HR 3200: A Deadly Swamp Of Socialized Medicine

The actual text of health care reform legislation is starting to percolate up from the depths of the committees, and it contains a plethora of hard stops on the freedoms that Americans are guaranteed and have come to expect.  President Obama remains inordinately fond of continuing to campaign about all the “choice” he wants us to see in his vision of health care reform, but what’s in this House version of the bill contains anything but.

Since our unrepresenting representatives can’t be bothered to do so, let’s put on our waders and tiptoe through the alligator-infested swamp and take a gander at it, shall we?

The Biggest and Baddest provision turns President Obama into a bald-faced liar.  The party line is that if you currently have health insurance, sure, you can keep it.  They call this “grandfathering” in your plan.  But Section 102: PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE doesn’t protect anything except the government-run “gateways” and “exchanges” because the day you decide to give up your current plan, it’s all over but the shouting because unless you enroll in an employer-provided plan (that must provide no less than exactly the same benefits as the government’s plan), it’s straight into the machine for you.

These are the key excerpts:

(1) LIMITATION ON NEW ENROLLMENT-

(A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.

(Notice that this is the sum total of verbiage in “this paragraph”.  There are NO exceptions.  Health insurers may no longer enroll new plan participants.)

(c) Limitation on Individual Health Insurance Coverage-

(1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan.

This means that if a health insurance company wants to stay in business, it must get in bed with the government.

(2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage.

How very kind of them.  Separate insurance policies will be “permitted” by the government.  If you didn’t ask “What are excepted benefits?” then you deserve the government we’ve got today and don’t come crying to us when Pater Obama tells you that your life isn’t worth the cost of saving it.  But because I’m feeling generous today, I’ll ask the question for you.  What are these “excepted benefits”?  Well, basically anything except what we all think of as common medical treatments, such as:

• Coverage only for accident, or disability income insurance, or any combination thereof.
• Coverage issued as a supplement to liability insurance.
• Liability insurance, including general liability insurance and automobile liability insurance.
• Workers’ compensation or similar insurance.
• Automobile medical payment insurance.
• Credit-only insurance.
• Coverage for on-site medical clinics
• Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

Not exactly the “choice” the President, Pelosi, Reid, and those other generous progressives (gag) are leading you to believe, is it?

So just what happens to your “health care” once the government gets their guaranteed hold of it?  Pull out your airsickness bag and read on.

What is covered:

From section 122 (Essential benefits)

(b) Minimum Services To Be Covered-

(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.

(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.

This is the 2008 list of those “preventative services” from the U.S. Preventive Services Task Force:

Grade A:

• Cervical cancer screening for women
• Colorectal cancer screening for men and women over 50
• Discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease
• Screening for high blood pressure in adults aged 18 and older
• Screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older nonpregnant women who are at increased risk
• Prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum
• Screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit
• Screening for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection
• Screening all pregnant women for HIV
• Screening persons at increased risk for syphilis infection
• Screening all pregnant women for syphilis infection
• Screening all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco
• Screening all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke
• Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care
• Screening for sickle cell disease in newborns

Grade B:

• One-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked
• Genetic counseling and evaluation for women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes (breast & ovarian cancer)
• Chemoprevention for women at high risk for breast cancer and at low risk for adverse effects of chemoprevention
• Screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older
• Screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk
• Screening all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors)
• Screening and behavioral counseling interventions to reduce alcohol misuse (go to Clinical Considerations) by adults, including pregnant women, in primary care settings
• Screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup
• Intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.  Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians
• Routine screening for iron deficiency anemia in asymptomatic pregnant women
• Routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia
• Screening all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults
• Screening women aged 65 and older routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures
• Structured breastfeeding education and behavioral counseling programs to promote breastfeeding
• Primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride
• Screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years

(2) ANNUAL LIMITATION-

Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year.

Pay particular attention to this.  It’s your annual out-of-pocket expenses for for anything not included in the Grade A or Grade B list of “preventative items and services”.  So although a preventative test may be covered, you’ll still be liable for co-pay expenses to walk in the door to get it.  And just like with most plans today, you’ll still be liable to share the costs of fixing anything found wrong with you by those tests.

Of course we have to have a “Health Benefits Advisory Committee to recommend covered benefits and essential, enhanced, and premium plans.”  This will be chaired by the Surgeon General and will have “9 members who are not Federal employees or officers and who are appointed by the President”, “9 members who are not Federal employees or officers and who are appointed by the Comptroller General”, and an “even number of members (not to exceed 8 ) who are Federal employees and officers, as the President may appoint.”  A committe with up to 27 members, 18 of whom are picked by the President.  The bill says these people will “reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies, and at least one practicing physician or other health professional and an expert on children’s health”.  But with no checks and balances on the selection of this group, you can bet they will reflect the President’s personal opinions and/or especially those to whom he owes campaign favors.

