What’s Actually IN The Health Care Reform Bills, Without the BS — Part One

I don't know about
you, but I'm getting sick of the right wingers (and frankly, everyone else)
talking about what's NOT in the health care reform bills before Congress. Don't
you think it's time someone actually looked at what's actually IN the bill?  You know, without the paranoid spin?

(And for those of you who are looking for my Deconstruction of the Right's Lies in the Health Care Bill go HERE, or click on the link at the top of the right column…)


President Obama has
been trying to tell us what's in the bill, but honestly, his
Administration seems to be too interested in getting input from everyone else,
and it has dropped the ball on getting information about the proposed system
out there. They have been on the defensive since day one, constantly responding
to the right wing fart machine, and allowing complete crap to enter the media


I'm going to start
by going through
HR 3200, which was the
original bill and tell you what it does, and why that will reform our health
insurance system in a positive way.  There are so many positives, above
and beyond creating a public insurance option, I just thought it was time to
explain what they are. So read and learn, folks. It's time we took back and led
the debate, and stopped simply reacting.


I encourage
everyone to read the bill. It's only 1000 pages because of the way Congress
writes bills — large print and large margins, so they can mark it up. If it
was in book form, it'd be less than 300 pages.  And there is some legalese
in it, but there is a lot that is absolutely easy and straightforward to read,
as well. I have a lot of experience reading legal documents and bills and such,
and my goal here is to make this easy for you to explain to reasonable people.
This is not meant to change the minds of the right wingers on your Christmas
card list, or those whack jobs who are invading the town halls. Use this to be
pro-active about health care reform. It's not enough to simply counter the
right; if we're to convince moderates and other reasonable people to support it
on this, we're going to have to accentuate the positives in the new bill, and
not just scream "Public Option!" at the top of our lungs. There is so
much wrong with our system, and this fixes a lot of it, far beyond simply
creating a public insurance system.


Okay, let's get


The first thing you
should take note of is the section at the beginning, just before the table of
contents (pages 4-5). It's important to read, because it describes the purpose of the bill.
I'm sure you've heard the term "legislative intent." This
section forms the essence of legislative intent. It puts the lie to the assertions
by many that, somehow, Democrats intend for the government  to take over
the entire health care system, and force people into a national public
insurance system. The legislative intent of this bill is straightforward, and
is as follows:





(1) IN GENERAL.—The purpose of this
division is to provide affordable, quality health care for all  Americans
and reduce the growth in health care spending.

division achieves this purpose by building on what

works in today’s health care system, while
repairing the aspects that are broken.

(3) INSURANCE REFORMS.—This division—

(A) enacts strong insurance market reforms;

(B) creates a new Health Insurance
Exchange, with a public health insurance option alongside private plans;

(C) includes sliding scale affordability
credits; and

(D) initiates shared responsibility among
workers, employers, and the government; so that all Americans have coverage of
essential health benefits.

institutes health delivery system reforms both to increase quality and to
reduce growth in health spending so that health care becomes more affordable
for businesses, families, and government.


Now, this is the
first thing you should keep in mind as you read the bill itself. The bill's
intent is to provide health care for all AMERICANS (note that term, folks;
undocumented immigrants are not, by definition AMERICANS) by building on the
current system
and reforming the entire insurance system. The intent
is to create more competition, and to make the entire health care system by
controlling costs. It's not intended to revolutionize the system, and scrap it completely. There is no stated intention to take over the entire system. Even the Health Delivery System section only intends to "reduce growth;" it does not describe an intent to cut costs to the bone.


So, when people
suggest that government intends to take over the entire health care system, you
can point to their stated intent and call that argument nonsense.

This could very
well be one of the most misunderstood sections in the entire bill. It's
certainly the part about which I receive the most mail.


Page 14 —


Subtitle A—General Standards


This part of the bill is designed
to protect consumers, period. See, when the public option is put into play, it
will likely be less expensive than many of the private insurance options. This
part of the law protects consumers, by creating a set of minimal standards for
a qualified health plan. This is actually a good thing, because it prevents
insurance companies from creating plans that aren't actually health insurance
plans from entering into the field. This is not only a protection for
consumers; ironically, it's a protection for the insurance companies as well.


