The House Healthcare Bill

I have spent the last week wading through the House version of healthcare, HR 3200, all 1018 pages of it. I am not an attorney and I am as good at reading "legaleeze" as any of you, but I felt it was important to read the bill myself. Sadly most of our representatives don't feel it is important to read the legislation they are voting on, so I guess I must take that responsibility upon myself. To be clear, I did not read every word of the bill. I read as much of it as I could without having access to the Internal Revenue Code or the Social Security Act. There were also parts of it that I didn't find pertinent to my purposes in understanding the goals of this legislation. (In other words, there's a lot of fine detail and changing of words that amends old legislation, etc.) I did spend a lot of time on the parts that will have the greatest affect on our lives. I have read the passages I am about to address thoroughly and have done my level best to honestly read and understand what is in the bill. I will include the references and the web address where you can find the bill yourself in the case you doubt me or what I have understood. This will be a long post, for which I am truly sorry. But it is not as long as the bill itself and I hope you will make the time to educate yourselves on this vital subject. It is far too important for us to ignore or leave to others. In fact, our esteemed President went so far as to say, "I don't want the folks who created the mess to do a lot of talking. I just want them to get out of the way so we an clean up the mess." (Implying that the people who oppose this legislation are the ones who created the problems.) (August 7, 2009--Google it) Now if that's not the American way I don't know what is. Just shut up and get out of my royal way. By the way, I thought a few Obama quotes would be appropriate here. The first is from his inaugural speech and the last two are from his victory speech on election night in Chicago. Haunting words based on current events. "To those who cling to power through corruption and deceit and the silencing of dissent, know that you are on the wrong side of history, but that we will extend a hand if you are willing to unclench your fist." "There are many who won't agree with every decision or policy I make as President, and we know that government can't solve every problem. But I will always be honest with you about the challenges we face. I will listen to you, especially when we disagree." "Let us resist the temptation to fall back on the same partisanship and pettiness and immaturity that has poisoned our politics for so long. Let us remember that it was a man from this state who first carried the banner of the Republican Party to the White House - a party founded on the values of self-reliance, individual liberty, and national unity. Those are values we all share, and while the Democratic Party has won a great victory tonight, we do so with a measure of humility and determination to heal the divides that have held back our progress. As Lincoln said to a nation far more divided than ours, We are not enemies, but friends...though passion may have strained it must not break our bonds of affection. And to those Americans whose support I have yet to earn - I may not have won your vote, but I hear your voices, I need your help, and I will be your President too."

Yeah, right. On that note, I dive in to the bill (if this seems disjointed, sorry, I'm going to follow the order that these items appear in the bill):

Where to find it: http://edlabor.house.gov/blog/2009/07/americas-affordable-health-choices-act.shtml

Problem #1:

1 SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT

2 COVERAGE.

3 (a) GRANDFATHERED HEALTH INSURANCE COV-

4 ERAGE DEFINED.—Subject to the succeeding provisions of

5 this section, for purposes of establishing acceptable cov-

6 erage under this division, the term ‘‘grandfathered health

7 insurance coverage’’ means individual health insurance

8 coverage that is offered and in force and effect before the

9 first day of Y1 if the following conditions are met:

10 (1) LIMITATION ON NEW ENROLLMENT.—

11 (A) IN GENERAL.—Except as provided in

12 this paragraph, the individual health insurance

13 issuer offering such coverage does not enroll

14 any individual in such coverage if the first ef-

15 fective date of coverage is on or after the first

16 day of Y1. (Page 16)

My understanding: In spite of Obama's promises that "if you like your healthcare, you can keep it", this clearly states otherwise. Once the government plan is in place, private insurers will be prohibited from enrolling new people. If you move, change jobs or your employer makes changes to your policies, your private insurance is history.

Problem #2:

3 (2) ANNUAL LIMITATION.—

4 (A) ANNUAL LIMITATION.—The cost-shar-

5 ing incurred under the essential benefits pack-

6 age with respect to an individual (or family) for

7 a year does not exceed the applicable level spec-

8 ified in subparagraph (B).

9 (B) APPLICABLE LEVEL.—The applicable

10 level specified in this subparagraph for Y1 is

11 $5,000 for an individual and $10,000 for a

12 family. Such levels shall be increased (rounded

13 to the nearest $100) for each subsequent year

14 by the annual percentage increase in the Con-

15 sumer Price Index (United States city average)

16 applicable to such year. (Page 29)

My understanding: The maximum out-of-pocket expenses will be $5,000 for individuals and $10,000 for families. That is a lot of money. We, as a family, have never had an insurance policy with out-of-pocket expenses that high. In fact, we currently have the highest out-of-pocket we've ever had and it's $5,000. I thought that was a lot. But under the government plan that amount will increase annually. We have opened a Health Savings Account to bridge that gap, but aren't allowed by law to put the full $10,000 in an HSA annually. So, we'd still have to come up with over $5,000 before our health coverage kicks in. Furthermore, this is the deductible for the "essential benefits package" which is the least expensive policy. Don't you think that the poorest among us will be buying the "essential package"? But then they still have to find a way to come up with $10,000 for their family's coverage. So what the hell does it cover?

Problem #3:

11 SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.

12 (a) ESTABLISHMENT.—

13 (1) IN GENERAL.—There is established a pri-

14 vate-public advisory committee which shall be a

15 panel of medical and other experts to be known as

16 the Health Benefits Advisory Committee to rec-

17 ommend covered benefits and essential, enhanced,

18 and premium plans.

19 (2) CHAIR.—The Surgeon General shall be a

20 member and the chair of the Health Benefits Advi-

21 sory Committee.