And, of course we have to have a Health Choices Administration and a Health Choices Commissioner.  At least the commissioner will be appointed by the President “by and with the advice and consent of the Senate”.  This will be an independent agency that will audit and enforce compliance for all “qualified health benefit plans”, whether or not the plan participates in the government’s “exchange”.  They will be able to levy financial penalties and shut down plans that fail to make their grade.  The Commissioner will appoint a “Qualified Health Benefits Plan Ombudsman” to help people stuck in the maze of government’s plan find their way out, but must do so “in a linguistically appropriate manner” (read:  “press 1 for English”).

Section 1173a of the bill discusses “Standardizing Electronic Administrative Transactions”.  Everything from enrollment to payment for services will be automated.  A good thing?  The bill allows up to 5 years to implement it so in the meantime we may look forward to not only the lumbering pace of bureaucracy, but utter chaos and confusion.

Section 164 outlines a “Reinsurance Program For Retirees”.  The government intends to pick up some of the tab for “participating employment-based plans” in order to lower the costs to the plan’s participants.  It includes the word “temporary”, but in the interim it is your tax dollars that will go to cushion employers who perhaps bit off more than they could chew with regards to retiree health benefits.  (Why do unions immediately come to mind?)

The “Health Insurance Exchange” is such a behemoth that it gets its own title within the bill.  It’s essentially the “Obama Does Costco”, one-stop shopping center where you can go to choose from the various government-seal-of-approval plans, including the government’s “public health insurance option”.  Meaning you can choose between vanilla and vanilla via “culturally and linguistically appropriate communication”.

Section 205, “OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN”, is interesting.  It defines “outreach” as informing and educating “individuals and employers about the Health Insurance Exchange and Exchange-participating health benefits plan options. Such outreach shall include outreach specific to vulnerable populations, such as children, individuals with disabilities, individuals with mental illness, and individuals with other cognitive impairments.”  Nice.  But down in (d)(1) we reach “COVERAGE FOR CERTAIN NEWBORNS” and weasel words that are sure to have the hearts of La Raza going pitter-patter with excitement.  And I don’t mean just the closing, “In carrying out this section, the Commissioner shall establish effective methods for communicating in plain language and a culturally and linguistically appropriate manner.”

(A) IN GENERAL- In the case of a child born in the United States who at the time of birth is not otherwise covered under acceptable coverage, for the period of time beginning on the date of birth and ending on the date the child otherwise is covered under acceptable coverage (or, if earlier, the end of the month in which the 60-day period, beginning on the date of birth, ends), the child shall be deemed–

(i) to be a non-traditional Medicaid eligible individual (as defined in subsection (e)(5)) for purposes of this division and Medicaid; and
(ii) to have elected to enroll in Medicaid through the application of paragraph (3).

Since the bill makes is mandatory for every American to have health insurance, I’ll let you figure out how a child will be born here without being covered.

To pay for the “Health Insurance Exchange”, we’ll have a “Health Insurance Trust Fund”.  And where will we get the money for it?  Easy!

Section 207 (c)(1) DEDICATED PAYMENTS- There is hereby appropriated to the Trust Fund amounts equivalent to the following:

(A) TAXES ON INDIVIDUALS NOT OBTAINING ACCEPTABLE COVERAGE– The amounts received in the Treasury under section 59B of the Internal Revenue Code of 1986 (relating to requirement of health insurance coverage for individuals).

Yes, Harry & Louise, if you choose to not buy health insurance or want to pay for a plan that is structured differently than the government wants a health insurance plan to be structured, the IRS is going to make you pay for it anyway.

(B) EMPLOYMENT TAXES ON EMPLOYERS NOT PROVIDING ACCEPTABLE COVERAGE– The amounts received in the Treasury under section 3111(c) of the Internal Revenue Code of 1986 (relating to employers electing to not provide health benefits).

(C) EXCISE TAX ON FAILURES TO MEET CERTAIN HEALTH COVERAGE REQUIREMENTS– The amounts received in the Treasury under section 4980H(b) (relating to excise tax with respect to failure to meet health coverage participation requirements).

(2) APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS– There are hereby appropriated, out of any moneys in the Treasury not otherwise appropriated, to the Trust Fund, an amount equivalent to the amount of payments made from the Trust Fund under subsection (b) plus such amounts as are necessary reduced by the amounts deposited under paragraph (1).

Numerous other “trust funds” are also embedded in the bill  for enormous and far-flung entire government-run programs  to fund the education of doctors and nurses and all kinds of research, which is essentially a huge step smack into the middle of the private sector.

