HR 3962 is 1,990 pages, in ADOBE PDF format. You may download your PDF copy here. It reads in in legal-eze, meaning not too many folks will understand unless they’re attorneys, judges, or well-versed in such terms. It defines, overthrows, and changes fundamental principles. Obamacare. What’s in it for us?
The purpose of this article is simple: give everyone a simple summary of what the bill means, as best understood by one man who has enough legal understanding and education to at least take a crack at it (or perhaps I am just morbidly curious). However, reading 1,990 pages does tend to make a person take several deep breaths and sighs.
To keep this simple, and readable for the general folk, let’s state the great goal of this bill, in its own words:
“To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.”
Further down, the bill is given its nickname: “The Affordable Health Care for America Act.”
These are indeed lofty, noble goals. Is it possible to summarize this bill? Please realize that every word of this bill is subject to legal interpretation, to court rulings, and to the pending Supreme Court case, which may make this bill “fully legal” or just a “puff of smoke.”
Realistically, the true nature of this bill may take years to comprehend and to implement, if it goes as it stands. This suggests that whatever may be written here may be changed with the opinions of the courts, through time. The extent of the bill (again, 1,990 pages) and its complexity makes one wonder how long it took to draft, and just how well everyone on Capitol Hill understands it!
The author has taken a stab at the highlights, and found there are far too many highlights for our purpose here. Without clear guidance, we are left to listen to the media, to the hawkers, to the gainsayers, and to the naysayers, all of whom have their own agendas to peddle. Someone writing notes in Yahoo! News challenged everyone to read the bill.
So starts this article. We shall see how it ends. Curl-up and relax. It will take but a short time to run through it. All the page numbers are also referenced in the downloadable PDF.
Page 1 – 8: introduction, table of contents.
Page 9 – appx Pg. 17: Definitions of various terms. I’ll ignore these, as we know what Medicare means.
Pg 17: High Risk Pool Program
This starts 1/1/2010 and ends when the Health Insurance Exchange (HIE) is established. It’s managed by the Secretary of Health and Human Services. High risk suggests that those in this program are difficult to insure for a variety of reasons (including pre-existing conditions). This appears to be a temporary concept, therefore.
Anyone without prior coverage, with prior “conditions” that prevent coverage, and such, is eligible. Apparently, we must apply for this “High Risk Pool Program,” but how that happens is not yet defined by the “Secretary.”
Anyone who is a “resident” of the 50 States or of District of Columbia may apply. Note well, there is no definition of “resident” in this section and there is no mention of “US Citizen” in this section (Pg 19, Lines 23-25). This may require further study.
Premiums are based on age, on local customary charges for similar healthcare premiums, at a rate no more than 125% of the “charges” we mention. There’s a $1,500 individual deductible (Secretary sets “family” limit, not mentioned), and maximum out-of-pocket costs of $5,000 for an individual ($10,000 for a family) per year. There is no lifetime limit imposed. There are no pre-existing conditions clauses.
States appear to be required to contribute financially in some degree to the pool as well, based on state residency.
Budget, $5 billion. Premiums and benefits can be changed by the Secretary as financial needs dictate.
We are reminded at the end of this section that it is temporary and that the “Health Exchange” takes-over this issue at some time in the future.
That pretty much ends the “High Risk Pool Program” section. We are now at page 27. Whew!
NOTE: What follows below appears to be a “general” rule, across-the-board. Okay, read-on!
Value and Lower Premiums
We’re told we may see rebates on premiums we pay if the medical loss ratio is no less than 85%. This seems to be a standard measure, comparing premiums paid to medical payments rendered. The Secretary tells the insurance companies how to calculate that ratio. The goal is reduced premiums and premiums used for medical payments. It seems regulatory fees and taxes paid by insurance companies are not included in this ratio calculation.
There is a requirement that the Secretary do nothing to “destabilize” the individual health insurance premium market. This term is not defined further.
Cancellation of Policies, etc.
We’re at Page 28, Line 18. Except in clear cases of fraud, insurance companies cannot cancel, refuse to pay, or refuse to renew health insurance. There is an appeals process which appears to be something similar to 3rd party binding arbitration.
