Specifications for Reform:

Specifications for Reform:

1. Health care reform must be a national priority.

1. Yes.

2. Health care reform must be systemic.

2. No. Leaves existing programs in place and doesn’t address shortcomings of those program.

3. Health care reform must be system-wide.

3. Yes. Covers all persons not presently covered by federal health insurance programs and employer provided coverage.

Principles

Principles

1. Health coverage for all:

Coverage for all within 2-3 years of enabling legislation.

1. Health coverage for all:

Vague. Funding starts in 2009 and implementation appears to start in 2011.

· Basic coverage defined for everyone.

· Partially Yes. New programs based on FEHBP, but other federal health coverage plans aren’t touched.

· Optional supplemental coverage.

· Not mentioned

· Include adequate subsidies for those who are less affluent.

· Full Subsidies provided for persons with incomes of below 125% of poverty line (150% for families), pregnant women and children. Partial subsidies for persons with incomes up to 250% of poverty line (300%) for families. Subsidies cannot exceed 75% of premiums.

· Assure continuity of coverage for those who move from one form or context of coverage to another

· Coverage is guaranteed for all, but it seems that one must change plans when moving between employer coverage and government coverage, or when moving from one Region to another.

· Facilitate enrollment by all those eligible for coverage

· Procedure is left up to Commissioner. Those who don’t voluntarily enroll will be enrolled in lowest premium plan.

· Require individuals to establish that they have coverage.

· Not necessary, because Commissioner will see that all are enrolled. It isn’t specified how the Commissioner will find everyone who doesn’t enroll voluntarily.

· Group purchasing is recommended

· Group purchasing is inherent in the plan.

· High-Risk insurance pool is established to pay costs above an established threshold.

· Should be a National strategy, not state level except pending National legislation

· Yes. AHBP is established as equivalent to the National Social Security program. State SCHIP plans are phased out.

2. Cost Management:

2. Cost Management:

· Serve long term goal of increasing the value generated by health care expenditures (health benefits to patient for a given level of overall spending)

· No such goal is expressed. Cost containment measures are limited. Commission is charged with studying certain areas of cost, but not charged with implementing anything that might save costs.

· Long term goal of limiting total spending to % of per capita GDP.

· No.

· Establish rates of reimbursement for providers

· Generally the same as FEHB Program. These rates would normally be established between insurance companies and health care providers.

· Limitations on increases in insurance premiums.

· Nothing specific. Commissioner is responsible for negotiating plan benefits and premiums. Qualified health plans must use at least 90% of premiums on benefits or improvements, such as Health IT.

· Independent board to establish and administer programs, rates (e.g. capitation) and limitation to keep costs in line with annual targets.

· Semi-independent Health Benefits Commission is established in Executive Branch. It is to “examine and make recommendations regarding major issues and cost drivers,” but it has no administrative resposibilities.

· Make health insurance premiums comparable

· Premiums are similar to FEHBP, but are set regionally rather than nationally.

· Plan requires Community-rated premiums, i.e. prohibits premiums based on health status, gender, age, etc.

· Increase effectiveness of capital spending

· Not addressed.

· Ensure cost sharing and other tools to control over and under use of care, with subsidies for those who are less affluent

· Cost-sharing is a feature of the plan. There are subsidies for the less affluent, which the individual must apply for.

3. Improvement of Health Care Quality and Safety:

3. Improvement of Health Care Quality and Safety:

· A comprehensive, national effort.

· Commission not given a general charge to monitor and improve quality and safety. Commission is given specific issues to “examine and make recommendations regarding.”

1. Comparison of AHBP to other programs

2. Implementation and Use of electronic records

3. Effects of malpractice and defensive medicine on health care

4. Effects of over-utilization of AHBP

5. Factors affecting retiree health coverage

6. Prescription drug prices

7. Effects of insurance monopolies

· Independent Board chartered & overseen by Congress.

· Yes. Its structure is the same as the Social Security Administration.

· More public funding to improve quality and safety

· Not addressed

· Develop and publicize quality measures.

· Not addressed

· Reduce quality variations across regions and providers

· Not addressed

· Link payment for care to quality of care

· Not addressed

· Establish National information system; establish protocols for patient records, prescriptions, billing, privacy standards, updating based on experience & technological advances: “incentivize“ by supplemental payments, tax policy, loans, grants.

· Commissioner, with Secretary of HHS, to “establish guidelines that promote the proper use and understanding of health information technologies.” Assumes system is developed by other means. Claims a yearly savings of $77 billion from HIT, but no backup provided.

4. Equitable Financing:

4. Equitable Financing:

· Reduce or eliminate cost-shifting across programs & payers.

· Payments are made from a single source, the American Health Benefits Program Trust Fund

· Qualified plans must agree to participate in high-risk reinsurance pool.

· Possible funding sources: General revenues, earmarked taxes, employer contributions, individual contributions.

· IRS collects premiums, tax on employers, wages, self-employment earnings, hospital revenues (for-profit hospitals only? Not clear). Tax on wages and self-employment refunded if individual has employer-provided coverage. Employer- provided coverage must be equivalent to FEHBP plans with employer support greater or equal to Government’s cost.

· Individual obligations based on ability to pay.

· Yes. Subsidies are based on ability to pay. Derived from previous year’s income. Tax credits are provided for premiums paid.

5. Simplified Administration

5. Simplified Administration

· Reduce complexity, produce streamlined, rationalized health care system.

· Partially. Converts all individual insurance to plans that qualify for FEHBP. But, system still has many parts, including American Health Benefits Program (AHBP), employer based health care, Medicare, Medicaid, Tricare, Indian health services and Veterans Health.

· For basic coverage, consistent set of ground rules and understandings for patients, payers and providers

· Yes for the new offerings based on FEHBP, but does not address the differences between existing systems that will remain.

· Develop national practice guidelines.

· No.