Sections 241-245 are essentially premium subsidies for those who fall “below 400 percent of the Federal poverty level for a family of the size involved” and individuals; this also includes subsidizing “unaffordable employer coverage”, which is defined as “full-time employees for which the cost of the employee premium for coverage under a group health plan would exceed 11 percent of current family income”.

In the “Employer Responsibility” part of the bill, a nice double-dip can be found in section 311:  “if an employee declines [their employer’s plan]but otherwise obtains coverage in an Exchange-participating health benefits plan (other than by reason of being covered by family coverage as a spouse or dependent of the primary insured), the employer shall make a timely contribution to the Health Insurance Exchange with respect to each such employee”.  What this is saying is that employers will be penalized 8% of the employee’s average salary if their employees don’t want what they offer.  The employer isn’t paying the employee’s premiums, either.  This money goes right into the Health Insurance Exchange Trust Fund.

Small businesses get hit with this double-dip penalty, too, though “only” up to 6% on a sliding scale up to an annual payroll of $400,000.

Employers will be held liable for “civil penalties” if they do not provide health insurance; to the tune of $100/day up to $500,000.  Interestingly, the money collected “shall be deposited as miscellaneous receipts in the Treasury of the United States” instead of funding the government’s snake-oiled medicine machine.  The IRS will also be involved, collecting employment taxes on employers who “fail” to participate – 10% of what should have been paid up to $500,000.

Section 2793 addresses what’s required if an employer wants to use the government’s plan.  “Such election shall be treated as the establishment and maintenance of a group health plan” and because, say, Joe’s Plumbing & Heating is now Joe’s Plumbing & Heating Health Insurance Plan, the now-infamous “Secretary shall regularly audit…and conduct investigations and other activities…so as to discover noncompliance with the health coverage participation requirements….”  Anything wrong will be sent to the “Secretary of the Treasury and the Health Choices Commissioner. The Secretary shall take such timely enforcement action as appropriate to achieve compliance.”  The same civil and IRS-driven penalties noted above will also apply if Joe’s Plumbing & Heating Health Insurance Plan fails to “satisfy the health coverage participation requirements with respect to any employee.”

Of course, complying is going to be as easy as filing with the IRS, because the “Secretary” is given the authority to make up “such regulations as may be necessary or appropriate to carry out the provisions of this section”.  Section 6050X spells out how information will be provided to about everyone that Joe’s Plumbing & Heating Health Insurance Plan covers; provided both to the IRS and Joe’s employees, of course.

Because the federal government intends to not just reform health care for Americans, but to control it from birth to (early) death, section 324 has to spell out that cooperation between “the Secretary of Labor, the Secretary of the Treasury, the Secretary of Health and Human Services, and the Health Choices Commissioner” will insure that everyone is singing from the same songbook when it comes to “enforcing” adherence to this sweeping new law of the land.

Title IV of the bill amends the already impossible tonnage of the Internal Revenue Code of 1986.  Here is where individuals without coverage will be forced to pay a 2.5% tax, except for non-resident aliens and anyone living outside the United States, or folks who have a “religious exemption” on file.  If Joe’s Plumbing & Heating decides not to provide any kind of health insurance for its employees, Joe will pay a tax equal to 8% of his employee’s salaries, though if his business is very small and his payroll is less than $400,000, he’ll pay on a sliding scale up to 6%.

And just in case you were wondering, go ahead and substitute “state” for “Joe’s Plumbing & Heating”.  In a behind-the-scenes look at the crafting of this bill, the House Energy & Commerce Republicans reported that:

An amendment offered by Rep. Nathan Deal, R-GA., would prohibit the Federal government from taxing or withholding benefits from States whose health plans don’t comply with the new arbitrary essential benefits mandates that the HHS Secretary is authorized to make under this legislation. These could include mandated coverage of abortion or Botox injections, and if States don’t comply they would face an 8% tax on their employee payroll or drastic cuts in Federal grants.

The issue was outlined starkly in questions posed by the ranking Republican, Joe Barton of Texas, to the committee’s chief Democratic staff counsel:

Barton: “Is it true that if we don’t strike this and the bill stays as is, the federal government could withhold grants from states if they didn’t comply with some of the mandated requirements for health coverage of their state employees?

Democratic counsel: “Yes.”

Barton: “Is it true under the provisions of the bill if not struck or amended that if the federal government required abortions to be covered, a state would have to do that or lose grants?

Democratic counsel: “If the secretary, acting on advice of the benefits advisory commission, had made abortion a minimum benefit for any acceptable insurance package, yes, sir. They could withhold that.”

“We can’t tell states what to do directly,” Waxman said later, explaining why withholding funding would be necessary. “We have to use whatever leverage we have over them.”