22 (3) MEMBERSHIP.—The Health Benefits Advi-

23 sory Committee shall be composed of the following

24 members, in addition to the Surgeon General:

1 (A) 9 members who are not Federal em-

2 ployees or officers and who are appointed by

3 the President.

4 (B) 9 members who are not Federal em-

5 ployees or officers and who are appointed by

6 the Comptroller General of the United States in

7 a manner similar to the manner in which the

8 Comptroller General appoints members to the

9 Medicare Payment Advisory Commission under

10 section 1805(c) of the Social Security Act.

11 (C) Such even number of members (not to

12 exceed 8) who are Federal employees and offi-

13 cers, as the President may appoint.

14 Such initial appointments shall be made not later

15 than 60 days after the date of the enactment of this

16 Act.

17 (4) TERMS.—Each member of the Health Bene-

18 fits Advisory Committee shall serve a 3-year term on

19 the Committee, except that the terms of the initial

20 members shall be adjusted in order to provide for a

21 staggered term of appointment for all such mem-

22 bers.

23 (5) PARTICIPATION.—The membership of the

24 Health Benefits Advisory Committee shall at least

25 reflect providers, consumer representatives, employ-

32

1 ers, labor, health insurance issuers, experts in health

2 care financing and delivery, experts in racial and

3 ethnic disparities, experts in care for those with dis-

4 abilities, representatives of relevant governmental

5 agencies. and at least one practicing physician or

6 other health professional and an expert on children’s

7 health and shall represent a balance among various

8 sectors of the health care system so that no single

9 sector unduly influences the recommendations of

10 such Committee. (pages 30-32)

My understanding: This Health Benefits Advisory Committee will be staffed by a majority of presidential appointees. The head of the committee will be the Surgeon General and up to 17 appointees (minimum of 11) will be appointed by the President. That makes these posts political posts. They will serve at the pleasure of the President and will be answerable only to him--not directly to the voters. Yet they will be determining our healthcare benefits. Another glaring issue to me is that only one doctor is required to be a part of this committee. All kinds of special interest groups are represented, but only one doctor will have input into what benefits should be provided. I thought that Mr. Obama wanted to give the power for our healthcare choices back to us and our doctors?

Problem #4:

10 (a) IN GENERAL.—There is hereby established, as an

11 independent agency in the executive branch of the Govern12

ment, a Health Choices Administration (in this division

13 referred to as the ‘‘Administration’’).

14 (b) COMMISSIONER.—

15 (1) IN GENERAL.—The Administration shall be

16 headed by a Health Choices Commissioner (in this

17 division referred to as the ‘‘Commissioner’’) who

18 shall be appointed by the President, by and with the

19 advice and consent of the Senate. (page 41)

My understanding: How can you have an independent agency that is part of the Executive Branch? The Health Choices Commissioner is a presidential appointee. No political appointees are above or outside of politics. I can't trust any politician, either Republican or Democrat, to appoint an individual purely on the basis of who would be best in that post. It doesn't happen. Cabinet positions are filled by cronies and philosophical allies and usually are paybacks to somebody. That has no place in our medical care.

Problem #5:

7 SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.

8 (a) ESTABLISHMENT OF HEALTH INSURANCE EX-

9 CHANGE TRUST FUND.—There is created within the

10 Treasury of the United States a trust fund to be known

11 as the ‘‘Health Insurance Exchange Trust Fund’’ (in this

12 section referred to as the ‘‘Trust Fund’’), consisting of

13 such amounts as may be appropriated or credited to the

14 Trust Fund under this section or any other provision of

15 law.

16 (b) PAYMENTS FROM TRUST FUND.—The Commis-

17 sioner shall pay from time to time from the Trust Fund

18 such amounts as the Commissioner determines are nec-

19 essary to make payments to operate the Health Insurance

20 Exchange, including payments under subtitle C (relating

21 to affordability credits).

22 (c) TRANSFERS TO TRUST FUND.—

23 (1) DEDICATED PAYMENTS.—There is hereby

24 appropriated to the Trust Fund amounts equivalent

25 to the following:

110

1 (A) TAXES ON INDIVIDUALS NOT OBTAIN-

2 ING ACCEPTABLE COVERAGE.—The amounts re-

3 ceived in the Treasury under section 59B of the

4 Internal Revenue Code of 1986 (relating to re-

5 quirement of health insurance coverage for indi-

6 viduals).

7 (B) EMPLOYMENT TAXES ON EMPLOYERS

8 NOT PROVIDING ACCEPTABLE COVERAGE.—The

9 amounts received in the Treasury under section

10 3111(c) of the Internal Revenue Code of 1986

11 (relating to employers electing to not provide

12 health benefits).

13 (C) EXCISE TAX ON FAILURES TO MEET

14 CERTAIN HEALTH COVERAGE REQUIRE-

15 MENTS.—The amounts received in the Treasury

16 under section 4980H(b) (relating to excise tax

17 with respect to failure to meet health coverage

18 participation requirements).

19 (2) APPROPRIATIONS TO COVER GOVERNMENT

20 CONTRIBUTIONS.—There are hereby appropriated,

21 out of any moneys in the Treasury not otherwise ap-

22 propriated, to the Trust Fund, an amount equivalent

23 to the amount of payments made from the Trust

24 Fund under subsection (b) plus such amounts as are

111

1 necessary reduced by the amounts deposited under

2 paragraph (1). (Pages 109-111)

My understanding: A Health Insurance Exchange will be created and a trust fund which will be funded by the following:

1) The tax placed on individuals who do not have "adequate" health care as defined by the government.

