PRACTICING MEDICINE
HealthCare Reform:
What is Congress Considering?
Here are some of the more prominent Health Care
Reform proposals that have been offered this year,

compiled from a variety of sources.*
AMERICA’S AFFORDABLE HEALTH
CHOICES ACT OF 2009 (H.R. 3200)
SPONSOR: Rep. John Dingell (D-MI)
DESCRIPTION: Comprehensive legislation seeking to
expand health coverage to 40 million uninsured and
make the current system more efficient; amended ver-
sions approved by key House committees - Ways &
Means, Education & Labor, and Energy & Commerce;
1,018 pages.
HIGHLIGHTS: Bill mandates “acceptable health cover-
age” for all individuals, penalty for those without, with
some exceptions, and prohibits coverage purchased
through individual market from qualifying as “accept-
able” coverage unless grandfathered in; creates health
insurance exchange with premium and cost-sharing
credits for individuals/families up to 400% of the FPL
(federal poverty level); mandates employers to provide
coverage or pay into a Health Insurance Exchange Trust
Fund, with exceptions or credits for some small employ-
ers; creates public health insurance option offered
through exchange, meeting same requirements as pri-
vate plans; provider payments in public plan set at
Medicare rates plus 5% bonus for participators, and
Medicare providers participate unless they opt-out; pub-
lic plan allowed to develop innovative payment mecha-
nisms including medical home and other care manage-
ment payments, bundling of services, value-based pur-
chasing, performance-based payment, differential pay-
ment rates and partial capitation; insurance market
reforms for exchange plans and small group insurance
including development of four benefit levels (basic,
enhanced, premium and premium plus), guaranteed
issue and renewability, premium rating and prohibitions
on preexisting conditions exclusions; expands Medicaid
to all individuals up to 133% FPL; requires coverage for
CHIP enrollees through exchange; creates a Center for
Comparative Effectiveness Research and an independ-
ent CER Commission to support comparative effective-
ness and quality, and increases Medicare and Medicaid
payments for primary care while testing payment incen-
tive models for Accountable Care Organizations; creates
Center for Quality Improvement to find and promote best
practices in and national priorities for delivery of health

care. Amendments include requiring EPSDT services for
children under 21; prohibiting use of comparative effec-
tiveness findings to deny or ration care; prohibiting
abortion coverage requirement as part of essential ben-
efits and require segregation of public funds from pri-
vate premiums for plans that choose to cover abortion.
All three House committee versions of this bill will
be merged into a single bill for House floor considera-
tion when Congress returns.
COST: $1.042 trillion over 10 years; financed through sav-
ings and rising surcharge on individuals making
$280,000 or more and families making $350,000 or more.
AMERICA’S AFFORDABLE HEALTH
CHOICES ACT OF 2009
(SENATE HELP COMMITTEE BILL)
SPONSORS: Sen. Edward Kennedy (D-MA), Christopher
Dodd (D-CT)
DESCRIPTION: Senate version of comprehensive
House bill, said to be written mainly by Sen. Kennedy
and his staff; 615 pages
HIGHLIGHTS: Requires all individuals to have health
insurance or pay tax penalty of no more than $750 per
year, with some exceptions; creates state-based
American Health Benefit Gateways for individual and
small business health plan purchases, with subsidies
for up to 400% FPL; Gateways to include a community
health insurance option meeting same requirements as
other health plans – community option required to
negotiate payment rates with providers, and can devel-
op innovative payment policies to promote quality, effi-
ciency and savings; Gateway plans provide three bene-
fit tiers offering essential benefits and three levels of
cost coverage and must guarantee issue and renewa-
bility; mandates employer coverage or pay annual fee,
with exceptions or credits for small employers; expand
Medicaid to all with up to 150% FPL; insurance reforms
include guarantee issue, premium rating and prohibi-
tions on preexisting conditions exclusions, financial
incentives to providers for case and chronic disease
management, wellness and health improvement,
improved safety and fewer medical errors, dependent
coverage for children up to age 26, and allowed sale of
TENNESSEE MEDICINE / SEPTEMBER 2009
health policies outside of the Gateway, and adoption of
simplified standards for financial and administrative
transactions; creation of temporary state
“RightChoices” programs to provide uninsured with
immediate access to preventive and chronic disease
care; establishment of federal Health Care Program
Integrity Coordinating Council to oversee fraud, waste
and abuse; development of national strategy to improve
healthcare delivery, outcomes and overall health and
publish national healthcare quality report card, quality
measures and public reporting online, creation of a
Center for Health Outcomes Research and Evaluation to
gauge effectiveness of care and share results with
providers; grants to improve health system efficiency
through medical homes, medication management, and
regional emergency care and trauma systems; mandat-
ed hospital reporting f preventable readmission rates,
creation of Patient Safety Research Center and devel-
opment of interoperable standards for HIT use to enroll
patients in public programs; national prevention and
health promotion strategy and grants, employer well-
ness programs; offer national, voluntary insurance pro-
gram for long-term care; create National Health Care
Workforce Commission to review and recommend
changes in training, supply and retention, and reform
graduate medical education to increase workforce.
