Sie sind auf Seite 1von 49

;D8JH on

Health Reform
H>9:"7N"H>9:8DBE6G>HDCD;B6?DG=:6AI=86G:G:;DGBEGDEDH6AH

This side-by-side compares the leading comprehensive reform proposals across a number of key characteristics and plan components. Included in this side-by-
side are proposals for moving toward universal coverage that have been put forward by the President and Members of Congress. In an effort to capture the most
important proposals, we have included those that have been formally introduced as legislation as well as those that have been offered as principles or in White
Paper form. This side-by-side will be regularly updated to reflect changes in the proposals and to incorporate major new proposals as they are announced.
The House Tri-Committee summary incorporates the major amendments to the legislation adopted by the three committees of jurisdiction during their mark-ups
of the bill. These amendments are identified using an abbreviation for the House panel that approved it — “E&C” for the Committee on Energy and Commerce;
“E&L” for the Committee on Education and Labor; and “W&M” for the Committee on Ways and Means.

House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Date plan announced September 16, 2009 June 9, 2009 June 19, 2009 February 26, 2009
Overall approach Require most U.S. citizens and Require individuals to have health Require all individuals to have President Obama outlined eight
to expanding access legal residents to have health insurance. Create state-based health insurance. Create a Health principles for health care reform
to coverage insurance. Create state-based American Health Benefit Gateways Insurance Exchange through which in his FY 2010 Budget overview.
health insurance exchanges through through which individuals and small individuals and smaller employers The President has indicated that
which individuals can purchase businesses can purchase health can purchase health coverage, with comprehensive health reform should:
coverage, with premium and coverage, with subsidies available to premium and cost-sharing credits • Reduce long-term growth of
cost-sharing credits available to individuals/families with incomes up available to individuals/families health care costs for businesses
individuals/families with income to 400% of the federal poverty level with incomes up to 400% of the and government.
between 100-400% of the federal (or $73,240 for a family of three in federal poverty level (or $73,240 for
• Protect families from bankruptcy or
poverty level (the poverty level is 2009). Require employers to provide a family of three in 2009). Require
debt because of health care costs.
$22,050 for a family of four in 2009) coverage to their employees or employers to provide coverage to
• Guarantee choice of doctors and
and create separate exchanges pay an annual fee, with exceptions employees or pay into a Health
health plans.
through which small businesses for small employers, and provide Insurance Exchange Trust Fund,
can purchase coverage. Assess certain small employers a credit with exceptions for certain small • Invest in prevention and wellness.
a fee on certain employers that to offset the costs of providing employers, and provide certain • Improve patient safety and quality
do not offer coverage for each coverage. Impose new regulations small employers a credit to offset care.
employee who receives a tax credit on the individual and small group the costs of providing coverage. • Assure affordable, quality health
for health insurance through an insurance markets. Expand Impose new regulations on plans coverage for all Americans.
exchange, with exceptions for small Medicaid to all individuals with participating in the Exchange and in • Maintain coverage when you
employers. incomes up to 150% of the federal the small group insurance market. change or lose your job.
poverty level. Expand Medicaid to 133% of the • End barriers to coverage for
poverty level. people with pre-existing medical
conditions.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Overall approach Impose new regulations on health


to expanding access plans in the exchange and in the
to coverage (continued) individual and small group markets.
Expand Medicaid to all individuals
with incomes up to 133% of the
federal poverty level and expand
CHIP eligibility to all children up to
250% of the federal poverty level.
Individual mandate • Require U.S. citizens and legal • Require individuals to have • Require all individuals to have • The plan must put the country
residents to have qualifying health qualifying health coverage. “acceptable health coverage”. on a clear path to cover all
coverage. Enforced through a Enforced through a minimum Those without coverage pay Americans.
tax penalty of $750 per year for tax penalty of no more than a penalty of 2.5% of modified
taxpayers with incomes between $750 per year. Exemptions to the adjusted gross income up to
100-300% FPL (maximum penalty individual mandate will be granted the cost of the average national
per family of $1,500) and $950 per to residents of states that do not premium for self-only or
year for taxpayers with incomes establish an American Health family coverage under a basic
above 300% FPL (maximum Benefit Gateway, members of plan in the Health Insurance
penalty per family of $3,800). Indian tribes, those for whom Exchange. Exceptions granted for
Exemptions will be granted for affordable coverage is not dependents, religious objections,
financial hardship, religious available, and those without and financial hardship.
objections, American Indians, coverage for fewer than 90 days.
and if the lowest cost plan option
exceeds 10% of an individual’s
income or if the individual has
income below 133% of the poverty
level.
Employer requirements • Assess a fee on employers with • Require employers to offer health • Require employers to offer Not specified.
more than 50 employees that coverage to their employees and coverage to their employees and
do not offer coverage for each contribute at least 60% of the contribute at least 72.5% of the
employee who receives a health premium cost or pay $750 for premium cost for single coverage
insurance tax credit through an each uninsured full-time and 65% of the premium cost for
exchange. The penalty is the employee and $375 for each family coverage of the lowest cost
lesser of a flat dollar amount uninsured part-time employee plan that meets the essential
equal to the average tax credit for who is not offered coverage. For benefits package requirements or
each full-time employee receiving employers subject to the pay 8% of payroll into the Health
a tax credit or $400 times the total assessment, the first 25 workers Insurance Exchange Trust Fund.
number of employees in the firm. are exempted. [E&L Committee amendment:
• Exempt employers with 50 or • Exempt employers with 25 or Provide hardship exemptions
fewer employees from the penalty. fewer employees from the for employers that would be
requirement to provide coverage. negatively affected by job losses
as a result of requirement.]

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Employer requirements • Require employers with 200 or • Eliminate or reduce the pay
(continued) more employees to automatically or play assessment for small
enroll employees into health employers with annual payroll of
insurance plans offered by the less than $400,000:
employer. Employees may opt out – Annual payroll less than
of coverage if they have coverage $250,000: exempt
from another source. – Annual payroll between
$250,000 and $300,000: 2% of
payroll;
– Annual payroll between
$300,000 and $350,000: 4% of
payroll;
– Annual payroll between
$350,000 and $400,000: 6% of
payroll.
[E&C Committee amendment:
Extend the reduction in the pay
or play assessment for small
employers with annual payroll of
less than $750,000 and replace
the above schedule with the
following:
– Annual payroll less than
$500,000: exempt
– Annual payroll between
$500,000 and $585,000: 2% of
payroll;
– Annual payroll between
$585,000 and $670,000: 4% of
payroll;
– Annual payroll between
$670,000 and $750,000: 6% of
payroll.]
• Require employers that offer
coverage to automatically enroll
into the employer’s lowest cost
premium plan any individual who
does not elect coverage under the
employer plan or does not opt out
of such coverage.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Expansion of public • Expand Medicaid to all • Expand Medicaid to all individuals • Expand Medicaid to all individuals • As a foundation for health
programs individuals (children, pregnant (children, pregnant women, (children, pregnant women, reform, the President signed
women, parents, and adults parents, and adults without parents, and adults without the Children’s Health Insurance
without dependent children) dependent children) with incomes dependent children) with incomes Program Reauthorization
with incomes up to 133% FPL up to 150% FPL. Individuals up to 133% FPL. Newly eligible, Act (CHIPRA), which provides
(to be implemented in 2014). eligible for Medicaid will be non-traditional (childless adults) coverage to 11 million children.
Adults with incomes between covered through state Medicaid Medicaid beneficiaries may
100-133% FPL will have the programs and will not be eligible enroll in coverage through the
option of obtaining coverage for credits to purchase coverage Exchange if they were enrolled
through Medicaid or with federal through American Health Benefit in qualified health coverage
subsidies through the exchange. Gateways. during the six months before
All newly eligible adults will be • Grant individuals eligible for becoming Medicaid eligible.
guaranteed a benchmark benefit the Children’s Health Insurance Provide Medicaid coverage for all
package that at least meets the Program (CHIP) the option of newborns who lack acceptable
minimum creditable coverage enrolling in CHIP or enrolling in coverage and provide optional
standards. Require states to a qualified health plan through a Medicaid coverage to low-income
provide premium assistance to Gateway. HIV-infected individuals and for
any Medicaid beneficiary with family planning services to certain
access to employer-sponsored low-income women. In addition,
insurance if it is cost-effective for increase Medicaid payment
the state. To finance the coverage rates for primary care providers
for the newly eligible (those who to 100% of Medicare rates.
were not previously eligible for a [E&C Committee amendment:
full benchmark benefit package Require states to submit a state
or who were eligible for a capped plan amendment specifying the
program but were not enrolled), payment rates to be paid under
states will receive an increase in the state’s Medicaid program.]
the federal medical assistance The coverage expansions (except
percentage (FMAP). Initially, the the optional expansions) and the
percentage point increase in the enhanced provider payments
FMAP will be 27.3 for states that will be fully financed with
already cover adults with incomes federal funds. [E&C Committee
above 100% FPL and 37.3 for other amendment: Replace full federal
states. These percentage point financing for Medicaid coverage
increases will be adjusted over expansions with 100% federal
time so that by 2019, all states will financing through 2014 and 90%
receive an FMAP increase of 32.3 federal financing beginning in year
percentage points for the newly 2015.]
eligible.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Expansion of public • Beginning in 2013, expand • Require Children’s Health


programs (continued) eligibility for the Children’s Insurance Program (CHIP)
Health Insurance Program enrollees to obtain coverage
(CHIP) to 250% FPL and enroll through the Health Insurance
CHIP beneficiaries in exchange Exchange (in the first year the
plans. Require states to provide Exchange is available) provided
services not covered by plans in the Health Choices Commissioner
the exchange, including Early and determines that the Exchange
Periodic Screening, Diagnosis, has the capacity to cover these
and Treatment (EPSDT) services, children and that procedures
as wrap-around benefits. are in place to ensure the timely
transition of CHIP enrollees
into the Exchange without an
interruption of coverage. [E&C
Committee amendment: Require
that CHIP enrollees not be
enrolled in an Exchange plan
until the Secretary certifies that
coverage is at least comparable
to coverage under an average
CHIP plan in effect in 2011. The
Secretary must also determine
that there are procedures to
transfer CHIP enrollees into the
exchange without interrupting
coverage or with a written plan of
treatment.]

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Premium subsidies • Provide refundable and • Provide premium credits on a • Provide affordability premium • The plan must protect families’
to individuals advanceable premium credits sliding scale basis to individuals credits to eligible individuals from bankruptcy or debt because
to individuals and families with and families with incomes up to and families with incomes up to of health care costs.
incomes between 133-400% FPL 400% FPL to purchase coverage 400% FPL to purchase insurance • The American Recovery and
in 2013, and including individuals through the Gateway. The through the Health Insurance Reinvestment Act makes coverage
and families with incomes premium credits will be based Exchange. The premium credits more affordable for Americans
between 100-133% FPL in 2014, to on the average cost of the three will be based on the average cost who lose their jobs and their
purchase insurance through the lowest cost qualified health plans of the three lowest cost basic access to employer-based health
health insurance exchanges. The in the area, but will be such that health plans in the area and will coverage by offering a subsidy of
premium credits will be tied to the individuals with incomes less be set on a sliding scale such 65 percent of the premium costs
second lowest-cost silver plan in than 400% FPL pay no more than that the premium contributions for COBRA coverage.
the area and will be provided on 12.5% of income and individuals are limited to the following
a sliding scale basis from 3% of with incomes less than 150% FPL percentages of income for
income for those at 100% FPL to pay 1% of income, with additional specified income tiers:
13% of income for those between limits on cost-sharing. 133-150% FPL: 1.5 - 3% of income
300-400% FPL. • Limit availability of premium 150-200% FPL: 3 - 5% of income
• Exclude individuals with incomes credits through the Gateway to 200-250% FPL: 5 - 7% of income
below 100% FPL from eligibility individuals who are not eligible 250-300% FPL: 7 - 9% of income
for the premium credits. These for employer-based coverage that
300-350% FPL: 9 - 10% of income
individuals will be eligible for meets minimum qualifying criteria
coverage through the Medicaid and affordability standards, 350-400% FPL: 10 - 11% of income
program. Medicare, Medicaid, TRICARE, [E&C Committee amendment:
• Provide cost-sharing subsidies to or the Federal Employee Health Replaces the above subsidy
eligible individuals and families Benefits Program. Individuals schedule with the following:
with incomes between 100-200% with access to employer-based 133-150% FPL: 1.5 - 3% of income
FPL. For those with incomes coverage are eligible for the 150-200% FPL: 3 – 5.5% of income
between 100-150% FPL, the cost- premium credits if the cost of the 200-250% FPL: 5.5 - 8% of income
sharing subsidies will result in employee premium exceeds 12.5% 250-300% FPL: 8 - 10% of income
coverage for 90% of the benefit of the individuals’ income.
300-350% FPL: 10 - 11% of income
costs of the plan. For those with
350-400% FPL: 11 - 12% of income]
incomes between 150-200%, the
[E&C Committee amendment:
cost-sharing subsidies will result
Increase the affordability credits
in coverage for 80% of the benefit
annually by the estimated savings
costs of the plan.
achieved through adopting a
formulary in the public health
insurance option, pharmacy
benefit manager transparency
requirements, developing
accountable care organization
pilot programs in Medicaid, and
administrative simplification.]

