House Introduces Health Care Bill

Speaker Nancy Pelosi introduced the House Health Care reform bill today. As predicted, it does not have the "robust" public option:

House leaders abandoned an earlier effort to include a public option that would have established reimbursement rates to providers based on Medicare. Although the provision was backed by liberals, it lacked enough votes to pass. Rural Democrats strongly opposed that approach because of the potentially ruinous effect on doctors and hospitals in their districts, where Medicare rates are generally well below the national average.

Instead, Pelosi is offering a more moderate alternative in which rates would be negotiated between providers and federal health officials, similar to the way in which private insurance operates. Majority Leader Harry M. Reid (D-Nev.) said he would include a similar provision in the Senate bill, though with an "opt out" clause for states that don't want to participate.

A four page summary is here. The full text is here. The top 14 provisions that take effect immediately are here. The top ten changes from the current system are here. The implementation timeline is here. The benefits to seniors and the disabled are here. [More...]


The main revenue sources in the House bill include a surcharge on wealthy taxpayers and changes to Medicaid and Medicare worth about $500 billion in cost savings over 10 years, according to the nonpartisan Congressional Budget Office.

Who are the wealthy being taxed? "... only the wealthiest 0.3% of Americans would pay a surcharge on the portion of their income above $500,000 (instead of $280,000) for individuals and $1 million (instead of $350,000) for couples, in order to help make health insurance affordable for middle class families."

Let the critiques and praises begin. Will anyone be happy with the bill? Are you? (I'm still reading it and thus reserving judgment.)

< Thursday Morning Open Thread | Negotiated Rates vs. Medicare +5% >
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    While Medicare +5 would have been better, of (5.00 / 1) (#4)
    by steviez314 on Thu Oct 29, 2009 at 11:33:12 AM EST
    course, negotiated rates isn't the worst thing.

    If you remove the insurance companies profit margins and marketing/administrative costs, a public option should be about 20-25% cheaper than a private plan.

    When you combine that with the insurance exchange,  a small business (like the 2 person one I have with my wife) will be able to get rates negotiated on the basis of a much larger group--also a big plus.

    Remember, doctors can't be forced to accept patients.  If more doctors will sign up with the negotiated rates than with Medicare+5, especially in poorly served areas, then that's a tradeoff that has to be considered.

    Medicare + 5 (none / 0) (#10)
    by gyrfalcon on Thu Oct 29, 2009 at 11:50:25 AM EST
    is worse than negotiated rates, seems to me.  Certainly the case for my apparently despised "rural area."

    This public option will only be offered to (none / 0) (#19)
    by inclusiveheart on Thu Oct 29, 2009 at 12:01:42 PM EST
    about 35-36 million people - remember we are a nation of over 300 million.  It's not going to do much if anything to change the global problems we face.

    I wish the bill had the soda pop tax (5.00 / 1) (#6)
    by magster on Thu Oct 29, 2009 at 11:39:12 AM EST
    just because those anti soda pop tax ads are so obnoxious.

    Wow, aren't those ads something? (5.00 / 2) (#12)
    by gyrfalcon on Thu Oct 29, 2009 at 11:51:46 AM EST
    They're really ridiculous.

    you would think (none / 0) (#34)
    by Capt Howdy on Thu Oct 29, 2009 at 02:10:19 PM EST
    they were planning to tax insulin instead of soda pops and "juice" drinks.

    I hate them too.


    not nearly enough (5.00 / 2) (#13)
    by cawaltz on Thu Oct 29, 2009 at 11:52:38 AM EST
    in this bill to address costs IMO.

    Variability in payments means (5.00 / 2) (#20)
    by MyLeftMind on Thu Oct 29, 2009 at 12:07:31 PM EST
    inconsistency in care, more government overhead, more complex analysis and a less unified desire for true reform. Both sides will be able to put out ads saying here's how we helped you and here's how our opponent hurt you. In reality, both the Repubs and Dems will be complicit in making us pay more to prop up the industry that's already stealing from us.

    yikes (5.00 / 2) (#26)
    by pitachips on Thu Oct 29, 2009 at 12:25:17 PM EST
    can't wait to hear the horror stories of the federal officials who were responsible for negotiating rates leaving the gov't to work for the same insurers.

    BINGO! (none / 0) (#43)
    by DFLer on Thu Oct 29, 2009 at 04:41:11 PM EST
    According to PFD, bill has slightly (5.00 / 1) (#31)
    by MO Blue on Thu Oct 29, 2009 at 01:26:32 PM EST
    increased the size for employer based access to the exchange.