2) Taxes on employers who do not provide acceptable coverage, as defined by the government.

3) Excise taxes on employers for "(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" (page 159). So once again, an employer may elect to go with the government coverage for employees, but if he/she fails to provide adequate healthcare as defined by the government, he/she will be taxed.

We have been told that medical and insurance costs will go down once the government takes over, but this insurance exchange will be funded by people who don't meet whatever standard the government decides to set through taxes. Assuming that people will comply rather than pay these penalties, how will it then be funded? As the costs of this bill add up, which are monumental and astounding in their size and scope, where will the funding come from? The taxpayer. So technically, they may be right, our medical expenses will go down, but at what cost? If we are paying 60% of our income to fund "free" healthcare, where is the benefit?

Problem #6:

7 SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH

8 INSURANCE EXCHANGES.

9 (a) IN GENERAL.—If—

10 (1) a State (or group of States, subject to the

11 approval of the Commissioner) applies to the Com-

12 missioner for approval of a State-based Health In-

13 surance Exchange to operate in the State (or group

14 of States); and

15 (2) the Commissioner approves such State-

16 based Health Insurance Exchange,

17 then, subject to subsections (c) and (d), the State-based

18 Health Insurance Exchange shall operate, instead of the

19 Health Insurance Exchange, with respect to such State

20 (or group of States). The Commissioner shall approve a

21 State-based Health Insurance Exchange if it meets the re-

22 quirements for approval under subsection (b).

23 (b) REQUIREMENTS FOR APPROVAL.—The Commis-

24 sioner may not approve a State-based Health Insurance

112

1 Exchange under this section unless the following require-

2 ments are met:

3 (1) The State-based Health Insurance Ex-

4 change must demonstrate the capacity to and pro-

5 vide assurances satisfactory to the Commissioner

6 that the State-based Health Insurance Exchange will

7 carry out the functions specified for the Health In-

8 surance Exchange in the State (or States) involved,

9 including— (pages 111-112)

My understanding: If a state has a healthcare plan that the Federal Government deems worthy, they may continue using that plan. But that determination will be made by a political appointee, the Commissioner (see Problem #4). Again, who's to say that we can trust a political appointee to keep politics out of that kind of decision? What if that person hates Texas or Utah or New Jersey? Isn't it possible that state could be punished for political reasons unrelated to their medical care? Who would stop it?

Furthermore, the last time I read the Constitution, I thought it said that any powers not delineated therein specific to the Federal Government, were reserved to be the rights of the states. It is both backwards and unconstitutional for the Federal Government to be the final say on anything a state does unless that power is specifically given to them. The Constitution says nothing about healthcare--this is gross over-reaching by the Federal Government to say the least. We are only guaranteed the right to "pursue" life, liberty and happiness. Everything else is beyond the scope and authority of the Federal Gov't.

Problem #7:

3 SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.

4 (a) RATES ESTABLISHED BY SECRETARY.—

5 (1) IN GENERAL.—The Secretary shall establish

6 payment rates for the public health insurance option

7 for services and health care providers consistent with

8 this section and may change such payment rates in

9 accordance with section 224.

10 (2) INITIAL PAYMENT RULES.—

11 (A) IN GENERAL.—Except as provided in

12 subparagraph (B) and subsection (b)(1), during

13 Y1, Y2, and Y3, the Secretary shall base the

14 payment rates under this section for services

15 and providers described in paragraph (1) on the

16 payment rates for similar services and providers

17 under parts A and B of Medicare. (page 121)

12 (d) CONSTRUCTION.—Nothing in this subtitle shall

13 be construed as limiting the Secretary’s authority to cor-

14 rect for payments that are excessive or deficient, taking

15 into account the provisions of section 221(a) and the

16 amounts paid for similar health care providers and serv-

17 ices under other Exchange-participating health benefits

18 plans.

19 (e) CONSTRUCTION.—Nothing in this subtitle shall be

20 construed as affecting the authority of the Secretary to

21 establish payment rates, including payments to provide for

22 the more efficient delivery of services, such as the initia-

23 tives provided for under section 224.

24 (f) LIMITATIONS ON REVIEW.—There shall be no ad-

25 ministrative or judicial review of a payment rate or meth-

125

1 odology established under this section or under section

2 224. (page 124-125)

My understanding:

This one is absolutely unbelievable. The "Secretary" will have the absolute authority to determine what the reimbursement rates will be for doctors, hospitals, etc. However, those rates will be based on what Parts A & B of Medicare already reimburse. Healthcare providers in any form are getting totally shafted by Medicare already. If they are really, really lucky they will get reimbursed 18% of what they bill. In most cases, it is far less than that. In talking about "the people that created this mess", let's lay this blame squarely where it belongs--the Federal Government. Their pathetic reimbursement rates have been the single biggest factor increasing the cost of medical care for everyone. Period. Their refusal to pay appropriately for services provided has forced healthcare providers to pass those costs on to anyone else who actually pays--whether out of pocket or through private insurance. To compound the problem, as Medicare goes, so go the insurance companies. They are more than happy to use Medicare reimbursement rates to justify paying less and less to reimburse for healthcare costs. Those two things have had a HUGE impact on the increasing costs of medical care. We will compound this problem exponentially when one individual has the right to tell all healthcare providers what they will and will not get paid for. The costs for medical care will not go down simply because the government mandates it to be so. The result will be catastrophic for our future health care. Health care providers will go out of business left, right and center because they simply will not be able to afford to work. No, the government is not planning on rationing healthcare, but it is the inevitable result of their short-sighted and foolish policies.

