October 30, 2009
House Speaker Nancy Pelosi wants you to read all 1,990 pages of the Obamacare plan. “We are putting it online for all Americans to see,” she announced. Most Americans will probably not read the bill. You’ll need Washington-ese decoder ring to plow through the monstrosity.
If you are adventurous, however, here is a link to Pelosi’s “transparent” bill.
Republican John Boehner has posted the details of this boat anchor tribute to coercive government on his website. According to Boehner, the government take-over of health care includes: a plethora of new taxes on middle class families, massive cuts to Medicare benefits, no protections for small business, increased costs in the form of higher premiums, budget gimmickry to hide the massive total cost for future generations, imposes job-killing employer mandates, rigs the health care game in favor of a government-run insurance company, forces unfunded mandates on the states, adds more arcane gobbledegook to the tax code, and much more.
In fact, the bill — excluding the creation of the Federal Reserve and confiscatory income taxes — is the largest and most egregious intervention of the government into the private lives of Americans in history.
Americans for Tax Reform have posted the following points taken from the bill:
Employer Mandate Excise Tax (Page 275): If an employer does not pay 72.5 percent of a single employee’s health premium (65 percent of a family employee), the employer must pay an excise tax equal to 8 percent of average wages. Small employers (measured by payroll size) have smaller payroll tax rates of 0 percent (<$500,000), 2 percent ($500,000-$585,000), 4 percent ($585,000-$670,000), and 6 percent ($670,000-$750,000).
Individual Mandate Surtax (Page 296): If an individual fails to obtain qualifying coverage, he must pay an income surtax equal to the lesser of 2.5 percent of modified adjusted gross income (MAGI) or the average premium. MAGI adds back in the foreign earned income exclusion and municipal bond interest.
Medicine Cabinet Tax (Page 324): Non-prescription medications would no longer be able to be purchased from health savings accounts (HSAs), flexible spending accounts (FSAs), or health reimbursement arrangements (HRAs). Insulin excepted.
Cap on FSAs (Page 325): FSAs would face an annual cap of $2500 (currently uncapped).
Increased Additional Tax on Non-Qualified HSA Distributions (Page 326): Non-qualified distributions from HSAs would face an additional tax of 20 percent (current law is 10 percent). This disadvantages HSAs relative to other tax-free accounts (e.g. IRAs, 401(k)s, 529 plans, etc.)
Denial of Tax Deduction for Employer Health Plans Coordinating with Medicare Part D (Page 327): This would further erode private sector participation in delivery of Medicare services.
Surtax on Individuals and Small Businesses (Page 336): Imposes an income surtax of 5.4 percent on MAGI over $500,000 ($1 million married filing jointly). MAGI adds back in the itemized deduction for margin loan interest. This would raise the top marginal tax rate in 2011 from 39.6 percent under current law to 45 percent—a new effective top rate.
Excise Tax on Medical Devices (Page 339): Imposes a new excise tax on medical device manufacturers equal to 2.5 percent of the wholesale price. It excludes retail sales and unspecified medical devices sold to the general public.
Corporate 1099-MISC Information Reporting (Page 344): Requires that 1099-MISC forms be issued to corporations as well as persons for trade or business payments. Current law limits to just persons for small business compliance complexity reasons. Also expands reporting to exchanges of property.
Delay in Worldwide Allocation of Interest (Page 345): Delays for nine years the worldwide allocation of interest, a corporate tax relief provision from the American Jobs Creation Act
Limitation on Tax Treaty Benefits for Certain Payments (Page 346): Increases taxes on U.S. employers with overseas operations looking to avoid double taxation of earnings.
Codification of the “Economic Substance Doctrine” (Page 349): Empowers the IRS to disallow a perfectly legal tax deduction or other tax relief merely because the IRS deems that the motive of the taxpayer was not primarily business-related.
Application of “More Likely Than Not” Rule (Page 357): Publicly-traded partnerships and corporations with annual gross receipts in excess of $100 million have raised standards on penalties. If there is a tax underpayment by these taxpayers, they must be able to prove that the estimated tax paid would have more likely than not been sufficient to cover final tax liability.