COST: $615 billion over 10 years; funding mechanisms
not yet developed.
SENATE FINANCE COMMITTEE
POLICY OPTIONS
SPONSOR: N/A
DESCRIPTION: Not a formal proposal but a series of
papers summarizing financing options for health
reform to guide the Finance Committee as it considers
health reform proposals.
HIGHLIGHTS: Includes mandated health insurance cover-
age for all; health insurance exchanges for individuals
and small businesses, with subsidies for those between
100%-400% FPL (federal poverty level); expansion of
Medicaid to 115% FPL and CHIP to 275% FPL; allow pre-
Medicare individuals to buy-in to Medicare; possible man-
date for large employers and subsidies for small busi-
33
 PRACTICING MEDICINE
ness; insurance market reforms including benefit restruc-
turing, guaranteed issue and renewability and mandated
participation in exchanges; mandated state oversight;
cost containment includes HIT adoption, increased fraud,
waste and abuse detection, quality thresholds for
providers, prevention and wellness focus, and restruc-
tured payments to Medicare Advantage plans.
COST: N/A
PATIENTS’ CHOICE ACT OF 2009
(S. 1099 / H.R. 2520)
SPONSORS: Sens. Tom Coburn, MD (R-OK) and
Richard Burr (R-NC); Reps. Paul Ryan (R-WI) and
Devin Nunes (R-CA)
DESCRIPTION: Plan that supporters said aims to
deliver on the “shared principles of shared principles
of promoting universal access to quality, affordable
health care, and does so without adding billions of
dollars in new debt or taxes.”
HIGHLIGHTS: Coverage remains voluntary; allows state-
based health insurance exchanges with mandated benefits
matching those enjoyed by Congress members, allowing
states to automatically enroll individuals in low-cost, high-
deductible coverage and provide incentives to maintain
coverage; employer tax credit replaced with tax credit for
individuals and families to provide incentives for insurance
coverage, and supplemental debit card for private health
insurance costs to families at 200% FPL; integrate low-
income families currently eligible for Medicaid into private
insurance while keeping low-income disabled, children in
foster care, cancer and some TB patients and other excep-
tions on Medicaid; allow private facilities to compete with
VA to care for veterans, and American Indians to access
care outside Indian Health Services; tax code changes to
benefit those with low-cost, high-deductible plans includ-
ing Health Savings Accounts; encourages adoption of HIT
through incentives to hospitals and providers and creation
of personal health records and use of health record card;
allow providers to form ACOs and receive Medicare bonus-
es for improving quality; adopt competitive bidding for
Medicare Advantage; raise Part B and Part D premiums for
Medicare beneficiaries making more than $170,000 per
year; enhance fraud and abuse efforts in Medicare; adopt
medical malpractice reforms including independent panels
to review and decide cases with court as a second resort;
create Health Care Services Commission to set and enforce
standards for price and quality reporting; develop national
strategic prevention plan; lower premiums for Medicare
patients who adopt healthier behaviors.
COST: Budget-neutral; funding to come from cost-con-
tainment and savings through Medicaid changes and
elimination of employer tax exclusions.
U.S. NATIONAL HEALTH CARE ACT
(H.R. 676)
SPONSOR: Rep. John Conyers (D-MI)
DESCRIPTION: Establishes a universal healthcare sys-
tem utilizing public financing and non-profit delivery,
similar to nationalized health systems in Canada and
other industrialized countries.
