Reading HR 3200: The IRS as Enforcer

I have often admired the intelligence and persistence of Talmudic Scholars, those wise men who dedicate their lives to understanding the law, Hebrew Law, the law of God. The writings are presented and then discussed, debated, and interpreted. Then the opinions are recorded. In HR 3200 we need the wisdom of a fine group of such men. This is not a statement meant for humor of any type, it is a statement of sincere respect and of desperate need.

There are many blogs out there which a flailing about making statements that have at best questionable merit. I have been spending time reading this bill, slowly and not as well as any scholar, but having been through this process many times before helps but still leaves much in question.

In today's discussion we talk about the IRS becoming the police force for the Health Care Bill, HR 3200, a fact which seems to have been missed. People speak of getting health care from the motor vehicle bureau, but imaging having the IRS oversee your compliance. One agency more feared than the Taliban is the IRS. Never, never, I repeat, never, get the IRS upset. Overpay taxes, avoid deductions, and do whatever to stay away from their tentacles. But alas this Bill places them in the middle as the enforcer. Let me quote from the Bill.

"TITLE III—SHARED RESPONSIBILITY

Subtitle A—Individual Responsibility

SEC. 301. INDIVIDUAL RESPONSIBILITY.

For an individual’s responsibility to obtain acceptable coverage, see section 59B of the Internal Revenue Code of 1986 (as added by section 401 of this Act).

SEC. 322. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS UNDER THE INTERNAL REVENUE CODE OF 1986.

(a) FAILURE TO ELECT, OR SUBSTANTIALLY COMPLY WITH, HEALTH COVERAGE PARTICIPATION REQUIREMENTS.—For employment tax on employers who fail to elect, or substantially comply with, the health coverage participation requirements described in part 1, see section 3111(c) of the Internal Revenue Code of 1986 (as added by section 412 of this Act).

(b) OTHER FAILURES.—For excise tax on other failures of electing employers to comply with such requirements, see section 4980H of the Internal Revenue Code of 1986 (as added by section 411 of this Act).

TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A—Shared Responsibility

PART 1—INDIVIDUAL RESPONSIBILITY

SEC. 401. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.

(a) IN GENERAL.—Subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by adding at the end the following new part: ‘‘Subpart A—Tax on Individuals Without Acceptable Health Care Coverage ‘‘Sec. 59B. Tax on individuals without acceptable health care coverage. ‘‘SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.

‘‘(a) TAX IMPOSED.—In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of—

‘‘(1) the taxpayer’s modified adjusted gross income for the taxable year, over

‘‘(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer.


SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE.

‘‘(a) REQUIREMENT OF REPORTING.—Every person who provides acceptable coverage (as defined in section 59B(d)) to any individual during any calendar year shall, at such time as the Secretary may prescribe, make the return described in subsection (b) with respect to such individual.

‘‘(b) FORM AND MANNER OF RETURNS.—A return is described in this subsection if such return—

‘‘(1) is in such form as the Secretary may prescribe, and

‘‘(2) contains—

‘‘(A) the name, address, and TIN of the primary insured and the name of each other individual obtaining coverage under the policy,

‘‘(B) the period for which each such individual was provided with the coverage referred to in subsection (a), and

‘‘(C) such other information as the Secretary may require.

‘‘(c) STATEMENTS TO BE FURNISHED TO INDIVIDUALS WITH RESPECT TO WHOM INFORMATION IS REQUIRED.—Every person required to make a return under subsection (a) shall furnish to each primary insured whose name is required to be set forth in such return a written statement showing—

‘‘(1) the name and address of the person required to make such return and the phone number of the information contact for such person, and

‘‘(2) the information required to be shown on the return with respect to such individual. The written statement required under the preceding sentence shall be furnished on or before January 31 of the year following the calendar year for which the return under subsection (a) is required to be made."

Well, what does this say. I think it simply states that the IRS will become the policeman for compliance. You must report your coverage to the IRS, if you do not have any you them must pay a fine, and if you falsely make statements then you are guilty of tax fraud. Remember that the IRS already has rules and regulations to take your property if you defraud them and in addition you have now added to your tax burden. Our Secretary of the Treasury has just gathered more power, and one who himself had problems with the taxes.

One must also remember that the Bill from Congress when signed by the President becomes an authorizing legislation. It authorizes HHS and Treasury Secretaries to them create the Administrative law to enforce this. Administrative law is the billions of lines of law which implement the legislation passed. It is controlled by administrative law judges, not judges and juries, who make non recourse decisions. There are more administrative law judges than civil and criminal judges combined.

This is a shadow judicial system which in many ways flies in the face of the Constitution. The create Star Chambers, a practice which the Constitution eschewed, but via these types of legislation have returned.