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Premium subsidies • Limit availability of premium [E&C Committee amendment:


to individuals (continued) credits and cost-sharing subsidies Increase the affordability credits
through the exchanges to U.S. annually by the estimated
citizens and legal immigrants who savings achieved through limiting
meet income limits. Employees increases in premiums for plans
who are offered coverage by in the Exchange to no more than
an employer are not eligible 150% of the annual increase in
for premium credits unless the medical inflation and by requiring
employer plan does not have an the Secretary to negotiate
actuarial value of at least 65% directly with prescription drug
or if the employee share of the manufacturers to lower the prices
premium exceeds 13% of income. for Medicare Part D plans.]
• Require verification of both • Provide affordability cost-sharing
income and citizenship status credits to eligible individuals and
in determining eligibility for the families with incomes up to 400%
federal premium credits. FPL. The cost-sharing credits
reduce the cost-sharing amounts
and annual cost-sharing limits
and have the effect of increasing
the actuarial value of the basic
benefit plan to the following
percentages of the full value of the
plan for the specified income tier:
133-150% FPL: 97%
150-200% FPL: 93%
200-250% FPL: 85%
250-300% FPL: 78%
300-350% FPL: 72%
350-400% FPL: 70%

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Premium subsidies • Limit availability of premium and


to individuals (continued) cost-sharing credits to US citizens
and lawfully residing immigrants
who meet the income limits
and are not enrolled in qualified
or grandfathered employer or
individual coverage, Medicare,
Medicaid (except those eligible
to enroll in the Exchange),
TRICARE, or VA coverage (with
some exceptions). Individuals
with access to employer-based
coverage are eligible for the
premium and cost-sharing
credits if the cost of the employee
premium exceeds 11% of
the individuals’ income [E&C
Committee amendment: To be
eligible for the premium and cost-
sharing credits, the cost of the
employee premium must exceed
12% of individuals’ income.].
Premium subsidies • Provide small employers with • Provide qualifying small • Provide small employers with Not specified.
to employers fewer than 25 employees and employers with a health options fewer than 25 employees and
average annual wages of less program credit. To qualify for the average wages of less than
than $40,000 that purchase health credit, employers must have fewer $40,000 with a health coverage
insurance for employees with a than 50 full-time employees, pay tax credit. The full credit of 50% of
tax credit. an average wage of less than premium costs paid by employers
$50,000, and must pay at least is available to employers with 10
60% of employee health expenses. or fewer employees and average
annual wages of $20,000 or less.
The credit phases-out as firm size
and average wage increases and
is not permitted for employees
earning more than $80,000 per
year.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Premium subsidies Phase I: For tax years 2011 and The credit is equal to $1,000 • Create a temporary reinsurance
to employers (continued) 2012, provide a tax credit of up to for each employee with single program for employers providing
35% of the employer’s contribution coverage and $2,000 for each health insurance coverage to
toward the employee’s health employee with family coverage, retirees ages 55 to 64. Program
insurance premium if the adjusted for firm size (phasing will reimburse employers for 80%
employer contributes at least out as firm size increases) and of retiree claims between $15,000
50% of the total premium cost or number of months of coverage and $90,000. Payments from the
50% of a benchmark premium. provided. Bonus payments are reinsurance program will be used
The full credit will be available given for each additional 10% of to lower the costs for enrollees in
to employers with 10 or fewer employee health expenses above the employer plan. Appropriate
employees and average annual 60% paid by the employer. $10 billion over ten years for the
wages of less than $20,000. Employers may not receive reinsurance program.
Phase II: For tax years 2013 and the credit for more than three
later, for eligible small businesses consecutive years. Self-employed
that purchase coverage through individuals who do not receive
the state exchange, provide a premium credits for purchasing
tax credit of up to 50% of the coverage through the Gateway are
employer’s contribution toward eligible for the credit.
the employee’s health insurance • Create a temporary reinsurance
premium if the employer program for employers providing
contributes at least 50% of the health insurance coverage to
total premium cost or 50% of a retirees ages 55 to 64. Program
benchmark premium. The credit will reimburse employers for
will be available for two years. 80% of retiree claims between
The full credit will be available $15,000 and $90,000. Program
to employers with 10 or fewer will end when the state Gateway
employees and average annual is established. Payments from the
wages of less than $20,000. reinsurance program will be used
to lower the costs for enrollees in
the employer plan.
Tax changes related • Impose a tax on individuals • Impose a minimum tax on • Impose a tax on individuals Not specified.
to health insurance without qualifying coverage of individuals without qualifying without acceptable health care
$750 for those with incomes health care coverage of no more coverage of 2.5% of modified
between 133-300% FPL and $950 than $750 per year. adjusted gross income.
for those with incomes greater
than 300% FPL.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Tax changes related • Impose an excise tax in 2013 on


to health insurance insurers for employer-sponsored
(continued) health plans with aggregate
values that exceed $8,000 for
individual coverage and $21,000
for family coverage (these threshold
values will be indexed to the
consumer price index for urban
consumers (CPI-U)). The tax is
equal to 35% of the value of the
plan that exceeds the threshold
amounts and is imposed on the
issuer of the health insurance
policy, which in the case of a
self-insured plan is the plan
administrator or, in some cases,
the employer. The aggregate value of
the health insurance plan includes
reimbursements under a flexible
spending account for medical
expenses (health FSA) or health
reimbursement arrangement
(HRA), employer contributions to
a health savings account (HSA),
and coverage for dental, vision,
and other supplementary health
insurance coverage.
• Conform the definition of
medical expenses for purposes
of employer provided health
coverage (including HRAs and
health FSAs), HSAs, and Archer
medical savings accounts to the
definition for purposes of the
itemized deduction for medical
expenses. This change will
exclude the costs for over-the-
counter drugs not prescribed by
a doctor from being reimbursed
through an HRA or health FSA
and from being reimbursed on a
tax-free basis through an HSA or
Archer MSA.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 10
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Tax changes related • Increase the tax on distributions


to health insurance from a health savings account that
(continued) are not used for qualified medical
expenses to 20% (from 10%) of the
disbursed amount.
• Limit the amount of contributions
to a flexible spending account for
medical expenses to $2,000 per
year.
• Impose new fees on segments of
the health care sector:
– $2.3 billion annual fee on the
pharmaceutical manufacturing
sector;
– $4 billion annual fee on the
medical device manufacturing
sector;
– $6 billion annual fee on the
health insurance sector; and
– $750 million annual fee on the
clinical laboratories sector.
Creation of insurance • Provide immediate assistance • Create state-based American • Create a National Health Insurance • The plan should provide portability
pooling mechanisms until the new insurance market Health Benefit Gateways, Exchange, through which individuals of coverage and should offer
rules go into effect for those administered by a governmental and employers (phasing-in eligibility Americans a choice of health
with pre-existing conditions by agency or non-profit organization, for employers starting with smallest plans.
creating a temporary high-risk through which individuals and employers) can purchase qualified
pool. Individuals who have been small employers can purchase insurance, including from private
denied health coverage due to a qualified coverage. States may health plans and the public health
pre-existing medical condition and form regional Gateways or allow insurance option.
who have been uninsured for at more than one Gateway to operate • Restrict access to coverage
least six months will be eligible in a state as long as each Gateway through the Exchange to
to enroll in the high-risk pool and serves a distinct geographic area. individuals who are not enrolled
receive subsidized premiums. The • Restrict access to coverage in qualified or grandfathered
high-risk pool will exist until 2013. through the Gateways to employer or individual coverage,
• Create state-based exchanges for individuals who are not Medicare, Medicaid (with some
the individual market and small incarcerated and who are not exceptions), TRICARE, or VA
business health options program eligible for employer-sponsored coverage (with some exceptions).
(SHOP) exchanges for the small coverage that meets minimum
group market. qualifying criteria and affordability
standards, Medicare, Medicaid,
TRICARE, or the Federal Employee
Health Benefits Program.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 11
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Creation of insurance • Restrict access to coverage • Create a community health [E&C Committee amendment:
pooling mechanisms through the exchanges to U.S. insurance option to be offered Permit members of the armed
(continued) citizens and legal immigrants. through state Gateways that forces and those with coverage
• Create the Consumer Operated complies with the requirements through TRICARE or the VA to
and Oriented Plan (CO-OP) of being a qualified health plan. enroll in a health benefits plan
program to foster the creation of Require that the costs of the offered through the Exchange.]
non-profit, member-run health community health insurance plan • Create a new public health
insurance companies in all 50 be financed through revenues insurance option to be offered
states and District of Columbia. from premiums, require the through the Health Insurance
To be eligible to receive funds, plan to negotiate payment rates Exchange that must meet the same
organizations must not be an with providers, and contract requirements as private plans
existing organization, substantially with qualified nonprofit entities regarding benefit levels, provider
all of its activities must consist of to administer the plan. Permit networks, consumer protections,
the issuance of qualified health the plan to develop innovative and cost-sharing. Require the
benefit plans in each state in payment policies to promote public plan to offer basic, enhanced,
which it is licensed, governance of quality, efficiency, and savings to and premium plans, and permit it to
the organization must be subject consumers. Require each State to offer premium plus plans. Finance
to a majority vote of its members, establish a State Advisory Council the costs of the public plan through
must operate with a strong to provide recommendations on revenues from premiums. For
consumer focus, and any profits policies and procedures for the the first three years, set provider
must be used to lower premiums, community health insurance payment rates in the public plan
improve benefits, or improve the option. at Medicare rates and allow bonus
quality of health care delivered to • Create three benefit tiers of payments of 5% for providers
its members. plans to be offered through the that participate in both Medicare
• Require all state-licensed insurers Gateways based on the percentage and the public plan and for
in the individual and small group of allowed benefit costs covered by pediatricians and other providers
markets to participate in the the plan: that don’t typically participate in
exchanges. – Tier 1: includes the essential Medicare. In subsequent years,
• Require guarantee issue and health benefits and covers 76% permit the Secretary to establish
renewability and allow rating of the benefit costs of the plan; a process for setting rates. [E&C
variation based only on age – Tier 2: includes the essential Committee amendment: Require
(limited to 5 to 1 ratio), tobacco health benefits and covers 84% the public health insurance option
use (limited to 1.5. to 1 ratio), of the benefit costs of the plan; to negotiate rates with providers
family composition, and – Tier 3: includes the essential so that the rates are not lower
geography in the non-group and health benefits and covers 93% than Medicare rates and not
the small group market (new rules of the benefit costs of the plan. higher than the average rates paid
for small group market will be by other qualified health benefit
phased-in over five years). Require plan offering entities.] Health care
risk adjustment in individual providers participating in Medicare
and small group markets and are considered participating
prohibit insurers from rescinding providers in the public plan unless
coverage. they opt out.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 12
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Creation of insurance • Require the exchanges to • Require guarantee issue and Permit the public plan to develop
pooling mechanisms develop a standardized format renewability of health insurance innovative payment mechanisms,
(continued) for presenting insurance policies in the individual and small including medical home and other
options, create a web portal to group markets; prohibit pre- care management payments,
help consumers find insurance, existing condition exclusions; and value-based purchasing, bundling
maintain a call center for allow rating variation based only of services, differential payment
customer service, and establish on family structure, geography, rates, performance based
procedures for enrolling the actuarial value of the health payments, or partial capitation
individuals and businesses and plan benefit, tobacco use, and age and modify cost sharing and
for determining eligibility for tax (with only 2 to 1 variation). payment rates to encourage use
credits. • Require plans participating in of high-value services. [E&C
• Create four benefit categories the Gateway to provide coverage Committee amendment: Clarify
of plans plus a separate “young for at least the essential health that the public health insurance
invincible plan” to be offered care benefits, meet network option must meet the same
through the exchange, and in adequacy requirements, and requirements as other plans
the individual and small group make information regarding plan relating to guarantee issue and
markets: benefits service area, premium renewability, insurance rating
– Bronze plan represents and cost sharing, and grievance rules, network adequacy, and
minimum creditable coverage and appeal procedures available transparency of information.]
and would cover 65% of the to consumers. [E&C Committee amendment:
benefit costs of the plan, with • Require states to adjust payments Require the public health
an out-of-pocket limit equal to health plans based on the insurance option to adopt a
to the Health Savings Account actuarial risk of plan enrollees prescription drug formulary.]
(HSA) current law limit ($5,950 using methods established by the • Create four benefit categories of
for individuals and $11,900 for Secretary. plans to be offered through the
families); • Require the Gateway to certify Exchange:
– Silver plan includes minimum participating health plans, provide – Basic plan includes essential
benefits, covers 70% of the consumers with information benefits package and covers
benefit costs of the plan, with allowing them to choose among 70% of the benefit costs of the
the HSA out-of-pocket limits; plans (including through a plan;
– Gold plan includes the minimum centralized website), contract with – Enhanced plan includes
benefits, covers 80% of the navigators to conduct outreach essential benefits package,
benefit costs of the plan, with and enrollment assistance, create reduced cost sharing compared
the HSA out-of-pocket limits; a single point of entry for enrolling to the basic plan, and covers
– Platinum plan includes the in coverage through the Gateway 85% of benefit costs of the plan;
minimum benefits, covers 90% or through Medicaid, CHIP or – Premium plan includes essential
of the benefit costs of the plan, other federal programs, and assist benefits package with reduced
with the HSA out-of-pocket consumers with the purchase cost sharing compared to the
limits; of long-term care services and enhanced plan and covers 95%
supports. of the benefit costs of the plan;