No Price Gouging.
Page 31, Line 17: It’s as simple as that. There can be no unjustified premium increases. The Secretary determines if a premium hike is justified. This seems universal. There is no mention of group or individual.
Young Adult Coverage.
Page 32, Line 8 begins this subject, but it’s repeated elsewhere in the bill (see Pg 101, Line 18). Basically:
A child is under 27 years of age (that is mostly standard from recollection).
A coverable child has no other forms of insurance.
It is optional, rather than required, apparently.
Premiums are subject to normal family premium experience, as judged by the Secretary.
Pre-existing conditions appear to be positively-impacted by shorter waiting periods of either three or nine months. It is a complicated section here, from Pg 38 – 40. There is a profound amount of cross-referencing to various other codes and terms.
It all starts January 1, 2010. Of course, this legislation is not yet implemented, and as mentioned, that will doubtlessly take a while. We’re at Page 40, Line 5. Gulp!
Any collective bargaining (Union employees & Union shops) over policies will end after the implementation date, or no later than three years, apparently.
Page 41, Line 1 and Domestic Violence Coverage:
ERISA refers to an extensive catalog of laws, meaning “Employee Retirement Income Security Act.” There is a modification of this act to include victims of domestic violence to “pregnancy” as covered items (companies cannot object to coverage for these items).
Birth defect and other forms of childhood disease or injury coverage (cognitive development is not mentioned, but is covered elsewhere, see Pg 183, Line 1):
Pg 43, Line 5: Birth defects are covered. Children here are defined as 21 years of age or younger. Only “cosmetic surgery” is not included (to improve appearance or self esteem).
Pg 47, Line 5: Surgery on children to restore an approximated normal appearance (due to congenital defects, trauma, disease, tumors, for example) are allowed. These types of surgery are not considered “cosmetic.”
Lifetime or Annual limits on payouts: None! Pg 49, Line 1, and Pg 50, Line 4. See also Pg 52, Line 20.
Can’t reduce post-retiree group insurance benefits, Pg 53, Line 13.
The bill introduces a “wellness” programs grant for small employers, repaying 50% of costs incurred or paid on approved plans. Pg 62, Line 22.
COBRA coordination, Pages 70 – 72.
State Health Access Program Grants, Starting at Pg 72, Line 19, discusses a myriad of changes. States must apply for the grant, but states already having such laws and processes on their books are not eligible. This appears to include hidden costs, including systems standardization (program/database changes). This is a complicated section.
Page 90, Line 12 appears to begin the “consumer part” of the bill.
Mentions of affordability, consumer benefits, consumer protection standards (set by the Secretary).
Mentions grandfathering to keep one’s current coverage, if desired, with lots of conditions (Pg 91 – 93).
Only “exchange-participating individual health plans” are allowed (Pg 94, Line 3). However things seem to be ambiguous, upon inspecting Pg 103, Line 11 (also, cf Page 140, which discusses such plans, including employer-based group plans).
No pre-existing clauses and guaranteed renewability (Pg 95).
Premium rates are age-based but cannot exceed a 2:1 ratio between highest and lowest prices.
Premium rates are geographically calculated, and include family rates as well.
The Secretary qualifies all rates, basically.
There may be no discrimination, and assurance of adequate network providers is included (Pg 100, Line 21).
Emphasis on no annual or lifetime benefits (Pg 105, Line 6).
Rubber-stamped medical treatments (not always good, not always bad) are allowed on individual or group plans, but only with clear medical evidence and with clear indications that the treatment is individually-appropriate (Pg 105, Line 7).
It appears we can get vision, dental, etc. coverage as well (Pg 104, Line 13).
Cost sharing is eliminated on some items and capped on others (Pg 107, Line 3).
“Abortion Coverage Prohibited as part of Minimum Benefit Package” (Pg 109, Line 7-8). However, we must also read Pg 111, starting Line 8. Federal funding for abortions is prohibited in some cases and allowed in others. These appear (uncertain?) to relate to the Hyde Amendment which prohibits federal funding of most abortions under Medicaid. See also Pg 147, Line 3 (ff) for more details on abortion. In a nutshell, things appear unchanged.
