Saturday, August 8, 2009

HR 3200, Section 122 continued: The New Face of Health Care

HR 3200, Section 122 (continued)

Now we get into the real meat of the issue. This is what your health care will look like, regardless of whether you “choose” the private option or the public option.

“(b) Minimum Services To Be Covered- The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician's or a health professional's delivery of care in institutional settings, physician offices, patients' homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.”

Benefits offered by the private insurance companies must include the following:
1. Hospitalization
2. Outpatient care
3. Emergency room care
4. Doctor visits
5. “Other health professionals” – this term is so vague it’s terrifying. What is included in this??? Nurse practitioners working unsupervised? Shamans? Acupuncturists? Chiropractors? Herbalists? Marijuana dealers? This leaves the door wide open for them to thoroughly ruin primary care specifically, and the physician community at large.
6. Durable medical equipment (as deemed necessary by Der Kommissar and his/her board of government goons).
7. Prescription drugs (no doubt only the ones allowed by Der Kommissar). You won’t be getting Levaquin. I’m sure generic penicillin will work fine. If not, it’s cheaper for us if you just go ahead and die.
8. Rehabilitation
9. Mental health care
10. Substance abuse treatment
11. Preventive care (as defined by the USPSTF, the government agency that decides what you need and don’t need).
12. Maternity care
13. Well-baby and well-child care
14. Full-coverage, including dental, oral health, vision, orthodontics, and all equipment and supplies thereto appertaining for all “children” 21 years of age or younger. You get to buy other kids’ braces.

HR 3200, Section 122 (Part One)

(a) In General- In this division, the term `essential benefits package' means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that--
(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;
(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services;
(4) complies with section 115(a) (relating to network adequacy); and
(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.
(c) Requirements Relating to Cost-sharing and Minimum Actuarial Value-
(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.
(A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year.
(C) USE OF COPAYMENTS- In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance.
(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).
(B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.”
1. The “private option” has to meet the following standards:
a. It must provide certain benefits, to be outlined below.
b. “Cost sharing” is the term used to describe the ways insurance companies pass costs on to their enrollees to account for increasing medical costs. These methods include co-pays, annual limits on what they will cover, etc.
c. Under this bill, insurance companies will not be allowed to cost-share with an enrollee unless that enrollee spends more than $5,000 in one year on health care, or the enrollee’s family spends more than $10,000. This number adjusts upward each year, based on the consumer price index.
d. No matter how much well-baby care or well-child care or any other preventive care a person receives, even if it’s a million dollars each year, a private insurance company can’t charge them a penny in cost-sharing for it. These costs just get passed along to everybody else through higher premiums. More nails in the private insurance coffin.
e. They will not be able to impose any limits on what they will cover, either annually or lifetime. If you want it, they have to give it (and then pass their costs on to everybody else).
This is socialized medicine by proxy – using a private entity to do the dirty work for them. In this sense, they aren’t destroying the private insurance market, any more than a virus destroys its host cell. They will simply ruin the private insurance market by imposing regulations that create socialized medicine through them.
f. Private insurance has to be “equivalent” to the “average” employer-provided coverage in a particular area. It can’t be worse, but it can’t be any better, either. We’re all in the same crummy boat.

HR 3200, Section 121

(a) In General- A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 124 for the essential benefits package described in section 122 for the plan year involved.
(b) Choice of Coverage-
(1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify.
(2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of an Exchange-participating health benefits plan, such plan is required under section 203 to provide specified levels of benefits and, in the case of a plan offering a premium-plus level of benefits, provide additional benefits.
(3) CONTINUATION OF OFFERING OF SEPARATE EXCEPTED BENEFITS COVERAGE- Nothing in this division shall be construed as affecting the offering of health benefits in the form of excepted benefits (described in section 102(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance.
(c) No Restrictions on Coverage Unrelated to Clinical Appropriateness- A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services.”
1. Private insurance has to meet government-approved standards for the benefits they offer.
2. You will be permitted by your government to buy additional insurance to supplement the lousy insurance they offer – just like Medicare enrollees have to buy additional “Medigap” insurance to cover some of their expenses.
3. Insurance companies that want to be part of the new government “insurance exchange” and actually try and live under their thumb as I’ve described above have to meet certain requirements, as will be outlined in part in the next section.
4. Once again, you will be permitted to buy coverage for “extras” like vision, dental, etc. Permitted. Ugh.
5. A QHBP, “qualified health benefits plan” (one of the insurance companies that’s playing ball with the government) will not be permitted to restrict benefits except when that restriction is deemed to be “clinically-appropriate”.
This one almost slipped right by me. Who gets to determine what is and what is not “clinically-appropriate”? Well, Der Kommissar, of course! He/she will make this determination after consulting with a health board, which is described in later sections. This board will only have a few doctors on it. The vast majority of its members? Government appointees from the ranks of “labor” (unions), federal employees, etc. That’s right. A bunch of bureaucrats and political spoils will be deciding what is and is not “clinically appropriate” for us. Evidence-based medicine will be drowned out by the voices speaking for the government bureaucracy. Sick.