What's even better is the lovely parting shot of this section, "There shall be no administrative or judicial review of a payment rate or methodology established under this section..." Health care providers will be told what they can bill and then have no recourse. It is simply not discussable, nor can they appeal to the courts. Is that even legal? It certainly doesn't seem to pass the Constitutionality sniff test. I don't care what business you're in, if the government came in and did that to you, you would scream bloody murder. Imagine the grocers being told they will be paid 18 cents on the dollar and they have to shut up and like it. Is this America or the Soviet Union? And how long do you think the grocers could stay in business under those circumstances? It is beyond foolish to think that this kind of governmental bullying will solve more problems than it will create. Rationing will be your future, I guarantee it.

Problem #8:

24 (c) PAYMENT TERMS FOR PROVIDERS.—

127

1 (1) PHYSICIANS.—The Secretary shall provide

2 for the annual participation of physicians under the

3 public health insurance option, for which payment

4 may be made for services furnished during the year,

5 in one of 2 classes:

6 (A) PREFERRED PHYSICIANS.—Those phy-

7 sicians who agree to accept the payment rate

8 established under section 223 (without regard

9 to cost-sharing) as the payment in full.

10 (B) PARTICIPATING, NON-PREFERRED

11 PHYSICIANS.—Those physicians who agree not

12 to impose charges (in relation to the payment

13 rate described in section 223 for such physi-

14 cians) that exceed the ratio permitted under

15 section 1848(g)(2)(C) of the Social Security

16 Act. (pages 126-127)

My understanding: The good news here is that doctors have a choice. They can either get screwed badly or worse. It's always nice to have a choice, though. It must be nice to be able to get paid from the benevolent hand of the government.

Problem #9:

14 SEC. 313. EMPLOYER CONTRIBUTIONS IN LIEU OF COV-

15 ERAGE.

16 (a) IN GENERAK.—A contribution is made in accord- (their typo, not mine)

17 ance with this section with respect to an employee if such

18 contribution is equal to an amount equal to 8 percent of

19 the average wages paid by the employer during the period

20 of enrollment (determined by taking into account all em-

21 ployees of the employer and in such manner as the Com-

22 missioner provides, including rules providing for the ap-

23 propriate aggregation of related employers). Any such con-

24 tribution—

150

1 (1) shall be paid to the Health Choices Com-

2 missioner for deposit into the Health Insurance Ex-

3 change Trust Fund, and

4 (2) shall not be applied against the premium of

5 the employee under the Exchange-participating

6 health benefits plan in which the employee is en-

7 rolled. (pages 149-150)

8 (b) SPECIAL RULES FOR SMALL EMPLOYERS.—

9 (1) IN GENERAL.—In the case of any employer

10 who is a small employer for any calendar year, sub-

11 section (a) shall be applied by substituting the appli-

12 cable percentage determined in accordance with the

13 following table for ‘‘8 percent’’:

If the annual payroll of such employer for

the preceding calendar year:

The applicable

percentage is:

Does not exceed $250,000 ..................................... 0 percent

Exceeds $250,000, but does not exceed $300,000 2 percent

Exceeds $300,000, but does not exceed $350,000 4 percent

Exceeds $350,000, but does not exceed $400,000 6 percent

14 (2) SMALL EMPLOYER.—For purposes of this

15 subsection, the term ‘‘small employer’’ means any

16 employer for any calendar year if the annual payroll

17 of such employer for the preceding calendar year

18 does not exceed $400,000. (page 150)

My understanding: If an employer does not provide health insurance, then he/she has to pay a payroll tax equal to 8% of their total payroll. But they go out of their way to specify that none of those monies will go to subsidize the insurance premiums of his/her employees. It's purely a penalty used to go in to the Health Exchange Trust Fund. They are "kind" enough to make some adjustments for really small businesses, but I'm sure they've given no thought to how many people this will put out of work. The people that will be first to lose their jobs will be the poorest and least educated thus creating a larger group of uninsured or of people purely insured on the taxpayers backs.

Problem #10:

17 ‘‘(11) HEALTH COVERAGE PARTICIPATION RE-

18 QUIREMENTS.—

19 ‘‘(A) CIVIL PENALTIES.—In the case of

20 any employer who fails (during any period with

21 respect to which an election under section

22 801(a) is in effect) to satisfy the health cov-

23 erage participation requirements with respect to

24 any employee, the Secretary may assess a civil

25 penalty against the employer of $100 for each

156

1 day in the period beginning on the date such

2 failure first occurs and ending on the date such

3 failure is corrected.‘‘

7 ‘‘(E) COORDINATION WITH EXCISE TAX.—

8 Under regulations prescribed in accordance

9 with section 324 of the America’s Affordable

10 Health Choices Act of 2009, the Secretary and

11 the Secretary of the Treasury shall coordinate

12 the assessment of penalties under this section

13 in connection with failures to satisfy health cov-

14 erage participation requirements with the impo-

15 sition of excise taxes on such failures under sec-

16 tion 4980H(b) of the Internal Revenue Code of

17 1986 so as to avoid duplication of penalties

18 with respect to such failures.

(F) DEPOSIT OF PENALTY COLLECTED.—

20 Any amount of penalty collected under this

21 paragraph shall be deposited as miscellaneous

22 receipts in the Treasury of the United States.’’. (page 156 & 158)

My understanding:

Employers that somehow fail to "participate" properly will be penalized, enforceable by the IRS at $100 per day until the problem is corrected. Oddly enough, these monies will not be deposited in the Health Exchange Trust Fund, or any other healthcare account, they will be deposited as "miscellaneous receipts in the Treasury". That seems a lot like petty theft.