It is a shame that we have many bloggers making statements without basis. There are true concerns in this Bill, concerns which need study. Where are the Talmudic Scholars in this realm? It may not be our souls at risk but it is our bodies!

For anyone who has ever been audited, remember, the IRS code is the only US code which assumes you are guilty until you prove you are innocent!

Bernake,the Fed, and What We Have Worried About!

Fed Chairman Bernake published a letter in the WSJ today stating:

"The exit strategy is closely tied to the management of the Federal Reserve balance sheet. When the Fed makes loans or acquires securities, the funds enter the banking system and ultimately appear in the reserve accounts held at the Fed by banks and other depository institutions. These reserve balances now total about $800 billion, much more than normal. And given the current economic conditions, banks have generally held their reserves as balances at the Fed.

But as the economy recovers, banks should find more opportunities to lend out their reserves. That would produce faster growth in broad money (for example, M1 or M2) and easier credit conditions, which could ultimately result in inflationary pressures—unless we adopt countervailing policy measures. When the time comes to tighten monetary policy, we must either eliminate these large reserve balances or, if they remain, neutralize any potential undesired effects on the economy."

This is what we have been complaining about for months, since October of last year and it was the basis of our most recent White Paper. He continues:

"The exit strategy is closely tied to the management of the Federal Reserve balance sheet. When the Fed makes loans or acquires securities, the funds enter the banking system and ultimately appear in the reserve accounts held at the Fed by banks and other depository institutions. These reserve balances now total about $800 billion, much more than normal. And given the current economic conditions, banks have generally held their reserves as balances at the Fed."

Again this is exactly what we have been arguing. It is the control of M2 growth as the Fed balance sheet implodes. This still means drastic inflation. Bernake knows the problem and this may be a plea to Congress to keep him there to manage it. Not to put Summers in his place. We feel the replacement of Bernake with Summers would potentially destroy the US economy. Bernake is always looking over his shoulder, reconsidering and re-planning, he is highly adaptive. In our opinion Summers totally believes in his current plan at least until he comes up with another. Just look at the stimulus plan, it frankly is not working. Bernake is an adaptive self checking individual, so keep him there.

Just look at his options for an exit strategy:

"First, the Federal Reserve could drain bank reserves and reduce the excess liquidity at other institutions by arranging large-scale reverse repurchase agreements with financial market participants, including banks, government-sponsored enterprises and other institutions. Reverse repurchase agreements involve the sale by the Fed of securities from its portfolio with an agreement to buy the securities back at a slightly higher price at a later date.

Second, the Treasury could sell bills and deposit the proceeds with the Federal Reserve. When purchasers pay for the securities, the Treasury’s account at the Federal Reserve rises and reserve balances decline....

Third, using the authority Congress gave us to pay interest on banks’ balances at the Fed, we can offer term deposits to banks—analogous to the certificates of deposit that banks offer their customers....

Fourth, if necessary, the Fed could reduce reserves by selling a portion of its holdings of long-term securities into the open market.

Each of these policies would help to raise short-term interest rates and limit the growth of broad measures of money and credit, thereby tightening monetary policy..."

Yes, increasing short term rates will occur and we believe there will be an inversion of the yield curve and a modest recession resulting from that rebound. It is necessary. Yet the snake in the wood pile of this plan is the tax and deficit explosions created by the current President. We are already seeing the destruction of many small venture capital companies and thus the elimination of long term value. If the policies continue we could become worse than France, Germany perhaps...

Comparative Clinical Effectiveness and HR 3200

In evaluating parts of HR 3200 as we did yesterday we have now begun to delve into the more arcane parts.Let us address the parts of the bill that refer to CCE. There appear to be two. and they are:

DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS

TITLE IV—QUALITY

Subtitle A—Comparative Effectiveness Research

SEC. 1181. (a) CENTER FOR COMPARATIVE EFFECTIVENESS RESEARCH ESTABLISHED.—

(1) IN GENERAL.—The Secretary shall establish within the Agency for Healthcare Research and Quality a Center for Comparative Effectiveness Research (in this section referred to as the "Center") to conduct, support, and synthesize research (including research conducted or supported under section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003) with respect to the outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically.

Thus the Secretary of HHS shall establish another Government Agency to do this CCE effort. Amongst its duties will be:

"(A) conduct, support, and synthesize research relevant to the comparative effectiveness of the full spectrum of health care items, services and systems, including pharmaceuticals, medical devices, medical and surgical procedures, and other medical interventions;

(B) conduct and support systematic reviews of clinical research, including original research conducted subsequent to the date of the enactment of this section;"

Yet it does not end here for it further states:

"(1) IN GENERAL.—The Secretary shall establish an independent Comparative Effectiveness Research Commission (in this section referred to as the "Commission") to oversee and evaluate the activities carried out by the Center under subsection (a), subject to the authority of the Secretary, to ensure such activities result in highly credible research and information resulting from such research..."