Deal pointed out that the requirement seemed at odds with the Democrats’ long-stated intention to enact health care reform in order to cover people without insurance. “If the thrust of this bill is to cover the uninsured, state employees are not uninsured,” Deal pointed out. “Local municipal employees are not uninsured.”

However, Health Subcommittee Chairman Frank Pallone, D-N.J., stuck with the story that states might require federal intervention, “All we’re doing here is saying the state has to act like other employers.”

Nice, eh?  Anything the “Secretary’s” black little hole-where-the-heart-should-be desires will be funded by your hard-earned tax dollars.  Including abortions.

In Section 45R, “Health Coverage Expenses”, the smallest “qualified” businesses will get a 50% tax credit on the cost of providing health insurance, and there’s a sliding scale that decreases the credit based on the number of employees and their pay.  Starting in 2012.

Gee whiz.  Such generosity, eh?

In “Subtitle C—Disclosures to Carry Out Health Insurance Exchange Subsidies“, it states that the “Secretary” can “disclose to officers and employees of the Health Choices Administration or such State-based health insurance exchange, as the case may be, return information of any taxpayer whose income is relevant in determining any affordability credit”.  Just what information about you will be made available?

• Taxpayer identity information
• Filing status
• Modified adjusted gross income
• Number of dependents
• Such other information as is prescribed by the Secretary by regulation as might indicate whether the taxpayer is eligible for such affordability credits (and the amount thereof), and
• The taxable year with respect to which the preceding information relates or,if applicable, the fact that such information is not available.

The government will spend $750 million to tell you just how you should raise your children.  Section 1904: GRANTS TO STATES FOR QUALITY HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN AND FAMILIES EXPECTING CHILDREN, subpart 3: Support for Quality Home Visitation Programs, Section 440: HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN AND FAMILIES EXPECTING CHILDREN intends to provide parents with a “one size fits all” —

• knowledge of age-appropriate child development in cognitive, language, social, emotional, and motor domains (including knowledge of second language acquisition, in the case of English language learners);
• knowledge of realistic expectations of age-appropriate child behaviors;
• knowledge of health and wellness issues for children and parents;
• modeling, consulting, and coaching on parenting practices;
• skills to interact with their child to enhance age-appropriate development;
• skills to recognize and seek help for issues related to health, developmental delays, and social, emotional, and behavioral skills; and
• activities designed to help parents become full partners in the education of their children

If you’re a woman pregnant with your first child or have a child under the age of 2 and use the government’s plan the government is going to monitor you.  And don’t be surprised to find someone knocking at your door to check on you, in part to increase “birth intervals between pregnancies”.  (Can’t have poor people reproducing too quickly, can we?)

Other invasions of privacy are found in Section 2521, NATIONAL MEDICAL DEVICE REGISTRY, where private sector health-related electronic data (such as pharmaceutical purchase data and health insurance claims data) will be gathered to “facilitate analyses of postmarket safety and patient outcomes for devices.”  It is intended to be viewable by the general public but, of course, “in a manner and form that protects patient privacy and proprietary information and is comprehensive, useful, and not misleading to patients, physicians, and scientists.”

The government intends to spend $88 billion for a “PUBLIC HEALTH INVESTMENT FUND” (Section 2002) to pay for

• Community health centers
• The National Health Service Corps Program
• The National Health Service Corps Scholarship and Loan Repayment Programs
• Primary care loan funds (including funds appropriated for schools of medicine or osteopathic medicine under the authority of section 735(f) of such Act (42 U.S.C. 292y(f))
• Primary care education programs
• Nursing workforce development
• The National Center for Health Statistics
• The Agency for Healthcare Research and Quality

So how do we pay for all this?  Subtitle D—Other Revenue 8 Provisions cuts out the heart of the American dream so that the federal government can River Dance on it until it resembles British comfort food.

• SURCHARGE ON HIGH INCOME INDIVIDUALS
  1 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $350,000 but does not exceed $500,000
• 1.5 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $500,000 but does not exceed $1,000,000
• 5.4 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $1,000,000

In 2013, the amounts go up from 1% to 2%, and from 1.5% to 3% unless the “excess Federal health reform savings is more than $150,000,000,000 but not more than $175,000,000,000”.  If the “excess Federal health reform savings” is more than $175,000,000,000, then this tax won’t apply.

From what we’ve seen so far, I’m not going to hold my breath on those “savings” happening.  (And we’re only up to page 199.)  Not when section 4 of this Subtitle states, “The tax imposed under this section shall not be treated as tax….”

DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS has a 7-page table of contents.  Suffice it to say that is bodes ill for those who use the systems.  Skimming through it find that home infusion therapy will be reassessed, as will the effectiveness of “bone mass measurements”.  Hospitals with high readmission rates will see their Medicare payments reduced, and hospitals will be “monitored” to insure they aren’t turning people away.  The bill will control a hospital’s growth (number of beds, procedure or operating rooms, etc.)  but research will be conducted and a “demonstration program” deployed to find out “the extent to which Medicare service providers utilize, offer, or make available language services” so that “on-site interpreters, including interpreters who work as independent contractors and interpreters who work for agencies that provide on-site interpretation…could directly bill Medicare”.

