Inclusion of Cost of Employer-Sponsored Health Coverage on W-2

(Note : For the next few weeks, Health Reform Talk will focus on detailed explanations for specific provisions in the new health reform law.)

So what’s included in the Sec. 9002 of the Affordable Care Act, concerning the inclusion of the cost of employer-sponsored health coverage on W-2 forms?

Starting in 2011, employers are required to disclose the aggregate cost of "applicable employer-sponsored coverage" provided to employees annually on the employee's Form W-2. Regardless of whether the employee or employer pays for the coverage, the aggregate cost of the coverage reported is determined under rules similar to those to determine the applicable premiums for purposes of the COBRA continuation coverage requirements of group health plans.

Coverage is treated as applicable employer-sponsored coverage regardless of whether the employer or employee pays for the coverage. Applicable employer-sponsored coverage does not include coverage for long-term care, accidents, or disability income insurance. Nor does it include coverage that applies to only a specified disease or illness, hospital indemnity, or other fixed indemnity insurance, the payment for which is not excludable from gross income and deductible under Code Sec. 162(l) (Code Sec. 4980I(d)(1)(B) and (C), as added by the Affordable Care Act).

Applicable employer-sponsored coverage includes coverage under any group health plan established and maintained by the U.S. government, the government of any state or its political subdivision, or by any agency or instrumentality of such government. In the case of self-employed individuals, coverage under any group health plan providing health insurance coverage will be treated as employer-sponsored coverage if a deduction is allowable for the health coverage under IRC Sec. 162(l).

Employer-sponsored coverage does not include any salary reduction contributions to a flexible spending arrangement (FSA) under a cafeteria plan or contributions to an Archer medical savings account or health savings account (HSA) of the employee or the employee's spouse.

Note that a 40% excise tax will be imposed on health coverage providers starting in 2018 to the extent that the aggregate value of employer-sponsored health coverage for an employee exceeds $10,200 for individuals, and $27,500 for families.  In part, inclusion of health costs on the W-2 will be used to determine this tax on so-called "Cadillac" health plans.

This provision only requires disclosure of the aggregate cost of employer-sponsored health insurance coverage by the employer. It does not require a specific breakdown of the various types of medical coverage. For example, if an employee enrolls in employer-sponsored health insurance coverage under a medical plan, a dental plan, and a vision plan, the employer must report the total cost of the combination of all of these health related insurance policies.

Effective date. The provision applies to tax years beginning after Dec. 31, 2010.

CCH Law, Explanation And Analysis Of Health Reform Act Available Soon

CCH's Law, Explanation And Analysis of the Patient Protection and Affordable Care Act of 2010 provides the most comprehensive and practical guidance available to professionals needing to make sense of this historic legislation. CCH editorial staff, together with leading experts, provide clear and practical guidance on the many new areas of compliance in the law, so professionals can quickly understand, comply with new requirements, and plan for the future. The book is available for $149.

For more information or to order, please call 1-800-248-3248 or click here. Discounts are available for multiple copies.

President Signs Reconciliation

President Barack Obama has signed H.R. 4872, the Health Care and Education Reconciliation Act of 2010.

The reconciliation bill makes tax and revenue changes to the Patient Protection and Affordable Care Act (P.L. 111-148), which was signed by President Barack Obama on March 23.  Those changes are summarized here.

Mr. Obama, who today signed the reconciliation bill at Northern Virginia Community College in Alexandria, Va., was introduced by Dr. Jill Biden, the wife of Vice President Joe Biden and a faculty member at the community college.

As Ms. Biden and Mr. Obama pointed out, Health Care and Education Reconciliation Act (in Title II, Subtitle A), also makes significant changes to the ways in which student loans are provided and how schools are funded.

Mr. Obama said that $68 billion will be saved over ten years in what he called a victory in the battle between between “banks and interests of students” and the end of “unnecessary middlemen wasting billions of dollars.”