Thus we have a new Government body plus an oversight group. Its purpose is:

"(A) determine national priorities for research described in subsection (a) and in making such determinations consult with a broad array of public and private stakeholders, including patients and health care providers and payers;"

Thus this group will decide what the research priorities should be. This is a bit bassakwards to say the least. There is a well established infrastructure in the US and elsewhere where such research is being done in a peer review manner on a daily basis. Why do we need a Government entity and oversight. As far as one can see this is acting as the guiding light. Research is NOT done that way, it is highly distributed and combative. Ideas and data are thrown into the arena and allowed to be digested and the truth, whatever it may be, is supposed to emerge. I continue to come back to the prostate studies and the rebuttals. This can be done and is done daily in NEJM and the other professional journals. Why have the Government do what is already being done, and done well.

Then the Bill continues as follows:

"DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE IV—QUALITY AND SURVEILLANCE

Subtitle D—Adapting Workforce to Evolving Health System Needs

SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH CARE.

‘‘PART D—IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH CARE

‘‘SEC. 931. CENTER FOR QUALITY IMPROVEMENT."

It is to create:

"(a) IN GENERAL.—There is established the Center for Quality Improvement (referred to in this part as the ‘Center’), to be headed by the Director."

Its function is to:

‘‘(1) identify existing best practices under sub section (e);

‘‘(2) develop new best practices under sub section (f);

‘‘(3) evaluate best practices under subsection (g);

‘‘(4) implement best practices under subsection (h);

‘‘(5) ensure that best practices are identified, developed, evaluated, and implemented under this section consistent with standards adopted by the Secretary..."

Now in reading the above one sees that implementing under subsection (h) is most critical. This states:

"(h) IMPLEMENTATION OF BEST PRACTICES.—

‘‘(1) IN GENERAL.—The Director shall enter into voluntary arrangements with health care providers (including hospitals and other health facilities and health practitioners) in a State or region to implement best practices identified or developed under this section. Such implementation—

‘‘(A) may include forming collaborative multi-institutional teams; and

‘‘(B) shall include an evaluation of the best practices being implemented, including the measurement of patient outcomes before, during, and after implementation of such best practices.

‘‘(2) PREFERENCES.—In carrying out this sub section, the Director shall give priority to health care providers implementing best practices that—

‘‘(A) have the greatest impact on patient outcomes and satisfaction;

‘‘(B) are the most easily adapted for use by health care providers across a variety of health care settings;

‘‘(C) promote coordination....""

Thus as best we can see, there are now two new CCE institutions and several committees but the implementation is voluntary.

This question is why is this necessary since it is being done and done well already, and why does the Government believe that it can not only do this but do it better! This is centralizing medical research and the results when the process is naturally a distributed process. No one study is ever definitive, no two patients are the same, and no Government plan ever works as anticipated.

HR 3200 : Health Care I Think

HR 3200 is the health care bill approved by Dodd and Kennedy sent from the House. We look at it in some detail here. Here we go:

H. R. 3200 : ‘‘America’s Affordable Health Choices Act of 2009’’

DIVISION A—AFFORDABLE HEALTH CARE CHOICES

TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A—General Standards

Subtitle B—Standards Guaranteeing Access to Affordable Coverage

Subtitle C—Standards Guaranteeing Access to Essential Benefits

Subtitle D—Additional Consumer Protections

Subtitle E—Governance

Subtitle F—Relation to Other Requirements; Miscellaneous

Subtitle G—Early Investments

1. Insurance Market Reforms. Subtitle A will reform the individual and group health insurance markets in all 50 states to promote availability of coverage for all individuals and employer groups. Under these new requirements, premium payments for insurance policies within each market will be permitted to vary only by family structure, geographic region, the actuarial value of benefits provided, tobacco use and age. Rates specifically will not be permitted to vary based on gender, class of business, or claims experience. Rating by age will be permitted to vary by no more than a factor of two to one. Insurers will be permitted to incentivize health promotion and disease prevention practices. Guaranteed issue and guaranteed renewability will be required in all states in each individual and group health insurance market. (§ 2701, 2702, 2703)
   

They will allow for age but not weight! There are many healthy old folks but a great deal more fat young people. This is clear age discrimination, but wait it gets worse.

2. Bringing Down the Cost of Health Care Coverage. Health insurers offering group or individual policies will be required to publically report the percentage of total premium revenue that is expended on clinical services, quality and all other non-claims costs as determined by the Secretary of Health and Human Services. (§ 2704)
   

Transparency should apply even to their public option.

3. Prohibiting Discrimination Based on Health Status. In issuing health insurance policies, insurers will not be permitted to establish terms of coverage based on any applicant’s health status, medical condition (including physical and mental illness), claims experience, prior receipt of health care, medical history, genetic information, evidence of insurability (such as being a victim of domestic violence), or disability. (§2706)
   

This is essential if you want universal coverage.