Problem #11:

18 ‘‘SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE

19 HEALTH CARE COVERAGE.

20 ‘‘(a) TAX IMPOSED.—In the case of any individual

21 who does not meet the requirements of subsection (d) at

22 any time during the taxable year, there is hereby imposed

23 a tax equal to 2.5 percent of the excess of—

168

1 ‘‘(1) the taxpayer’s modified adjusted gross in-

2 come for the taxable year, over

3 ‘‘(2) the amount of gross income specified in

4 section 6012(a)(1) with respect to the taxpayer.

5 ‘‘(b) LIMITATIONS.—

6 ‘‘(1) TAX LIMITED TO AVERAGE PREMIUM.—

7 ‘‘(A) IN GENERAL.—The tax imposed

8 under subsection (a) with respect to any tax-

9 payer for any taxable year shall not exceed the

10 applicable national average premium for such

11 taxable year. (page 167-168)

14 ‘‘(6) NOT TREATED AS TAX IMPOSED BY THIS

15 CHAPTER FOR CERTAIN PURPOSES.—The tax im-

16 posed under this section shall not be treated as tax

17 imposed by this chapter for purposes of determining

18 the amount of any credit under this chapter or for

19 purposes of section 55. (page 174)

My understanding: If you as an individual don't have "acceptable" health coverage, you will be taxed (again enforceable by the IRS) 2.5% of your gross income. The penalty will not exceed the cost of the premium for basic health coverage. So the crux of this part is, "You get insurance or else." You will be paying the same amount either way so you might as well get insurance. What ever happened to our individual freedom? Does the government have the authority to demand that we have health insurance? We caved on being insured drivers, so I guess we're screwed. Not that I'm opposed to insurance--we have both health and auto. But I wonder if it's proper for the gov't to mandate it?

Then the bill states that this tax won't be treated like a tax. Huh? I'm sure it will feel like a tax to whoever has to pay it. Anybody's guess what that means.

Problem #12:

16 ‘‘SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

17 ‘‘(a) GENERAL RULE.—In the case of a taxpayer

18 other than a corporation, there is hereby imposed (in addi-

19 tion to any other tax imposed by this subtitle) a tax equal

20 to—

21 ‘‘(1) 1 percent of so much of the modified ad-

22 justed gross income of the taxpayer as exceeds

23 $350,000 but does not exceed $500,000,

198

1 ‘‘(2) 1.5 percent of so much of the modified ad-

2 justed gross income of the taxpayer as exceeds

3 $500,000 but does not exceed $1,000,000, and

4 ‘‘(3) 5.4 percent of so much of the modified ad-

5 justed gross income of the taxpayer as exceeds

6 $1,000,000. (pages 197-198)

My understanding: In order to fund this bill, there will be an automatic "soaking" of the rich. People making between $350,000-$500,000 will be taxed at a rate of 1% of their modified gross income. Incomes between $500,000-$1,000,000 will be taxed at 1.5% and over $1,000,000 will be a whopping 5.4%. Further down on page 198 you will see that they don't anticipate those tax revenues to be sufficient because in 2012 the first two rates will double to 2% and 3% respectively. There is a provision for this not to be implemented if we save HUGE amounts of money through this healthcare, but I wouldn't bank on that. Do you really think it's okay to force other U.S. citizens to subsidize your healthcare? And if they want to, nobody's stopping them. Make a voluntary contribution. Does the government have the right to forcibly take if from them? It sickens me. It's class warfare of the worst kind. It's morally wrong and goes against everything the founding fathers tried to establish.

Problem #13:

IN RELATION TO MEDICARE/MEDICAID:

10 ‘‘(p) ADJUSTMENT TO HOSPITAL PAYMENTS FOR

11 EXCESS READMISSIONS.—

12 ‘‘(1) IN GENERAL.—With respect to payment

13 for discharges from an applicable hospital (as de

14 fined in paragraph (5)(C)) occurring during a fiscal

15 year beginning on or after October 1, 2011, in order

16 to account for excess readmissions in the hospital,

17 the Secretary shall reduce the payments that would

18 otherwise be made to such hospital under subsection

19 (d) (or section 1814(b)(3), as the case may be) for

20 such a discharge by an amount equal to the product

21 of— (page 280)

My understanding: If any hospital has what the government deems to be "excess readmissions" they will have their payments reduced or simply won't get paid. This makes so many assumptions and creates so many problems, I hardly know where to start. This whole section assumes that the government can determine excess readmissions by crunching numbers. It totally eliminates the possibility for individual health issues/complications, the failure or inability of patients to follow discharge instructions, infections contracted outside the hospital or the erstwhile inexplicable complication. You cannot treat people's healthcare as a formula--it cannot simply be controlled by legislating it.

Secondly, do you think a hospital benefits by making "mistakes" and re-admitting patients? It doesn't do good things for their reputation and they are already penalized financially for readmissions. But this legislation will have unintended results, causing one of two problems, or both. 1)Hospitals will be slower to discharge patients creating bed shortages and increasing the length and cost of the stay. 2)Hospitals will be very reluctant to re-admit people if there's any chance they don't need it because they have to get paid. That's a really crappy reason to be making a decision about someone's healthcare. But it will be reduced to a financial decision. Again, that doesn't sound like my healthcare decisions will be made between me and my doctor.