Mr. Obama added that neither the health reforms nor the education reforms will solve all the problems, but he did note that the health reforms “represent the toughest insurance reforms in history ” and that “we expect colleges and universities to hold down cost increases.”

No Lifetime or Annual Coverage Limits

(Note : For the next few weeks, Health Reform Talk will focus on detailed explanations for specific provisions in the new health reform law.)

So what’s included in the Sec. 1001(5) of the Affordable Care Act, concerning lifetime and annual coverage limits?

Group health plans, as well as individual and group health insurers are subject to limits on imposing benefits caps. Specifically, lifetime limits on the dollar value of benefits for any participant or beneficiary are prohibited. Also, annual limits on the dollar value of benefits for any participant or beneficiary are also barred, subject to an exception for pre-2014 annual limits.

Pre-2014 annual limits. For plan years beginning before January 1, 2014, group health plans and health insurers offering group or individual health insurance coverage may impose a restricted annual limit on the dollar value of benefits per participant or per beneficiary only for “essential health benefits” under the Patient Protection and Affordable Care Act.

The Secretary of Health and Human Services (HHS) is to determine what benefits are considered “essential health benefits.” However, these items must be included:

• Ambulatory patient services.


• Emergency services.


• Hospitalization.


• Maternity and newborn care.


• Mental health and substance use disorder services, including behavioral health treatment.


• Prescription drugs.


• Rehabilitative and habilitative services and devices.


• Laboratory services.


• Preventive and wellness services and chronic disease management.


• Pediatric services, including oral and vision care.

In defining “restricted annual limits,”  the HHS Secretary must ensure that access to necessary services is made available with only a minimal impact on premiums.

Per beneficiary limits. The new rules on lifetime and annual coverage limits do not prevent group health plans or health insurance coverage from imposing an annual or a lifetime per beneficiary cap on specific covered benefits that are not considered “essential health benefits.”

Effective date. This provision is effective for plan years beginning on or after the date that is six months after the date of enactment of the Patient Protection and Affordable Care (Sept. 23, 2010).

CCH Law, Explanation And Analysis Of Health Reform Act Available Soon

CCH's LAW, EXPLANATION AND ANALYSIS of the Patient Protection and Affordable Care Act of 2010 provides the most comprehensive and practical guidance available to professionals needing to make sense of this historic legislation. CCH editorial staff, together with leading experts, provide clear and practical guidance on the many new areas of compliance in the law, so professionals can quickly understand, comply with new requirements, and plan for the future. The book is available for $149.

For more information or to order, please call 1-800-248-3248 or click here. Discounts are available for multiple copies.

Done, And Done

This afternoon, March 25, the Senate passed, by a vote of 56 to 43, a revised version of H.R. 4872, the Health Care and Education Reconciliation Act of 2010, and sent the bill to the House of Representatives. And this evening, the House also passed H.R. 4872, by a vote of 220 to 207, and sent the bill to President Barack Obama, who is expected to sign the bill quickly.

The Patient Protection and Affordable Care Act (P.L. 111-148) and the subsequent reconciliation act are the culmination of more than 70 years of attempts by the federal government to expand health care access and coverage. Passage of the legislation also is the result of an unusual and highly controversial legislative process.*

The reconciliation bill makes tax and revenue changes to the Patient Protection and Affordable Care Act (P.L. 111-148), which was signed by President Barack Obama on March 23.

Republican senators identified two provisions of the reconciliation bill that violated the budgetary requirements of reconciliation and had to be eliminated. These provisions affect Pell education grant provisions in Sec. 2101 of H.R. 4872. Because of these minor changes, the reconcilaition bill had to go back to the House for another vote.

Health Reform Changes

Among other provisions, H.R. 4872 makes the following changes to to the Patient Protection and Affordable Care Act:

• Reduces the tax penalty for individuals without coverage to the greater of $695 (from $750) per year up to a maximum of three times that amount ($2,085, down from $2,250) per family or 2.5% (up from 2.0%) of household income. Included among those who are exempt from from the tax penalty are individuals whose incomes are below the tax filing threshhold (was below 100% of the poverty level in P.L. 111-148).