And how about seeing if  “contracting directly with agencies that provide off-site interpretation including telephonic and video interpretation” so they, too, could directly bill Medicare?  Including “languages not frequently encountered in the United States”.  The participants providing language services in the “demonstration program” can use up to 10% of the “grant money” for their “administrative expenses”.

Maybe it’s just me, but it’s a little disconcerting to read that these “demonstration program” grantees “must ensure that their network providers receive at least 50 percent of the grant funds to pay for the provision of competent language services to Medicare beneficiaries who are limited English proficient, including physicians and pharmacies.”  Does anyone else wonder how a United States-licensed doctor or pharmacist functions without being proficient in English?  The bill itself defines “limited English proficient” as “an individual who speaks a primary language other than English and who cannot speak, read, write or understand the English language at a level that permits the individual to effectively communicate with clinical or nonclinical staff at an entity providing health care or health care related services.”

There are lots more outlays included as well (explaining in part why what doctors do is called “practice”?).

I’d say here’s the kicker in the Medicare portion of the bill, but that sounds almost cruel.  Section 1233 ADVANCE CARE PLANNING CONSULTATION actually spells out a 5-year doctor-patient talk that must include:

• An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.
• An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.
• An explanation by the practitioner of the role and responsibilities of a health care proxy.
• The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965).
• An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include—

• the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes
• the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and
• the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy)

An advance care planning consultation with respect to an individual may be conducted more frequently…if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.

…the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate.  Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.

And to top it off, they’ll update the “MEDICARE & YOU HANDBOOK” so it contains information about:

• Living wills
• Durable power of attorney
• Orders of life-sustaining treatment
• Health care proxies
• A description of Federal and State resources available to assist individuals and their families with advance care planning and advance directives, including—
  • Available State legal service
  • Organizations to assist individuals with advance care planning
  • Wbsite links or addresses for state-specific advance directive forms
  • Any additional information, as determined by the Secretary

I don’t know about you, but as insane as this whole bill reads, this is among the worst of it.  The government has no business mandating that my doctor to stick his or her nose into my personal life nor mandating how someone manages their personal affairs or how they want their life to end.

Now let’s run through some more of the laundry list of federal expenditures:

SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM

SEC. 1302. MEDICAL HOME PILOT PROGRAM

SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-MIDWIVES

SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE SERVICES

SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER SCREENING TESTS REGARDLESS OF CODING, SUBSEQUENT DIAGNOSIS, OR ANCILLARY TISSUE REMOVAL

SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND MENTAL HEALTH COUNSELOR SERVICES (80% covered)

Under TITLE IV:

SEC. 1181. (a) CENTER FOR COMPARATIVE EFFECTIVENESS RESEARCH ESTABLISHED
COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND; FINANCING FOR THE TRUST FUND.—For provision establishing a Comparative Effectiveness Research Trust Fund and financing such Trust Fund, see section 1802.

Subtitle B—Nursing Home Transparency
PART 1—IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING FACILITIES AND NURSING FACILITIES
SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL DISCLOSABLE PARTIES INFORMATION.

In a nutshell, if you own, operate, serve on the board of, provide services to, or simply work in any kind of managerial position for a nursing home, the government wants your name made available to the general public.  (The better for ACORN to march outside your home, my dear.)

The government is also going to supervise nursing home operations with an even bigger magnifying glass than it does today, down to the level of requiring reporting of even the staff’s qualifications, the hours they work, and their tenure, and there are civil fines waiting for those who fail to comply.  The feds even mandate how states can impose fines.  All of which results in yet another “pilot program”:  SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PROGRAM

Let’s not forget government training:  SECTION 1431. DEMENTIA AND ABUSE PREVENTION TRAINING.  But then we have to figure out just what should be required:  SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED FOR CERTIFIED NURSE AIDES AND SUPERVISORY STAFF.

And, of course, “The Secretary shall establish and periodically update, not less frequently than triennially, national priorities for performance improvement.”  To the tune of $2 million each year.

We’ll spend $5 million a year for SECTION 1192. DEVELOPMENT OF NEW QUALITY MEASURES, which is intended to be done with a broad cross-section of “stakeholders” and includes the word “transparency” and states that public input will be allowed, too.  Kinda like recovery.gov and allowing 5 days for public viewing of bills, I suppose?