HR 3200, Sections 114-116

(a) Nondiscrimination in Benefits- A qualified health benefits plan shall comply with standards established by the Commissioner to prohibit discrimination in health benefits or benefit structures for qualifying health benefits plans, building from sections 702 of Employee Retirement Income Security Act of 1974, 2702 of the Public Health Service Act, and section 9802 of the Internal Revenue Code of 1986.
(b) Parity in Mental Health and Substance Abuse Disorder Benefits- To the extent such provisions are not superceded by or inconsistent with subtitle C, the provisions of section 2705 (other than subsections (a)(1), (a)(2), and (c)) of section 2705 of the Public Health Service Act shall apply to a qualified health benefits plan, regardless of whether it is offered in the individual or group market, in the same manner as such provisions apply to health insurance coverage offered in the large group market.
(a) In General- A qualified health benefits plan that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials between in-network coverage and out-of-network coverage.
(b) Provider Network Defined- In this division, the term `provider network' means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan.
(a) In General- A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio.
(b) Building on Interim Rules- In implementing subsection (a), the Commissioner shall build on the definition and methodology developed by the Secretary of Health and Human Services under the amendments made by section 161 for determining how to calculate the medical loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by QHBP offering entities, competition in the health insurance market in and out of the Health Insurance Exchange, and value for consumers so that their premiums are used for services.”

1. Private insurance companies can’t discriminate against people. Duh.
2. Private insurance companies have to cover mental health problems and substance abuse treatment.
3. Private insurance companies that use “provider networks” – you know, the lists of approved doctors you can see on the plan – have to be able to demonstrate that those networks are able to meet the standards that Der Kommisar sets for them.
4. Private insurance companies have to refund money to their enrollees for any year they don’t spend enough on providing care. This places a cap on the amount of money private insurance companies can make. Too bad the “public option” doesn’t have such a provision – refunding tax dollars in such cases.
Remember something here. The socialized “public option” will be taxpayer-funded. All this stuff I’m telling you about is simply the set of rules governing the insurance you may choose to have instead of using the crummy government health care. It’s a lot like school. Sometimes you live in an area with lousy public schools, so you may choose to spend extra to send your kid to private school or even home-school them. But you still have to pay taxes for the public schools. This is simply ludicrous, that the government is not just messing up the public insurance they’re going to offer; they are also trying to ruin the private insurance option. Yet, they still maintain that they aren’t trying to destroy private insurance. Right.