Dental health is to be considered later in time, based on committee study (Pg 111, Line 1).
Around Page 119, we see assurances regarding Marketing Practices, Appeals, Grievances, Information Disclosure, and Plan Transparency. It ends on Pg 127 with Timely Payment of Claims.
The whole of our healthcare will be governed by an independent arm of the Executive Branch, named the Health Choices Administration (HCA). This starts on Pg. 131, Line 14. Thereafter, we see the formal establishment of the Health Insurance Exchange (HIE) and Individual Affordability Credits (IAC), which suggest that ability-to-pay is related to amounts of credits, which seem to affect total premium amount.
Pg 138, Line 10 creates an Ombudsman for hearing of complaints, etc.
Pg 150, Line 18; antitrust laws now apply to health sector insurers.
Pg 155, Line 1: the teeth of the Health Insurance Exchange (HIA) within the auspices of the Health Choices Administration (HCA).
What is acceptable coverage (Pg 159, Line 3)?
Qualified health benefits plans.
Grandfathered health insurance coverage.
Medicare, Medicaid.
Members of armed forces & dependents (Including TRICARE).
VA Coverage (Service-Related, etc.).
State Health Benefits Risk Pool.
Types of HIA Coverage (not all areas have all plans) (Pg 167, Line 1):
Basic
Enhanced
Premium
Premium-Plus
On Page 196, we find an ominous series of permissible transfers to the “trust fund” that covers HealthCare. These include:
Taxes on individuals failing to obtain healthcare.
Taxes on companies failing to obtain healthcare.
Excise taxes on anyone failing to obtain adequate healthcare.
Page 206, Line 13 allows for non-profit-run “CO-OPS” to provide healthcare alternatives for their subscribing members. These provide insurance through the Healthcare Insurance Exchange as well.
Starting on Page 211, Line 5, the “Public Health Insurance Option” discussion begins more formally.
Page 224, Line 19: Public Health Insurance participation is voluntary. Considering the taxes imposed (Pg 196), one must wonder what these words mean. Something appears ambiguous. Pg 225, Line 1: Congress has the option of joining into Public Health Insurance. They are also not required to join. However, they are otherwise covered by their own Federal-provided insurance.
If one now reads starting at Page 268, Line 1, Title IV, “Shared Responsibility,” the words are clarified. Everyone must obtain coverage. Employers must provide coverage. Section 501 of the Bill adds the words to IRS code (see Page 296, Line 9) “Tax on individuals without acceptable healthcare coverage.” It is, indeed, a tax. Here’s a great article on the subject, which seems to be at the heart of so much fear (and probably the biggest push to get this before the Supreme Court).
Page 226, Line 17 begins a discussion on Individual Affordability Credits, governed by Sections 343 (credit applied) and 344 (cost-sharing applied).
NOTE: An individual applying for Individual Affordability Credits MUST be a legal US Citizen or otherwise lawfully present (Page 228, Line 14, fwd).
Who is eligible for credits? (Pg 247, Line 1, ff).
A legal US Citizen/Resident.
No other coverage but the Public Healthcare Option.
Modified Adjusted Gross Income 400% or less of federal poverty level, based on family size.
Not in Medicaid or other healthcare like program.
How much credit do I get? (Pg 250, Line 17). See also Page 253, Line 3.
It’s based on your income and lots of calculations. Read it if you were a math major. There are out-of-pocket limits.
“My Fellow Americans.” This phrase was used by many presidents, and I can trace it back to Franklin Delano Roosevelt’s first inaugural address.
My Fellow Americans, I am ending this article where it is best ended. The Bill, HR 3962, is far too long to provide a logical, correct, legally proper discourse in a single article. I can only point to the words and hope they mean what I think they do, and I believe I have identified some or most of the major concerns and sticking points. I know I may often be incorrect, having missed some points (I ignored some things which were not pertinent) and I certainly did not finish the whole Bill. However, this editorial at least tries to put some “meat on the bones.”
I suspect that the greatest expense and barrier to implementation will be in educating not only the various government and health care entities, but also the vast population of the American People.
I urge all Americans to do what they can to read-through this bill. Perhaps this thumbnail will be a catalyst for starting.