Subtitle D—Physician Payments Sunshine Provision makes into law similar ethical constraints under which the private sector normally operates and puts it all out for public viewing.  (SECTION 1451. REPORTS ON FINANCIAL RELATIONSHIPS BETWEEN MANUFACTURERS AND DISTRIBUTORS OF COVERED DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL SUPPLIES UNDER MEDICARE, MEDICAID, OR CHIP AND PHYSICIANS AND OTHER HEALTH CARE ENTITIES AND BETWEEN PHYSICIANS AND OTHER HEALTH CARE ENTITIES.)

TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION, SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSITIONS is where the government will allocate how many residents a hospital may have.

The Secretary shall give preference to:

• Hospitals with 3-year primary care residency training programs, such as family practice and general internal medicine
• Hospitals insofar as they have in effect formal arrangements (as determined by the Secretary) that place greater emphasis upon training in Federally qualified health centers, rural health clinics, and other nonprovider settings
• Hospitals that receive additional payments under subsection (d)(5)(F) and emphasize training in an outpatient department
• Hospitals that place greater emphasis upon training in a health professional shortage area (designated under section 332 of the Public Health Service Act) or a health professional needs area (designated under section 2211 of such Act)

And, of course, we’ll pay for these “preferred” hospitals to have residents on staff, too.

“The Secretary of Health and Human Services shall conduct a demonstration project under which an approved teaching health center…would be eligible for payment …for its own direct costs of graduate medical education activities for primary care residents, as well as for the direct costs of graduate medical education activities of its contracting hospital for such residents, in a manner similar to the manner in which such payments would be made to a hospital if the hospital were to operate such a program.”

Oxymoron alert! “TITLE VI—PROGRAM INTEGRITY Subtitle A—Increased Funding to Fight Waste, Fraud, and Abuse”.  (There are also increased penalities, and even unannounced “surprise” on-site visits.)

Section 1636 reduces the maximum amount of time allowed to file Medicare claims from 36 down to 12 months.  “Narrowing the window for claims processing will not overburden providers and will reduce fraud and abuse.”  If you believe that, I have a bridge for sale….

Section 1639 says you can forget ordering that motorized scooter from the companies that advertise them on tv.  Your doctor must provide proof of a face-to-face visit with you first or else Medicare won’t pay for it.

Now if I’m reading it correctly, state’s rights to control how they administer Medicaid are eliminated.  SECTION 1702, REQUIREMENTS AND SPECIAL RULES FOR CERTAIN MEDICAID ELIGIBLE INDIVIDUALS removes the state’s ability to determine eligibility for Medicaid, and must accept anyone the government decides is to be covered.  And buried in SECTION 1703. CHIP AND MEDICAID MAINTENANCE OF EFFORT, “a State is not eligible for payment…for a calendar quarter …if eligibility standards, methodologies, or procedures under its plan…that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan…as in effect on June 16, 2009.”  And, “a State is not eligible for payment…for a calendar quarter…if the State applies any asset or resource test in determining (or redetermining) eligibility of any individual.”

Section 1704 outlines the elimination of Medicaid DSH.

Section 1712 allows coverage for tobacco cessation outpatient drugs.

Section 1741 PAYMENTS TO PHARMACISTS includes drug pricing that is determined, in part, by providing “opportunity for public comment”.  Not that some drugs do seem to be priced solely as a get-rich scheme, but I fail to understand how forcing a business to charge a certain price for something will do anything except stifle innovation in the private sector.  Which is, actually, a prime directive of the Obama administration.  But I digress.

Section 1744 describes how we’ll all pay for doctors to go to school; states will be reimbursed by the government for “graduate medical education”.

Section 1801 is where the bill describes how your federal tax return will be used to determine whether or not you’re eligible for a low-income prescription drug subsidy.

Section 4375 is where you’ll find the tax they are calling a “fee equal to the fair share per capita amount” that will be levied on all private sector health insurance plans (even auto insurance plans will be taxed if they contain any kind of medical coverage).  It takes great pains, however, to exempt government plans, of course.

If it isn’t clear to you already, the final sections of the bill are chock-full of spending on what is nothing short of a government takeover of the  field of human medicine in the United States, including a handover of states’ sovereignty:

DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
TITLE I—COMMUNITY HEALTH CENTERS
Sec. 2101. Increased funding
TITLE II—WORKFORCE
Subtitle A—Primary Care Workforce
PART 1—NATIONAL HEALTH SERVICE CORPS
Sec. 2201. National Health Service Corps
Sec. 2202. Authorizations of appropriations
PART 2—PROMOTION OF PRIMARY CARE AND DENTISTRY
Sec. 2211. Frontline health providers
SUBPART XI—HEALTH PROFESSIONAL NEEDS AREAS
Sec. 340H. In general
Sec. 340I. Loan repayments
Sec. 340J. Report
Sec. 340K. Allocation
Sec. 2212. Primary care student loan funds
Sec. 2213. Training in family medicine, general internal medicine, general pediatrics, geriatrics, and physician assistantship.   Preference given to individuals who are from underrepresented minority groups or disadvantaged backgrounds.
Sec. 2214. Training of medical residents in community-based settings.  Preference give to individuals who are from underrepresented minority groups or disadvantaged backgrounds; or individuals who practice in settings having the principal focus of serving underserved areas or populations experiencing health disparities.
Sec. 2215. Training for general, pediatric, and public health dentists and dental hygienists.  Preference given to individuals who are from underrepresented minority groups or disadvantaged backgrounds; practice settings having the principal focus of serving in underserved areas or populations experiencing health disparities; teaching programs that address the dental needs of vulnerable populations.
Sec. 2216. Authorization of appropriations
Subtitle B—Nursing Workforce
ADVANCED EDUCATION NURSING GRANTS…to train advanced education nurses who will practice in health professional shortage areas (and) to increase diversity among advanced education nurses.
Sec. 2221. Amendments to Public Health Service Act
Subtitle C—Public Health Workforce
Sec. 2231. Public Health Workforce Corps
SUBPART XII—PUBLIC HEALTH WORKFORCE
Sec. 340L. Public Health Workforce Corps
Ensures an adequate supply of public health professionals throughout the Nation. The Corps shall consist of such officers of the Regular and Reserve Corps of the Service as the Secretary may designate; and such civilian employees of the United States as the Secretary may appoint.
Sec. 340M. Public Health Workforce Scholarship Program
Sec. 340N. Public Health Workforce Loan Repayment Program
Sec. 2232. Enhancing the public health workforce
Sec. 2233. Public health training centers
Sec. 2234. Preventive medicine and public health training grant program
Sec. 2235. Authorization of appropriations
Subtitle D—Adapting Workforce to Evolving Health System Needs
PART 1—HEALTH PROFESSIONS TRAINING FOR DIVERSITY
Sec. 2241. Scholarships for disadvantaged students, loan repayments and fellowships regarding faculty positions, and educational assistance in the health professions regarding individuals from disadvantaged backgrounds.
Sec. 2242. Nursing workforce diversity grants.
Sec. 2243. Coordination of diversity and cultural competency programs.
PART 2—INTERDISCIPLINARY TRAINING PROGRAMS
Sec. 2251. Cultural and linguistic competency training for health care professionals, including nurse professionals, consisting of awarding grants and contracts to test, develop, evaluate and implement models of cultural and linguistic competency training (including continuing education) for health professionals.  Preference given (in part) to “entities” placing health professionals in regions experiencing significant changes in the cultural and linguistic demographics of populations, including communities along the United States-Mexico border.
Sec. 2252. Innovations in interdisciplinary care training.
Awards and grants to test, develop, evaluate, then implement health professional training programs (including continuing education) designed to promote the delivery of health services through interdisciplinary and team-based models, which may include patient-centered medical home models, medication therapy management models, and models integrating physical, mental, or oral health services; and coordination of the delivery of health care within and across settings, including health care institutions, community-based settings, and the patient’s home.