I'm sure you've
seen those late night infomercials and commercials for "affordable health
insurance" for something like $150-300 per month. Well, if you look at them, they don't
cover jack. I saw one that pays $500 per day hospitalization, or $1000 per day for time in the ICU, for up to 30
days. That's not health insurance, because there's no way that would cover much of anything. And it didn't cover physician coverage at all. I'd like to call it a scam,  but I stop short of that, and
simply remind you that you get what you pay for. But there is no current law defining
what can be called "health insurance." This bill creates that. It
creates minimum standards for health insurance plans, and no one can
"qualify" as a health insurance plan until they meet that standard.


Section 102 seems
to be the biggest stumbling block to comprehension for a lot of people, if my mail is any indication. The title
says it all:



The lack of
comprehension comes with the tendency people have with reading every part of
the bill as if it was separate from every other part of the bill. That's not the case.


This bill would create
an Insurance Exchange. In the Exchange, qualified insurance companies offer
their wares side by side with the public insurance option. In other words, it
creates the same sort of system that Congress and most federal employees have,
in which companies appear on a rate and benefits sheet and the employee picks
the plan that suits them. I'll get into this more later on.


Section 102 allows
for the "grandfathering" of current health insurance for the first
few years. What this means is, if your company has offered the same insurance
for many years, they can continue to offer it, and you can continue. BUT, if anything about that plan
changes, the employer will have to offer the Exchange plans, which will include
your current plan, unless your insurance company has decided to opt out, which
is frankly unimaginable.


The grandfathering
provision seems to trouble a lot of people, because they claim it
"forces" people into the public option, which is simply not true. It
does, however, "force" people to choose among the public option and a potentially large
number of private options, which I fail to see as a negative.  Basically,
this section forces insurance companies to compete in an open market, which has
never been done before in this country. You will be completely free to choose
your current insurance company, to choose any other insurance company that
agrees to be part of the Exchange, which will probably be all of them, or to choose a public health insurance policy, if Congress doesn't do the right thing and decides to opt for a co-op system.


The next section of
the bill to consider is one the right wing just sort of glosses over most of
the time when they're complaining.


Page 19 – 25 —

Subtitle B—Standards Guaranteeing Access to
Affordable Coverage


This section effectively makes your health insurance portable., whether you choose public or private insurance. Under the status
quo, you could conceivably pay hundreds of thousands of dollars into a health plan with one
company and get nothing in return but annual doctor's visits for you and your
family, and maybe the occasional broken arm or bout with the flu, and actually be
denied coverage when you change jobs and discover, through tests, that you have
a congenital heart condition, or you have diabetes or something. Essentially, you've spent hundreds of thousands of dollars for nothing. If you develop
bone cancer in the arm that was broken and repaired years earlier, your new insurance company can label it a
"pre-existing condition" and refuse to pay for treatment.


With this bill,
insurance companies must allow you to buy a policy. They will also have
to pay for any treatment that can be considered necessary, medically speaking.



 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.


In other words,
under this plan, you will be able to choose your insurance; your insurance
won't be able to choose you. They can't deny you because you actually might have
to use your health insurance, as they currently do.  And if you continue
to Section 112, you'll note that this bill also prevents insurance companies
from dropping you for as long as you continue to pay your premiums. They can't
drop you for getting sick, they can't drop you because you might cost them some
money; they can only drop you for non-payment. And since your employer will be
responsible for three-quarters of the bill in most cases, there is no reason
to think you'll ever be dropped.  And there is a mandated grace period, as
well, so that you have time to make alternate arrangements, should you not be
able to pay your premium for a short period of time, or you change jobs.