• Employers with at least 50 employees that do not offer coverage and have at least one full-time employee who receives a premium tax credit will be assessed a fee of $2,000 per full-time employee (up from $750 but also excluding the first 30 employees from the assessment).


• Effective in 2014, employees who are offered coverage by an employer are not eligible for premium credits unless the employer plan does not have an actuarial value of at least 60% or if the employee share of the premium exceeds 9.5% of income (9.8% in P.L. 111-148).

• Effective Jan. 1, 2018, an excise tax is imposed on insurers of employer-sponsored health plans with aggregate values that exceed $10,200 (up from $8,500) for individual coverage and $27,500 (up from $23,000) for family coverage. The effective date in P.L. 111-148 is Jan. 1, 2013.


• Delays until 2013 (instead of 2011) the $2,500 limit on the amount of contributions to a health flexible spending account.


• Effective six months after enactment grandfathered plans must offer coverage to adult children to age 26 and eliminate waiting periods for coverage of greater than 90 days. Beginning in 2014, grandfathered plans must eliminate lifetime and annual limits on coverage (grandfathered plans in P.L. 111-148 are exempt from these provisions).


• Effective in 2013, eliminate the tax deduction for employers who receive Medicare Part D retiree drug subsidy payments (2011 in P.L. 111-148).


• Increase the annual fees imposed on health insurers, which are set to go to $14.3 billion in 2018 ($10 billion in P.L. 111-148). Provisions added to the reconciliation bill :only 50% of premiums are used to calculate the fee for non-profit insurers, and voluntary employee beneficiary associations (VEBAS)are exempt from the fee.

Medicare, Medicaid Changes

• The Reconciliation Act provides a $250 rebate for all Medicare Part D enrollees who enter the “donut” hole—where the beneficiary must pay for all prescription drug spending out of pocket--in 2010, and will receive their payment no later than the 15th day of the third month following the end of the quarter. Each enrollee is limited to one payment.


• The Reconciliation Act requires that beginning in 2014, Medicare Advantage (MA) plans spend at least 85 percent of their revenue on medical costs or activities that improve the quality of care, rather than profit or overhead. An MA plan that fails to satisfy the spending requirement would be subject to monetary penalties, membership enrollment postponement, or termination from the program.


• The Reconciliation Act advances Medicare disproportionate share hospital cuts to begin in fiscal year 2014, instead of 2015. Instead of the amount of disproportionate share hospital payment expected to be received, the Secretary would pay the hospital 25 percent of such amount, plus an additional amount based upon a factor equal derived from: (1) the number of uninsured individuals under age 65 for 2014 through 2017, and (2) the number of uninsured individuals for 2018 and 2019.


• The Act changes the date from August 1, 2010, to December 31, 2010, after which physician ownership of hospitals to which they self-refer is prohibited.  There is a limited exception for grandfathered physician-owned hospitals that are not the sole hospital in a county and treat the highest percentage of Medicaid patients in their county.


• The Reconciliation Act eliminates the provision for a permanent 100 percent federal matching rate for Nebraska for the Medicaid costs of newly eligible individuals, and establishes a uniform system federal matching payments for newly eligible individuals in all states.


• Medicaid payment rates to primary care physicians for furnishing primary care services can be no less than 100 percent of the Medicare payment rates in 2013 and 2014. States would receive 100 percent federal funding for the incremental costs of meeting this requirement.


• The Reconciliation Act will lower the reduction in federal Medicaid DSH payments from $18.1 billion to $14.1 billion and advance the reductions to begin in FY 2014. The Secretary of HHS must develop a methodology for reducing federal DSH allotments to all states in order to achieve the mandated reductions. The federal DSH allotment for a state that has a $0 allotment after FY 2011 would be extended through FY 2013.


