Saturday, December 19, 2009


struck to get Nelson and Manager's Amendment is being introduced.
Republicans objected to waiving reading of amendment as predicted and they are reading it now...estimate is 8-10 hours. They must finish by 11:59 tonight to have cloture vote to break filibuster at scheduled 1am vote on Monday (apparently one entire calendar day must pass).

Text of managers amendment is here. Going into work to print and read....more later.

Some Big Changes I see from managers amendment:

*CLASS stays in.

*Larger High Income Payroll tax increase. Original Senate bill had 0.5 % increase of Medicare payroll tax for persons making over $250,000 per year now 0.9% increase.

Current law 1.45%>>>>2.35% for $250,001st dollar on up proposed, to take effect Jan 1, 2013.

*High cost insurance tax. Longshore workers classified as high risk, which exempts their benefits from the tax. Also exempts flexible spending account amounts from contributing to the total value of making a 'plan' meet the high cost tax level if the employer limits indivdiual contributins to flexible spending accounts to $2,500. So, if an employer doesn't limit to $2,500, the amount in a flex spending account would count toward the total [along with employer share of major med, employee share]. p. 362-364.

*Abortion: language tightening and walling off federal money from paying for abortion. Also a state level clause that would let states ban all private insurance policies from covering abortion sold in exchanges. [Currently, there are 6 states that ban abortion covered by private insurance outright.] Here is what I wrote about Stupak. pp. 38-54. Lots of detailed language about what is not meant by abortion lingo, notably not altering EMTALA, Civil rights Act(s), etc.+

*Tax on medical device makers. Delayed by one year, now start 2011. But fee rises from $2 Billion put on industry in pro-rated manner to $3 Billion after 2017.

*Tax on insurance providers. I think I have this straight, but would like to see what others say here. The amount of the industry wide annual tax before was $6.7 Billion. Now it will be 2011 $2Billion; 2012 $4 Billion; 2013 $7 billion; 2014-16 $9 Billion; 2017 and later $10 Billion.

Other change is that revenue generated by third party administration fees are exempted from determining the share of the tax that a given company would owe (now only premiums received as a measure of their business). And the schedule for how premium totals are exposed to this tax for a given company is the same. If $25Million or less total net premiums in a year, then 0 tax; if $25M to $50M then 50% are exposed to determine the amount of tax owed. If above $50 Million, then total premiums used. All of this is for determining how this 'industry tax' is apportioned among said industry. pp. 365-370.

Insurance doesn't include LTC insurance, Medicare supplement,

*Tanning bed tax! Cosmetic surgery tax gone, but 10% tax on tanning beds effective July 2, 2010. [Hint: just go outside and you can avoid this one] p.373

Other Changes, More or less straight through the document.
*Nebraska: Full funding of Nebraska Medicaid expansions in bill, up to 133% of poverty (other states get 94% I believe)....cost of $45 Million over 10. Landrieu got $300 Million. No word on federal building namings or bridges....

*Insurance regulations (I think I have this straight, would like to see what others think): No lifetime limits on dollar value of benefits after exchanges up and going (Jan. 1, 2014). Before then, annual limits are allowed if they are judged to be reasonable by Sec of HHS. The above applies to "essential benefits" under the Patient Protection and Affordable Care Act.

short version seems to be no annual limits on essential services per the existing law after exchanges up and going in 2014. pp.2-3

*Guns: None of the Act provisions, including the wellness and prevention provisions of original bill that included data collection efforts of risk factors for death, etc. cannot ask about guns or ammunition. And the amendment forbids use of gun ownership to risk rate premiums...Nelson is a big hunter and this stuff is right at the top. pp. 5-7, new section called Protection of Second Amendment Gun Rights.

*Insurance regs, II: starting in 2011, group insurance must spend 85% [or higher if state regulates differently] of premiums on health care, and issue pro rata rebate to consumers if they do not do so (meaning, bring in more premiums than needed to achieve this); 80% [or higher if state regulates] for individual policies. pp. 8-10

*No public option, but national NP plan. Insurers can create multi-state plans (sell across state lines) with states agreeing and Office of Personnel Management overseeing (who runs federal employees health plan). Plans must meet benefit reqiruements of the Act and have the benefit levels available (bronze, silver, gold, platinum) and then the plans can be sold in multiple state exchanges if state agree. States can also require extra benefits to allow multi-state plans to be sold (p.59). But, multi stating and/or states requiring extra benefits can't increase cost to federal govt [eg can't make subsidy rise]. States that have premium rating requirements of less than the Acts 3:1 can continue to impose them....I am pretty sure this is a big change from before (p.60). Phase in of what proportion of states a multi-state plan must be made available in for OPM to certify it as a national plan (60% of states in year 1 up to 100% in year 4). pp. 54-62.

*Individual mandate strengthened/penalties increased. The penalties for not purchasing coverage are higher. For example, initial said starting penalty was $350 in 2015 and now $495. In later years as penalites rise, there is now an income based penalty, more similar to House bill....I think. I will need to circle back here as it is complicated text in original and more complicated text in managers amendement. pp. 67-73

*Wyden's Amendment notion is contained in Sec. 10108 (p. 80) which is essentially a demonstration allowing employers to offer employees a voucher if they don't want the employer provided insurance that they (employee) can go into the exchange and purchase cover with. It opens this up to employees who premium contribution range between 8% and 9.8% of gross income. If more than that, they can get premium support subsidy through initial bill given income applicaibility. But, this lets a larger group of employees go and shop in exchange if employer willing. Interestingly, if the free choice voucher ($ to be spent on insurance) is greater than cost of plan, employee gets difference in income. So, could have employees wanting catastrophic only but at company with very expansive benefits picking this and employers being ok with it as 'free choice voucher' amount set at less than they pay now. A good dissertation topic for someone down the road, looking at the behavior here. pp. 80-89.

*Sec 10202. Incentive Program to get states to reconfigure Medicaid dollars toward community based services to keep folks out of nursing homes. Lots of detailed info here. Targeted at states where less than 50% of LTC is for non -institutional care. pp. 111-120.
Also extension of CHIP funding through 2015 and other CHIP stuff pp.121-132. STuff on pregnancy and prevention and then Indian Health Service funding up through pp. 146.

*Medicare innovation center and payment bundling demonstration. both important to actually move away from fee for service and old means of payments. pp. 153-161.

*Independent Medicare Advisory Board, Sec. 10320. Some additions, including in years when a recommendation is not reuired to be submitted to congress a plan for changes to Medicare, the board can still send an advisory recommendation. But, in most years, Medicare has slower rate of growth than full health system. I had hoped for a stronger change here. House bill doesn't have such a Board, so just keeping it in is good. This will need to be expanded and given more power down the road to improve ability to address cost inflation. Also, the Board now submits to the Congress and the President. Some other lingo here that I don't totally get...will circle back. pp. 180-190.

*Delay prospective payment update of SNF...RUG IV. Can't implement prior to October 1, 2011. I think it was to get into effect Oct. 1, 2010. This may be one of things Nelson was talking about when he said worries about payment changes for long term care provoiders. p. 212

*Pay for performance demos....more stuff to help move away from straight fee for service for Medicare doc payment. Can't increase total pay in an area. p. 213-215

*Amendments to Title IV p. 250-301 relate to research funding, NIH, and getting rid of co-pays for preventive services like mammography.

*Tort Reform. Extra demonstrations for states to address medical malpractice/tort. The requirements are that state must have demos that focus on alternative dispute resolution but which also address/focus on reducing medical errors. Also directs MedPac to do study on alternatives to current tort system. pp. 344-359.

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