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 13
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Creation of insurance – Young Invincible plan available to • Following initial federal support, – Premium plus plan is a premium
pooling mechanisms those 25 years old and younger the Gateway will be funded by plan that provides additional
(continued) and provides catastrophic a surcharge of no more than benefits, such as oral health and
coverage only with the coverage 4% of premiums collected by vision care.
level set at the HSA current law participating health plans. • Require guarantee issue and
levels except that prevention renewability; allow rating variation
benefits would be exempt from based only on age (limited to 2 to
the deductible. 1 ratio), premium rating area, and
• Require that at least one plan in family enrollment; and limit the
the exchanges provide coverage medical loss ratio to a specified
for abortions beyond those for percentage.
which federal funds are permitted • Require plans participating
and require that at least one in the Exchange to be state
plan in the exchange does not licensed, report data as required,
provide coverage for abortions implement affordability credits,
beyond those for which federal meet network adequacy
funds are permitted (in cases of standards, provide culturally and
rape or incest or to save the life linguistically appropriate services,
of the woman). Prohibit plans contract with essential community
participating in the exchanges providers, and participate in risk
from discriminating against any pooling. Require participating
provider because of a willingness plans to offer one basic plan for
or unwillingness to provide, pay each service area and permit
for, provide coverage of, or refer them to offer additional plans.
for abortions. [E&C Committee amendment:
Require plans to provide
information related to end-of-life
planning to individuals and provide
the option to establish advance
directives and physician’s order
for life sustaining treatment.]
• Require risk adjustment of
participating Exchange plans.
• Provide information to consumers
to enable them to choose among
plans in the Exchange, including
establishing a telephone hotline
and maintaining a website and
provide information on open
enrollment periods and how to
enroll.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 14
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Creation of insurance • [E&C Committee amendment:


pooling mechanisms Prohibit plans participating in the
(continued) Exchange from discriminating
against any provider because of
a willingness or unwillingness to
provide abortions.] .
• [E&C Committee amendment:
Facilitate the establishment of
non-for-profit, member-run
health insurance cooperatives
to provide insurance through the
Exchange.]
• Allow states to operate state-
based exchanges if they
demonstrate the capacity to
meet the requirements for
administering the Exchange.
Benefit design • Create minimum creditable • Create the essential health care • Create an essential benefits Not specified.
coverage that provides a benefits package that provides a package that provides a
comprehensive set of services, comprehensive array of services comprehensive set of services,
covers 65% of the actuarial value and prohibits inclusion of lifetime covers 70% of the actuarial value
of the covered benefits, limits or annual limits on the dollar of the covered benefits, limits
annual cost-sharing to $5,950/ value of the benefits. The essential annual cost-sharing to $5,000/
individual and $11,900/family, health benefits must be included individual and $10,000/family,
and does not impose annual or in all qualified health plans and and does not impose annual or
lifetime limits on coverage. (See must be equal to the scope of lifetime limits on coverage. The
description of benefit categories benefits provided by a typical Health Benefits Advisory Council,
in Creation of insurance pooling employer plan. Create a chaired by the Surgeon General,
mechanism.) temporary, independent will make recommendations on
commission to advise the specific services to be covered by
Secretary in the development of the essential benefits package as
the essential health benefit well as cost-sharing levels. [E&L
package. Committee amendment: Require
early and periodic screening,
diagnostic, and treatment (EPSDT)
services for children under age
21 be included in the essential
benefits package.]

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 15
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Benefit design • Prohibit abortion coverage from • Specify the criteria for minimum [E&C Committee amendment:
(continued) being required as part of the qualifying coverage for purposes Prohibit abortion coverage from
minimum benefits package; of meeting the individual mandate being required as part of the
require segregation of public for coverage, and an affordability essential benefits package;
subsidy funds from private standard such that coverage is require segregation of public
premium payments for plans that deemed unaffordable if the subsidy funds from private
choose to cover abortion services premium exceeds 12.5% of an premiums payments for plans that
beyond Hyde—which allows individual’s adjusted gross income. choose to cover abortion services
coverage for abortion services to beyond Hyde—which allows
save the life of the woman and coverage for abortion services to
in cases of rape or incest; and save the life of the woman and
require there be no effect on state in cases of rape or incest; and
or federal laws on abortions. require there be no effect on state
or federal laws on abortions.]
• All qualified health benefits plans,
including those offered through
the Exchange and those offered
outside of the Exchange (except
certain grandfathered individual
and employer-sponsored plans)
must provide at least the essential
benefits package.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 16
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Changes to private • Impose the same insurance • Impose the same insurance • Prohibit coverage purchased • The plan must end barriers to
insurance market regulations relating market regulations relating through the individual market from coverage for people with pre-
to guarantee issue, premium to guarantee issue, premium qualifying as acceptable coverage existing medical conditions.
rating, prohibitions on pre- rating, and prohibitions on pre- for purposes of the individual
existing condition exclusions, existing condition exclusions in mandate unless it is grandfathered
risk adjustment, and rescissions the individual and small group coverage. Individuals can purchase
in the individual market, in the markets and in the American a qualifying health benefit plan
exchange, and in the small group Health Benefit Gateways (see through the Health Insurance
market, phasing in the new rules creation of insurance pooling Exchange.
for small group market over five mechanism). • Impose the same insurance
years. (See new rating and market • Require health insurers to report market regulations relating to
rules in Creation of insurance their medical loss ratio. guarantee issue, premium rating,
pooling mechanism.) • Require health insurers to provide and prohibitions on pre-existing
• Require health plans to report the financial incentives to providers condition exclusions in the insured
proportion of premium dollars to better coordinate care through group market and in the Exchange
spent on items other than medical case management and chronic (see creation of insurance pooling
care and require plans to compile disease management, promote mechanism).
information on coverage in a wellness and health improvement • Limit health plans’ medical
standard format. activities, improve patient safety, loss ratio to a percentage
• Require all new policies to comply and reduce medical errors. specified by the Secretary to be
with one of the four benefit • Provide dependent coverage enforced through a rebate back
categories, including those for children up to age 26 for all to consumers. [E&L Committee
offered through the exchanges individual and group policies. amendment: Limit health plans’
and those offered outside of • Require insurers and group plans medical loss ratio to at least 85%.]
the exchanges. Require health to notify enrollees if coverage does • Improve consumer protections by
plans in the individual and small not meet minimum qualifying establishing uniform marketing
group markets to at least offer coverage standards for purposes standards, requiring fair grievance
coverage in the silver and gold of satisfying the individual and appeals mechanisms,
categories. Existing individual and mandate for coverage. and prohibiting insurers from
employer-sponsored plans do • Permit licensed health insurers rescinding health insurance
not have to meet the new benefit to sell health insurance policies coverage except in cases of fraud.
standards. (See description of outside of the Gateway. States • Adopt standards for financial
benefit categories in Creation of will regulate these outside-the- and administrative transactions
insurance pooling mechanism.) Gateway plans. to promote administrative
• Allow states the option of merging simplification.
the individual and small group
markets.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 17
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Changes to private • Create a temporary reinsurance • Create the Health Choices


insurance (continued) program to help stabilize Administration to establish
premiums during the first the qualifying health benefits
three years of operation of standards, establish the
the exchanges when the risk Exchange, administer the
of adverse selection due to affordability credits, and
enforcement of the new rating enforce the requirements for
rules and market changes is qualified health benefit plan
greatest. Finance the reinsurance offering entities, including those
program through mandatory participating in the Exchange or
contributions by health insurers. outside the Exchange.
• Allow insurers to offer a national
health plan with a uniform
benefits package in the states in
which they are licensed. National
plans would be required to offer
plans with silver and gold benefit
packages and would be exempt
from state benefit requirements.
• Permit states to form health
care choice compacts and allow
insurers to sell policies in any
state participating in the compact.
Insurers selling policies through
a compact would only be subject
to the laws and regulations of the
state where the policy is written or
issued.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 18
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

State role • Require states to create • Establish American Health • Require states to enroll newly Not specified.
health insurance exchanges Benefit Gateways meeting eligible Medicaid beneficiaries
for individuals and small federal standards and adopt into the state Medicaid
businesses and require state individual and small group market programs and to implement the
insurance commissioners to regulation changes. specified changes with respect
provide oversight of health • Implement Medicaid eligibility to provider payment rates,
plans with regard to the new expansions and adopt federal benefit enhancements, quality
insurance market regulations, standards and protocols for improvement, and program
consumer protections, rate facilitating enrollment of integrity.
reviews, solvency, reserve fund individuals in federal and state • Require states to maintain
requirements, and premium taxes, health and human services Medicaid and CHIP eligibility
and to define rating areas. programs. standards, methodologies, or
• Require states to enroll newly • Create temporary “RightChoices” procedures that were in place as
eligible Medicaid beneficiaries programs to provide uninsured of June 16, 2009 as a condition of
into state Medicaid programs, individuals with immediate access receiving federal Medicaid or CHIP
coordinate enrollment with the to preventive care and treatment matching payments.
new exchanges, and implement for identified chronic conditions. • Require states to enter into a
other specified changes to the States will receive federal grants Memorandum of Understanding
Medicaid program. Require states to finance these programs. with the Health Insurance
to maintain Medicaid and CHIP Exchange to coordinate
eligibility levels until 2013 for enrollment of individuals in
those with incomes above 133% Exchange-participating health
FPL and until 2014 for those with plans and under the state’s
incomes at or below 133% FPL. Medicaid program.
• Require states to establish an • May require states to determine
ombudsman office to serve as an eligibility for affordability credits
advocate for people with private through the Health Insurance
coverage in the individual and Exchange.
small group markets.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 19
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Cost containment • Restructure payments to • Establish a Health Care Program • Simplify health insurance • The plan should reduce high
Medicare Advantage plans to base Integrity Coordinating Council administration by adopting administrative costs, unnecessary
payments on plan bids with bonus and two new federal department standards for financial and tests and services, waste, and
payments for quality, performance positions to oversee policy, administrative transactions, other inefficiencies that consume
improvement, care coordination program development, and including timely and transparent money with no added benefit.
and efficiency. oversight of health care fraud, claims and denial management
• Reduce annual market basket waste, and abuse in public and processes and use of standard
updates for inpatient hospital, private coverage. electronic transactions.
home health, skilled nursing • Simplify health insurance • [E&C Committee amendment:
facility, hospice and other administration by adopting Limit annual increases in the
Medicare providers, and adjust for standards for financial and premiums charged under any
productivity. administrative transactions, health plans participating in the
• Freeze the threshold for income- including timely and transparent Exchange to no more than 150%
related Medicare Part B premiums claims and denial management of the annual percentage increase
through 2019, and reduce the processes and use of standard in medical inflation. Provide
Medicare Part D premium subsidy electronic transactions. exceptions if this limit would
for those with incomes above threaten a health plan’s financial
$85,000/individual and $170,000/ viability.]
couples. • Modify provider payments under
• Establish an independent Medicare including:
Medicare Commission to submit – Modify market basket updates
proposals for reducing excess to account for productivity
Medicare cost growth by targeted improvements for inpatient
amounts. Proposals submitted by hospital, home health, skilled
the Commission must be acted nursing facility, and other
on by Congress and if a legislative Medicare providers; and
package with the targeted level of – Reduce payments for
Medicare savings is not enacted, potentially preventable hospital
the Commission’s proposal will go readmissions.
into effect automatically. • Restructure payments to Medicare
• Reduce Medicare DSH payments Advantage plans, phasing to 100%
by an amount proportional to of fee-for-services payments, with
the percentage point decrease bonus payments for quality.
in the uninsured for the period • Increase the Medicaid drug
evaluated. rebate percentage and extend
• Eliminate the Medicare the prescription drug rebate to
Improvement Fund. Medicaid managed care plans.
Require drug manufacturers to
provide drug rebates for dual
eligibles enrolled in Part D plans.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 20
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Cost containment • Allow providers organized as • [E&C Committee amendment:


(continued) accountable care organizations Require the Secretary to negotiate
(ACOs) that voluntarily meet directly with pharmaceutical
quality thresholds to share in manufacturers to lower drug
the cost-savings they achieve for prices for Medicare Part D plans
the Medicare program. To qualify and Medicare Advantage Part D
as an ACO, organizations must plans.]
agree to be accountable for the • [E&C Committee amendment:
overall care of their Medicare Authorize the Food and Drug
beneficiaries, have adequate Administration to approve generic
participation of primary care versions of biologic drugs and
physicians and specialists, define grant biologics manufacturers
processes to promote evidence- 12 years of exclusive use before
based medicine, report on generics can be developed.]
quality and costs measure, and • Reduce Medicaid DSH payments
coordinate care. by $6 billion in 2019, imposing the
• Create an Innovation Center largest percentage reductions in
within the Centers for Medicare state DSH allotments in states
and Medicaid Services to test, with the lowest uninsured rates
evaluate, and expand in Medicare and those that do not target DSH
different payment structures and payments.
methodologies to foster patient- • Require hospitals and ambulatory
centered care, improve quality, surgical centers to report on
and slow Medicare costs growth. health care-associated infections
Payment reform models that to the Centers for Disease Control
improve quality and reduce the and Prevention and refuse
rate of costs could be expanded Medicaid payments for certain
throughout the Medicare program. health care-associated conditions.
• Reduce payments for preventable • Reduce waste, fraud, and abuse
hospital readmissions in in public programs by allowing
Medicare: for hospitals with provider screening, enhanced
readmission rates above a certain oversight periods, and enrollment
threshold reduce payments by moratoria in areas identified as
20% if a patient is re-hospitalized being at elevated risk of fraud
with a preventable readmission in all public programs, and by
within seven days and by 10% if a requiring Medicare and Medicaid
patient is re-hospitalized with a program providers and suppliers
preventable readmission within 15 to establish compliance programs.
days, and reduce payments by 1%
to hospitals with the highest rates
of hospital acquired conditions.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 21
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Cost containment • Increase the Medicaid drug rebate


(continued) percentage for brand name drugs
to 23.1, increase the Medicaid
rebate for non-innovator, multiple
source drugs to 13% of average
manufacturer price, and extend
the drug rebate to Medicaid
managed care plans.
• Reduce a state’s Medicaid DSH
allotment by 50% (25% for low
DSH states) once the uninsured
rate decreases by at least 50%.
DSH allotments will be further
reduced, not to fall below 35%
of the total allotment in 2012 if
states’ uninsured rates continue
to decrease. Exempt any portion of
the DSH allotment used to expand
Medicaid eligibility through a
section 1115 waiver.
• Prohibit federal payments to
states for Medicaid services
related to health care acquired
conditions.
• Eliminate fraud, waste, and abuse
in public programs through more
intensive screening of providers,
the development of the “One PI
database” to capture and share
data across federal and state
programs, increased penalties
for submitting false claims, and
increase funding for anti-fraud
activities.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 22
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Improving quality/health • Simplify health insurance • Develop a national strategy to • Support comparative effectiveness • The plan must ensure the
system performance administration by adopting a improve the delivery of health research by establishing a Center implementation of patient safety
single set of operating rules for care services, patient health for Comparative Effectiveness measures and provide incentives
eligibility verification, claims outcomes, and population Research within the Agency for changes in the delivery
status, claims payment, and the health that includes publishing for Healthcare Research and system to reduce unnecessary
electronic transfer of funds. an annual national health care Quality to conduct, support, and variability in patient care. It must
• Establish a non-profit Patient- quality report card. Create an synthesize research on outcomes, support the widespread use of
Centered Outcomes Research inter-agency Working Group on effectiveness, and appropriateness health information technology
Institute to identify research Health Care Quality to coordinate of health care services and and the development of data
priorities and conduct research and streamline federal quality procedures. An independent on the effectiveness of medical
that compares the clinical activities related to the national CER Commission will oversee interventions to improve the
effectiveness of medical quality strategy. the activities of the Center. [E&C quality of care delivered.
treatments. The Institute will be • Develop, through a multi- Committee amendment: Prohibit • To lay the foundation for improving
overseen by an appointed multi- stakeholder process, quality use of comparative effectiveness the health care delivery system
stakeholder Board of Governors measures that allow assessments research findings to deny or and quality of care, the American
and will be assisted by expert of health outcomes; continuity ration care or to make coverage Recovery and Reinvestment
advisory panels. and coordination of care; safety, decisions in Medicare.] Act invests $19 billion in health
• Encourage states to develop effectiveness and timeliness • Strengthen primary care and information technology, including
and test alternatives to the of care; health disparities; care coordination by increasing $17 billion in incentives to
current civil litigation system as and appropriate use of health Medicaid payments for primary providers to encourage their use
a way to improve patient safety, care resources. Require public care providers, providing Medicare of electronic medical records,
reduce medical errors, increase reporting on quality measures bonus payments to primary care and provides $1.1 billion for
the availability of a prompt through a user-friendly website. practitioners (with larger bonuses comparative effectiveness
and fair resolution of disputes, • Create a Center for Health paid to primary care practitioners research.
and improve access to liability Outcomes Research and serving in health professional
insurance, while preserving an Evaluation within the Agency shortage areas).
individual’s right to seek redress for Healthcare Research and • Conduct Medicare pilot programs
in court. Recommend that Quality to conduct and synthesize to test payment incentive models
Congress consider establishing research on the effectiveness for accountable care organizations
a state demonstration project of health care services and and bundling of post-acute
to evaluate alternatives to the procedures to provide providers care payments, and conduct
current litigation system. and patients with information on pilot programs in Medicare and
the most effective therapies for Medicaid to assess the feasibility
preventing and treating health of reimbursing qualified patient-
conditions. centered medical homes. [E&C
• Provide grants for improving health Committee amendment: Adopt
system efficiency, including grants accountable care organization,
to establish community health bundled payment, and medical
teams to support a medical home home models on a large scale if
model; to implement medication pilot programs prove successful at
management services; to design reducing costs.]
and implement regional emergency
care and trauma systems.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 23
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Improving quality/health • Establish a national Medicare pilot • Require hospitals to report [E&C Committee amendment:
system performance program to develop and evaluate preventable readmission rates; Conduct accountable care
(continued) paying a bundled payment hospitals with high re-admission organization pilot programs in
for acute, inpatient hospital rates will be required to work with Medicaid.]
services and post-acute care local patient safety organizations • [E&C Committee amendment:
services for an episode of care to improve their rates. Establish the Center for
that begins three days prior to a • Create a Patient Safety Research Medicare and Medicaid Payment
hospitalization and spans 30 days Center charged with identifying, Innovation Center to test
following discharge. If the pilot evaluating, and disseminating payment models that address
program achieves stated goals, information on best practices for populations experiencing poor
develop a plan for making the pilot improving health care quality. clinical outcomes or avoidable
a permanent part of the Medicare • Create an inter-agency expenditures. Evaluate all models
program. Working Group to coordinate and expand those models that
• Establish a hospital value-based and streamline federal quality improve quality without increasing
purchasing program in Medicare activities. spending or reduce spending
to pay hospitals based on • Develop interoperable standards without reducing quality, or both.]
performance on quality measures for using HIT to enroll individuals • [W&M Committee amendment:
and extend the Medicare physician in public programs and provide Require the Institute of Medicine
quality reporting initiative beyond grants to states and other to conduct a study on geographic
2010. governmental entities to adopt variation in health care spending
• Improve care coordination for and implement enrollment and recommend strategies for
dual eligibles by creating a new technology. addressing this variation by
office within the Centers for promoting high-value care.]
Medicare and Medicaid services, • Improve coordination of care
the Office of Coordination for Dual for dual eligibles by creating a
Eligible Beneficiaries, to align new office or program within
Medicare and Medicaid financing, the Centers for Medicare and
administration, oversight rules, Medicaid Services.
and policies for dual eligibles. • Establish the Center for Quality
Improvement to identify, develop,
evaluate, disseminate, and
implement best practices in the
delivery of health care services.
Develop national priorities for
performance improvement and
quality measures for the delivery
of health care services.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 24
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Improving quality/health • Develop a national quality • Require disclosure of financial


system performance improvement strategy that relationships between health
(continued) includes priorities to improve the entities, including physicians,
delivery of health care services, hospitals, pharmacists, and other
patient health outcomes, and providers, and manufacturers
population health. Create and distributors of covered drugs,
processes for the development of devices, biologicals, and medical
quality measures involving input supplies.
from multiple stakeholders and • Reduce racial and ethnic
for selecting quality measures disparities by conducting a study
to be used in reporting to and on the feasibility of developing
payment under federal health Medicare payment systems for
programs. Establish the Medicaid language services, providing
Quality Measurement Program Medicare demonstration grants
to establish priorities for the to reimburse culturally and
development and advancement linguistically appropriate services
of quality measures for adults in and developing standards for
Medicaid. the collection of data on race,
• Require enhanced collection ethnicity, and primary language.
and reporting of data on race, • [E&C Committee amendment:
ethnicity, and primary language. Conduct a national public
Also require collection of access education campaign to raise
and treatment data for people with awareness about the importance
disabilities. of planning for care near the end
of life.]
Prevention/wellness • Provide Medicare beneficiaries • Develop a national prevention and • Develop a national strategy to • The plan must invest in public
access to a comprehensive health health promotion strategy that improve the nation’s health health measures proven to reduce
risk assessment and creation of sets specific goals for improving through evidenced-based cost drivers in our system, such as
a personalized prevention plan, health. Create a prevention and clinical and community-based obesity, sedentary lifestyles, and
eliminate cost-sharing for certain public health investment fund prevention and wellness smoking, as well as guarantee
preventive services in Medicare. to expand and sustain funding activities. Create task forces access to proven preventive
Cover only proven preventive for prevention and public health on Clinical Preventive Services treatments. The American
services in Medicare and Medicaid programs. and Community Preventive Recovery and Reinvestment Act
and provide incentives to Medicare • Award competitive grants to Services to develop, update, and provides $1 billion for prevention
and Medicaid beneficiaries to state and local governments and disseminate evidenced-based and wellness.
complete behavior modification community-based organizations recommendations on the use of
programs. to implement and evaluate clinical and community prevention
proven community preventive services.
health activities to reduce chronic
disease rates and address health
disparities.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 25
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Prevention/wellness • Require Medicaid coverage • Permit insurers to create • Improve prevention by covering
(continued) for tobacco cessation services incentives for health promotion only proven preventive services in
for pregnant women, and for and disease prevention practices. Medicare and Medicaid. Eliminate
states that provide coverage for • Encourage employers to provide any cost-sharing for preventive
and remove cost-sharing for wellness programs by conducting services in Medicare and increase
preventive services recommended targeted educational campaigns Medicare payments for certain
by the US Preventive Services to raise awareness of the value of preventive services to 100% of
Task Force and recommended these programs and by increasing actual charges or fee schedule
immunizations, provide a one the allowable premium discount rates.
percentage point increase in the for employees who participate in
FMAP for these services and for these programs from 20 percent
the tobacco cessation services. to 30 percent.
• Create a new Medicaid state • Create a temporary Right Choices
plan option to permit Medicaid Program to provide uninsured
enrollees with at least two chronic adults with access to preventive
conditions or one condition and services.
risk of developing another to
designate a provider as a health
home. Provide states taking up
the option with 90% FMAP for two
years.
• Prohibit insurance plans (except
existing grandfathered plans and
those that use a value-based
insurance design) from charging
cost-sharing for preventive
services.
• Allow insurers to vary premium
rates based on tobacco use.
Any insurer that rates based
on tobacco use must provide
coverage for comprehensive
tobacco cessation programs,
including counseling and
pharmacotherapy.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 26
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Long-term care • Allow cafeteria plans to offer • Establish a national, voluntary • [E&C Committee amendment: Not specified.
long-term care insurance insurance program for purchasing Establish a national, voluntary
contracts as a qualified benefit community living assistance insurance program for purchasing
so that employee contributions services and supports (CLASS community living assistance
for the long-term care insurance program). The program will services and supports (CLASS
premiums can be made on a pre- provide individuals with functional program). The program will
tax basis. Permit reimbursement limitations a cash benefit to provide individuals with functional
for employee premiums for purchase non-medical services limitations a cash benefit to
long-term care insurance through and supports necessary to purchase non-medical services
flexible spending accounts on a maintain community residence. and supports necessary to
pre-tax basis. The program is financed through maintain community residence.
• Extend the Medicaid Money voluntary payroll deductions: The program is financed through
Follows the Person Rebalancing all working adults will be voluntary payroll deductions:
Demonstration program through automatically enrolled in the all working adults will be
September 2016 and allocate $10 program, unless they choose to automatically enrolled in the
million per year for five years to opt-out. program, unless they choose to
continue the Aging and Disability opt-out.]
Resource Center initiatives. • Improve transparency of
• Improve transparency of information about skilled nursing
information about skilled nursing facilities and nursing facilities.
facilities (SNF) and nursing
homes, enforcement of SNF and
nursing home standards and
rules, and training of SNF and
nursing home staff.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 27
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Other investments • Provide a 50% discount on brand- • Establish a National Health • Make improvements to the • As an initial investment in
name prescriptions filled in the Care Workforce Commission to Medicare program: strengthening the health care
Medicare Part D coverage gap for make recommendations and – Reform the sustainable growth workforce, the American Recovery
enrollees, other than those who disseminate information on health rate for physicians, with and Reinvestment Act provides
receive low-income subsidies workforce priorities, goals, and incentive payments for primary $500 million to train the next
and those with incomes above policies including education and care services, and for services in generation of doctors and nurses.
$85,000/individual and $170,000/ training, workforce supply and efficient areas;
couples. demand, and retention practices. – Eliminate the Medicare Part D
• Provide a one-year increase • Reform Graduate Medical coverage gap (phased in over
in physician payments under Education to increase the supply, 15 years) and require drug
Medicare to prevent a reduction education, and training of doctors, manufacturers to provide a
in fees that would otherwise take nurses, and other health care 50% discount on brand-name
effect, with 10% bonus payments workers, especially in pediatric, prescriptions filled in the
for primary care. Provide general geriatric, and primary care. coverage gap;
surgeons and primary care • Improve access to care by – Increase the asset test for
physicians practicing in health providing additional funding Medicare Savings Program and
professional shortage areas with a to increase the number of Part D Low-Income Subsidies to
10% Medicare bonus. community health centers and $17,000/$34,000; and
• Establish a multi-stakeholder school-based health centers. – Eliminate any cost-sharing for
Workforce Advisory Committee preventive services in Medicare
to develop a national workforce and increase Medicare payments
strategy for recruiting, training, for certain preventive services
and retaining a health care to 100% of actual charges or fee
workforce that meets current and schedule rates.
projected health care needs. • Reform Graduate Medical
• Increase the number of Graduate Education to increase training
Medical Education (GME) training of primary care providers
positions by redistributing by redistributing residency
currently unused slots, with positions and promote training in
priorities given to primary care outpatient settings and support
and general surgery, and increase the development of primary care
flexibility in laws and regulations training programs.
that govern GME funding to • Support training of health
promote training in outpatient professionals, including advanced
settings, and ensure the education nurses, who will practice
availability of residency programs in underserved areas; establish
in rural and underserved areas. a public health workforce corps;
and promote training of a diverse
workforce and provide cultural
competence training for health
care professionals.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 28
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Other investments • Impose additional requirements [E&C Committee amendment:


(continued) on non-profit hospitals to conduct Support the development of
a community needs assessment interdisciplinary mental and
every three years and adopt behavioral health training
an implementation strategy to programs.] [E&C Committee
meet the identified needs, adopt amendment: Establish a
and widely publicize a financial training program for oral health
assistance policy that indicates professionals.]
whether free or discounted • Provide grants to each state health
care is available and how to department to address core public
apply for the assistance, limit health infrastructure needs.
charges to patients who qualify • Conduct a study of the feasibility of
for financial assistance to the adjusting the federal poverty level
amount generally billed to insured to reflect variations in the cost of
patients, and make reasonable living across different areas.
attempts to inform patients about • [E&L Committee amendment:
the financial assistance policy Grant waivers to requirements
before undertaking extraordinary related to the Employee
collection actions. Retirement Income Security Act
of 1974 (ERISA) to states seeking
to establish a state single payer
system.]
Financing CBO estimates the cost of the The Congressional Budget Office The Congressional Budget President Obama dedicated $630
coverage components of the plan estimates this proposal will cost Office estimates the net cost billion over ten years toward a
to be $774 billion over ten years. $615 billion over 10 years. Because of the proposal (less payments Health Reform Reserve Fund in his
These costs are financed through the Senate HELP Committee does from employers and uninsured budget outline released in February
a combination of savings from not have jurisdiction over the individuals) to be $1.042 trillion 2009 to partially offset the cost of
Medicare and Medicaid and new Medicare and Medicaid programs over ten years. Approximately half health reform.
taxes and fees. The primary sources nor revenue raising authority, of the cost of the plan is financed
of Medicare and Medicaid savings mechanisms for financing the through savings from Medicare and
include incorporating productivity proposal will be developed in Medicaid, including incorporating
improvements into Medicare conjunction with the Senate Finance productivity improvements into
market basket updates, reducing Committee. Medicare market basket updates,
payments to Medicare Advantage reducing payments to Medicare
plans, creating the Medicare Advantage plans, changing drug
Commission charged with finding rebate provisions, reducing
savings in the program, changing potentially preventable hospital
the Medicaid drug rebate provisions, readmissions, and cutting Medicaid
and cutting Medicaid and Medicare DSH payments.
DSH payments. (See descriptions
of cost savings provisions in Cost
containment.)

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 29
House Tri-Committee
Senate Finance Committee America’s Affordable Health
America’s Healthy Future Act Senate HELP Committee Choices Act of 2009 President Obama
of 2009 Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Financing (continued) The largest source of new revenue The remaining costs are financed
will come from an excise tax on through a surcharge imposed
high cost insurance—insurance on families with incomes above
plans that exceed $8,000 for single $350,000 and individuals with
coverage and $21,000 for family incomes above $280,000. The
coverage—which CBO estimates surcharge is equal to 1% for
will raise $215 billion over ten families with modified adjusted
years. The threshold values for gross income between $350,000
high cost plans are indexed to the and $500,000; 1.5% for families with
CPI-U, which typically increases at modified adjusted gross income
a lower rate than health insurance between $500,000 and $1,000,000;
premiums, so it is expected that this and 5.4% for families with modified
tax will raise more money over time. adjusted gross income greater
CBO estimates the proposal will than $1,000,000. These surcharge
reduce the deficit by $49 billion over percentages may be adjusted if
ten years. federal health reform achieves
greater than expected savings.
Sources of information http://www.finance.senate.gov/ http://help.senate.gov/ Ways and Means Committee: http://www.whitehouse.gov/omb/
sitepages/baucus.htm http://waysandmeans.house.gov/ budget/
MoreInfo.asp?section=52 http://www.HealthReform.gov
Energy and Commerce Committee:
http://energycommerce.house.
gov/index.php?option=com_content
&view=article&id=1687&catid=156&
Itemid=55
Education and Labor Committee:
http://edlabor.house.gov/
newsroom/2009/07/ed-labor-
approves-historic-hea.shtml

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 30
Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes Rep. John Conyers Rep. John Dingell
Patients’ Choice Act of 2009 U.S. National Health Care Act National Health Insurance Act
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)

Date plan announced May 20, 2009 January 26, 2009 January 6, 2009
(Has introduced similar legislation in each
Congressional session since 1957)
Overall approach Create state-based health insurance exchanges Create a public health insurance program for Create a national health insurance program for
to expanding access through which private plans offer coverage all U.S. residents. Replace employer coverage individuals meeting eligibility requirements.
to coverage meeting certain benefit and other standards. and eliminate the Medicare, Medicaid and CHIP Require states to administer the program
Employers can continue to provide coverage programs. Individuals are not required to pay and provide for equivalent care for “needy”
to their employees, but the current tax premiums or cost-sharing. Require conversion individuals who do not meet eligibility
preference for employer-sponsored insurance to a non-profit health care system. Provide requirements. A National Health Insurance
will be replaced with a tax credit of $2,290 for for global budgets for hospitals and negotiate Board determines allotments for the classes of
individuals and $5,710 for families to provide annual reimbursement rates with physicians covered services. Financed by a value-added tax
incentives for insurance coverage. Maintain and other non-institutional providers. Finance imposed on certain transactions.
Medicaid coverage for low-income people with program by redirecting current federal and state
disabilities, but integrate low-income families health care spending, impose an employer/
currently eligible for Medicaid into private employee payroll tax, and leverage additional
insurance. taxes.
Individual mandate • No requirement for individuals to have • All individuals residing in the US are covered • Individuals meeting certain requirements are
coverage. Permit states to establish procedures under the United States National Health Care entitled to benefits under the National Health
to automatically enroll individuals into low- Act (USNHC). Insurance Program.
cost, high-deductible coverage through the
exchange and to provide incentives to individuals
to maintain coverage from year to year.
Employer requirements No provision. No provision. No provision.
Expansion of public • Restructure the Medicaid program to provide • Create a new public plan, the USNHC program, • Create a new public plan, covering medical,
programs acute care only to low-income people with that provides coverage for a comprehensive set dental, podiatric, home-nursing, hospital, and
disabilities, children in foster care, low-income of benefits, including long-term care services, auxiliary services. A National Health Insurance
women with breast or cervical cancer, and to all US residents. Board, in consultation with a National Advisory
certain TB-infected individuals. Integrate • Eliminate the Medicare, Medicaid, and CHIP Medical Council determines the scope of
low-income families into private insurance programs as beneficiaries of these programs benefits consistent with the statute.
by providing them with a tax credit plus other are eligible for the USNHC program. • Continue Medicare, but enrollees may be
financial support. Eliminate the entitlement • VA health programs will remain independent transferred into the new program in the future.
for long-term care services under Medicaid for 10 years after which they will either remain Medicare beneficiaries are covered under the
and replace it with a block grant to states for independent or be integrated into the USNHC new program for services that are not covered
long-term care services for eligible elderly and program. The Indian Health Service will remain by Medicare.
disabled individuals. independent for 5 years after which it will be • Require states to provide equivalent services to
• Allow private facilities to compete with integrated into the USNHC program. those not eligible under the new plan. Current
Veteran’s Administration facilities to provide federal Medicaid funds and other federal funds
care to veterans. provided to states under the Social Security Act
• Allow eligible American Indians to access are available for this purpose.
medical care outside of Indian Health Service
facilities.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 31
Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes Rep. John Conyers Rep. John Dingell
Patients’ Choice Act of 2009 U.S. National Health Care Act National Health Insurance Act
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)

Premium subsidies • Provide a qualified health insurance credit of • Individuals are not required to pay premiums • Individuals are not required to pay premiums to
to individuals $2,290 for individuals and $5,710 for families to obtain coverage nor are they charged obtain coverage.
to be used to purchase health insurance. copayments or coinsurance for covered
Individuals enrolled in Medicare or military benefits.
coverage and people with disabilities enrolled
in Medicaid are not eligible for the tax credit.
Any tax credit amount exceeding the cost
of a health insurance plan purchased by an
individual or family will be deposited into a
medical savings account.
• Provide a supplemental debit card to families
with incomes below 200% FPL to be used to
pay for private health insurance costs. The
amounts available on the debit cards range
from $5,000 for families with incomes below
100% FPL to $2,000 for families with incomes
between 180 and 200% FPL. Additional
amounts provided for pregnancy ($1,000) and
infants under age 1 ($500).
Premium subsidies No provision. No provision. No provision.
to employers
Tax changes related • Reform the tax code to eliminate the exclusion No provision. No provision.
to health insurance of the value of health insurance plans offered
by employers from workers’ taxable income.
• Allow individuals and families purchasing
high-deductible health plans that are less than
the value of the tax credit to deposit the excess
amount into a medical savings account.
• Change health savings account (HSA)
requirements by allowing health insurance
premiums for high-deductible health plans to
be paid tax-free from an HSA, increasing the
allowable contribution amounts for people
with chronic conditions, and permitting high-
deductible health plans to cover preventive
services, maintenance costs of chronic
diseases, and concierge-style primary care
services.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 32
Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes Rep. John Conyers Rep. John Dingell
Patients’ Choice Act of 2009 U.S. National Health Care Act National Health Insurance Act
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)

Creation of insurance • Provide states with the option of creating State No provision other than pooling achieved through No provision other than pooling achieved through
pooling mechanisms Health Insurance Exchanges through which USNHC. new public program.
individuals can purchase qualified private
insurance. To encourage the establishment of
exchanges, states may be eligible for grants
to develop and implement exchanges and
may also receive a 1% increase in federal
Medicaid payments. States may form regional
exchanges.
• Require plans participating in the Exchanges
to provide coverage on a guarantee issue basis
and prohibit discrimination based on pre-
existing conditions.
• Require plans to provide coverage similar to
that provided to Members of Congress.
• Require establishment of a mechanism to
prevent insurers from charging excessive
premiums. Such mechanism may include
risk-adjustment among insurance plans
participating in the Exchange, health security
pools for high-risk individuals, or reinsurance
for high-risk individuals.
Benefit design • Provide coverage that meets the same • Provide coverage for all medically necessary • Provide the following classes of personal
statutory requirements used for the services, including primary care and health services:
health benefits for Members of Congress. prevention; inpatient care; outpatient care; – Medical services including primary and
Qualifying health insurance for purposes emergency care; prescription drugs; durable specialty care;
of obtaining premium credits includes medical equipment; long-term care; palliative – Dental services;
coverage for inpatient and outpatient care, care; mental health services; dental services; – Podiatric services;
emergency benefits, and physician care and chiropractic services; basic vision correction;
– Home-nursing services;
has responsible annual and lifetime benefit hearing services; and podiatric care.
maximums. – Hospital services, for a maximum of 60 days
in a benefit year;
– Auxiliary services including diagnostic
laboratory services, X-ray and related
therapy, physiotherapy, optometry services,
prescription drugs, and eyeglasses.
Changes to private No provision. • Prohibit insurers from duplicating USNHC No provision.
insurance benefits but they may offer coverage for
benefits not covered by the USNHC program.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 33
Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes Rep. John Conyers Rep. John Dingell
Patients’ Choice Act of 2009 U.S. National Health Care Act National Health Insurance Act
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)