Problem #14:

3 SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM

4 PLAN AND BUNDLING PILOT PROGRAM.

5 (a) PLAN.—

6 (1) IN GENERAL.—The Secretary of Health and

7 Human Services (in this section referred to as the

8 ‘‘Secretary’’) shall develop a detailed plan to reform

9 payment for post acute care (PAC) services under

10 the Medicare program under title XVIII of the So-

11 cial Security Act (in this section referred to as the

12 ‘‘Medicare program)’’. The goals of such payment

13 reform are to—

14 (A) improve the coordination, quality, and

15 efficiency of such services; and

16 (B) improve outcomes for individuals such

17 as reducing the need for readmission to hos-

18 pitals from providers of such services. (page 299)

My understanding:

"Bundling" under this heading or elsewhere means that the government will bundle a group of healthcare costs into one set fee. It is supposed to save money and improve quality of care, but ignores some glaring problems. Medicare already bundles fees to doctors. For example, they would get paid a flat fee for a knee replacement. That fee includes a grossly "discounted" amount for the hospital stay, the doctor's fees, the nurses and the knee hardware. What it doesn't account for is the individual needs or complications that vary from patient to patient. A knee replacement in an otherwise healthy former football player at age 45 is totally different than a knee replacement in someone who is 80 with almost inevitable additional health issues. Their healing time, individual needs, possible complications and susceptibility to infection are going to be very different. To pay them as one and the same thing is the kind of bureaucrat-think that has driven healthcare costs to their current levels. If hospitals and doctors lose money on most knee replacements, they either make up the costs somewhere else (what currently happens), write off the losses (what currently happens) or will stop doing it (our future under this bill).

Problem #15:

9 SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR

10 MEDICARE BENEFICIARIES WITH LIMITED

11 ENGLISH PROFICIENCY BY PROVIDING REIM-

12 BURSEMENT FOR CULTURALLY AND LINGUIS-

13 TICALLY APPROPRIATE SERVICES.

14 (a) IN GENERAL.—Not later than 6 months after the

15 date of the completion of the study described in section

16 1221(a), the Secretary, acting through the Centers for

17 Medicare & Medicaid Services, shall carry out a dem-

18 onstration program under which the Secretary shall award

19 not fewer than 24 3-year grants to eligible Medicare serv-

20 ice providers (as described in subsection (b)(1)) to improve

21 effective communication between such providers and Medi-

22 care beneficiaries who are living in communities where ra-

23 cial and ethnic minorities, including populations that face

24 language barriers, are underserved with respect to such

25 services. In designing and carrying out the demonstration

406

1 the Secretary shall take into consideration the results of

2 the study conducted under section 1221(a) and adjust, as

3 appropriate, the distribution of grants so as to better tar-

4 get Medicare beneficiaries who are in the greatest need

5 of language services. The Secretary shall not authorize a

6 grant larger than $500,000 over three years for any grant-

7 ee. (pages 405-406)

My understanding: I include this section as just one of multiple examples where commissions and studies and special-interest groups are created, all funded by the taxpayer. I could not begin to calculate the hundreds of millions of dollars that are promised in this bill. The Congressional Budget Office estimates the cost of this bill to be $239 billion for the 2010-2019 period. (see http://www.cbo.gov/ftpdocs/104xx/doc10400/07-26-InfoOnTriCommProposal.pdf) That estimate includes the projected taxes that will be imposed by this bill, and that will be insufficient funding. Do you know what a billion looks like? Just by way of reminder: $1,000,000,000.

Problem #16:

11 SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL

12 EQUIPMENT OR HOME HEALTH SERVICES RE-

13 QUIRED TO BE MEDICARE ENROLLED PHYSI-

14 CIANS OR ELIGIBLE PROFESSIONALS. (page 719)

My understanding:

If a physician wants to get paid for ordering durable medical equipment or home health services he/she has to be Medicare enrolled. Again, this eliminates choice. The doctor must accept Medicare's provisions and restrictions or they won't get paid. If your doctor isn't on board with Medicare (and many aren't because they can't afford to take Medicare patients any longer) he can't order these services for you, which means you can no longer choose your physician.

Problem #17:

9 ‘‘Subchapter B—Insured and Self-Insured

10 Health Plans

‘‘Sec. 4375. Health insurance.

‘‘Sec. 4376. Self-insured health plans.

‘‘Sec. 4377. Definitions and special rules.

11 ‘‘SEC. 4375. HEALTH INSURANCE.

12 ‘‘(a) IMPOSITION OF FEE.—There is hereby imposed

13 on each specified health insurance policy for each policy

14 year a fee equal to the fair share per capita amount deter-

15 mined under section 9511(c)(1) multiplied by the average

16 number of lives covered under the policy. (page 829)

AND

11 ‘‘(c) TREATMENT AS TAX.—For purposes of subtitle

12 F, the fees imposed by this subchapter shall be treated

13 as if they were taxes. (page 835)

My understanding: This one is very vague and I may be wrong about this, but it appears that those people who are grandfathered in to their existing plans have to pay a fee to do so. The fee will be determined by the government--their "fair share". And they were nice enough to inform us that this is indeed, a tax. This fee will be imposed on employers who provide either health insurance or are self-insured, increasing the costs of providing insurance. This seems to be a back-door effort to make this type of insurance so cost-prohibitive as to get them to cancel their plans and shift the public on to the government plan.

Problem #18:

10 ‘‘SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES

11 WITH YOUNG CHILDREN AND FAMILIES EX12

PECTING CHILDREN.