• The Act raises the caps on federal Medicaid funding for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa for the period beginning July 1, 2011, and ending on September 30, 2019, by such amounts that the total additional Medicaid payments would equal $6,300,000,000. Territories will have the option to establish a Health Benefit Exchange and will be treated as a state for payment purposes.

* Here’s a brief history--

The modern era of government involvement in health began in 1965, when President Lyndon Johnson signed the Social Security Act of 1965, which established the Medicare program for individuals ages 65 and older and the Medicaid program for low income individuals.

During the next four decades, Congress and the White House attempted a variety of health care reforms, some successful, some not. Enacted legislation included the following:

• Medicare as secondary payor to employer plans, 1980


• Disproportionate Medicaid payments, 1981


• Medicare prospective payment system, 1983


• COBRA Continuation of Coverage, 1986


• IRC Sec. 89, which included qualification and nondiscrimination rules for health care plans, 1986 (repealed in 1989)


• Medicare Catastrophic Coverage Act (MCCA), 1988 (repealed in 1989)


• Mandated Medicaid coverage for children birth to age 18, 1989 and 1990


• Health Insurance Portability and Accountability Act (HIPAA) restricts use of pre-existing conditions in health insurance coverage determinations, sets standards for medical records privacy, and establishes tax-favored treatment of long-term care insurance, 1996.


• Mental Health Parity Act, 1996, 2008


• Medicare Drug, Improvement, and Modernization Act (MMA), creating a voluntary, subsidized prescription drug benefit under Medicare, 2003.

2009-2010

In 2009, comprehensive health care reform became a priority both for President Barack Obama and the 111^th Congress.

Between July and October 2009, five Congressional committees reported out versions of health care reform: H.R. 3200, America's Affordable Health Choices Act, with versions reported by the House Ways and Means, Energy and Commerce, and Education and Labor Committees; S. 1679, Affordable Health Choices Act, reported by the Senate Health, Education, Labor, and Pensions Committee; and S. 1796, America's Healthy Future Act, reported by the Senate Finance Committee.

The full House then considered H.R. 3962, the Affordable Health Care for America Act, which combined the earlier proposals from the three House committees. The House passed the legislation on Nov. 17, 2009 by a vote of 220-215. The Senate passed its own health reform legislation, H.R. 3590, the Patient Protection and Affordable Care Act, by a vote of 60-39 on Dec. 24, 2009. Substantial differences in the two bills included the structure of a health insurance exchange, the nature of a public option, and financing mechanisms. This set the stage for the Congress to reconcile the differences between the two bills.

Congressional Democrats had virtually no Republican support for either the House or the Senate version of health reform (only Republican Rep. Joseph Cao (La.) voted for the House bill), and the passage of national health care reform suffered another significant blow in January 2010 when Massachusetts, the only state with recently passed comprehensive health reform legislation (and the lowest number of uninsured of any state), elected state senator Scott Brown as the Senate's 41st Republican, effectively ending the Democrats' filibuster-proof majority and its best hope for passage of a compromise reform bill worked on in early 2010 by Senate and House Democrats.

After considering several alternatives, House Democrats agreed to vote on the existing H.R. 3590 and also to consider a series of changes to that bill in a budget reconciliation bill, H.R. 4872, the Health Care and Education Reconciliation Act of 2010. Both House and Senate Democratic leadership, and the White House agreed to the changes proposed in the reconciliation bill, which only included budgetary changes, such as to taxes and spending.

Subsequently, on March 21, 2010, the House approved H.R. 3590 by a vote of 219 to 212, and President Barack Obama signed the bill into law on March 23 (P.L. 111-148). Immediately after passing the Affordable Care Act, the House passed, by a vote of 220 to 211, the Health Care Reconciliation Act of 2010. No Republicans voted for either bill.

