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Change to the Senate bill

Here's the summary document Reid's office is sending around on the changes in the manager's amendments. I've bolded the bits I think are important.

Tougher Accountability Policies for Health Insurance Companies

• Stronger medical loss ratios. Health insurers will be required to spend more of their premium revenue on clinical services and quality activities, with less going to administrative costs and profit – or else pay rebates to policyholders. These more rigorous limits will continue even after the Exchanges begin in 2011, and apply to all plans, including grandfathered plans.

• Accountability for excessive rate increases. A health insurer’s participation in the Exchanges will depend on its performance. Insurers that jack up their premiums before the Exchanges begin will be excluded – a powerful incentive to keep premiums affordable.

• Immediate ban on preexisting condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage of preexisting conditions for children.

• Patient protections. Health insurers will have to abide by a set of patient protections that, for example, protect choice of doctors and ensure access to emergency care.

• Ensuring access to needed care. The use of annual limits on benefits will be tightly restricted to ensure access to needed care immediately, and will be prohibited completely beginning in 2014.

• Guaranteed opportunity to appeal coverage denials. All health insurers will be required to implement an internal appeals process for coverage denials, and states will ensure the availability of an external appeals process that is independent and holds insurance companies accountable.

Stronger Policies to Make Health Care Affordable

• Innovation. Medicare will be able to test new models and, if successful, implement them via a stronger Innovation Center, Independent Payment Advisory Board, and other authorities.

• Transparency. New requirements will ensure that insurers and health care providers report on their performance, empowering patients to make the best possible decisions.

• Small businesses. A package of improvements include starting the health insurance tax credit in 2010, expanding eligibility for the credit, and improving the buying power of small businesses.

More Health Insurance Choices

• Multistate option. Health insurance carriers will offer plans under the supervision of the Office of Personnel Management, the same entity that oversees health plans for Members of Congress. At least one plan must be nonprofit, and the plans will be available nationwide. This will promote competition and choice.

• Free choice vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an exchange plan.

Improved Access to Quality Health Care for Seniors, Children, and Vulnerable Populations

• Quality of care in Medicare. Seniors will benefit when additional health care providers are reimbursed by Medicare for the quality of care they deliver, not the quantity of services they provide.

• Children’s health. Support will be extended for the Children’s Health Insurance Program and the adoption tax credit. Foster care children aging out of Medicaid will be able to retain its comprehensive coverage.

• Community Health Centers. A substantial investment in Community Health Centers will provide funding to expand access to health care in communities where it is most needed.

• Rural and underserved communities. Access will be expanded through funding for rural health care providers and training programs for physician and other types of health care providers.

• Vulnerable populations. A range of new programs will tackle diseases such as cancer, diabetes and children’s congenital heart disease, will improve the Indian Health System and will provide support for pregnant teens and victims of domestic violence.

Identifying Alternatives to Litigation

• Testing new models. States will be eligible for grants to test alternatives to civil tort litigation that emphasize patient safety, disclosure of health care errors, and early resolution of disputes, with a provision for patients to opt-out of these alternatives at any time. Alternatives will be evaluated to determine their effectiveness.

By Ezra Klein  |  December 19, 2009; 1:39 PM ET
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Next: Sentences I am happy about in the Senate bill: Part II


Being a resident of Illinois I am disappointed in Senators Durbin and Burris.

They should of held out for more money, 300 million dollars, than has been promised to Senator Landrieu for medicaid bills in Lousiana.

They should of held out for more than was promised to Senator Nelson, which is the Federal government will pay all of Nebraska's medicare bills forever.

Durbin and Burris should demand that the Federal government pays all of Illinois' medicaid bills plus 300 million dollars.

The citizens of Illinois deserve no less!

Posted by: mwhoke | December 19, 2009 1:56 PM | Report abuse

It is important not to view things in isolation, because many positive changes are synergistic. For example, the appeal p[rocess in and of itslef may not be a biog deal, but it is a way to collect information on plans that gouge or discriminate, and that, in turn, could be the basis of exclusion from the exchanges. This is in addition to the explicit provision that is highlighted.