In addition to the list of taxes for in the ATR report, our people found the following:
Employer FINE Under Mandated Excise Tax (Page 310): A $100 per day excise tax imposed on employers for each employee for whom employer fails to “satisfy the health coverage participation requirements”. Excise tax will not apply if Secretary determines even after “exercising reasonable diligence” employer was unaware of employee’s lack of participation in health coverage.
“CADILLAC” INSURANCE PLANS
Credit vs. Points (Pages 318-320) This portion gives the appearance of providing a temporary two-year credit while at the same time deducting “points” if the Secretary deems that the employer is too generous with its health care benefit package. Ex. p. 319, lines 11-18: “Credit not allowed with respect to certain highly compensated employees. No credit shall be determined under subsection (a) with respect to qualified employee health coverage expenses paid or incurred with respect to any employee for any taxable year if the aggregate compensation paid by the employer to such employee during such taxable year exceeds $80,000”.
Uncompensated Care Increase (Page 389-390) Page 389, lines 14-19 detail a “significant” decrease in uninsurance will be triggered by only 8% decrease – “There is a “significant” decrease in the national rate of uninsurance as the result of this Act” if there is a decrease in the national rate of uninsurance from 2012 to 2014 that exceeds 8 percentage points.” Page 390, lines 4-9 detail the increase in uncompensated care – “For each fiscal year (beginning with 2017) , the Secretary shall estimate the aggregate reduction in the amount of Medicare DSH payment that would be expected to result from the adjustment under paragraph (1)(A)”. This, in turn, will lower payments to hospitals in reimbursement rates.
Gov’t to legislate Pain Research, page 1493 line 14
Begins with Line 14 ‘‘SEC. 409J. PAIN RESEARCH.
This section covers research that will be conducted at National Institutes of Health (NIH)
Provides for a “Pain Consortium” and a committee to be known as “Interagency Pain Research Coordinating Committee”
page 1496 describes the attributes of committee members (6 members are scientists, physicians, other health professionals while another 6 members are from general public representatives from leading in research, advocacy and service organizations for individuals with pain-related conditions)
This committee will coordinate all efforts within the Department of Health and Human Services and other Federal agencies that relate to pain research. Appears to be a decision making board on treatment protocols (could rationing be involved here?), create a public awareness campaign on pain,
15 AUTHORIZATION OF APPROPRIATIONS.—For
16 purposes of carrying out this section, there are authorized
17 to be appropriated $2,000,000 for fiscal year 2011 and
18 $4,000,000 for each of fiscal years 2012 and 2015.’’.
Employer Excise Tax (Pages 313-317): If an employer chooses not to provide health insurance to employees, an excise tax on the total wages paid is imposed on the employer. The excise tax percentage ranges from 2% of total payroll of $500,000 to 8% of payroll of $750,000 or more. If an employer has less than $500,000 annual payroll, he pays no excise tax.
Employer Health Coverage Tax Credit (Pages 317-319): Small business owners receive a tax credit of 50% of health insurance paid for employees whose wages are $20,000 or less per year when the employer has 10 or fewer employees. The tax credit is prorated as the amount of wages increases, leaving no tax credit for the employer when such employee’s wages total $80,000 or more per year.
For employers with more than 10 employees, the tax credit calculated by the proratio shall be reduced by an amount in the ratio of 10 to total number of employees.
SEC. 1416. Ensuring Staffing Accountability
(a) Skilled Nursing Facilities
(b) Nursing Facilities
Page #: 822 – 826
This section of the bill calls for an amendment to the Social Security Act “(C) Submission of Staffing Information Based on Payroll Data in a Uniform Format.”
The Secretary of Health and Human Services shall require a skilled nursing facility to electronically submit to the Secretary direct care staffing information including agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format (GE?) (as established by the Secretary in consultation with among others, consumer advocacy groups (ACORN?))