13 ‘‘(a) PURPOSE.—The purpose of this section is to im-

14 prove the well-being, health, and development of children

15 by enabling the establishment and expansion of high qual-

16 ity programs providing voluntary home visitation for fami-

17 lies with young children and families expecting children. (page 838)

16 ‘‘(1) IN GENERAL.—In this section, the term

17 ‘eligible expenditures’—

18 ‘‘(A) means expenditures to provide vol-

19 untary home visitation for as many families

20 with young children (under the age of school

21 entry) and families expecting children as prac-

22 ticable, through the implementation or expan-

23 sion of high quality home visitation programs

24 that—

1 ‘‘(i) adhere to clear evidence-based

2 models of home visitation that have dem-

3 onstrated positive effects on important pro-

4 gram-determined child and parenting out-

5 comes, such as reducing abuse and neglect

6 and improving child health and develop-

7 ment;

8 ‘‘(ii) employ well-trained and com-

9 petent staff, maintain high quality super-

10 vision, provide for ongoing training and

11 professional development, and show strong

12 organizational capacity to implement such

13 a program;

14 ‘‘(iii) establish appropriate linkages

15 and referrals to other community resources

16 and supports;

17 ‘‘(iv) monitor fidelity of program im-

18 plementation to ensure that services are

19 delivered according to the specified model;

20 and

21 ‘‘(v) provide parents with—

22 ‘‘(I) knowledge of age-appro-

23 priate child development in cognitive,

24 language, social, emotional, and motor

25 domains (including knowledge of sec-

845

1 ond language acquisition, in the case

2 of English language learners);

3 ‘‘(II) knowledge of realistic ex-

4 pectations of age-appropriate child be-

5 haviors;

6 ‘‘(III) knowledge of health and

7 wellness issues for children and par-

8 ents;

9 ‘‘(IV) modeling, consulting, and

10 coaching on parenting practices;

11 ‘‘(V) skills to interact with their

12 child to enhance age-appropriate de-

13 velopment;

14 ‘‘(VI) skills to recognize and seek

15 help for issues related to health, devel-

16 opmental delays, and social, emo-

17 tional, and behavioral skills; and

18 ‘‘(VII) activities designed to help

19 parents become full partners in the

20 education of their children; (page 843-845)

1 ‘‘(m) APPROPRIATIONS.—Out of any money in the

2 Treasury of the United States not otherwise appropriated,

3 there is appropriated to the Secretary to carry out this

4 section—

5 ‘‘(1) $50,000,000 for fiscal year 2010;

6 ‘‘(2) $100,000,000 for fiscal year 2011;

7 ‘‘(3) $150,000,000 for fiscal year 2012;

8 ‘‘(4) $200,000,000 for fiscal year 2013; and

9 ‘‘(5) $250,000,000 for fiscal year 2014. (page 852)

My understanding:

You have to read this section to believe it. If ever there was a more perfect definition of the "nanny state", I've never seen it. This is not mandatory...yet. Once they get it implemented, who's to say it won't become so? Where in the Constitution is the Federal Government given the authority to provide child-rearing instruction? Who decides who the experts are? Who decides what the standards are? Anyone with kids knows that there's not a formulaic solution to any aspect of parenting. Parenting cannot be reduced to statisitics and studies which can never replace a loving parent. Every INDIVIDUAL child is just that, and individual, differing from parents and siblings. Sure there are many consistent behaviors and patterns, but why on earth do they feel the government has any business in this arena?! And did you see the escalating costs? $250,000,000 by 2014!!

Problem #19:

5 PART 2—PROMOTION OF PRIMARY CARE AND

6 DENTISTRY

7 SEC. 2211. FRONTLINE HEALTH PROVIDERS.

8 Part D of title III (42 U.S.C. 254b et seq.) is amend-

9 ed by adding at the end the following:

10 ‘‘Subpart XI—Health Professional Needs Areas

11 ‘‘SEC. 340H. IN GENERAL.

12 ‘‘(a) PROGRAM.—The Secretary, acting through the

13 Administrator of the Health Resources and Services Ad-

14 ministration, shall establish a program, to be known as

15 the Frontline Health Providers Loan Repayment Pro-

16 gram, to address unmet health care needs in health profes-

17 sional needs areas through loan repayments under section

18 340I. (page 870)

5 ‘‘(b) SUPPORT AND DEVELOPMENT OF PRIMARY

6 CARE TRAINING PROGRAMS.—

7 ‘‘(1) IN GENERAL.—The Secretary shall make

8 grants to, or enter into contracts with, eligible enti-

9 ties—

10 ‘‘(A) to plan, develop, operate, or partici-

11 pate in an accredited professional training pro-

12 gram, including an accredited residency or in-

13 ternship program, in the field of family medi-

14 cine, general internal medicine, general pediat-

15 rics, or geriatrics for medical students, interns,

16 residents, or practicing physicians;

17 ‘‘(B) to provide financial assistance in the

18 form of traineeships and fellowships to medical

19 students, interns, residents, or practicing physi-

20 cians, who are participants in any such pro-

21 gram, and who plan to specialize or work in

22 family medicine, general internal medicine, gen-

23 eral pediatrics, or geriatrics;

24 ‘‘(C) to plan, develop, operate, or partici-

25 pate in an accredited program for the training

880

1 of physicians who plan to teach in family medi-

2 cine, general internal medicine, general pediat-

3 rics, or geriatrics training programs including

4 in community-based settings;

5 ‘‘(D) to provide financial assistance in the

6 form of traineeships and fellowships to prac-

7 ticing physicians who are participants in any

8 such programs and who plan to teach in a fam-

9 ily medicine, general internal medicine, general

10 pediatrics, or geriatrics training program; and

11 ‘‘(E) to plan, develop, operate, or partici-

12 pate in an accredited program for physician as

13 sistant education, and for the training of indi-

14 viduals who plan to teach in programs to pro-

15 vide such training. (pages 879-880)

10 ‘‘SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVEST-

11 MENT FUND.

12 ‘‘(a) PROMOTION OF PRIMARY CARE AND DEN-

13 TISTRY.—For the purpose of carrying out subpart XI of

14 part D of title III and sections 723, 747, 748, and 749,

15 in addition to any other amounts authorized to be appro-

16 priated for such purpose, there is authorized to be appro-

17 priated, out of any monies in the Public Health Invest-

18 ment Fund, the following:

19 ‘‘(1) $240,000,000 for fiscal year 2010.