    Opens the Health Insurance Exchange to individuals without other coverage and to small employers with 25 or fewer employees.


    EXPANDS HEALTH INSURANCE EXCHANGE:  Opens the Health Insurance Exchange to small businesses with 100 or fewer employees and provides the Health Choices Commissioner the authority, from 2015 forward, to continue expanding the Exchange to larger employers as the system is ready to handle increased capacity.

    IF the public option and this provision is included in the final legislation, it could expand the size of the public option pool. That would be a good thing.

    Negotiation position (none / 0) (#32)
    by waldenpond on Thu Oct 29, 2009 at 01:50:39 PM EST
    The pharmaceutical cartel will demand this...

    [10. HHS NEGOTIATION OF DRUG PRICES--Under the revised bill, the Secretary of HHS is required to negotiate drug prices on behalf of Medicare beneficiaries.]

    be stripped.  Since I expect it to be stripped, hopefully the progressives will use it and other items for negotiation to keep the PO in.

    I'm am pleased that individuals would be able to stay on their parents insurance until 27.  That takes care of my 17 year old son, who would have been kicked off at 18.  The PO may be substantially expanded by then.


    Why (none / 0) (#1)
    by Ga6thDem on Thu Oct 29, 2009 at 11:25:33 AM EST
    did I have this horrible feeling that Pelosi or the house progressives would cave?

    Yep. Well, I just saved some money (none / 0) (#7)
    by Cream City on Thu Oct 29, 2009 at 11:42:35 AM EST
    that won't be donated to my member of Congress who was so quick to sign on with the Progressive Caucus.

    I said then here that, from past performance of my member of Congress, I would not put money on it.  So now I will not put money into saving that seat.


    Why?: (5.00 / 1) (#17)
    by gyrfalcon on Thu Oct 29, 2009 at 11:57:10 AM EST
    Can somebody explain to me why negotiated rates are a bad thing compared to Medicare plus 5?  Negotiated means the rates have to be acceptable to both sides, no?  Medicare plus 5 in my rural area and around the country is less than what could be gotten through negotiation.  Last thing we need is a "public option" physicians and hospitals won't accept patients from.

    Actually, the first problem I see is that (none / 0) (#24)
    by Inspector Gadget on Thu Oct 29, 2009 at 12:19:24 PM EST
    this does not consider the needs of everyone. Not Universal if only 30-35 Million have access. It's actually not even a good beginning IMHO.

    I'm sending an email to my rep today to give my thoughts on it.


    Look up what they promised (none / 0) (#27)
    by Cream City on Thu Oct 29, 2009 at 12:31:45 PM EST
    to support and compare it with this bill, in terms of both quality of coverage and quantity covered.

    and it's written in the bill that (none / 0) (#50)
    by suzieg on Fri Oct 30, 2009 at 03:54:52 AM EST
    doctors and hospitals cannot be forced to accept patients. Without a clause to the contrary most of the people in the new exchange/public option will end up like my husband who's on medicare and cannot find a primary doctor who treats medicare patients! What a joke!

    What are changes to Medicaid and Medicare ...??? (none / 0) (#2)
    by robrecht on Thu Oct 29, 2009 at 11:30:39 AM EST
    What are changes to Medicaid and Medicare worth about $500 billion in cost savings over 10 years???

    One of the Medicaid changes is (none / 0) (#15)
    by inclusiveheart on Thu Oct 29, 2009 at 11:54:45 AM EST
    that they plan on expanding coverage to a group of people that, at present, they are paying subsidies to cover their private insurance policies.  Surprisingly, (she said sarcastically) putting those folks under the existing government insurance plan is cheaper than paying for private insurance...

    The specifics of Medicare I do not know other than that they are planning cuts which I think is political suicide - even if the cuts make total sense for one reason or another - the GOP will sieze on Medicare cuts as a weapon against the Democrats.


    Medicare Advantage (none / 0) (#37)
    by christinep on Thu Oct 29, 2009 at 02:42:49 PM EST
    I believe that the other cuts primarily involve cuts to Medicare Advantage. That was the Bush-pushed program of several years back that--in my opinion--poses through slick (& misleading) brochures as "medicare" additions.  From what I have observed: It is difficult to tell that this Advantage program is really a "supplement" to the insurance industry marketed confusingly to many seniors. It is a supplement to be sure, but at rather high industry rates. It appears to now be equally difficult to explain these cuts as ones designed to pull back the Bush giveaway rather than conveying the impression that unsuspecting individuals who ponied up for the pricey program would be dis-advantaged.