GOVERNMENT REGULATION OF CARE AND RESEARCH
*Government Panel for Senior Care Decisions (Pages 649-661): The Secretary has the right to waive requirements of the Social Security Act Titles XI & XVIII. These providers will put together patient decisions aids and share in seniors’ decisions regarding their health care. Seniors will attend counseling provided by said panel. Compensation will be granted to providers who generate less cost for care with regards to Parts A and B of Medicare.
Government Legislation of Pain Research (Pages 1493-1501): Page 1496 describes the attributes of committee members (6 members are scientists, physicians, other health professionals while another 6 members are from general public representatives from leading in research, advocacy and service organizations for individuals with pain-related conditions). This committee will coordinate all efforts within the Department of Health and Human Services and other Federal agencies that relate to pain research. Appears to be a decision making board on treatment protocols, create a public awareness campaign on pain. Ramifications include overly regulated treatment protocols for chronic pain and the possible end result of rationing. The viability of private research is questioned in light of this section.
(Page 1501): Lines 15-18 establish the authorization of appropriations – “For purposes of carrying out this section, there are authorized to be appropriated $2,000,000 for fiscal year 2011 and $4,000,000 for each of fiscal years 2012 and 2015”.
Government Regulation of Staffing in Nursing Facilities (Pages 822-826): In a specific motion to alter state authority of nursing facilities and to provide the Secretary and consumer advocacy groups with overreaching authority, this section of the bill calls for an amendment to the Social Security Act “(C) Submission of Staffing Information Based on Payroll Data in a Uniform Format.” The Secretary of Health and Human Services shall require a skilled nursing facility to electronically submit to the Secretary direct care staffing information including agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format as established by the Secretary in consultation with among others, consumer advocacy groups.
[efoods]Government Authority in Determining Medical Home Models (Pages 680-690): Secretary is provided wide latitude to fund and create both independent and community-based medical home models in order to reward physicians and others to coordinate treatment for chronically ill patients in underserved (rural) areas. Patient need not designate a doctor as their caregiver.
NATIONAL HEALTH SERVICE CORPS
Obligated Service Requirement (Page 1220): “The entity and the Corps member agree in writing that the Corps member will perform half-time clinical practice”. Essentially, this details “those individuals who have entered into a contract for obligated service under the Scholarship Program or Loan Repayment Program un which the individuals are authorized to satisfy the requirement of obligated service through providing clinical practice”. Essentially these individuals are obliged to work off debt in this capacity.
Abortion Coverage (Page 110): “Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in paragraph (4)(A)”. Paragraph (4)(A) Abortion Services – Abortions for which public funding is prohibited. That said, paragraph (4)(B) “The services described in this subparagraph are for abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted.”
GOVERNMENT REGULATION OF INDUSTRY
Health Czar (Page 133): Establishes Health Czar and bureaucracy, i.e. “Health Choices Commissioner” and “Health Choices Administration”. Essentially, this area lends the Health Commissioner and Health Choices Administration power over health insurance plans both inside and outside of the Health Insurance Exchange. The concern is that the provision invites overreaching authority and oversight of plans specifically set up to provide timely and needed care not readily available through the government exchange-controlled plans.
Health Czar Health Plan Audits (Page 133-134) Provides “Health Commissioner”/Czar with wide discretion to audit “qualified health benefits plans” and then bill the plan for the cost of the audit, regardless of grounds for the audit and regardless of whether or not the plan was found to have violated any regulation. The concern is the overreaching of authority and power over private health plans and the conjecture is that this will force a process by which consumers are significantly limited in their health plan choices. As written, no protection from abuse of power in this regard is provided.
Word/Topic Reviewed: Subtitle E—Public Reporting on Health Care-Associated Infections
SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED INFECTIONS.
This section is vaguely disturbing in the way it micro-manages hospitals, a vast overreach of federal power, but that’s nothing surprising in this bill. Two specific red flags:
Page #. 915Paragraph #. 2
Subject: 02, 03
Remarks: Infections are to be publicly posted and compared by demographic information. (Age? Race?)