34 TENNESSEE MEDICINE / SEPTEMBER 2009
HIGHLIGHTS: Creates a national public health insurance
program (USHNC) for all U.S. residents, replacing employer
coverage and eliminating Medicare, Medicaid and CHIP –
VA and Indian Health Care to be phased out over time; pro-
vides comprehensive benefits including long-term care;
individuals not required to pay premiums or cost-sharing;
converts to a non-profit healthcare system utilizing only
public or not-for-profit institutions; provide global budgets
for hospitals with monthly lump sums for operating expens-
es and salaried staff, and negotiating annual reimburse-
ment rates with physicians and other non-institutional
providers on simplified fee structure or capitation pay-
ments; private insurers may offer coverage for benefits not
covered by USHNC; establishes uniform electronic billing
and patient record systems; private physicians, clinics and
other participating providers may not be investor-owned;
participating providers to meet state quality and licensing
guidelines; creates National Board of Universal Quality and
Access to oversee the system; establish universal stan-
dards of care including staffing, technology, scope of work,
best practices and salary levels; create USHNC Employment
Transition Fund to assist those who lose jobs in the transi-
tion to the new system; raises income tax for top five-per-
cent of earners, and imposes payroll tax and stock and
bond transaction taxes to help fund the program.
COST: Budget-neutral; savings to come from redirection
of current healthcare dollars, tax increases and new tax.
NATIONAL HEALTH INSURANCE ACT
(H.R. 15)
SPONSOR: Rep. John Dingell (D-MI)
DESCRIPTION: Also known as “expanded and
improved Medicare for all,” the proposal is another
single-payer healthcare system that would allow
patients to choose their doctors and hospitals.
HIGHLIGHTS: Creates a national health insurance pro-
gram (NHIP) for eligible individuals with no payment of
premiums; requires states to administer as well as pro-
vide care for those not meeting eligibility requirements;
coverage is comprehensive, except for long-term care;
Medicare continues but may be phased out, new pro-
gram covers services Medicare does not; required study
of cost-control mechanisms, including impact of med-
ical malpractice and liability claims; administrators
required to promote quality and health system perform-
ance between providers, public health centers and edu-
cational and research institutions; disease, disability
and premature death prevention and wellness empha-
sized; grants for training benefit administrators.
COST: Financed through 5% value-added tax on cer-
tain transactions.
EMPOWERING PATIENTS FIRST ACT
(H.R. 3400)
SPONSOR: Rep. Tom Price (R-GA)
DESCRIPTION: Plan that emphasizes patient control
and choice through tax incentives for insurance pur-
chasing, encouraging states to assist consumers with
pre-existing conditions, and promoting the employer-
based insurance system.
HIGHLIGHTS: No requirement for coverage; allows income
tax deduction of premiums for individual insurance plans;
refundable tax credits for individuals and families below
300% FPL to buy insurance on the individual market;
establishes Association Health Plans and Individual
Membership Associations offering insurance; state high-
risk pools or reinsurance to cover people with pre-existing
health conditions; states required to provide coverage for
90% of children in families at below 200% FPL as a con-
dition for expanding child eligibility to 300% FPL; require
states to provide premium assistance for Medicaid and
CHIP enrollees with access to employer-sponsored insur-
ance, and vouchers to Medicaid- and CHIP-eligibles for pur-
chasing private insurance; allows employers to automati-
cally enroll individuals in the lowest-cost group health plan
as long as they can opt out, offer defined contributions for
workers who purchase their own coverage on the individual
market, and requires them to disclose to employees the
total amount spent on employee’s health insurance premi-
um; small employers get a temporary tax credit to adopt
auto-enrollment and contribute to employee private insur-
ance coverage; allow physicians to deduct costs of uncom-
pensated care required under EMTALA; private insurers
allowed to sell across state lines, required to disclose true
health insurance plan costs to employers; adoption of med-
ical malpractice reforms and create state health care tri-
bunals to review and decide cases, with court as second
option; reduce Medicaid and Medicare Disproportionate
Hospital Share (DSH) funds if national uninsured rate
decreases; enhance fraud and abuse efforts in Medicare
and Medicaid; reinstate the Medicare Trigger to contain
costs; prohibit comparative effectiveness research from
being used to deny coverage; create a process to develop
performance-based quality measures for physician servic-
es under Medicare; create a health plan and provider por-
tal website to provide standardized information on insur-
ance plans, provider price and quality data; allow premium
discounts/rebates for individuals who adhere to health pro-
motion and disease prevention programs and employer
cost-sharing based on participation in wellness plans;
establish student loan fund for non-profit or osteopathic
medical schools; up to $50,000 loan forgiveness for primary
care providers serving 3-5 years in medically underserved
areas; reform the Medicare SGR rate.
COST: Funding from cost savings in liability reform,
DSH payment reductions, non-defense spending caps
and waste, fraud and abuse efforts.