Many antiabortion Democrats opposed H.R. 3590 because of a perceived weak ban on abortion funding, but President Obama promised to sign (and did sign on March 24) an executive order to establish “an adequate enforcement mechanism to ensure that Federal funds are not used for abortion services (except in cases of rape or incest, or when the life of the woman would be endangered), consistent with a longstanding Federal statutory restriction that is commonly known as the Hyde Amendment.”

Under budget reconciliation rules, the Health Care Reconciliation Act then went to the Senate, which needed only a 51 majority vote for passage (that is, the budget reconciliation is not subject to the 60-vote filibuster rules for other legislation considered in the Senate). The Senate passed the reconciliation provisions, with two minor changes in education provisions, on March 25, by a vote of 56-43. That reconciliation bill then was returned to the House, which passed the bill, also on March 25 by a vote of  xxx-xxx, and sent the bill to the President for his signature.

CCH Law, Explanation And Analysis Of Health Reform Act Available Soon

CCH's LAW, EXPLANATION AND ANALYSIS of the Patient Protection and Affordable Care Act of 2010 provides the most comprehensive and practical guidance available to professionals needing to make sense of this historic legislation. CCH editorial staff, together with leading experts, provide clear and practical guidance on the many new areas of compliance in the law, so professionals can quickly understand, comply with new requirements, and plan for the future. The book is available for $149.

For more information or to order, please call 1-800-248-3248 or click here. Discounts are available for multiple copies.

Health Reform Becomes Law And Is Challenged In Court

Yesterday, just after President Barack Obama signed into law the Patient Protection and Affordable Care Act, Sen. Jim DeMint (S.C) introduced S. 3152, a bill to repeal the health reform law.

The repeal bill as introduced has 12 cosponsors, including Lindsey Graham (S. C.), Robert Bennett (Utah), Kit Bond (Mo.), Saxby Chambliss (Ga.), Mike Crapo (Id.), John Ensign (Nev.), Kay Bailey Hutchinson (Texas), James Inhofe (Okla.), George LeMieux (Fla.), James Risch (Id.), Pat Roberts (Kan.), and David Vitter (La.).

In the last 25 years, Congress has repealed two health-related pieces of legislation. In 1989, the Medicare Catastrophic Coverage Act was repealed, in large part because of opposition from older Americans who thought the law would be too costly. Also in 1989, Congress repealed IRC Sec. 89, which would have imposed complicated nondiscrimination rules on health care plans. The complications in the Sec. 89 legislation convinced Congress that the provisions were unworkable.

States File Lawsuits

In addition to the Senate repeal bill, 14 states have filed lawsuits challenging the constitutionality of the health reform law.

In Tallahassee, Fla., 13 attorneys general joined filed a 22-page complaint filed in federal court, charging that the new healthcare reform package exceeds Congress’s powers to regulate commerce, violates 10th Amendment protections of state sovereignty, and imposes an unconstitutional direct tax. The states involved in the lawsuit are Utah, Florida, South Carolina, Nebraska, Texas, Michigan, Pennsylvania, Alabama, South Dakota, Idaho, Washington, Colorado and Louisiana

Virginia filed a separate suit challenging the individual mandate. The Virginia lawsuit focuses on a recent state law that asserts that that no state resident "shall be required to obtain or maintain a policy of individual insurance coverage.”

Senate Moves On Reconciliation Bill

Meanwhile, the Senate continues to consider H.R. 4872, the Health Care and Education Reconciliation Act of 2010, which strikes out and modifies a number of tax and revenue provisions in the Affordable Care Act. Under budget reconciliation rules, the Health Care Reconciliation Act, already passed in the House of Representatives, can pass in the Senate with a 51 majority that is not subject to the 60-vote filibuster rules for other legislation considered in the Senate.

Yesterday, the Senate voted 56-40 to begin the debate. Under Senate rules, discussion of the reconciliation bill is limited to 20 hours. However, senators are permitted to offer as many amendments as they want, which don't count on toward the time limit.