20 ‘‘(2) $253,000,000 for fiscal year 2011.

21 ‘‘(3) $265,000,000 for fiscal year 2012.

22 ‘‘(4) $278,000,000 for fiscal year 2013.

23 ‘‘(5) $292,000,000 for fiscal year 2014.

24 ‘‘(6) $307,000,000 for fiscal year 2015.

25 ‘‘(7) $322,000,000 for fiscal year 2016.

892

1 ‘‘(8) $338,000,000 for fiscal year 2017.

2 ‘‘(9) $355,000,000 for fiscal year 2018.

3 ‘‘(10) $373,000,000 for fiscal year 2019.’’. (page 891-892)

My understanding:

This section of the bill duplicates something that already exists in the government. In an effort to encourage students to go into certain primary care specialties (pediatrics, family practice, general practice, etc.) they're creating a special Loan Repayment Program. Why this cannot be handled through the existing Dept. of Education and the loans they already provide for medical education is beyond me. It creates additional layers of bureaucracy and costs that are typical government waste. Furthermore, throwing more money at these areas of medical education does not solve the problems that have created the shortages. Without fixing the problems of astronomical malpractice insurance rates through tort reform and paying physicians for the work they do, the shortages will continue regardless of any millions of dollars they make available for educational loans. Primary care specialists cannot make a decent living based on the hours worked, student loan repayments, operating expenses and wages lost in years of education. If they want more primary care providers then they must address these issues. Again, look at the amounts of money to be spent. It's mind-boggling.

Problem #20:

14 ‘‘Subpart XII—Public Health Workforce

15 ‘‘SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS.

16 ‘‘(a) ESTABLISHMENT.—There is established, within

17 the Service, the Public Health Workforce Corps (in this

18 subpart referred to as the ‘Corps’), for the purpose of en-

19 suring an adequate supply of public health professionals

20 throughout the Nation. The Corps shall consist of—

21 ‘‘(1) such officers of the Regular and Reserve

22 Corps of the Service as the Secretary may designate;

23 and

24 ‘‘(2) such civilian employees of the United

25 States as the Secretary may appoint. (page 898)

My understanding:

This one is really sneaky and it's a loo-loo. I hope I'm wrong in my reading of this, but what I understand from this is that the doctors in the military, either active or the Reserve, can be called upon to fill any holes the government sees. What does that mean to those people? Can they simply be ordered to go live in X state and do X work until the government doesn't need them anymore? Is that what they signed on for when they entered the military? Then it says "such civilian employees of the United States as the Secretary may appoint" to the Public Health Workforce Corps. That sounds like a draft for physicians to me. The government sees a need or shortage and "appoints" certain physicians to fill holes. Again, that sounds a lot like Communist China, not the United States. Unbelievable.

Problem #21 and on:

Lastly, from what I can ascertain, the Health Insurance Exchange created, will give you the choice as to where you get your policy, but the coverage will end up being the same everywhere. The government will set the standards for a basic, enhanced or enhanced-plus policies with decreasing out-of-pocket expenses respectively. The policy costs will also increase respectively. When the government is supplying a taxpayer subsidized policy, there is no way a private insurer will be able to compete fairly with the government in the marketplace. Insurers run companies for profit and that's not a dirty, illegal or a bad thing. Profits motivate people to provide a better product. That also doesn't mean the insurance industry has entirely clean hands either. They definitely need to make some changes. But if we remove competition, they lose their incentive to improve. For example, if Safeway, Albertson's and Wal-mart are selling the exact same head of lettuce for $1.59, but the government can provide the same taxpayer subsidized lettuce for $.99, where's the competition? Everyone will get the government lettuce. These policies will end up being mirror images of each other so there will be no point in offering a better product when you will still get beat by the government pricing. There is no incentive for insurance companies to improve their product. This seems to be another back door approach to getting people out of the private insurance sector on to the government plan. Not good. Then we have absolute government control and no choice at all.

In Summary:

The bill stinks. And it stinks for all the reasons listed above and many I didn't even address.

This is absolute government takeover of healthcare and gives them absolute power, leaving us

with no say and no recourse. I don't pretend to be an expert. I am however, a citizen of this great country and I care deeply about my future and my children's future. Therefore, I will exercise my right to free speech and expression. We must understand this legislation and make our opinions heard. Be assured, the louder you protest this legislation, the stronger you will be opposed. When the Democrats are losing an argument they always resort to their favorite tactics: projection of their own corrupt motives, name-calling, labeling, raw emotion, vitriol and condescension. They will not address the argument and discuss it in a rational and logical way because they know they will lose the argument. The terrifying truth is that the people that profess to represent us in Washington, don't give a flying fig what the citizens think. They have reached a pinnacle of arrogance where they are so superior, in their own minds, to their constituents, that they simply do not have to listen. Government without representation is tyrrany. It always has been. The founding fathers declared independence from England for the very reasons that I am standing up today to say, "NO!". They work for US, the people, and they have completely forgotten that. It is time they are reminded. We, the people, will be heard.