AMERICAN HEALTH SECURITY ACT
OF 2009 (S. 703)
SPONSOR: Sen. Bernie Sanders (I-VT)
DESCRIPTION: A single-payer healthcare plan provid-
ing state-administered coverage to all Americans and
lawful residents.
HIGHLIGHTS: Creates a state-based public health insur-
ance program for all U.S. residents, with no premium pay-
ment or cost-sharing, replaces employer coverage and elim-
inates Medicare, Medicaid and CHIP, with VA and Indian
Health Service programs remaining independent; compre-
hensive coverage to include long-term care with some
 PRACTICING MEDICINE
spending limits; states to create and run program and may
join other states to form regional programs; provide global
budgets for hospitals and negotiate annual reimbursement
rates with physicians and other non-institutional providers;
employers prohibited from offering health benefits duplicat-
ing those provided by state Health Security programs; new
2.2% health care income tax imposed on all individuals;
limits on spending growth tied to average annual percent-
age increase in gross domestic product (GDP); other cost
containment to include individual and state capitation
amounts, risk adjustment, limits on administrative costs,
provider payment methodologies that include global fees for
related services furnished to individuals over time, state
fraud and abuse prevention and control, and established
prices for approved prescription drugs, devices and equip-
ment; creation of American health Security Quality Council
to review and develop guidelines for quality improvement
and performance, as well as profile practice patterns and
identify outliers; improve access through grants to primary
care centers in underserved areas and expansion of school
health service sites; create Office of Primary Care and
Prevention Research; boost workforce by redesigning health
professional education programs to promote primary care,
fund education efforts to support National Health Service
Corps, provide grants to states for core public health func-
tions and health and wellness efforts.
COST: Funded through redirected federal healthcare
dollars and new taxes.
AMERICARE HEALTH CARE ACT OF
2009 (H.R. 193)
SPONSOR: Rep. Pete Stark (D-CA)
DESCRIPTION: Modeled on Medicare, proposal creates a
new public plan as default coverage for all Americans.
HIGHLIGHTS: All residents entitled to coverage under
AmeriCare, individuals may choose not to enroll if they
have group health coverage; enrollees pay small
deductibles and coinsurance; low-income individuals
below 200% FPL pay no premiums or coinsurance; pre-
miums and deductibles adjusted for those between
200% and 500% FPL; no deductibles or coinsurance for
covered pregnancy and pediatric services; individual pre-
mium payments considered a tax and subject to with-
holding; benefits the same as available through current
Medicare program with addition of well-child, EPSDT,
prenatal/obstetric care and family planning services;
prohibit state Medicaid and CHIP programs from offering
benefits covered by AmeriCare; employers required to
contribute at least 80% of employee AmeriCare or group
plan premiums, with delayed compliance for small
employers; AmeriCare insurers required to guarantee
issue and renewability and prohibited from charging
higher premiums based on health status; states required
to make maintenance of effort payments equal to their
share of Medicaid and CHIP spending to AmeriCare plan;
cost containment includes current Medicare payment
mechanisms adjusted for AmeriCare population, pay-
ment limits to private plans offered through AmeriCare
(similar to Medicare Advantage), required fee schedule
and price negotiation for outpatient drugs and biologics,
required electronic claims submission and applied fraud
and abuse and administrative simplification provisions;
Medicare quality improvement provisions duplicated.
COST: Funded through premium payments, state main-
tenance of effort payments and premium subsidies.
HEALTHY AMERICANS ACT (S. 391)
SPONSORS: Ron Wyden, D-OR, Bob Bennett, R-UT; co-
sponsors include Sen. Lamar Alexander (R-TN) and
Rep. Jim Cooper (D-TN)
DESCRIPTION: Bipartisan bill setting up a mandate for
most Americans through health insurance exchanges.