4. Ensuring the Quality of Care. Health insurance policies will be required to include financial incentives to reward the provision of high quality care that include case management, care coordination, chronic disease management, wellness and health promotion activities, child health measures, activities to improve patient safety and reduce medical errors, as well as culturally and linguistically appropriate care. (§2707)
   

This is the door to rationing. They get to define "quality" and like Pirsig and his motorcycle it can drive you crazy or kill you!

5. Coverage of Preventive Health Services. Health insurance policies will not be allowed to impose more than minimal cost sharing for certain preventive services endorsed by the U. S. Preventive Services Task Force as clinically and cost effective, for immunizations recommended by the CDC, and for certain child preventive services recommended by the Health Resources and Services Administration. (§2708)
   

Again the Government gets to define preventive. Why one wonders is the Government in the profession of Medicine, they do not even have a license.

6. Extension of Dependent Adults: All individual and group coverage policies will be required to continue offering dependent coverage for children until the child turns age 26, according to regulations to be established by the Secretary of Health & Human Services. (§2709)
   

The extension to age 26 is nothing more than forcing parents to pay for their liberated children. At 21 they should be on their own. The pressure of doing so will make them responsible.

7. No Lifetime or Annual Limits. No individual or group health insurance policy will be permitted to establish lifetime or annual limits on the dollar value of benefits for any enrollee or beneficiary. (§ 2710)
   

8. Notification by Plans Not Providing Minimum Qualifying Coverage. Health plans that fail to provide minimum qualifying coverage shall notify enrollees prior to enrollment or re-enrollment, according to regulations to be established by the Secretary of Health & Human Services. (§ 2711)
   

9. Promotion of Choice of Health Insurance. The Secretary will develop standards for Gateways plans to provide summaries of benefits in a standard format. Also prohibits rescission of coverage after plan issue and provides grants to States to establish health insurance customer assistance Prohibition of Discrimination Based on Salary. Health insurers will not be permitted to limit eligibility based on the wages or salaries of employees. (§ 2719)
   

10. No Changes to Existing Coverage. There is no requirement that an individual must terminate his or her coverage in a plan in which the individual was enrolled prior to enactment of this Act. Family members, new employees, are able to enroll in health plans operating prior to enactment. This provisions in this subtitle will not apply to any individual or plan in which enrollment began prior to the effective date of the Act regardless of whether the individual renews coverage. The provisions of the subtitle do not apply to collective bargaining agreements ratified prior to the date of enactment or self-insured group health plans. Existing coverage plans are also excluded from the risk adjustment procedures established in section 142. The subtitle applies if significant changes are made to the existing health insurance plan, according to regulations to be established by the Secretary of Health & Human Services. (§ 131, 132, 133)

You must really read the Bill and between the lines.

TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A—Health Insurance Exchange

Subtitle B—Public Health Insurance Option

Subtitle C—Individual Affordability Credits

1. Building on the Success of the Federal Employees Health Benefit Program so All Americans have Affordable Health Benefit Choices. It is the sense of the Senate that Congress should establish a means for All Americans to have affordable choices in health benefit plans, in the same manner as Members of Congress. (§ 141)
   

2. Affordable Choices of Health Benefit Plans. Each state will have an Affordable Health Benefit Gateway, established either by the state or by the Secretary of Health and Human Services that will be administered through a governmental agency or non-profit organization. Within 60 days of enactment, the Secretary will make planning grant awards to states to undertake activities related to establishing their own Gateway. The Gateway exists to facilitate voluntary purchase of health insurance coverage and related insurance products at an affordable price by qualified individuals and qualified employer groups. States may require benefits in addition to essential health benefits but must assume additional costs. Risk pools include all enrollees in an individual plan or a group health plan. The Gateway will include a public health insurance option. The Gateway will establish procedures to qualify interested health plans to offer their health insurance policies through the Gateway. (§ 3101)
   

3. Gateway Functioning. The Gateway will develop tools to enable consumers to make coverage choices, and set up open enrollment periods to enroll in qualified health plans. After initial federal financial support, Gateways will become financially self-sustaining through establishing a surcharge on participating health plans. The Gateways will use risk adjustment mechanisms to remove incentives for plans to avoid offering coverage to those with serious health needs. Gateways will establish enrollment procedures to enable individuals to sign up for coverage, including Gateway plans with premium credits, Medicaid, CHIP, and others. The Secretary will establish a website through which individuals may connect to their state Gateway to purchase coverage. States may form regional Gateways operating in more than one state; states may establish subsidiary regional Gateways, as long as each Gateway serves a distinct region. (§ 3101)
   