PART 3—ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND ASSESSMENT
This is a permanent advisory committee, 15 members appointed by the Secretary, to be known as the Advisory Committee on Health Workforce Evaluation and Assessment, providing recommendations on the supply, diversity, and geographic distribution of the health workforce; the retention of the health workforce to ensure quality and adequacy of such workforce; and policies to carry out the recommendations.  These are to include health professionals within the health workforce; health care patients and consumers; employers; labor unions; and third-party health payors.
Sec. 2261. Health workforce evaluation and assessment.
PART 4—HEALTH WORKFORCE ASSESSMENT
Sec. 2271. Health workforce assessment.
Collect data about the supply (including retention) of and demand for health professionals; the diversity of health professionals (including with respect to race, ethnic background, and gender); the geographic distribution of health professionals; and data on individuals participating in the programs authorized by subtitles A, B, 14 and C and part 1 of subtitle D of title II of division 15 C of the America’s Affordable Health Choices Act of 16 2009
PART 5—AUTHORIZATION OF APPROPRIATIONS
Sec. 2281. Authorization of appropriations.
TITLE III—PREVENTION AND WELLNESS
Sec. 2301. Prevention and wellness.
TITLE XXXI—PREVENTION AND WELLNESS
Subtitle A—Prevention and Wellness Trust
Sec. 3111. Prevention and Wellness Trust
Subtitle B—National Prevention and Wellness Strategy
Sec. 3121. National Prevention and Wellness Strategy
This is for our own good.  To improve our health “through evidence-based clinical and community prevention and wellness activities (in this section referred to as ‘prevention and wellness activities’), including core public health infrastructure improvement activities; identification of specific national goals and objectives in prevention and wellness activities that take into account appropriate public health measures and standards, including departmental measures and standards (including Healthy People and National Public Health Performance Standards).
Establishment of national priorities for prevention and wellness, taking into account unmet prevention and wellness needs.
Establishment of national priorities for research on prevention and wellness, taking into account unanswered research questions on prevention and wellness.
Identification of health disparities in prevention and wellness.
A plan for addressing and implementing them.
Subtitle C—Prevention Task Forces
Sec. 3131. Task Force on Clinical Preventive Services
This is a group of 30 members, all appointed by the Secretary to identify clinical preventive services for review;  review the scientific evidence related to the benefits, effectiveness, appropriateness, and costs of them for the purpose of developing, updating,publishing, and disseminating evidence-based recommendations on the use of such services; then as appropriate, take into account health disparities in developing, updating, publishing, and disseminating evidence-based recommendations on the use of such services;  identify gaps in clinical preventive services research and evaluation and recommend priority areas for such research and evaluation.
Sec. 3132. Task Force on Community Preventive Services.
Subtitle D—Prevention and Wellness Research
Sec. 3141. Prevention and wellness research activity coordination
Sec. 3142. Community prevention and wellness research grants
Subtitle E—Delivery of Community Prevention and Wellness Services
Sec. 3151. Community prevention and wellness services grants
Subtitle F—Core Public Health Infrastructure
Sec. 3161. Core public health infrastructure for State, local, and tribal health departments.
Sec. 3162. Core public health infrastructure and activities for CDC
Subtitle G—General Provisions
Sec. 3171. Definitions.
TITLE IV—QUALITY AND SURVEILLANCE
Sec. 2401. Implementation of best practices in the delivery of health care
Sec. 2402. Assistant Secretary for Health Information
Sec. 2403. Authorization of appropriations
TITLE V—OTHER PROVISIONS
Subtitle A—Drug Discount for Rural and Other Hospitals
Sec. 2501. Expanded participation in 340B program
Sec. 2502. Extension of discounts to inpatient drugs
Sec. 2503. Effective date
Subtitle B—School-Based Health Clinics
Sec. 2511. School-based health clinics
Subtitle C—National Medical Device Registry
Sec. 2521. National medical device registry
Subtitle D—Grants for Comprehensive Programs To Provide Education to Nurses and Create a Pipeline to Nursing
Enormous and far-flung; includes employer-match for tuition and paid leave time from a job to go to school
Sec. 2531. Establishment of grant program
Subtitle E—States Failing To Adhere to Certain Employment Obligations
Sec. 2541. Limitation on Federal funds
Federal funds are available “only if the State agrees to be subject in its capacity as an employer to each obligation under division A of this Act and the amendments made by such division applicable to persons in their capacity as an employer; and assures that all political subdivisions in the State will do the same.”

Welcome to the end of 1,017 pages.  Is your head spinning?  Does your head hurt?  Mine sure did.  But through the pain, one thing is crystal clear:   this is NOT what America needs to help make sure that those who need medical care can receive it in a way that is affordable.

Only the gods know how this version will end up, if it ever makes it out of all the committees.  But the cost estimates for this bill show a 10-year “net increase in the deficit of an estimated $65 billion.”  The Congressional Budget Office also caveats that “…the figures do not include certain costs that the government would incur to administer the proposed changes and the impact of the bill’s provisions on other federal programs, and they do not reflect any modifications or amendments made after the bill was introduced.”

The Republican Ways & Means Committee staff put together a spiffy graph that demonstrates this, and projects the numbers beyond the 10 years forecasted by the CBO:

And so the Congressional Budget Office is shaking its head at it all.

“We do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount,” Douglas Elmendorf, director of the Congressional Budget Office, told the Senate Budget Committee. “On the contrary, the legislation significantly expands the federal responsibility for health-care costs,” he added.

Of course, Pelosi and Reid were quick to poo-poo them, trotting out the empty old, sad (and unmeasurable) sack of “better health care decreases health care costs”.

In his appearance, Mr. Elmendorf suggested lawmakers could take steps to control costs. Among other things, he said Congress could reduce the tax subsidy that critics say encourages employers to offer large health-insurance policies. That idea was being considered by members of the Senate Finance Committee, but dropped after Senate Democratic leaders — including Mr. Reid — voiced concern. The proposal has been sharply opposed by labor unions, among other groups, that have big tax-advantaged plans.

On Thursday, Mr. Reid expressed disdain when asked by reporters about Mr. Elmendorf’s suggestion. “What he should do is maybe run for Congress,” the Nevada Democrat said.

That’s an excellent idea, Harry.  How about we start by replacing YOU?  And replacing every other wanker in Washington who thinks that this is a road down which America should be driven.