Posted by: Mimikatz | December 19, 2009 1:59 PM | Report abuse

Can you provide a bit more details on what becomes of CHIP under the Senate bill? Under current law, CHIP expires at the end of 2013. And I was very surprised to learn this week that the House bill envisions ending CHIP at that point and moving kids into Medicaid or the Exchanges. But that seems an incomplete plan to me, since Medicaid would only go up to 150% FPL under the House bill, whereas CHIP currently goes up to 400% FPL, if I recall correctly. Jay Rockefeller said this week that he'd vote against the bill if it included the House provisions on CHIP.

This statement says "support will be extended." Does that mean it is authorized beyond 2013? Do you know for how long?

Posted by: HBurton1 | December 19, 2009 2:01 PM | Report abuse

The soon-to-be amended Senate health care bill will cost $871 billion over 10 years according to a new, long-awaited report by the Congressional Budget Office.

That's about $22 billion more than the bill was originally expected to cost, before the new changes--including nixing the public option--were offered to the bill. Democrats replaced the public option with a new plan to allow national or multi-state, non-profit insurance plans, regulated by the federal government, to sell insurance on state exchanges.

The CBO has concluded that, on average, premiums will be the same as they would have been if the Senate had the public option, but that the public option saved the federal government more money by putting downward pressure on the premiums of low-cost private plans, which will be heavily subsidized.

The bill remains a big deficit slayer--$132 billion in the first 10 years. Over the next 10 years, CBO warns all estimates are very uncertain. But here's a key conclusion: "CBO expects that the legislation, if enacted, would reduce federal budget deficits over the ensuing decade relative to those projected under current law--with a total effect during that decade that is in a broad range around one-half percent of GDP."

Senior Democratic aides are suggesting that the bill could reduce the deficit, compared to deficits projected under current law, by as much as $1.3 trillion.

Posted by: omaarsblade | December 19, 2009 2:25 PM | Report abuse

From my Dutch perspective, the outlines of this plan is quite similar to the Dutch system.

It all depends on how strong the ‘guardians’ of the Exchange will be: only allowing insurance plans into the Exchange who provide insurance for at minimum basic care for a reasonable price. The Dutch plan goes further in that government, insurers (all private, no "public option") ánd representatives of consumers agree on a basic plan, and it's price, and giving the insurers the freedom to offer additional plans.
The Exchange could function in a similar way: only plans that meet the requirements of at minimum basic care for a reasonable price are allowed in the Exchange. And because the Government has to guard against excessive costs through tax breaks and subsidies can act as a massive single buyer (with big leverage over the insurers).

Posted by: wimprange | December 19, 2009 2:58 PM | Report abuse

"Insurers that jack up their premiums before the Exchanges begin will be excluded" ...

Good forethought! This makes me smile.

Wish something similar had been applied to the credit card industry ... who jacked up their fees as soon as they heard restrictions and regulations were on the horizon.

Posted by: onewing1 | December 19, 2009 3:03 PM | Report abuse

The earmarks that Landrieu and Nelson obtained in the health care bill make "the bridge to no where" look like small potatoes!

Posted by: mwhoke | December 19, 2009 3:04 PM | Report abuse

What a joke. These so called reforms are meaningless. The Congress has been unable to enforce existing law against the Financial Industry how are they going to be able to enforce laws against an industry that will be the richest and most powerful ever seen. One that takes upwards of $10,000 from every American family and keep 20% for profit. One that will be richer and more solvent than the U.S. Gov't. One that has been non-compliant for decades. Particularly comical is the guarantee to appeal denials. People can appeal denials now. The problem is people who need to appeal are already in a compromised position due to illness and at a huge monetary disadvantage in appealing Giant Insurers. The appeals in many cases outlast the lives of those who are appealing. The companies count on that. Reform regarding pre-existing conditions? What good is no pre-existing exclusions if the price for those with these conditions is too high? There aren't even any anti-trust laws to protect consumers. When (not if) the insurance companies violate the regulations and they get caught and someone actually has the time or the strength to fight them, any penalty will be also be a joke. Any penalty will be miniscule compared to the amount of money these companies will extract from the taxpayers pockets. This entire reform package is a farce.

Posted by: ophelia3 | December 19, 2009 3:13 PM | Report abuse

I just want to say thanks for working on a Saturday. This morning, after reading the manager's amendments (gobbledy-gook to me) and listening to clerks reading same (more gobbledy-gook), and watching press conferences for both sides of the aisle, my mind was mush.