HR 3200, Section 113

HR 3200
(a) In General- The premium rate charged for an insured qualified health benefits plan may not vary except as follows:
(1) LIMITED AGE VARIATION PERMITTED- By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1.
(2) BY AREA- By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation with such regulators).
(3) BY FAMILY ENROLLMENT- By family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for family enrollment (or enrollments) to the premium for individual enrollment is uniform, as specified under State law and consistent with rules of the Commissioner.
(b) Study and Reports-
(1) STUDY- The Commissioner, in coordination with the Secretary of Health and Human Services and the Secretary of Labor, shall conduct a study of the large group insured and self-insured employer health care markets. Such study shall examine the following:
(A) The types of employers by key characteristics, including size, that purchase insured products versus those that self-insure.
(B) The similarities and differences between typical insured and self-insured health plans.
(C) The financial solvency and capital reserve levels of employers that self-insure by employer size.
(D) The risk of self-insured employers not being able to pay obligations or otherwise becoming financially insolvent.
(E) The extent to which rating rules are likely to cause adverse selection in the large group market or to encourage small and mid size employers to self-insure
(2) REPORTS- Not later than 18 months after the date of the enactment of this Act, the Commissioner shall submit to Congress and the applicable agencies a report on the study conducted under paragraph (1). Such report shall include any recommendations the Commissioner deems appropriate to ensure that the law does not provide incentives for small and mid-size employers to self-insure or create adverse selection in the risk pools of large group insurers and self-insured employers. Not later than 18 months after the first day of Y1, the Commissioner shall submit to Congress and the applicable agencies an updated report on such study, including updates on such recommendations.
Private insurance premiums have to be the same for everybody enrolled. In other words, whether you are 19 and in perfect health, or you are 19 and have drug-abuse-related diseases, your premiums are the same. Sound fair? There are a few exceptions to this rule:
1. Older people can be charged up to twice as much for their premiums as younger people
2. People in certain geographical areas may have to pay more than people in other areas.
3. Family coverage can cost more than individual coverage. Duh.
There will be a top-bureaucrat in the government called “The Commissioner” (or Kommisar, if you prefer). He/she will conduct studies to ensure to see which companies chose to self-insure rather than go with the other available options. He/she will then report to Congress how the self-insurance thing is going, and make recommendations so that it is less attractive for companies to self-insure.

HR 3200, Section 102 (Part Deaux)

HR 3200: Section 102 (continued)

“(c) Limitation on Individual Health Insurance Coverage-
(1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan.
(2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage.”

1. You will not be able to get private insurance ever again after “the first day” on which this bill becomes law and goes into effect. The only insurance you will be allowed by your government to get will be the “Exchange-participating health benefit plan” – their code-word term for “The Public Option”, which is socialized medicine.
2. You will be permitted by your government (doesn’t that sound a little odd to anyone else?) to continue to have “excepted benefits”. What are “excepted benefits”? Well, for that, you have to go to yet another enormous Congressional document, the 1200+page Public Health Service Act, and look for Section 2791(c). Don’t worry. I’ve done this for you.

Public Health Service Act, Section 2791
(c) EXCEPTED BENEFITS.—For purposes of this title, the term ‘‘excepted benefits’’ means benefits under one or more (or any combination thereof) of the following:

(A) Coverage only for accident, or disability income insurance, or any combination thereof.
(B) Coverage issued as a supplement to liability insurance.
(C) Liability insurance, including general liability insurance and automobile liability insurance.
(D) Workers’ compensation or similar insurance.
(E) Automobile medical payment insurance.
(F) Credit-only insurance.
(G) Coverage for on-site medical clinics.
(H) Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

(A) Limited scope dental or vision benefits.
(B) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
(C) Such other similar, limited benefits as are specified in regulations.

(A) Coverage only for a specified disease or illness.
(B) Hospital indemnity or other fixed indemnity insurance.

(4) BENEFITS NOT SUBJECT TO REQUIREMENTS IF OFFERED AS SEPARATE INSURANCE POLICY.—Medicare supplemental health insurance (as defined under section 1882(g)(1) of the Social Security Act), coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code, and similar supplemental coverage provided to coverage under a group health plan."

Okay. So what does this mean exactly? Let’s go back to the text of the bill…

The so-called “Public Option” will not include “excepted benefits”. So under your new government health insurance, you will not have any of the following benefits, and will have to buy them on your own or just not have them:
1. Dental
2. Vision
3. Accident or disability
4. Liability coverage
5. Workers’ compensation
6. Insurance for injuries sustained in automobile accidents
7. Long-term care
8. Nursing home care
9. Home health care

How does the Public Option sound so far to you? To me, it sounds like pretty lousy coverage. I mean, seriously. No dental? No vision? No long-term care, nursing home care, or home health care? Most private insurance includes stuff like this.