Senate Democrats have the goal of sending a final package to the White House before its scheduled April recess begins on March 29. However, if the Senate makes any changes, the House and the Senate versions will go to a conference of House and Senate negotiators. An agreement by negotiators then will go back to the House and the Senate for a simple majority final vote by the two chambers under strict rules that set a timetable for action and that prohibit any amendments.

Health Reform Is Law

This morning, President Barack Obama signed into law H.R. 3590, the Patient Protection and Affordable Care Act of 2010. Mr. Obama said at the signing that “our presence here today is remarkable and improbable.”

And he added that “we have now just enshrined… the core principle that everybody should have some basic security when it comes to their health care.”

Reforms To Take Effect This Year

The Patient Protection and Affordable Care Act of 2010 makes the following reforms effective this year, according to Nancy-Ann DeParle, Director, White House Office of Health Reform:

·        Preexisting conditions exclusions are eliminated for children.

·        Parents can continue to cover their children until age 26.

·        Insurance companies will be banned from dropping people from coverage when they get sick (recission), and they will be banned from implementing lifetime caps on coverage.

·        A temporary subsidized high-risk pool will be available to adults with preexisting conditions.

·        A new, independent appeals process is established that provides consumers in new private plans with access to an effective process to appeal decisions made by their insurer.

·        Discrimination based on salary is outlawed. New group health plans will be prohibited from establishing any eligibility rules for health care coverage that discriminate in favor of higher-wage employees.

·        Small businesses that choose to offer coverage will begin to receive tax credits of up to 35% of premiums to help make employee coverage more affordable.

·        Private plans will be required to provide free preventive care with no co-payments and no deductibles for preventive services.

·        A temporary reinsurance program is established to help offset the costs of premiums for employers and retirees age 55-64.

·        The Medicare Part D 'donut hole' begins to close with a $250 rebate to Medicare beneficiaries who hit the gap in prescription drug coverage.

CCH Law, Explanation And Analysis Of Health Reform Act Available Soon

CCH's LAW, EXPLANATION AND ANALYSIS of the Patient Protection and Affordable Care Act of 2010 provides the most comprehensive and practical guidance available to professionals needing to make sense of this historic legislation. CCH editorial staff, together with leading experts, provide clear and practical guidance on the many new areas of compliance in the law, so professionals can quickly understand, comply with new requirements, and plan for the future. The book is available for $149.

For more information or to order, please call 1-800-248-3248 or click here. Discounts are available for multiple copies.

Employer Responsibilities Under Health Care Reform: Part 1

When President Barack Obama signs the Patient Protection and Affordable Care Act (H.R. 3590) today, health care reform becomes law, and some of provisions take effect quickly.

This is true with or without passage of the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), which makes tax and revenue changes to H.R. 3590 (see yesterday’s post).

Within the next few weeks, Health Reform Talk will examine those proposals that will affects employer-provided plans in the near future. Today, preventive care is examined.

Preventive Care

Sec. 1001(5) of H.R. 3590 requires group health plans to cover, with no cost sharing, the following:

• certain evidence-based items (with A or B ratings) in the recommendations of the United States Preventive Services Task Force;
• immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
• evidence-based preventive care and screenings for infants, children, and adolescents provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
• additional women's preventive care and screenings "in comprehensive guidelines supported by the Health Resources and Services Administration."

Employer plans and insurers are required to comply with these preventive services mandates within six months of enactment (Sept. 23, 2010). These preventive care provisions are now included in Sec. 2713 of the Public Health Service Act

The bill includes a provision that excludes controversial November 2009 recommendations from the Preventive Services Task Force regarding breast cancer screening, mammography, and prevention. For these services, plans presumably will rely on previous recommendations.

For all other preventive services, employers will have to review the existing recommendations of the Task Force and be prepared to offer a variety of preventive care with no cost sharing permitted.