4. Existing Markets. If individuals like their current coverage, they can keep it. Licensed health insurers will be able to sell health insurance policies outside of the Gateway. Any resident will be able to purchase health insurance outside the Gateway, including policies which do not meet standards to be a qualified health plan. States will regulate health insurance sold outside the Gateway. State insurance regulators will perform their traditional obligations regarding consumer protection and market conduct. For qualified health plans sold through the Gateway, the Secretary will issue regulations regarding marketing, network adequacy, and understandability for consumers. The Secretary will establish policies to facilitate enrollment, including use of electronic enrollment tolls, and provide grants to enhance community-based enrollment and public education campaigns, and policies for the certification of qualified health plans. (§ 3101)
   

5. Financial Integrity. The Department of Health and Human Services will oversee the financial integrity of Gateways by conducting annual audits, requiring financial reporting, and other measures, and the Secretary may rescind payments from state Gateways that fail to follow federal requirements. The Secretary shall also establish procedures and protections to guard against fraud and abuse. Additionally, the Comptroller General will conduct ongoing reviews of Gateway operations and administration. (§ 3102)
   

6. Program Design. The Secretary shall establish the essential health care benefit design which shall include at least ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitative and abilitative services and devices, laboratory services, preventive and wellness services, and pediatric services. The Secretary must submit a report to Congress certified by the Chief Actuary of the Centers for Medicare and Medicaid Services that the health benefits meet these requirements. Develops a one-time, temporary, and independent commission to advise the Secretary in the development of the essential benefit package. (§ 3103)
   

7. Qualifying Coverage. Qualifying coverage includes any coverage under which an individual is enrolled on the date of enactment of the law, and – after the date of enactment – coverage the meets the criteria for minimum qualifying coverage to satisfy personal responsibility standards, and coverage which meets grandfather standards. Coverage through Medicare, Medicaid, the CHIP, TRICARE, Veteran’s Health, FEHB, the medical program of the Indian Health Service, a state health benefit high risk pool, and others meet the conditions for minimum qualifying coverage. A religious exemption will also apply to these standards. Coverage is determined to be unaffordable if the premium paid by the individual is greater than 12.5 percent of the individual’s adjusted gross income. The Secretary shall establish an affordability standard and procedures for updating this standard linked to the Consumer Price Index for urban consumers. (§ 3103)
   

8. State Participation. States have three options regarding their preferred participation in the Gateway. An “establishing state” is one that proactively seeks such status to launch its Gateway as early as possible and which meets the requirements of the law. A “participating state” requests that the Secretary establish an initial Gateway once all necessary insurance market reforms have been enacted by the state into law, and other requirements have been met. In a state that does not act to conform to the new requirements, the Secretary shall establish and operate a Gateway in the state after a period of six years, and such state will become a “participating state.” Until a state becomes either an establishing or participating state, the residents of that state will not be eligible for premium credits, an expanded Medicaid match, or small business credits. (§ 3104)
   

9. Navigators. States will receive federal support to contract with private and public entities to act as health coverage “navigators” to assist employers, workers, and self-employed individuals seeking to obtain quality and affordable coverage through Gateways. Entities eligible to become navigators could include trade, industry and professional organizations, unions and chambers of commerce, small business development centers, and others. The navigators will conduct public education activities, distribute information about enrollment and premium credits, and provide enrollment assistance. Health insurers or parties that receive financial support from insurers to assist with enrollment are ineligible to serve as navigators. (§ 3105)
   

10. Community Health Insurance Option. The Secretary will establish a community health insurance option that complies with the health plan requirements established by this title and provides only the essential health benefits established in section 3103, except in States that offer additional benefits. There are no requirements that health care providers participate in the plan or that individuals join the plan. The premiums must be sufficient to cover the plan’s cost. The Secretary shall negotiate rates for provider reimbursement. Reimbursement rates will be negotiated by the Secretary and shall not be higher than the average of all Gateway reimbursement rates. A “Health Benefit Plan Start-up Trust Fund” will be created to provide loans for the initial operations of the community health insurance plan, which the plan will be required to pay back no later than 10 years after the payment is made. After the first 90 days of operation, the community health plan will be subject to a Federal solvency standard, established by the Secretary, and will be required to have a reserve fund that is at least equal to the dollar value of incurred claims. Each state will establish a State Advisory Council to provide recommendations to the Secretary on the policies and procedures of the community health insurance plan. (§ 3105)
    

11. Contracting of Community Health Insurance Option. The Secretary shall contract with qualified nonprofit entities to administer the community health insurance plan in the same manner as Medicare program contracting. The contractor will receive a fee from the Department of Health and Human Services, which may be increased or reduced depending on the contractor’s performance in reducing costs and providing high-quality health care and customer service. Contracts will last between 5 and 10 year-terms, at the end of which there will be a competitive bidding process for new and renewed contracts. (§ 3105)

TITLE III—SHARED RESPONSIBILITY

Subtitle A—Individual Responsibility

Subtitle B—Employer Responsibility

This section details the requirements for both personal and company payments. This should be read carefully.