State role • Create, at state option, state health insurance No provision. • Assume responsibility for administration of the
exchanges that meet federal standards. program. States must submit a state plan of
• Form voluntary compacts (at state option) with operations that designates a state agency for
other state exchanges to diversify pooling, administering the program benefits; creates,
ease administrative burdens, and increase the among other things, an advisory committee;
availability of innovative insurance products. establishes local health service areas to
further decentralize program administration;
and provides a plan for ensuring that benefits
will be provided efficiently and to all areas of
the state.
Cost containment • Encourage adoption and use of health • Establish annual budgets for health care • Require the National Health Insurance
information technology by providing incentives professional staffing, capital expenditures, Board to establish allotments for each of five
to hospitals and individual providers. Create reimbursement for providers, and health classes of services to be provided under the
personal health records maintained by an professional education. program (medical services, dental services,
independent health record bank and available • Pay institutional providers, including hospitals, home-nursing services, hospital services,
to the individual through a card, much like an nursing homes, community or migrant health and auxiliary services). Allotments are made
ATM card. centers, home care agencies, and other to the states based on population, medical
• Allow providers to form accountable care institutional and prepaid group practices, professionals and facilities, and cost of
organizations and receive bonuses in Medicare a monthly lump sum to cover operating services.
if they improve quality and satisfaction while expenses. • Require a study of cost control mechanisms,
also lowering costs. • Pay physicians and other non-institutional including an analysis of the impact on medical
• Adopt competitive bidding for Medicare providers based on a simplified fee scheduled malpractice claims and liability insurance on
Advantage plans and set the benchmark bid to or as a salaried employee in an institution health care costs.
106% of Medicare fee-for-service payments. receiving a global budget or in a group practice
• Require Medicare beneficiaries making or HMO receiving capitation payments.
more than $170,000 per year (for couples) • Establish a uniform electronic billing system
to pay more for Medicare Part B and Part D and create an electronic patient record system.
premiums. • Allow only public or not-for-profit institutions
to participate in USNHC. Private physicians,
clinics, and other participating providers may
not be investor owned.
• Require USNHC program to negotiate annually
prices for drugs, medical supplies, and
assistive equipment.
• Establish a prescription drug formulary that
encourages best practices in prescribing and
promotes use of generics and other lower cost
alternatives.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 34
Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes Rep. John Conyers Rep. John Dingell
Patients’ Choice Act of 2009 U.S. National Health Care Act National Health Insurance Act
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)

Cost containment • Enhance efforts to detect and eliminate


(continued) fraud and abuse in the Medicare program
by establishing procedures to identify and
investigate unusual billing, investigating
providers and suppliers using identification of
ineligible beneficiaries, and imposing penalties
on facilities employing physicians or other
employees convicted of Medicare or Medicaid
fraud.
• Adopt medical malpractice reforms that create
independent expert panels or state “health
courts” or both to review cases and render
decisions. Parties will still have access to state
courts if not satisfied with decisions.
Improving quality/health • Create a new Health Care Services • Require participating providers to meet state • Require state and local administration to:
system performance Commission to establish uniform measures quality and licensing guidelines. – Promote coordination among providers,
for reporting price and quality information. The • Create a National Board of Universal Quality between providers and public health centers
HSC, managed by five commissioners from the and Access to address issues, such as access and educational and research institutions.
private sector appointed by the President, will to care, quality improvement, administrative – Emphasize prevention of disease, disability,
issue a report containing guidelines regulating efficiency, budget adequacy, reimbursement and premature death.
the publication and dissemination of health levels, capital needs, long term care, and – Insure the provision of efficient, high quality
care information and will be authorized to staffing levels. services.
enforce these standards. • Establish a universal standard of care relating
to appropriate staffing levels; appropriate
medical technology; scope of work in the
workplace; best practices; salary levels for
medical professional and support staff.
Prevention/wellness • Emphasize prevention by developing a No provision. • Emphasize prevention of disease, disability,
national strategic prevention plan, creating and premature death.
a web-based prevention tool capable of
producing personalized prevention plans, and
implementing national science-based media
campaigns on health promotion and disease
prevention.
• Reward seniors who adopt healthier behaviors
with lower Medicare premiums.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 35
Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes Rep. John Conyers Rep. John Dingell
Patients’ Choice Act of 2009 U.S. National Health Care Act National Health Insurance Act
(S. 1099 and H.R. 2520) (H.R. 676) (H.R. 15)

Long-term care • Make changes to Medicaid long-term care • Provide coverage for long-term care services No provision.
services to provide sates with a defined through the USNHC program and establish
allotment for Medicaid long-term care services regional budgets to cover these long-term care
in exchange for having the Medicare program services.
assume responsibility for the premiums, • Encourage long-term care to be provided
cost-sharing, and deductibles for low-income in home and community-based settings, as
Medicare beneficiaries and ensure choice opposed to in institutions.
between institutionalized and home-based
long-term care services.
Other investments No provision. • Establish a USNHC Employment Transition • Provide grants for training and education of
Fund to assist people who lose their jobs as professional and technical personnel needed to
a result of the transition to the new national provide or administer benefits. Makes available
system. $5 million in 2010 and 2011; and up to one half
• Create a mechanism to facilitate the conversion of one percent of benefit payments annually
of for-profit providers of care to not-for-profit thereafter.
status and provide compensation for the
financial losses associated with the conversion.
Financing Financing will come from the specified cost- The USNHC program will be funded through Program will be financed through a National
containment provisions, converting Medicaid the USNHC Trust Fund. Funding for the Trust Health Care Trust Fund. The trust fund will
acute care services from defined benefits to Fund will come from redirecting existing federal be funded with a value-added tax of 5 percent
defined contributions, block granting Medicaid payments for health care; increasing the imposed on certain transactions.
long-term care services, and eliminating the tax income tax for the top 5% of earners, instituting
exclusion for employer-sponsored insurance. a modest and progressive payroll tax, and
To ensure revenue-neutrality of the reform imposing a tax on stock and bond transactions.
proposal, the qualified health insurance credits
in any year are limited to savings generated
through entitlement reform and repeal of the tax
exclusion for employer-sponsored insurance.
Sources of information http://coburn.senate.gov/public/index. http://conyers.house.gov/index. http://www.house.gov/dingell/issue_healthcare.
cfm?FuseAction=HealthCareReform. cfm?FuseAction=Issues.Home&Issue_ shtml
Home&ContentRecord_id=5e3b30a4-802a-23ad- id=063b74a4-19b9-b4b1-126b-f67f60e05f8c
4b44-14f0219114c6

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 36
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)

Date plan announced July 30, 2009 March 25, 2009 January 6, 2009
Overall approach Allow people who purchase coverage in the Create a state-based public health insurance Create a new public plan, modeled on Medicare,
to expanding access individual market to deduct the cost of premiums program for all U.S. residents. Replace employer as default coverage for all Americans. Individuals
to coverage from their income taxes. Provide refundable tax coverage and eliminate the Medicare, Medicaid in a qualified group plan or Medicare may opt
credits to individuals and families with incomes and CHIP programs. Individuals are not required out of AmeriCare. Require employers and
below 300% FPL to purchase insurance in the to pay premiums or cost-sharing. Provide for individuals to contribute toward the cost of the
individual market. Establish Association Health global budgets for hospitals and negotiate plan, with federal premium subsidies available
Plans and Individual Membership Associations annual reimbursement rates with physicians for individuals below 300% FPL. Use Medicare’s
through which employers and individuals can and other non-institutional providers. Finance administrative structure to govern the plan.
purchase coverage. Implement state high- program by redirecting current federal and state Financed by premium contributions from
risk pools or reinsurance programs to provide health care spending, impose an employer/ employers and individuals, state maintenance of
coverage for people with pre-existing health employee payroll tax, and leverage a new health effort payments, and from general revenue.
conditions. Require states to provide coverage to care income tax.
90% of children with family incomes below 200%
FPL as a condition for expanding child eligibility
to 300% FPL, and require states to provide
vouchers to children eligible for Medicaid and
CHIP, to be used to purchase private insurance.
Individual mandate • No requirement for individuals to have • All individuals residing in the US are entitled • All U.S. residents are entitled to coverage
coverage. Permit employers to automatically to coverage under the American Health under AmeriCare. Individuals may choose not
enroll individuals in the lowest cost group Security Act. to enroll in the AmeriCare plan if they have
health plan as long as they can opt out of coverage under a group health plan.
coverage.
Employer requirements • Permit employers to offer employees a • Prohibit employers from offering health • Require employers to contribute at least 80%
defined contribution for the purchase of health benefits that duplicate those provided by State of the AmeriCare premiums for employees
insurance in the individual market. health security programs. or at least 80% of the cost of the group plan
• Require employers to disclose to employees if the employer provides qualifying employee
the total amount the employer spends on the coverage. Employers with fewer than 100
employee’s health insurance premium. employees will be given an additional three
years to come into compliance with this
provision. A surcharge may be imposed on
employers to prevent adverse selection.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 37
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)

Expansion of public • Require states to achieve coverage for 90% of • Create a new state-based American Health • Create a new public plan, modeled on
programs children with family incomes below 200% FPL Security Program that provides coverage for Medicare, as default coverage for all
who are eligible for public coverage before a comprehensive set of benefits to all U.S. Americans.
they can expand CHIP for children with family residents. • AmeriCare plan enrollees are subject to
incomes between 200% FPL and 300% FPL. • Eliminate the Medicare, Medicaid, and CHIP deductibles ($350 individual/$500 family) and
Require states to provide premium assistance programs as beneficiaries of these programs coinsurance of 20% until limits on out-of-
for Medicaid and CHIP enrollees with access to are eligible for State Health Security Programs. pocket (OOP) expenses are met. The OOP limits
employer-sponsored insurance. Require states • Veteran’s Affairs and Indian Health Service are $2,500 per individual and $4,000 per family.
to offer vouchers to individuals who would programs remain independent. Deductibles and limits are indexed to inflation.
otherwise be eligible for Medicaid and CHIP • Prohibit coverage under state Medicaid
for the purchase of alternative private health and CHIP programs for benefits covered by
insurance. AmeriCare plans.
Subsidies to individuals • Provide a refundable tax credit of $2,000 for • Individuals are not required to pay premiums • Low-income individuals (family income <200%
individuals and $5,000 for a family of four with to obtain coverage nor are they charged FPL) are not required to pay premiums and are
incomes up to 200% FPL for the purchase of copayments or coinsurance for covered not subject to deductibles and co-insurance.
health insurance in the individual market. benefits. • Provide premium subsidies and reduced
Phase down the credit for individuals and deductibles for individuals with family incomes
families with incomes between 200% FPL between 200% and 300% FPL.
and 300% FPL. Citizens and legal permanent • Limit OOP costs for deductibles and
residents of the United States are eligible for coinsurance to 5% of income for those between
the tax credit. 200 and 300% FPL, and 7.5% of income for
• Permit individuals eligible for other health those between 300 and 500% FPL.
benefit programs, including Medicare, • No deductibles and coinsurance for pregnancy-
Medicaid, CHIP, TRICARE, Veterans’ Affairs, the related services and covered benefits provided
Federal Employee Health Benefits Program, to children (up to age 24).
and subsidized group coverage to receive a
tax credit instead of coverage through the
program.
Subsidies to employers • Provide small employers (50 and fewer No provision. No provision.
employees) with a temporary tax credit to adopt
auto-enrollment procedures and to contribute
toward coverage for employees who choose
to purchase private coverage in the individual
market.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 38
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)

Tax changes related • Reform the tax code to permit individuals • Impose a new health care income tax on • Individual premium payments for AmeriCare
to health insurance and families to deduct the amount paid for individuals of 2.2% of taxable income. coverage are considered a tax and subject to
premiums purchased in the individual market withholding.
from taxable income. Cap the deduction at the
value of the national exclusion for employer-
sponsored insurance.
• Provide tax credits to individuals and families
with incomes below 300% FPL to purchase
health insurance in the individual market.
• Allow physicians to deduct costs related to
providing uncompensated care required under
Emergency Medical Treatment and Active
Labor Act (EMTALA). Limit the deduction
amount to the Medicare payment amount for
the services provided.
Creation of insurance • Encourage states to implement a high- No provision other than pooling achieved through No provision other than pooling achieved through
pooling mechanisms risk pool, a reinsurance pool, or other risk state health security programs. AmeriCare.
adjustment mechanism to subsidize the
purchase of private health insurance for
a high-risk population. Current high-risk
pools may qualify if they only cover high-risk
populations. New high-risk pools are required
to offer at least one high-deductible plan
option with a health savings account, multiple
competing plan options, and may only cover
high-risk populations. Provide a Federal block
grant to states to operate qualified high-risk
pools and reinsurance pools.
• Establish certified Association Health Plans
through which member employers can purchase
health coverage for their employees. Permit
association health plans to determine what
benefits will be covered under the plans they
offer and allow the same variations in premiums
as is permitted in the small group market.
• Permit individuals to purchase health coverage
through Individual Membership Associations
(IMAs) that operate under the direction of an
association. Require IMAs to provide coverage
through contracts with licensed health insurers
that meet state standards relating to consumer
protections. Exempt IMAs from state laws
relating to benefit mandates. Permit more than
one IMA to operate in a geographic area.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 39
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)