HIGHLIGHTS: Require all Americans except those in
Medicare, retiree benefit plans or military coverage to have
standardized private coverage (Healthy Americans Private
Insurance, HAPI) through state-based purchasing plans
(Health Help Agencies), with those not insured facing a
financial penalty; allows federal subsidies for individu-
als/families up to 400% FPL and health care tax deduction
for those above 100% FPL, phasing out at higher incomes;
employers required to contribute a shared payment, deduct
premiums from workers’ payroll, and those continuing to
provide health plans must provide information on HAPI
plans to employers; automatic enrollment ensures maxi-
mum enrollment; eliminate Medicaid and CHIP as compre-
hensive coverage and instead provide supplemental wrap-
around coverage for low-income beneficiaries, with modi-
fied long-term care; eliminate exclusion of health plan
value from workers’ taxable income, with exceptions; HAPI
benefits similar to FEHBP, with coverage for mental health
and wellness programs and premium discounts for well-
ness participation; guaranteed issue and no discrimina-
tion based on health status; insurers required to create
electronic medical record for each covered individual and
adopt uniform billing and claims forms; provider payments
reward quality and cost efficiency, early detection and
chronic disease management; insurers and providers
required to publicly report data on outcomes, health care
quality and cost; provides bonuses to states that enact
medical malpractice reforms; encourage new drug and
device development with patent protections and exclusiv-
ity for those subjected to comparative effectiveness
reviews; disallow tax deductions for pharmaceutical com-
panies’ direct-to-consumer drug ads; require hospitals to
demonstrate quality control improvements; Medicare
changes include enhanced payments to primary care,
required chronic disease management; eliminate hospital
DSH payments; create website for sharing evidence-based
best practices and incorporating into medical school cur-
ricula; improvements in end-of-life care; grants for school-
based clinics; new long-term care insurance plans.
COST: Budget-neutral due to revenue and savings in
first year of implementation.
CROSSING OUR LINES: WORKING
TOGETHER TO REFORM THE U.S.
HEALTH SYSTEM
PROPOSERS: Former Sens. Howard Baker (R-TN), Tom
Daschle (D-SD) and Bob Dole (R-KS)
DESCRIPTION: Former Senate Majority Leaders offer a
TENNESSEE MEDICINE / SEPTEMBER 2009
bipartisan plan organized around four “pillars” of health
reform: promoting high-quality, high-value care; making
health insurance available, meaningful and affordable;
emphasizing and supporting personal responsibility and
healthy choices; and developing a workable and sus-
tainable approach to health care financing.
HIGHLIGHTS: Plan mandates coverage for all Americans
and legal residents; creates state-based health insurance
exchanges, with sliding scale premium tax credits for
those making up to 400% FPL; families below 100% FPL
will enroll in Medicaid and pay no premiums; allow states
to create their own health plan option for the exchange;
pay-or-play mandate for employer coverage with excep-
tions and credits for some small business; insurance
reforms include four federal standard benefit levels, guar-
anteed issue and renewability, claims processing simplifi-
cation and transparency; HIT investment; provider pay-
ment changes including transition to pay-for-
performance, medical home payments, expanded bundled
payments for ECGs, limited public program pay for unnec-
essary or inappropriate care, and establishment of ACOs
(accountable care organizations) for Medicare; expand
Medicaid to 100% FPL and implement changes including
adjusting market basket updates to reflect savings from
delivery system reforms, reducing payments to home
health and skilled nursing facilities, restructuring
Medicare Advantage payments to align more with fee-for-
service payments, adjust DSH funding to reflect reductions
in uncompensated care (one-third over 10 years), restruc-
ture Medicare and Medigap cost-sharing and reallocate
Medicare and Medicaid improvement funds, and creating
a regulatory pathway for approval of biosimilar and bio-
generic products; reform Graduate Medical Education with
increased training of primary care, nurses and allied
health professionals, and increased reliance on non-physi-
cian workforce; additional financial incentives for
providers in medically underserved areas; enable Medicare
or Medicaid “trigger” to slow spending growth; create
Public Health and Wellness Fund to promote evidence-
based prevention/wellness activities; invest in meaningful
and effective use of HIT with bonus payments to providers
coordinated with new payments for quality care.
COST: $1.2 trillion over 10 years; offset by $1 trillion in
savings and new revenues, including tax exclusions. +
*SOURCES:
MAIN-
“Focus on Health Reform,” Kaiser Family Foundation,
www.kff.org/healthreform/upload/healthreform_sbs_full.pdf
ADDITIONAL-
Bipartisan Policy Center, www.bpcleadersproject.org/
THOMAS, Library of Congress, http://thomas.loc.gov
Open Congress, www.opencongress.org
“Healthcare Reform and the Federal Budget,”
Congressional Budget Office,
www.cbo.gov/ftpdocs/103xx/doc10311/ 06-16-
HealthReformAndFederalBudget.pdf
“Health Reform,” “Paying for Health Reform,” Center on
Budget and Policy Priorities,
www.cbpp.org/research/index.cfm?fa=topic&id=71,
www.cbpp.org/research/index.cfm?fa=topic&id=32
RAND COMPARE Health Proposals: Federal Legislation,
http://www.randcompare.org/proposals/federal
35