    Medicare Advantage (none / 0) (#41)
    by vicndabx on Thu Oct 29, 2009 at 03:07:57 PM EST
    Is actually coverage seniors get in place of traditional Medicare.  It's not a supplement policy at all.  The monies that would normally be used for the beneficiary's coverage go toward a Medicare Advantage plan instead.  The issue is these plans reimburse providers at higher rates than do traditional Medicare and cover more services (drugs, vision, etc.) than traditional Medicare, thus the higher costs associated w/them.

    Not exactly (none / 0) (#42)
    by Anne on Thu Oct 29, 2009 at 04:03:24 PM EST
    Medicare Advantage Plans are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include prescription drug coverage. Medicare Advantage Plans include:

    Medicare Health Maintenance Organization (HMOs)
    Preferred Provider Organizations (PPO)
    Private Fee-for-Service Plans
    Medicare Special Needs Plans

    When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most of these plans, generally there are extra benefits and lower copayments than in the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services.

    To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer.

    If you join a Medicare Advantage Plan, your Medigap policy won't work. This means it won't pay any deductibles, copayments, or other cost-sharing under your Medicare Health Plan. Therefore, you may want to drop your Medigap policy if you join a Medicare Advantage Plan. However, you have a legal right to keep the Medigap policy.



    Don't really understand the 'not exactly.' (none / 0) (#48)
    by vicndabx on Thu Oct 29, 2009 at 10:39:45 PM EST
    It appears your post reiterates what I've just stated.

    I agree (none / 0) (#49)
    by Jeralyn on Fri Oct 30, 2009 at 12:38:13 AM EST
    seems like you are both saying the same thing.

    Your comment stated that Advantage (none / 0) (#52)
    by Anne on Fri Oct 30, 2009 at 07:19:44 AM EST
    replaces traditional Medicare and is not a supplemental plan.  When Medicare says:

    To join a Medicare Advantage Plan, you must have Medicare Part A and Part B.

    that says to me that traditional Medicare is the starting point.  From there, you can go with Medicare alone, purchase "Medi-Gap" coverage through a private company, or enroll in an Advantage plan, which are also run by private companies.

    The website clearly states that when you are in an Advantage Plan, you are still in Medicare, but as I read more on the website, I realized that it isn't so much that Advantage replaces traditional Medicare, because you still have all the benefits of it, but those benefits are now coordinated/offered through whichever private company you choose for your Advantage Plan.

    We may have, in fact, been saying the same thing in different ways, or making some distinctions without a difference.

    I still have a few years before I actually have to wade into this area, but the little reading I did suggests I may not want to wait til the last minute as I get closer!


    Medicare advantage plan is basically an HMO. The (none / 0) (#51)
    by suzieg on Fri Oct 30, 2009 at 03:59:37 AM EST
    clinic where my husband's doctor is practicing only accepts patients on medicare advantage because they get an additional $3,000 per patient and my husband has to go to their in-network doctors, which he refused to do, so was basically told that he would no longer be seen by his doctor of 20yrs.

    Rescission (none / 0) (#3)
    by TeresaInSnow2 on Thu Oct 29, 2009 at 11:31:58 AM EST
    The "new" policy is that rescission is not allowed, except in the case of clear and convincing evidence of fraud. The insuree can request an independent review of the rescisssion.

    Now I've seen a case where insurance was rescinded after the patient contracted cancer because they didn't report that benign mole that was removed a few years ago.  The mole was unrelated to the cancer. Obvious evidence of the mole removal was in their medical records, so clear and convincing evidence of fraud seems to be there too!

    So, my question is, what, about the rescission policy, has changed?  To me, the answer is nothing.

    Huh? (5.00 / 1) (#8)
    by gyrfalcon on Thu Oct 29, 2009 at 11:48:21 AM EST
    This seems exactly the kind of abuse that the requirement for "clear and convincing evidence of fraud" would end.

    Depends on how you define (5.00 / 1) (#16)
    by coast on Thu Oct 29, 2009 at 11:56:17 AM EST
    "clear and convincing evidence".  I have a feeling that the insurance company will define it differently from you and I.

    Wouldn't that be the point of (none / 0) (#22)
    by cawaltz on Thu Oct 29, 2009 at 12:10:55 PM EST
    an independant review? Although I do not see how it saves the government money to indulge the insurance companies and aid and abet them on dragging their feet on paying claims as this would seem to actually do.

    Congress should have included a penalty on insurance companies found guilty of utilizing stall tactics especially considering the whistleblower who testified told them straight out that kicking the can was one of the ways insurance comnpanies made money.