Benefit design • Allow tax credit and employer defined • Provide coverage for services including hospital • Provide the same benefits available through
contribution to be used for all HIPAA eligible and professional services; community-based Medicare, with the addition of benefits, such as
coverage, except certain limited or disease- primary health care; preventive care; long- well-child visits, early and periodic screening,
specific plans. term acute and chronic care services, including diagnostic, and treatment (EPSDT) services
• Prohibit use of federal funds to be used to home and community-based services; for children, prenatal and obstetric care, and
provide coverage for abortions, except to save prescription drugs; dental services; mental family planning services to reflect the needs of
the life of the woman or in cases of rape or health and substance abuse; diagnostics a younger population.
incest. tests; outpatient therapy; durable medical
equipment; and other services as specified by
the American Health Security Standards Board.
Changes to private • Permit insurers to sell insurance policies • Prohibit insurers from duplicating State health • Allow AmeriCare supplemental policies to be
insurance across state lines. Insurers must designate security program but they may offer coverage offered that meet minimum federal standards,
one state as its primary state and the laws for benefits not covered by the health security including standardized benefits, limitations on
and regulations in the primary state apply to program. sales commissions, and the following:
coverage offered in that state and in other – Require insurers that offer AmeriCare
states. Allow individuals whose premiums for supplemental policies to do so on a
individual health insurance exceed the national guarantee issue and renewability basis
average premium by 10 percent or more to and prohibit them from charging higher
purchase coverage in another state. premiums based on health status.
• Require insurance companies to disclose the – Require insurers offering AmeriCare
true health insurance plan costs to employers. supplemental policies to meet minimum
medical loss ratios (85% for group policies;
75% for individual policies).
State role • Encourage states to implement a high-risk • Create a state health security program to • Require states to make maintenance of effort
pool, reinsurance pool, or other risk adjusted provide health care services to state residents. payments in the amount of the state share
mechanism. States must have a high-risk May join with one or more neighboring states to of Medicaid and CHIP spending for benefits
pool, reinsurance pool, or other risk adjusted form a regional health security program. State replaced by the AmeriCare plan.
mechanism in place in order for state residents programs must designate a single state agency • Allow states to impose more stringent
to be eligible to receive tax credits to purchase to administer the program; establish state requirements on entities offering AmeriCare
insurance. health security budgets; establish provider supplemental policies than specified by the
• Allow states to establish a Health Plan and payment methodologies; license and regulate Secretary.
Provider Portal website to provide information health providers and facilities; establish a
on all health plans and health care providers in quality review system; create an independent
the state. ombudsman program to resolve consumer
complaints and disputes; publish an annual
report on the operation of the state program;
and create a fraud and abuse prevention and
control unit.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 40
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)

Cost containment • Adopt medical malpractice reforms that limit • Establish annual budgets for operating • Generally apply Medicare payment
lawsuit rewards and create state health care expenditures, administrative costs, health mechanisms, adjusted to reflect the AmeriCare
tribunals to review cases and render decisions. professional education, and quality assessment population.
Parties will still have access to state courts if activities. • Limit payments to private plans offered
not satisfied with decisions. • Require states to pay institutional providers, through AmeriCare (similar to Medicare
• Reduce Medicaid and Medicare Disproportionate including hospitals and nursing facilities, Advantage) to average per capita costs under
Hospital Share (DSH) funds if there is a decrease through an annual prospective global budget AmeriCare.
in the national uninsurance rate of 8% or more. and develop payment methodologies for • Require AmeriCare to develop a fee schedule
• Enhance efforts to detect and eliminate independent health practitioners that include for outpatient drugs and biologics, to negotiate
fraud and abuse in Medicare and Medicaid by incentives to encourage practitioners to choose directly with drug companies for the purchase
providing funding for the Office of the Inspector primary care medicine. price of those drugs and biologics, and to
General of the Department of Health and • Limit national health security spending growth encourage greater use of generics and lower
Human Services. Identify instances where to the average annual percentage increase in cost alternatives.
Medicare should be, but is not, acting as a the gross domestic product. • Require AmeriCare contractors to submit
secondary payer to an individual’s private • Establish individual and state capitation electronic claims.
coverage. amounts and risk adjustment methodologies • Apply Medicare provisions relating to fraud
• Reinstate the Medicare Trigger, which requires to be used for developing state and national and abuse and administrative simplification to
the President to submit a plan to contain global budgets. AmeriCare plans.
Medicare costs if 45% or more of the program’s • Limit state administrative costs to 3% of total
funding comes from general tax revenues for expenditures.
two consecutive years. • Create state fraud and abuse prevention and
control units to investigate and prosecute
violations of state law.
• Develop provider payment methodologies
that include global fees for related services
furnished to individuals over time.
• Establish prices for approved prescription
drugs, devices, and equipment.
Improving quality/health • Prohibit comparative effectiveness research • Create an American Health Security Quality • Apply Medicare provisions relating to outcomes
system performance from being used to deny coverage of a health Council to review and evaluate practice research and quality to AmeriCare.
care service under a Federal health care guidelines and performance measures; adopt
program and require the Federal Coordinating methodologies for profiling practice patterns
Council for Comparative Effectiveness and identifying outliers; and develop guidelines
Research to present research findings to for medical procedures to be performed at
relevant specialty organizations before publicly centers of excellence.
releasing them. • Improve access to care through grants to
• Create a process to develop performance- support the development of primary care
based quality measures that could be applied centers to serve medically underserved
to physician services under Medicare. populations in urban and rural areas and the
expansion of school health service sites.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 41
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)

Improving quality/health • Create a health plan and provider portal


system performance website to provide standardized information
(continued) on health insurance plans and provider price
and quality data. Provide states with funding to
implement the standardized health plan and
provider portal website.
Prevention/wellness • Allow insurers that offer health coverage • Create an Office of Primary Care and No provision.
through Individual Membership Associations Prevention Research to identify research
and the individual market to establish premium related to primary care and prevention
discounts/rebates for individuals for adherence for children and adults and to establish a
to health promotion and disease prevention system for collecting, storing, analyzing, and
programs. disseminating information related to primary
• Allow employers to vary premiums and cost- care and prevention research.
sharing up to 50 percent of the value of benefits
under the plan, based on participation in a
wellness program.
Long-term care Not specified. • Provide coverage for acute and chronic long- No provision.
term care services through the State American
Health Security Programs.
• Limit spending on home and community-based
care to no more than 65% (or an established
alternative ratio) of the average amount that
would have been spent if all of the home-
based long-term care beneficiaries had been
residents of nursing facilities in the same area.
Other investments • Establish a student loan fund with public or • Redesign health professional education No provision.
non-profit schools of medicine or osteopathic programs to promote primary care so that
medicine to provide loans for medical students, within five years at least 50% of residents in
including for those who enter training medical resident education programs are
programs in fields other than primary care. primary care residents and the number of
• Provide up to $50,000 of loan forgiveness for mid-level primary care practitioners and
primary care providers who serve for at least dentists meets certain targets.
5 years or 3 years in a medically underserved • Provide funding to the Public Health Service
area. to support the National Health Service Corps,
• Reform the sustainable growth rate for health professions education, and nursing
physicians in the Medicare program. education.
• Provide grants to states to support core public
health functions, including data collection and
analysis, investigation and control of adverse
health events, health promotion and disease
prevention activities, research on cost-effective
public health practices, and integration and
coordination of prevention programs and services.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 42
Rep. Tom Price (Republican Study Committee) Sen. Bernie Sanders Rep. Pete Stark
Empowering Patients First Act American Health Security Act of 2009 AmeriCare Health Care Act of 2009
(H.R. 3400) (S. 703) (H.R. 193)

Financing Financing for the proposal will come from The American Health Security Act will be funded Plan will be financed through an AmeriCare
limiting malpractice lawsuits, cutting through the American Health Security Act Trust Trust Fund. The trust fund will be financed with
government payments to hospitals that serve a Fund. Funding for the Trust Fund will come employer and individual premium payments,
disproportionate number of uninsured, capping from redirecting existing federal payments state maintenance of effort payments, and
non-defense discretionary spending, and for health care; imposing a payroll tax of 8.7% general revenue for premium subsidies.
increased detection and elimination of waste, on employers and employees; and imposing a
fraud and abuse in government programs. health care income tax of 2.2%.
Sources of information http://rsc.tomprice.house.gov/Solutions/ http://www.sanders.senate.gov/news/record. http://www.stark.house.gov/index.
EmpoweringPatientsFirstAct.htm cfm?id=313855 php?option=com_content&task=view&id=1081&
Itemid=103
http://www.stark.house.gov/index.
php?option=com_content&task=view&id=1238&
Itemid=84

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 43
Sens. Ron Wyden and Bob Bennett Former Majority Leaders:
Healthy Americans Act Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391) Crossing Our Lines: Working Together to Reform the U.S. Health System

Date plan announced February 5, 2009 June 17, 2009


Overall approach Require most Americans to purchase private coverage (called Healthy Require all Americans and legal residents to have health insurance. Create
to expanding access Americans Private Insurance or HAPI) meeting certain standards, with state-based health insurance exchanges through which individuals and
to coverage federal subsidies available for individuals/families up to 400% of the employers can purchase health coverage, with premium credits available
federal poverty level. State-based Health Help Agencies administer the to individuals/families with incomes up to 400% of the federal poverty level.
offering of HAPI plans, which have to meet federal benefit and other Require employers to provide coverage to employees or pay a fee based on
standards. Employers can continue to sponsor health plans but many are annual payroll, with exceptions for certain small employers, and provide
unlikely to do so because the favorable tax treatment for individuals of certain small employers a credit to offset the costs of providing coverage.
employer-paid and insurance is eliminated. Impose new regulations on plans participating in the exchanges and in the
individual and small group insurance markets. Expand Medicaid to 100% of
the poverty level.
Individual mandate • Require all citizens over age 19 to have insurance along with dependent • Require all Americans and legal residents to have health insurance that
children. Those without coverage are subject to a financial penalty based meets minimum creditable coverage standards. Enforcement options
on the number of uncovered months and the weighted average include: default enrollment in basic coverage through an employer or
of HAPI premiums. the exchange when starting a job, tax penalties including loss of federal
deductions or exemptions, and a “fair share” fee added to income tax
liability to reflect the cost of uncompensated care. Exceptions granted for
religious objections and financial hardship.
Employer requirements • Require employers to contribute an amount equal to a percentage of • Require employers to offer coverage to their employees or pay a fee
the average premium of their workforce times the number of workers. based on the percentage of payroll. The fees would range from 1% of
Percentage of the average premium varies for large and small employers payroll for firms with annual payrolls between $1 million and $2 million
from 2% to 25%. and 3% of payroll for firms with annual payrolls above $3 million.
• For the first two years, permit employers previously providing health • Exempt small businesses with payrolls less than $1 million.
insurance to increase their workers’ wages by the amount of the health
insurance premium in lieu of the employer shared responsibility payment
described above.
• Employers who continue to sponsor health plans must provide
information on HAPI plans to employees.
• Require employers to deduct individual and family premiums from
workers’ payroll.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 44
Sens. Ron Wyden and Bob Bennett Former Majority Leaders:
Healthy Americans Act Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391) Crossing Our Lines: Working Together to Reform the U.S. Health System