So, I was excited/relieved to see you're there already, doing what you do best ... making sense out of the non-sensical.

I appreciate what you do and how you do it.

Posted by: onewing1 | December 19, 2009 3:15 PM | Report abuse

Are you saying that there is no pre-existing exclusion ban for adults? Ever?

Posted by: lostinthemiddle | December 19, 2009 3:17 PM | Report abuse

There's some compelling stuff there, but I expect you'll be giving us the downside next, particularly what incentives and concessions the insurance industry has extracted from the process.

Keep up the good work, BTW.

Posted by: st50taw | December 19, 2009 3:19 PM | Report abuse

:-) :-)

Posted by: jkaren | December 19, 2009 3:28 PM | Report abuse

As everybody knows, insurers have two ways of gouging consumers: jacking up premiums (up to 25%) and slashing actuarial value (down to 60%AV). It's ironic that we're all trying to find a silver lining in this doomed policy. Rest assured the lobbyists have already worked it over.

Posted by: bmull | December 19, 2009 3:43 PM | Report abuse

Many fear this bill will inflate the health care industry into something so big no future government will be able to control it. This bill may not be just a start, it may be final. This is it. You wanted reform? You got it, stop complaining.

It may mark the end of the debate of single payer, or a public option apart from Medicaid and Medicare. This bill may represent the loss of the opportunity to install any cost controls.

Perhaps the threshold from which government no longer had a handle on the industry was already crossed and that is why this Senate bill has become what it is. Perhaps this is in fact a bipartisan agreement, appearances to the contrary.

Both parties agree, cost containment is a non-starter. Cue the strains of Kumbaya.

This is not about "flaws" that can be "tweaked" at some later date. This writes force fed, country-wide health care profiteering into federal law. The only chance for regulation of health care effectiveness, access and efficiency at the local level will be moved to Washington's K street. Good luck with that America.

People, we don't live in a tiny rich country like Holland, Switzerland, Sweden, or Norway. This country is the third largest in the world behind China and India. Do you know what that means about the cost of universal coverage combined with forced inefficiencies?

After our population comes Indonesia, Brazil and so on. So lets drop the bs about Shangrila's health system. This is the most expensive piece of legislation ever, ever in world history.

It moves the colossal American economy further into health care as its central economic activity...with no cost control mechanism, just a few fig leafs and some things that are good and right, like more FQHCs.

Posted by: shrink2 | December 19, 2009 3:54 PM | Report abuse

It is not true they will Nebraska's "medicare" bills forever. The provision Nelson negotiated for was about MEDICAID not Medicare. And it is not for ALL of the Medicaid costs, just for those newly enrolled. And it does not apply just to Nebraska, but to all states.

It would help if people at least tried to get correct information.

Posted by: tmcbride1 | December 19, 2009 4:07 PM | Report abuse

To lostinthemiddle: no the pre-existing condition ban for adults will take place in 2014.

Posted by: reader44 | December 19, 2009 4:22 PM | Report abuse

reader44, thanks.

Posted by: lostinthemiddle | December 19, 2009 4:37 PM | Report abuse

I don't understand the FREE CHOICE VOUCHER. If people are so poor that they're exempt from the mandate, then how can their employer contribution be enough to afford premiums? second, it sounds like these people would already have employer-sponsered insurance. Is this saying that anybody can chose opt out of their group insurance and take their employer contribution to shop for insurance in the exchange?

Posted by: lagnappe | December 19, 2009 5:16 PM | Report abuse

@lagnappe, it's a little complicated but it works like this. If the cost of your insurance would have cost you more than 8% of your household income, you are not subject to the penalty if you don't get insurance. But, if your employer offers you a qualifying plan, you aren't eligible for tax credits in the Exchange unless your share of the premiums exceeds 9.8% of your household income. So, for the people whose employer-based insurance premiums would cost them between 8% and 9.8% of their income, they could demand to get "paid" the portion of the premiums the employer would pay in the form of a voucher and take that to the Exchange in hopes of finding less expensive coverage.

Posted by: StokeyWan | December 19, 2009 5:43 PM | Report abuse

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