1. Shared Responsibility Payments. All individuals will be required to obtain health insurance coverage. Exemptions will also be made for individuals for whom affordable health care coverage is not available or for those for whom purchasing coverage creates an exceptional financial hardship. The minimum penalty to accomplish the goal of enhancing participation in qualifying coverage will be no more than $750 per year. Individuals deemed to lack availability to affordable coverage (as determined in section 3103), Indians, individuals living in states where Gateways are not yet, and individuals with

2. Reporting of Health Insurance Coverage. Health plans providing qualified health insurance will file a return containing information regarding health insurance coverage. The return shall include basic information including the number of months during which the individual was covered. Health plans shall provide this information in writing to covered individuals. The IRS shall notify individuals who file income tax returns and are not enrolled in qualifying coverage and shall include information on services available through the Gateway. Employers must provide written notification informing employees about the Gateway. (§ 6055)

3. Shared Responsibility of Employer. Employers with more than 25 employees who do not offer qualifying coverage (as determined in section 3103) or who pay less than 60 percent of their employees’ monthly premiums are subject to a $750 annual fee per uninsured full-time employees and $375 per uninsured part-time employees. For employers subject to the assessment, the first 25 workers will be exempted. Beginning in 2013, the penalty amounts will be adjusted using the Consumer Price Index for urban consumers. Employers with 25 or fewer employees are exempt from penalties and are eligible for program credits in section 3112. (§ 3115) Definitions: (§ 3116)
   

1. Public health insurance option: Policy under discussion.

2. Eligible individuals are citizens or lawfully admitted permanent residents of the U.S. who are enrolled in a qualified health plan. Those eligible for other public programs are not eligible for credits, but a special rule applies to CHIP. Those in CHIP (or their parents) are able to determine whether staying in CHIP works best for them, or whether moving to the Gateway is best. Either choice is permissible, but the individual cannot “double dip” by getting funding from both the Gateway and CHIP.

3. Qualified employer is an employer who chooses to make employees eligible for a qualified health plan. If enrollment takes place through a Gateway, the employer must meet State or federal criteria. The initial federal criteria are set so that only small firms are qualified. Participating employers with up to 50 employees may continue participation in the Gateway if they subsequently grow to more than 50 employees.

4. Qualified health plan means a plan has certification issued by a Gateway and is offered by a licensed health insurance company. The health insurer must agree to offer at least one qualifying health plan with appropriate cost sharing levels, comply with regulation and pay any surcharge. This includes the community health insurance option.

5. Additional health plan requirements: Plans must make available for enrollees and potential enrollees descriptions of benefits offered, service area, cost-sharing, premiums, access to providers and grievance/appeals procedures.

6. Quality standards for health plans: Plans must provide the essential health care benefits established in this Act and be accredited by the National Committee for Quality Assurance or an equivalent entity. Plans must implement incentives for high quality care and improving health outcomes through strategies such as reporting, case management, care coordination, chronic disease management compliance initiatives and prevention of hospital readmission. Plans must encourage patient safety and reduction of medical errors through best practices, evidence based medicine and health information technology.

7. A qualified individual is residing in a participating or establishing State, not incarcerated, not eligible for Medicare or Medicaid, TRICARE, FEHBP, or any qualifying employer-sponsored coverage.

8. An eligible employee is an individual for whom if the employer-sponsored coverage does not meet criteria for minimum qualifying coverage or is not affordable for the employee.

9. Adjusted gross income is determined by section 62(a) of the Internal Revenue Code.

TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A—Shared Responsibility

Subtitle B—Credit for Small Business Employee Health Coverage Expenses

Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies

Subtitle D—Other Revenue Provisions

DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I—IMPROVING HEALTH CARE VALUE