The bill also makes the cost of insurance predictable and fair (Section 113). Insurance
companies will be able to vary premium prices slightly based on age, geographic area, and by family enrollment, but other than those extremely limited circumstances, everyone will
pay their fair share. They will no longer be able to price policies for people
with "pre-existing conditions" so high that no one could afford coverage. In other words, everyone pays into the health
insurance pool, which equalizes the costs for everyone else. Though many on the far
right don't understand this, this type of policy actually REDUCES costs for
healthy people, because healthy people will no longer be subsidizing health
care for the chronically sick to the degree they do now.


Overall, this part
of the bill seeks to make everything equal and fair for everyone, and eliminate
the built-in disadvantages to consumers in the current market. It creates a
basic set of minimal standards, and ensures that everyone can count on their
insurance coverage should they need it. Compare that to the current system, in
which private insurance can;

  • cancel your coverage at any time
  • raise
    your premium at any time
  • deny any procedure they want

Not only that, but currently any
company can offer something they call "health insurance" that doesn't
really cover much of anything. This bill creates a system in which you know up front
what's covered, and you'll never again be faced with a surprise unpaid bill for
basic health care. 


Whatever insurance
company you choose, whether it's on the Exchange or not, you will be
guaranteed the same access to basic health care as everyone else. Subtitle C
(beginning  on page 25) specifies that all health insurance companies will cover
everything considered necessary care, through the implementation of an
"essential benefits package," which means you, the buyer, can be sure that everything is covered. The bill clearly defines what MUST be covered in
an "essential benefits package," and there is not a lot of room for
interpretation. Insurance companies are free to offer more coverage at a
greater price,  if they choose to do so, but this bill defines the minimum coverage that must be
available to everyone with insurance.



(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.


Note that there is
no room in the above for any insurance company to deny payment for necessary
medical services by a qualified professional caregiver. That means any doctor
you choose, as long as it's a real doctor, can perform services, and your
insurance will have to cover the cost. Period. Also note that the bill also prohibits the setting of a
lifetime limit. This is common sense, really. If someone needs medical care,
and the coverage of that medical care ends at $1 million, that doesn't mean the
health care ends at that point. SOMEONE pays for that care. Now, it won't be
your worry; it'll be the system's problem.

I would also point out that the prohibition of a lifetime limit certainly seems to run counter to the claims of "health care rationing" coming from some quarters.


But there's more to
this section:


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

(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.


This bill ends a LOT of private insurance companies' abuses of the system. This covers pretty
much everything anyone NEEDS with regard to health care, and it eliminates
many of the questions many policyholders have regarding care under the current
system. If a procedure or treatment falls into one of these categories, and it is necessary care,
it is covered; no ifs ands or buts.


The bill itself doesn't
specify specific benefit standards, but it sets up a committee that will use
current insurance industry standards, current Medicare and Medicaid standards,
and input from many sources to determine much more exact standards. (Page 35,
Section 124) But the bottom line is, there
will be standards, and patients and doctors will no longer have to submit a
bill, then hold their breath and HOPE the insurance company will pay it. Unless the bill is fraudulent — and the burden will be on the insurance company to prove fraud — it will be paid.

rules and regulations will be published and readily available to everyone, and
it will be more difficult for an insurance company bureaucrat  to deny
coverage based on some "technicality."  Of course, on those
rare occasions where it tries to do so, anyway, Subtitle D of Title I (Page 37)
creates a mechanism for grievances and appeals that all insurance companies
must adhere to. That section also allows for the creation of uniform marketing
practices on the part of insurance companies, and requires full transparency
and plan disclosure, which means, when you sign up for a plan, you have to know
what it does and does not cover, whether your coverage is just basic coverage,
or you opt for something a little more elaborate.


Gosh, we're only 40
pages in, and what does this bill create? It creates a system that guarantees availability of
coverage to everyone, at a reasonable price, with guaranteed minimum coverage,
and in which an insurance carrier, public or private)  would have to jump
through significant hoops to deny coverage for anything your doctor deems


This is only Part
I. Over the next week or so, I will continue to go through the bill, and reveal
even more things that it actually will do if enacted. As always, feel free to
go read the sections as I present them, and see for yourself. I don’t expect
anyone to simply take my word for anything.


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