Expansion of public • Eliminate Medicaid and CHIP as comprehensive coverage programs and • Expand Medicaid to all individuals with incomes up to 100% FPL.
programs instead provide supplemental, wrap-around coverage for low-income Initially, all individuals eligible for Medicaid and CHIP will obtain or
beneficiaries. Provides for a modified Medicaid long-term care services retain coverage through state Medicaid programs. After five years, the
program. HHS Secretary will be authorized to permit Medicaid and CHIP eligible
individuals to enroll in the exchange provided such coverage does not
result in increased cost sharing or loss of benefits.
• Allow states to create a state plan option to provide another choice of
coverage in the exchange. The state plan may be modeled after state
self-insured plan, co-op plans with consumer boards, or other designs.
The state plan must be actuarially sound; cannot be managed by the
same entity that regulates the state’s insurance markets; cannot
leverage participation in public programs as a means of developing
provider networks; cannot be provided special advantages with respect
to risk adjustment, premium rating, reserve rules, marketing, and
automatic enrollment; and must be self-sustaining. If, after five years,
HHS determines that affordability and coverage goals have not been met,
a proposal for a federal or a state plan to be offered in the exchanges will
be considered by Congress under an expedited procedure.
Subsidies to individuals • Provide premium subsidies for individuals and families with incomes • Provide tax credits on a sliding scale basis to individuals and families
between 100 and 400% FPL; those with incomes below 100% FPL would with incomes up to 400% FPL to purchase insurance through the Health
not pay premiums. Insurance Exchanges and families with incomes below 100% FPL will
• Provide a health care standard tax deduction for individuals and families be enrolled in Medicaid and pay no premiums. Within the exchange,
with incomes above 100% FPL; would phase-out at higher income levels. those with incomes between 100 and 150% FPL will pay 2% of income;
those with incomes between 150 and 250% FPL will pay 5% of income;
those with incomes between 250 and 350% FPL will pay 10% of income;
those between 350 and 400% FPL will pay 12.5%. The tax credits will be
refundable and advanceable.
• Limit premiums for individuals and families with incomes above 400%
FPL to no more than 15 percent of their income.
Subsidies to employers No provision. • Provide small employers with fewer than 25 employees who are mostly
low-wage with tax credits to help offer coverage to their workers.
Tax changes related • Reform the tax code to eliminate the exclusion of the value of health • Cap the income tax exclusion for employer-sponsored insurance at
to health insurance insurance plans offered by employers from workers’ taxable income the value of the FEHBP standard option and index that amount by
(with exceptions, such as for employer-paid retiree health coverage and medical inflation over time. Exempt retirees and individuals covered by
coverage through collectively bargained agreements until those agreements expire.
a collectively bargained plan).
• Provide a new health care standard deduction that phases out for higher
income taxpayers.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 45
Sens. Ron Wyden and Bob Bennett Former Majority Leaders:
Healthy Americans Act Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391) Crossing Our Lines: Working Together to Reform the U.S. Health System

Creation of insurance • Create new state-based purchasing pools (Health Help Agencies) that • Create state or regional Health Insurance Exchanges through which
pooling mechanisms would offer a choice of HAPI plans. all individuals and small employers with 50 or fewer employees can
• Everyone, except people enrolled in Medicare, retiree benefit plans, purchase qualified insurance. Implement a federal fallback if states or
or military-related coverage, are required to enroll in plans through regions do not create exchanges in a timely manner.
the Health Help Agencies. (Note: employers can still sponsor health • Require plans to offer benefits that are at least actuarially equivalent to
insurance but would have to inform employees of HAPI plans available four established federal standards. The four standard plan levels are:
through Health Help Agency.) high (similar to the FEHBP Blue Cross Blue Shield Standard Option),
• Participating plans provide coverage similar medium (similar to a typical small group market plan), standard (similar
to that available through FEHBP. to a typical individual market plan), and basic (equivalent to the federal
• Require insurers to offer HAPI coverage on a guaranteed issue basis and minimum creditable coverage standard). Plans have flexibility to vary
use adjusted community rating principles in setting premiums. cost sharing in each of the standard plan levels.
• Require guarantee issue and renewability; allow rating variation based
only on age (limited to 5 to 1 ratio), geographic region, and family
enrollment. States can opt to impose tighter consumer protections.
• Require risk adjustment of participating Exchange plans.
• Require exchanges to make available educational resources and
consumer support tools and to adopt strategies to improve plan choice.
Benefit design • Provide benefits through HAPI plans that are actuarially equivalent or • Create minimum creditable coverage standards for insurance plans
greater in value than the benefits offered under the Blue Cross/Blue offered in all markets. Creditable coverage will include: catastrophic
Shield Standard Plan provided under the Federal Employees Health protections, coverage for a comprehensive ranges of health care
Benefit Program (FEHBP). services, and coverage of preventive care and prescription drugs before
• Additionally provide benefits for wellness programs and incentives to the deductible. Creditable coverage must be at least as generous as a
promote the use of these programs, coverage for catastrophic medical federal high-deductible plan. Permit states to increase the minimum
events for an individual or family if lifetime limits are exhausted, and full standards provided that it does not increase federal costs.
parity for mental health benefits.
• Create the Healthy America Advisory Committee to issue annual reports
recommending modifications to the benefits, items, and services covered
by HAPI plans.
Changes to private • Require insurers to offer coverage on a guaranteed issue basis and use • Require guarantee issue and renewability and allow rating variation
insurance adjusted community rating principles in setting premiums; prohibit based only on age (limited to a 5 to 1 ratio with state option to reduce
discrimination based on health status. the ratio), geographic region, and family enrollment in the individual and
• Require insurers to meet established medical loss ratios. small group markets and the Exchange. Prohibit imposition of any pre-
• Require insurers to create an electronic medical record for each covered existing condition exclusions. Allow existing plans in the individual and
individual. small group markets to be grandfathered for five years before coming
into compliance with new insurance market reforms.
• Standardize health care claims processing to promote administrative
simplification of payment systems and collect and publish data on
medical loss ratios of plans participating in the individual and small
group markets.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 46
Sens. Ron Wyden and Bob Bennett Former Majority Leaders:
Healthy Americans Act Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391) Crossing Our Lines: Working Together to Reform the U.S. Health System

State role • Create Health Help Agencies and ensure that participating insurers meet • Require states to establish, operate, and regulate state or regional
requirements related to solvency and financial standards, consumer exchanges and to report annually on the number of plans offered through
protections, and establishment of wellness programs. the exchange, the range of premiums, and the number of individuals
• Implement mechanisms, such as automatic enrollment, to ensure covered through the exchange.
maximum enrollment
of individuals into private insurance.
Cost containment • Adopt payment policies that reward providers for achieving quality and • Invest in meaningful and effective use of HIT and ensure that HIT bonus
cost efficiency in prevention, early detection of disease, and chronic care payments to providers are coordinated with new payments to achieve
management. better care.
• Require insurers to create and implement electronic medical records for • Reform provider payments in federal health programs to pay for high-
each covered individual. value care.
• Require insurers to adopt uniform billing and claims forms. – Move from pay-for-reporting to pay-for-performance based on
• Encourage more rigorous study of new drugs and devices by granting measures reflecting overall quality and coordination of care;
additional exclusivity and patent protections to those subjected – Implement medical home payments that hold providers accountable
to comparative effectiveness reviews. Disallow tax deductions for for patient results over time;
pharmaceutical manufacturers for direct to consumer advertising for – Expand the use of bundled payments for episodes of care and link to an
most new drugs. expanded “Centers of Excellence” program in Medicare;
• Require insurers and providers to publicly report data on medical – Limit public program payments for unnecessary or inappropriate care,
outcomes, health care quality and costs. such as for hospital-acquired conditions or hospital readmissions; and
• Provide bonuses to states that enact medical malpractice reforms. – Establish accountable care organizations (ACOs) in Medicare and
permit ACOs that meet quality care benchmarks and reduce overall
costs to share in the savings achieved.
• Adjust Medicare market basket updates to reflect savings from delivery
system reforms, such as bundled payments, and reduce Medicare
payments to home health and skilled nursing facilities.
• Restructure payments to Medicare Advantage plans to align more closely
with fee-for-services payments and adopt incentives for quality reporting
and performance improvement.
• Reform prescription drug payments in Medicaid by increasing the drug
rebate rate while eliminating the “best price” provision.
• Adjust Medicare and Medicaid Disproportionate Share Hospital funding to
reflect reductions in uncompensated care. Payments should be reduced
by one-third over 10 years.
• Create a regulatory pathway for the approval of biosimilar and biogeneric
products.
• Restructure Medicare and Medigap cost sharing and reallocate Medicare and
Medicaid improvement funds.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 47
Sens. Ron Wyden and Bob Bennett Former Majority Leaders:
Healthy Americans Act Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391) Crossing Our Lines: Working Together to Reform the U.S. Health System

Improving quality/health • Encourage chronic care programs • Support comparative effectiveness research that compares the risks,
system performance • Require hospitals to demonstrate improvements in quality control, benefits, and costs of different health care practices, evaluates and
including rapid response teams, heart attack treatments, procedures revises policies that influence provider practices, and identifies
that reduce medication errors, infection prevention, procedures that strategies for targeting practices to specific groups of patients.
reduce the incidence of ventilator-related illnesses. • Improve quality monitoring and improvement by expanding funding for
• Provide enhanced Medicare payments to primary care providers and the prioritization, development, endorsement and implementation of
require Medicare to develop a chronic disease management program. qualify measures, requiring electronic quality reporting, and improving
• Establish a website for sharing evidence-based best practices and the evaluation of new payment reform programs.
develop a program for incorporating these best practices into medical • Improve care coordination for people with chronic conditions through
school curricula. the creation of community health teams composed of care coordinators,
• Provide for improvements in end-of-life care. nurse practitioners, social workers, nutritionists, and others to provide
patient-centered care that integrates existing prevention and care
management resources.
• Improve coordination of care for dual eligibles by creating a new program
that includes a mechanism for states and the federal government to
provide financial support to deliver integrated Medicare and Medicaid
services to this population.
• Address racial and cultural disparities by enhancing comparative
effectiveness research, realigning reimbursement to promote improved
patient outcomes, ensuring adequate provider capacity in underserved
areas, increasing the number of minorities entering the medical and
health professions, and developing and adopting standards for the
collection of data on race and ethnicity.
• Create an Independence Health Care Council (IHCC) to assess overall
system performance. The IHCC will analyze and report on cost and
quality data in federal programs and issue recommendations for
improving quality, reducing cost growth, and better coordinating the
delivery, reimbursement, and financing of federal health programs.
Prevention/wellness • Promote prevention by providing premium discounts (including for • Support a sustained, nationwide focus on public health wellness through
Medicare Part B premiums) for participation in approved wellness and creation of a Public Health and Wellness Fund to invest in evidenced-
chronic disease management programs. based prevention and wellness activities. These activities and provisions
• Require HAPI plans to ensure that primary care providers and individuals include: no or limited cost sharing for proven preventive services, a new
create a care plan focused on wellness and prevention as part of the wellness visit for Medicare beneficiaries to receive a personalized health
initial primary care visit. risk assessment and prevention plan, a federal tax credit for certified
employer-based wellness programs that meet accountability and
reporting requirements, and a $3 billion annual investment in wellness
and prevention programs.

Side-by-Side Comparison of Major Health Care Reform Proposals — Last Modified: September 18, 2009 48
Sens. Ron Wyden and Bob Bennett Former Majority Leaders:
Healthy Americans Act Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391) Crossing Our Lines: Working Together to Reform the U.S. Health System

Long-term care • Permit states to create State Choices for Long-term Care Programs No provision.
through their Medicaid programs to provide institutional and home and
community-based long-term care for eligible individuals.
• Create new long-term care insurance plans that meet standards
developed by NAIC or by federal regulations. Require additional
consumer protections for long-term care policies regarding guarantee
renewal, prohibitions on limitations and exclusions, pre-existing
conditions, and other issues.
Other investments • Provide grants to school districts and communities to increase access to • Reform Graduate Medical Education to increase training of primary care
school-based clinics. providers, promote training in settings and geographic areas where
• Permit states to create State Choices for Long-term Care Programs providers will practice, and encourage integrated systems of care to
through their Medicaid programs to provide institutional and home and increase reliance on a qualified non-physician workforce. Provide funding
community-based long-term care for eligible individuals. for the training of more nurses and allied health professionals. Revise
• Create new long-term care insurance plans that meet standards scope of practice laws to encourage use of advanced practice nurses,
developed by NAIC or by federal regulations. pharmacists, and other allied health professionals.
• Consider additional financial incentives to ensure adequate provider
capacity in medically underserved urban and rural areas.
• Provide full federal funding for the Medicaid expansion so that states are
not required to pay any of the costs for the newly eligible populations.
Financing In 2008, CBO scored an amended version of the bill which is very similar to The anticipated cost of health reform is $1.2 trillion over 10 years. The
this year’s version. In that CBO estimate, Federal costs would be offset by delivery system, reimbursement, employer “pay” contribution, and tax
revenues and savings in first year of full implementation, Thereafter, the exclusion reforms in the proposal (and related interactions) are expected
bill would be more than self-financing because of indexing growth in the to achieve over $1 trillion in savings and new revenues. To ensure budget
value of the health insurance deduction and the subsidized benefits. neutrality, Congress could enact additional Medicare or Medicaid savings,
Financing will come from combination of individual premiums, employer create an enforceable budget “trigger” mechanism to slow spending
assessments, state and federal savings in Medicaid, elimination of most growth above a target level, or empower the Independent Health Care
Medicare and Medicaid disproportionate share hospital (DSH) payments, Council to develop additional recommendations for achieving federal
and changes in tax treatment of insurance. spending growth targets.

Sources of information http://wyden.senate.gov/issues/Legislation/Healthy_Americans_Act.cfm http://www.bpcleadersproject.org/


http://wyden.senate.gov/issues/Health_Care.cfm
http://www.cbo.gov/ftpdocs/91xx/doc9184/05-01-HealthCare-Letter.pdf

THE HENRY J. KAISER FAMILY FOUNDATION www.kff.org


Headquarters: 2400 Sand Hill Road Menlo Park, CA 94025 650.854.9400 Fax: 650.854.4800
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW Washington, DC 20005 202.347.5270 Fax: 202.347.5274
The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis
and information on health issues.