    Who will be paying for the (none / 0) (#25)
    by Inspector Gadget on Thu Oct 29, 2009 at 12:21:46 PM EST
    independent review? People lean heavily toward those who pay them.

    Unfounded and unproved... (none / 0) (#28)
    by MileHi Hawkeye on Thu Oct 29, 2009 at 12:34:51 PM EST
    ...speculation on your part.  I've reviewed hundreds and hundreds of independent review decisions and I see absolutely no indication that they "lean heavily" towards those who pay them.

    Hence the term "independent".  By the way, they have to approved by the Commissioner and we're the ones who decides who gets used.  


    Thanks (none / 0) (#44)
    by Inspector Gadget on Thu Oct 29, 2009 at 04:59:25 PM EST
    That's exactly why there was a question mark. So, do you know who pays? Are these gov't agencies, or private reviewers?

    See... (none / 0) (#53)
    by MileHi Hawkeye on Fri Oct 30, 2009 at 10:10:22 AM EST
    ...here and here for the answers to your questions.

    No insurance company is going to (none / 0) (#35)
    by gyrfalcon on Thu Oct 29, 2009 at 02:36:50 PM EST
    win that argument with any sentient being.  Even my cats wouldn't buy it, and they're pretty cynical.

    But, forcing people to go through (5.00 / 1) (#40)
    by Anne on Thu Oct 29, 2009 at 02:53:11 PM EST
    a possibly long and drawn-out process just to get to the conclusion that should have been clear from jump street, is why insurance companies win even when they lose.  

    They get to say "no" when they should have said "yes," and a certain percentage of people are either not going to subject themselves to the appeals process, or will give up on it when things stall and threaten to go on indefinitely; those are all wins for the insurance companies.  

    So, it isn't just the obvious wrongness of the original decisions, but the process that allows insurance companies to get away with making them in the first place.


    Burden of Proof (none / 0) (#39)
    by christinep on Thu Oct 29, 2009 at 02:52:24 PM EST
    My understanding is that the insurer would have the Burden of Proof necessary for rescinding. Every district and circuit has caselaw regarding "clear & convincing."

    Look at it this way... (none / 0) (#30)
    by inclusiveheart on Thu Oct 29, 2009 at 12:35:49 PM EST
    You're sick - have cancer or something - and you're in the middle of treatment...  Your health insurer accuses you of fraud.  What are you supposed to do to fight that?  You're going to hire a lawyer.  Do you have the money to pay a lawyer at this point to fight them?  It doesn't seem like there is any provision in this "end" to recissions that prevents insurers from accusing people of fraud - like a clause awarding damages including covering legal costs accrued by a wrongly accused patient in an effort to clear themselves of the accusation.  So the private insurers with endless legal resources and you all sick with limited if not none at all - who do you think is going to win that dispute?

    Actually, I rather (none / 0) (#36)
    by gyrfalcon on Thu Oct 29, 2009 at 02:40:21 PM EST
    think the vast majority of insu cos will take this prohibition seriously because they know damn well if they don't, a much stricter law will be passed to force them to.  This is one of the restrictions they actually agreed to in return for the massive windful the individual mandate will provide for them.

    If it was in their medical record (none / 0) (#11)
    by cawaltz on Thu Oct 29, 2009 at 11:51:16 AM EST
    wouldn't that be evidence to the contrary regarding fraud? I would think fraud would mean that the person was purposefully attempting to conceal a condition, not forgot to list it.

    Not necessarily because (none / 0) (#23)
    by coast on Thu Oct 29, 2009 at 12:11:15 PM EST
    the insurance company does not see you medical record.  They rely on what you report on your application.  If you report a condition, then they have the right to request additional information to assess the risk.  However, they don't have access to your medical file.

    I'm trying to get my wife and kids on a seperate policy because the group policy that I'm in is so expensive.  My son went to the hospital this year with stomach pains.  They performed an MRI and could find nothing wrong with him, just a stomach ache.  Insurance didn't pay one penny of the nearly $4,000 bill because I hadn't reached the deductible.  When we were completing the application for the new policy I didn't include the visit because there was no diagnosis resulting from the visit.  If we got approved, which we didn't, and my son came down with something three years from now, I would bet they would be crying fraud.


    which "fraud" (none / 0) (#38)
    by christinep on Thu Oct 29, 2009 at 02:49:12 PM EST
    I assume that the fraud intended to serve as an exemption to the no rescission requirement is fraud on the part of the insured. Your write-up about the benign mole situation only serves to underscore the kind of situation that would NOT be regarded as fraud under the House proposal.