Page #. 916
Paragraph #. 2
Subject: 03, 04
Remarks: Infections are being studied in such detail in order to reduce costs, not because of quality of care concerns
Government Regulatio of Patient Care
Regulation of Services (Page 383) Lines 11-16 allot for using appropriate indicators for non-therapy ancillary services classification, which may include age, physical and mental status, ability to perform activities of daily living, etc. The concern is over the method of deciding care delivery, placing key decision-making elements in the hands of politicians and other non-medical staff as opposed to the hands of patients’ doctors and families.
Regulation on Patient Stay (Page 385) Establishes payment based on total costs during stay in a skilled nursing facility as opposed to the number of days in such stay.
Abortion Coverage (Page 110): “Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in paragraph (4)(A)”. Paragraph (4)(A) Abortion Services – Abortions for which public funding is prohibited. Paragraph (4)(B) “The services described in this subparagraph are for abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted.”
Federal Funding of Abortion (Page 147) Lines 14-(1) IN GENERAL.—“Nothing in this Act shall be construed to have any effect on Federal laws regarding – (A) conscience protection; (B) willingness or refusal to provide abortion; (C) discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion. The concern regards lines 20-23 (C) as it is viewed as a potential open door for funding of organizations such as Planned Parenthood. The document affirms that this bill has no effect on current law where discrimination based on either willingness or refusal to participate in abortion services, and thus, provides no additional protect against the use of Federal funds allocated for abortion services. As, additionally, the Hyde Amendment is in no way incorporated into this piece of legislation and because no additional explicit protections exist in this document, this piece of legislation will, indeed, provide authorization of federal funding of abortion under the public option.
Additionally, because there is no ban on abortion funding under the reauthorization of the Indian Health Service (IHS), and additionally no additional protections such as the Vitter Amendment, there is nothing to prevent abortion funding.
Mandated School-Based Health Clinics (Page 1354) Lines 9-21 states, “(c) Use of Funds – Funds awarded under a grant under this section …(2) may not be used to provide abortions. However, there is no specific language prohibiting either abortion referrals or the distribution of information materials regarding access to abortion.
Required Reporting Regarding Infections Sec. 1138A – Requirement for public reporting by hospitals and ambulatory surgical centers on health care-associated infections. Page 915 – States, “infections are to be publicly posted and compared by demographic information.” Page 916 – States “infections are being studied in such detail in order to reduce costs, not because of quality of care concerns”. The concern stems from both the ambiguity that exists in the statement referenced on page 915 as well as the lack of concern over quality of care in regards to infection.
Required Reporting Trumps State Laws Sec. 1128H – Financial reports on physicians’ financial relationships with manufacturers and distributors of covered drugs, devices, biologicals or medical supplies under Medicare, Medicaid, or CHIP and with entities that bill for services under Medicare. Page 910 – Concerns is that language pre-empts state laws requiring manufacturers to report their relationships to physicians. Page 912 – Establishes that “Comptroller General” is to file a report establishing that no loopholes exist in said section.
GOVERNMENT REGULATION OF NON-HEALTH INDUSTRY
Regulation of Disclosure of Nutrient Content/Menu Variability (Page 1514) Lines 5-14 – “The Secretary shall establish by regulation standards for determining and disclosing the nutrient content for standard menu items that come in different flavors, varieties, or combinations, but which are listed as a single menu item, such as soft drinks, ice cream, pizza, doughnuts, or children’s combination meals, through means determined by the Secretary, including ranges, averages, or other methods”. Rules extend to maintaining the calculation of combo meals an addition cost to restaurants.
Regulation of Vending Machine Owners/Suppliers (Page 1516) Lines 4-8 – Pertaining to businesses that own or operation 20 or more vending machines, “the vending machine operator shall provide a sign in close proximity to each article of food or the selection button that included a clear and conspicuous statement disclosing the number of calories contained in the article”.
