate improvements in quality control, benefits, and costs of different health care practices, evaluates and
including rapid response teams, heart attack treatments, procedures revises policies that influence provider practices, and identifies
that reduce medication errors, infection prevention, procedures that strategies for targeting practices to specific groups of patients.
reduce the incidence of ventilator-related illnesses. • Improve quality monitoring and improvement by expanding funding for
• Provide enhanced Medicare payments to primary care providers and the prioritization, development, endorsement and implementation of
require Medicare to develop a chronic disease management program. qualify measures, requiring electronic quality reporting, and improving
• Establish a website for sharing evidence-based best practices and the evaluation of new payment reform programs.
develop a program for incorporating these best practices into medical • Improve care coordination for people with chronic conditions through
school curricula. the creation of community health teams composed of care coordinators,
• Provide for improvements in end-of-life care. nurse practitioners, social workers, nutritionists, and others to provide
patient-centered care that integrates existing prevention and care
management resources.
• Improve coordination of care for dual eligibles by creating a new program
that includes a mechanism for states and the federal government to
provide financial support to deliver integrated Medicare and Medicaid
services to this population.
• Address racial and cultural disparities by enhancing comparative
effectiveness research, realigning reimbursement to promote improved
patient outcomes, ensuring adequate provider capacity in underserved
areas, increasing the number of minorities entering the medical and
health professions, and developing and adopting standards for the
collection of data on race and ethnicity.
• Create an Independence Health Care Council (IHCC) to assess overall
system performance. The IHCC will analyze and report on cost and
quality data in federal programs and issue recommendations for
improving quality, reducing cost growth, and better coordinating the
delivery, reimbursement, and financing of federal health programs.
Prevention/wellness • Promote prevention by providing premium discounts (including for • Support a sustained, nationwide focus on public health wellness through
Medicare Part B premiums) for participation in approved wellness and creation of a Public Health and Wellness Fund to invest in evidenced-
chronic disease management programs. based prevention and wellness activities. These activities and provisions
• Require HAPI plans to ensure that primary care providers and individuals include: no or limited cost sharing for proven preventive services, a new
create a care plan focused on wellness and prevention as part of the wellness visit for Medicare beneficiaries to receive a personalized health
initial primary care visit. risk assessment and prevention plan, a federal tax credit for certified
employer-based wellness programs that meet accountability and
reporting requirements, and a $3 billion annual investment in wellness
and prevention programs.
Long-term care • Permit states to create State Choices for Long-term Care Programs No provision.
through their Medicaid programs to provide institutional and home and
community-based long-term care for eligible individuals.
• Create new long-term care insurance plans that meet standards
developed by NAIC or by federal regulations. Require additional
consumer protections for long-term care policies regarding guarantee
renewal, prohibitions on limitations and exclusions, pre-existing
conditions, and other issues.
Other investments • Provide grants to school districts and communities to increase access to • Reform Graduate Medical Education to increase training of primary care
school-based clinics. providers, promote training in settings and geographic areas where
• Permit states to create State Choices for Long-term Care Programs providers will practice, and encourage integrated systems of care to
through their Medicaid programs to provide institutional and home and increase reliance on a qualified non-physician workforce. Provide funding
community-based long-term care for eligible individuals. for the training of more nurses and allied health professionals. Revise
• Create new long-term care insurance plans that meet standards scope of practice laws to encourage use of advanced practice nurses,
developed by NAIC or by federal regulations. pharmacists, and other allied health professionals.
• Consider additional financial incentives to ensure adequate provider
capacity in medically underserved urban and rural areas.
• Provide full federal funding for the Medicaid expansion so that states are
not required to pay any of the costs for the newly eligible populations.
Financing In 2008, CBO scored an amended version of the bill which is very similar to The anticipated cost of health reform is $1.2 trillion over 10 years. The
this year’s version. In that CBO estimate, Federal costs would be offset by delivery system, reimbursement, employer “pay” contribution, and tax
revenues and savings in first year of full implementation, Thereafter, the exclusion reforms in the proposal (and related interactions) are expected
bill would be more than self-financing because of indexing growth in the to achieve over $1 trillion in savings and new revenues. To ensure budget
value of the health insurance deduction and the subsidized benefits. neutrality, Congress could enact additional Medicare or Medicaid savings,
Financing will come from combination of individual premiums, employer create an enforceable budget “trigger” mechanism to slow spending
assessments, state and federal savings in Medicaid, elimination of most growth above a target level, or empower the Independent Health Care
Medicare and Medicaid disproportionate share hospital (DSH) payments, Council to develop additional recommendations for achieving federal
and changes in tax treatment of insurance. spending growth targets.
Sources of information http://wyden.senate.gov/issues/Legislation/Healthy_Americans_Act.cfm http://www.bpcleadersproject.org/

http://wyden.senate.gov/issues/Health_Care.cfm
http://www.cbo.gov/ftpdocs/91xx/doc9184/05-01-HealthCare-Letter.pdf
THE HENRY J. KAISER FAMILY FOUNDATION www.kff.org

Headquarters: 2400 Sand Hill Road Menlo Park, CA 94025 650.854.9400 Fax: 650.854.4800
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW Washington, DC 20005 202.347.5270 Fax: 202.347.5274
The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis
and information on health issues.

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Senate Finance Committee House Tri-Committee

Employer requirements – Annual payroll between

Premium subsidies citizens and legal immigrants who requirements, developing

Premium subsidies exceptions). Individuals with

Premium subsidies of up to 50% of the employer’s 80% of retiree claims between

Tax changes related age 55 and up and for employees

Tax changes related • Increase the tax on distributions

Creation of insurance woman). Prohibit plans • [E&C Committee amendment:

Changes to private • Allow insurers to offer a national

Cost containment • Reduce payments for preventable

Cost containment • Eliminate fraud, waste, and abuse

Prevention/wellness form of premium discounts, waivers

Other investments regulations that govern GME [E&C Committee amendment:

Cost containment • Enhance efforts to detect and eliminate

Improving quality/health • Create a health plan and provider portal

Date plan announced February 5, 2009 June 17, 2009

Sources of information http://wyden.senate.gov/issues/Legislation/Healthy_Americans_Act.cfm http://www.bpcleadersproject.org/

THE HENRY J. KAISER FAMILY FOUNDATION www.kff.org

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