HR 3200, Section 102 (Part 1)

(a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term `grandfathered health insurance coverage' means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met:
(A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.
(B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day.
(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1.”
Section 102 deals with your current health insurance through a non-government health insurance company – the insurance that you currently have, and that you will have on the day this law goes into effect:
1. Private insurance companies will be prohibited by law from enrolling any new customers in their plans after the first day this law goes into effect.
2. If you already have health insurance (and don’t try to change to another company), then your dependents will be allowed by your government to be enrolled on your plan.
3. Your benefits on your private plan are prevented by law from being changed, even if those changes are for your benefit. For example, you couldn’t switch to a better plan that suits your changing needs as time goes on.
Likely Effect:
If you decide you don’t like your private insurance plan, for whatever reason (and there are plenty of reasons made likely by the later provisions in the bill), you are prevented by your government from changing to another private insurance company or from changing your existing plan to one that is cheaper, or that better meets your needs!

Your President and your Congressional representatives are telling you that this bill will not serve to weaken or destroy the private insurance industry. Judge for yourselves. Just remember this: if there is no viable private option for you (and this portion of the bill tells you that there is not), your only recourse is to become enrolled in the “public option”, the socialized medicine plan run by the government – the same government that is calling those of us who oppose this bill “Nazis”.

The only thing "fishy" is HR 3200

Because President Obama has accused those of us opposing the socialized medicine bill, HR 3200, of disseminating "misleading information" and of resorting to despicable tactics of fear-mongering, I thought I'd turn to the bill itself. I don't have to scare you. The bill does that on its own. Following posts will excerpt directly from HR 3200.

HR 3200, Sections 111 and 112

HR 3200
A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.”

Rules for surviving private insurance providers:
1. They can’t exclude care for pre-existing conditions. This means that the premiums for everyone in the private plan will have to go up to cover these conditions; another nail in the private insurance coffin.

The requirements of sections 2711 (other than subsections (c) and (e)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and subsection (e)) of the Public Health Service Act, relating to guaranteed availability and renewability of health insurance coverage, shall apply to individuals and employers in all individual and group health insurance coverage, whether offered to individuals or employers through the Health Insurance Exchange, through any employment-based health plan, or otherwise, in the same manner as such sections apply to employers and health insurance coverage offered in the small group market, except that such section 2712(b)(1) shall apply only if, before nonrenewal or discontinuation of coverage, the issuer has provided the enrollee with notice of non-payment of premiums and there is a grace period during which the enrollees has an opportunity to correct such nonpayment. Rescissions of such coverage shall be prohibited except in cases of fraud as defined in sections 2712(b)(2) of such Act.”

A private insurance company can’t kick someone out for non-payment of premiums until a “grace period” has elapsed after notifying the insured person. Okay, whatever. It won’t really matter anyway, because there won’t be any private insurance companies left. Only the “public option” will be available.

Why I Fight

I am a General Practitioner Physician. I strongly oppose the health care reform bill being debated currently.
I oppose it for reasons of personal survival - I owe $250K in college and medical school debt. I ask no favors from anyone, but I DO ask for the opportunity to ply my trade as there is demand for it - not unlike a baker, plumber, or grocer - and negotiate directly with my customers, as they do.
I oppose it on ethical grounds - it has been conclusively proven throughout the ages that there are never enough "rich" people to exploit to the benefit of those more numerous voters extending their hands for favors from an indebted government. An organism can be parasitized only so long as blood remains in its veins. Then both host and parasite die together. I oppose it because it must, if it is to work properly, place greater value on some lives than on others, creating an Orwellian "tyranny of the productive", in which the elderly, chronically-infirm, disabled, or congenitally-imperfect are sacrificed to the benefit of those who can provide more tax revenue and drain less. It is the exercise of eminent domain applied to human life. This weapon, already visible in embryonic form among private insurers, would be utterly terrifying when wielded by an almost unstoppably-powerful and monolithically-large and deaf government.
Finally, I oppose it on historical grounds, as our government has shown itself pathologically and perpetually unworthy of even the most rudimentary trust.
In the final analysis, however, and part as a result of this well-earned lack of trust, I oppose it because they clearly want it so badly. I have come to the conclusion that anything they want badly enough to label their own constituents as unruly Nazi mobs, or to seek protection from their own voters using paid union thugs, just simply must be opposed with total abandon.