Subtitle A—Provisions Related to Medicare Part A

Subtitle B—Provisions Related to Part B

Subtitle C—Provisions Related to Medicare Parts A and B

Subtitle D—Medicare Advantage Reforms

Subtitle E—Improvements to Medicare Part D

Subtitle F—Medicare Rural Access Protections

TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS

Subtitle A—Improving and Simplifying Financial Assistance for Low Income

Medicare Beneficiaries

Subtitle B—Reducing Health Disparities

Subtitle C—Miscellaneous Improvements

TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE

TITLE IV—QUALITY

Subtitle A—Comparative Effectiveness Research

Subtitle B—Nursing Home Transparency

Subtitle C—Quality Measurements

Subtitle D—Physician Payments Sunshine Provision

Subtitle E—Public Reporting on Health Care-Associated Infections

TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION

TITLE VI—PROGRAM INTEGRITY

Subtitle A—Increased Funding To Fight Waste, Fraud, and Abuse

Subtitle B—Enhanced Penalties for Fraud and Abuse

Subtitle C—Enhanced Program and Provider Protections

Subtitle D—Access to Information Needed To Prevent Fraud, Waste, and Abuse

TITLE VII—MEDICAID AND CHIP

Subtitle A—Medicaid and Health Reform

Subtitle B—Prevention

Subtitle C—Access

Subtitle D—Coverage

Subtitle E—Financing

Subtitle F—Waste, Fraud, and Abuse

Subtitle G—Puerto Rico and the Territories

Subtitle H—Miscellaneous

TITLE VIII—REVENUE-RELATED PROVISIONS

TITLE IX—MISCELLANEOUS PROVISIONS

DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE I—COMMUNITY HEALTH CENTERS

TITLE II—WORKFORCE

Subtitle A—Primary Care Workforce

Subtitle B—Nursing Workforce

Subtitle C—Public Health Workforce

Subtitle D—Adapting Workforce to Evolving Health System Needs

TITLE III—PREVENTION AND WELLNESS

TITLE IV—QUALITY AND SURVEILLANCE

Subtitle A. National Strategy to Improve Health Care Quality

1. National Strategy for Quality Improvement in Health Care: The U.S. lacks a coherent strategy to improve the quality of the nation’s health care system. The Secretary of HHS is directed to establish a national quality strategy and implement its priorities. Health outcomes, as well as quality initiatives to improve them, vary widely across the country. The National Strategy aims to reduce geographic variations in care quality and reduce health disparities while improving the delivery of health care services, patient health outcomes, and population health. The Secretary will identify priority areas to improve the delivery of health care services. Additionally, quality improvements will eliminate waste and improve efficiency in the health care system. [§ 201]

2. Interagency Working Group on Health Care Quality: The U.S. lacks an effective way in which to share and implement quality initiatives. The President is directed to create an inter-agency Working Group to coordinate, collaborate and streamline federal quality activities around the national quality strategy. The Working Group will also share best practices and lessons learned among all health care sectors and government agencies. The quality activities will be related to the priorities defined in the national strategy. Agencies will be required to develop individual strategic plans and then to report to both Congress and the public on the progress toward implementing the strategic plans. [§ 202]
   

This is a very dangerous and potentially deadly action. It makes the Government the Chief of Medicine for all patients in the US. This is the dumbest thing I have ever seen.

3. Quality Measure Development: The U.S. lacks an effective way in which to comprehensively measure health care quality. The Director of the Agency for Health Care Research and Quality (AHRQ) is directed to provide grants to organizations, such as specialty societies, to develop measures in “gap” areas where no quality measures exist, or where existing quality measures need improvement, updating, or expansion. Measures will be developed according to priority areas related to care coordination, patient experience, health disparities, and the appropriateness of care. Quality measures developed through grants under this program will be made publicly available. [§ 203]
   

We have quality measures being developed and changed all the time. One need just look at NEJM or JAMA. Do we want the Government doing this! Are you insane!

4. Quality Measure Endorsement, Public Reporting; Data Collection: The U.S. lacks a streamlined, interoperable, quality measure endorsement and reporting system. AHRQ is directed to establish a streamlined quality measure endorsement process. It is directed to contract with a consensus based organization, such as the National Quality Forum, to evaluate and endorse quality measures for use with Federal health programs. The Secretary is given the discretion about whether to adopt the measure. The data from the reporting of these quality measures will be made available in a user-friendly format to inform providers, patients, consumers, researchers, and policymakers. [§ 204]
   

5. Collection and Analysis of Quality Measure Data: To facilitate public reporting, the Secretary will establish a process to collect, validate and aggregate data on quality measures. The Secretary will also provide grants and contracts for the collection and aggregation of quality measures as well as for analysis of health care data. [§ 205]

Subtitle B. Health System Quality Improvement

1. Health care delivery system research; Quality Improvement Technical Assistance. A Patient Safety Research Center is established in AHRQ. In addition to supporting research, technical assistance and process implementation grants will be made to local providers to teach and implement best practices. Best practices help deliver care safely. The Patient Safety Research Center will strengthen best practice research and dissemination. Creating grants to identify and disseminate best practices to local providers will prevent medical errors and reduce their associated costs. One such practice is the Pronovost Checklist, which uses ten simple steps to properly insert a catheter and eliminate line infections. [§ 211]
   

This is the "best practices" home. Imagine if you will a GS 10 writing the best practices. The GS10 has a BMI of 38 and can barely write. The GS10 has a GRE diploma and has worked their way up HHS. They will control your life. You cannot sue the Government and this GS10 is hidden from all. They will control your life, so just die now!