Regulation of Food Preparation/Presentation (Page 1517) Lines 14-22 – “The Secretary shall (aa) consider standardization of recipes and methods of preparation, reasonable variation in serving size and formulation of menu items, space on menus and menu boards, inadvertent human error, training of food service workers, variations in ingredients, and other factors, as the Secretary determines”.
19 solved with reasonable premium increases
lines 1 through 7 and no such
5 information or documentary material may be
6 made public
14 ‘‘(i) CIVIL PENALTY.—Any person
15 that violates a provision of this paragraph
16 shall be liable for a civil penalty of not
17 more than $11,000 for each day on which
18 the violation occurs.
5 (2) PERSONAL CARE ATTENDANT WORKFORCE
6 ADVISORY PANEL.—Section 202 of such Act (42
7 U.S.C. 3012)
22 ‘‘(3) PEER REVIEW PANELS18 ‘‘(e) PEER REVIEW PANELS.—The Secretary may
19 provide for the establishment of peer review panels, as nec20
essary, to review and evaluate applications using the cri21
teria developed pursuant to subsection (d)
12 ‘‘SEC. 307. LAND TRANSFER
15 departments of the United States are authorized to transfer, at
16 no cost, land and improvements to the Service
11 paid into a Life Independence Account for ob
12 taining assistance with decisionmaking
13concerning medical care
See attachment for a compilation of what’s been found so far on p. 110-200. Some highlights:
p. 110 (4) (B) Federal funding for abortion is in;
p. 111 Sec. 223 “Health Benefits Advisory Committee” to recommend covered benefits (AKA “rationing board”)
p. 120-130 HHS Sec. directed to clarify/define several bits in this section (reader found 50+ calls for Sec. to clarify/define, including in rest of bill)
p.133-134 “Health Choices Administration” with power over health insurance plans both inside and outside the Health Insurance Exchange invites harassment of non-Exchange plans and abuse aimed at driving private plans out of business.
Lots more where these tidbits came from in the attachment. Will get to work collating any reports which may have come in since 4:30PM Central Time today as soon as I post this.
Pages 1850 – 1860 Titled “HEALTH SERVICES FOR URBAN INDIANS” contains a lot of double talk. What it summarily says in plain English is that the Secretary now controls and approves any and all grants and/or contracts entered into or referred by an Indian Tribe, Urban Indians or Tribal Organizations, including but not limited to healthcare needs, education of any kind, desease prevention, wild life preservation, land preservation or land purchases, and anything else covered under the 1921 Snyder Act. I specifically found it interesting that on page 1860, lines 14-23, the purpose of a contract or grant…shall be the determination… in order to assist the Secretary in assessing the health status and health care needs of Urban Indians in the Urban Center involved and determining whether the Secretary should enter into a contract or make a grant…
ADDITIONAL ITEM RELATED TO INDIAN HEALTH:
Septic System Regulations (Pages 1780-1790) The Federal government will fund sanitation facilities for Indian Tribes with the following provisions: (Page1781) “Sec. 302 (a) (1) financial and technical assistance to operate and maintain sanitation facilities…. (a) (3) funding to operate and maintain sanitation facilities….(b) Congress reaffirms the primary responsibility and authority of the Service to provide the necessary sanitation facilities and services as provided in section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a)…..(Page 1783) – (c) (5) fund up to 100% of a tribes loan for sanitation facility….…(Page 1785)(c) (8) the Secretary of Health and Human Services shall, by regulation, establish standards applicable to the planning, design, and construction of sanitation facilities funded under this Act… (Page 1787) (d) The financial and technical capability of an Indian Tribe, Tribal Organization, or Indian community to safely operate, manage, and maintain a sanitation facility shall not be a prerequisite to the provision or construction of sanitation facilities by the Secretary”. It is posited that this item is a necessary item for the bill as septic-related issues directly affect health issues for the Indian Community. However, it is a concern that this is transition of power overrides local standards for the Indian Community and usurps local authority over key community infrastructure and systems. It is worthy to note, as well, that sanitation needs include a clean water source which involves a myriad of issues related to clean water and environmental concerns.