    On Medicare I notice (none / 0) (#5)
    by Jeralyn on Thu Oct 29, 2009 at 11:36:23 AM EST
    these two things (my emphasis):

    * Protects the Doctor-Patient Relationship and Improves Quality: Companion legislation resolves a longstanding problem with the physician payment formula to promote primary care and advance innovation. Investments in health delivery system reform will improve coordinated care, promote efficiency, and enhance quality.

    So it's not in this bill.

    * Extends the Medicare Trust Fund: Following the advice of non-partisan experts at the Medicare Payment Advisory Commission, the proposal makes numerous changes in provider payments that extend the life of the Trust Fund for five years and put the program on stronger financial footing for the future.

    Why the need to justify the extension rather than just setting forth what it does? Are they talking about controversial cuts in benefits?

    The specifics of the Medicare "savings" (5.00 / 1) (#14)
    by KeysDan on Thu Oct 29, 2009 at 11:53:31 AM EST
    has always been a well guarded mystery---all the more so when talking about stabilization of Medicare itself, provision for costly medical advances, and the financing of the  new program (about half) for those under 65.

    "Makes numerous changes (5.00 / 2) (#29)
    by MO Blue on Thu Oct 29, 2009 at 12:35:18 PM EST
    in provider payments"

    Sounds like they plan to reduce the $$ amount of payments to providers.

    If that is true, it may become even harder for some people to find doctors etc. who will accept Medicare patients.


    I haven't read the piece you (none / 0) (#9)
    by coast on Thu Oct 29, 2009 at 11:50:08 AM EST
    quote, but given the context, they could only be talking about cutting benefits.  Extension of the funds existance and the term "stronger financial footing" can only be achieved through reduced benfits or increased contributions to the fund.

    Consolation prize (none / 0) (#18)
    by MyLeftMind on Thu Oct 29, 2009 at 12:01:33 PM EST
    The new & improved bill lets each state negotiate rates with doctors and hospitals. Whoopee! More layers, more obfuscation, more government overhead, LESS ability to assess, analyze and prove this plan is just another despicable theft of middle class resources to support the super rich.

    The public option was already a watered-down compromise to single payer, and leadership just watered it down even more. So what do we have now? An albatross that will drag down the middle class, hurt the economy, and be used by Republicans for the next 30 years to prove tax and spend Dems can't be trusted to run the federal government.

    Sometimes you have to let things get really bad before you can get enough people to revolt. This plan could give seniors $500 less of a loophole, while they end up paying more elsewhere. But it'll be harder to convince them they're getting screwed. Nancy Pelosi should just go back to last week's bill, put it up for a vote and let it fail so we can see which of our elected Democrats sold us out. Then we could move on to REAL reform.

    Summary looks good (none / 0) (#21)
    by Coral on Thu Oct 29, 2009 at 12:09:11 PM EST
    Wish there weren't such a long road to walk in the Senate.

    I'm especially happy about the measures that kick in immediately.

    Single payer in the states is outlawed (none / 0) (#33)
    by lambert on Thu Oct 29, 2009 at 01:54:16 PM EST
    Absent the Kucinich Amendment, single payer experiments in the states are subject to successful challenges under ERISA.

    Remember how the "progressive" advocates of "public option" told us, over and over again, that "public option" would be an incremental approach to single payer? Oh, well...

    Co-ops (none / 0) (#47)
    by waldenpond on Thu Oct 29, 2009 at 08:16:09 PM EST
    and Dean stated that co-ops were added back in and doesn't know why as they won't work.

    Isn't it fair to assume costs of providing (none / 0) (#45)
    by oculus on Thu Oct 29, 2009 at 05:47:20 PM EST
    medical care in rural areas is actually lower than providing comparable care in urban areas?  Cost of living, office rent, salaries, etc. must be lower.  

    Not necessarily lower. (none / 0) (#46)
    by caseyOR on Thu Oct 29, 2009 at 07:08:45 PM EST
    The Medicare reimbursement formula is old, old, old and antiquated. And it applies to entire geographic areas, regardless of the mix of urban and rural. Here in Oregon the rates are the same in Portland (higher costs) as they are in very rural eastern Oregon.

    And, while rent and salaries for support staff may be somewhat lower, equipment costs are the same (no rural discount for an MRI machine or band-aids), and doctors are still expected to pay off their loans for medical school.

    It is hard enough to get doctors to set up practices in rural areas. Lower reimbursement rates make it even harder.

    And the problem of funding rural hospitals is even greater.