2. Community Health Teams. The Secretary is directed to create a program to fund Community Health Teams. States or state-designated entities would be eligible for grants under this program. Community Health Teams will be established to support the development of medical homes by increasing access to comprehensive, community based, coordinated care. A patient’s care is coordinated by an integrated team of providers that includes primary care providers, specialists, other clinicians and licensed integrative health professionals as well as community resources to enhance wellness and lifestyle improvements. It is patient-centered and holistic in its orientation. [§ 212]
   

3. Grants to Implement Medication Management Services in Treatment of Chronic Disease. The Secretary, through the new Patient Safety Research Center within AHRQ, will provide grants to support local health providers for medication management services. Medication management services help manage chronic disease, reduce medical errors, and improve patient adherence to therapies while reducing acute care costs and reducing hospital readmissions. This program attempts to evaluate and determine the best practices and develop quality measures specific to this service provided by pharmacists and other types of providers. [§ 213]
   

4. Regionalized Systems for Emergency Care, including Acute Trauma. This section provides funding by the Assistant Secretary for Preparedness and Response to states or local governments to help improve regional coordination of emergency services. Access to the emergency medical system will be facilitated and a mechanism to ensure that patients are directed to the most appropriate medical facility will be established. Inter-facility resources will be tracked and coordinated in real time. [§ 214]
   

5. Trauma Care Centers and Service Availability. This section reauthorizes and improves the trauma care program, providing grants by the Secretary of HHS to states and trauma centers to strengthen the nation’s trauma system. Grants are targeted to assist centers in underserved areas susceptible to funding and workforce shortages. [§ 215]
   

6. Reporting and Reducing Preventable Readmissions. Hospitals will be required by the Secretary of HHS to report preventable readmission rates. Hospitals with high re-admission rates will be required to work with local patient safety organizations to improve their care transition practices including the effective use of discharge planning and counseling. [§ 216]
   

This is the beginning of the bundling process which we have discussed.

7. Program to Facilitate Shared Decision Making. The Secretary of HHS will give grants to the National Quality Form to develop, test, and disseminate educational tools to help patients and caregivers understand their treatment options. Materials will assist patients to decide with their provider what treatments are best for them based on these beliefs and preferences, options, scientific evidence, and other circumstances. Providers will be educated on the use of these tools. Quality measures related to utilization of these tools as well as patient and caregiver experiences will be developed. [§ 217]
   

And they are adding in costs.

8. Presentation of Drug Information. A process will be established for the FDA to evaluate and determine if the use of drug fact boxes in advertising and other forms of communication for prescription medications is warranted. A standardized, quantitative summary of the relative risks and benefits developed by FDA is an effort to clearly communicate drug risks and benefits and support clinician and patient decision making processes. [§ 218]
   

9. Center for Health Outcomes Research and Evaluation. The Secretary of HHS shall establish a new Center within the AHRQ that will promote health outcomes research and evaluation that enables patients and providers to identify which therapies work best for most people and to effectively identify where more personalized approaches to care are necessary for others. An Advisory Commission representing diverse interests will be established by the Secretary and public input will be sought in order to ensure research conducted is meaningful to patients and providers. [§ 219]
   

This Committee will be politically appointed and they will also control your health. There will be no peer review and no recourse or remedy. They may likely be political cronies with no professional background practicing medicine at a meta level. No country does this now, not even Canada.

10. Demonstration Program to Integrate Quality Improvement and Patient Safety training into health professionals’ clinical education. Grants will be provided by AHRQ to academic institutions to develop and implement academic curricula that integrate quality improvement and patient safety into health professionals’ clinical education. [§ 220]

11. Improving the Health of Women. This section will improve the health and the quality of care for women by making permanent women’s health offices that currently exist within HHS and its agencies. Statutory authorization for federal women's health offices ensures women's health programs affecting prevention, treatment, and research will continue to receive the attention they require in the twenty-first century. [§ 221]
    

So what are men, chopped liver!

12. Administrative Simplification. Enacted in 1996, the HIPAA law promised to simplify the administration of health care – yet that promise has gone largely unrealized. Since 1996, the potential of information technology to streamline commerce has increased exponentially, but the HIPAA standards have not kept pace. This section updates administrative simplification standards for the electronic age by requiring new technical standards designed to provide a common technical platform for more seamless administration of health care. This section includes a provision to ensure timely updating of standards for electronic data interchange to meet evolving requirements in health care administration. [§ 222]

TITLE V—OTHER PROVISIONS

Subtitle A—Drug Discount for Rural and Other Hospitals

Subtitle B—School-Based Health Clinics

Subtitle C—National Medical Device Registry

Subtitle D—Grants for Comprehensive Programs To Provide Education to

Nurses and Create a Pipeline to Nursing

Subtitle E—States Failing To Adhere to Certain Employment Obligations