Here are just a few of the recommended services with the required A or B ratings which employers would have to offer and provide with no deductibles or coinsurance:

• screening adults for depression;
• intensive behavioral dietary counseling for adult patients with known risk factors for cardiovascu-lar and diet-related chronic disease;
• oral fluoride supplementation to preschool children older than six months of age;
• screening for high blood pressure in adults aged 18 and older; and
• screening and behavioral counseling interven-tions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

CCH Law, Explanation And Analysis Of Health Reform Act Available Soon

CCH's LAW, EXPLANATION AND ANALYSIS of the Patient Protection and Affordable Care Act of 2010 provides the most comprehensive and practical guidance available to professionals needing to make sense of this historic legislation. CCH editorial staff, together with leading experts, provide clear and practical guidance on the many new areas of compliance in the law, so professionals can quickly understand, comply with new requirements, and plan for the future. The book is available for $149.

For more information or to order, please call 1-800-248-3248 or click here. Discounts are available for multiple copies.

Health Reform Goes To President

The House of Representatives passed health care reform legislation late in the evening of March 21, 2010, after intense negotiations and a budget reconciliation bill that made changes to the original proposal. In the most sweeping health system changes since the passage of Medicare in 1965, the House first passed H.R. 3590, the Patient Protection and Affordable Care Act, by a vote of 219 to 212; subsequently, the House  passed H.R. 4872, the Health Care and Education Reconciliation Act of 2010 by a vote of 220 to 211.

The Affordable Care Act first was approved by the Senate on December 24, 2009, and President Barack Obama is expected to sign the legislation as soon as possible.

The Health Care Reconciliation Act strikes out and modifies a number of tax and revenue provisions in the Affordable Care Act to which the House objected. Under budget reconciliation rules, the Health Care Reconciliation Act now goes to the Senate, which can pass the bill with a 51 majority vote (that is, the budget reconciliation is not subject to the 60-vote filibuster rules for other legislation considered in the Senate).

The Senate is expected to take up the Health Care Reconciliation Act this week, and Senate Democrats have the goal of sending a final package to the White House before its scheduled April recess begins on March 29. However, if the Senate makes any changes, the House and the Senate versions will go to a conference of House and Senate negotiators. An agreement by negotiators then will go back to the House and the Senate for a simple majority final vote by the two chambers under strict rules that set a timetable for action and that prohibit any amendments. Assuming passage of this conference committee agreement, it will be sent to the President Obama for his signature.

The president’s signature of both H.R. 3590 and H.R. 4872 will put into effect the provisions of the Affordable Care Act as amended by the Health Care Reconciliation Act. These provisions include the following employer-related and private plan changes:

Employer Responsibilities. Effective in 2014, assess certain employers a fee of $2,000 per full-time employee, excluding the first 30 employees from the assessment: employers with more than 50 employees that do not offer coverage and have at least one full-time employee who receives a premium tax credit.  Employers with more than 50 employees that offer coverage but have at least one full-time employee receiving a premium tax credit, will pay the lesser of $3,000 for each employee receiving a premium credit or $750 for each fulltime employee..

Employers with 50 or fewer employees are exempt from penalties.

Effective in 2014, employers that offer coverage would be required to provide a free choice voucher to employees with incomes less than 400% FPL whose share of the premium exceeds 8% but is less than 9.8% of their income and who choose to enroll in a plan in the Exchange. The voucher amount is equal to what the employer would have paid to provide coverage to the employee under the employer’s plan and will be used to offset the premium costs for the plan in which the employee is enrolled. Employers providing free choice vouchers will not be subject to penalties for employees that receive premium credits in the Exchange.

Employers with more than 200 employees must automatically enroll employees coverage offered by the employer. Employees may opt out of coverage.

Individual Reponsibilities. Citizens and legal residents are required to have “qualifying health coverage.” Those without coverage pay a tax penalty of the greater of $695 per year up to a maximum of three times that amount ($2,085) per family or 2.5% of household income. The penalty will be phased-in according to the following schedule: $95 in 2014, $325 in 2015, and $695 in 2016 for the flat fee or 1.0% of taxable income in 2014, 2.0% of taxable income in 2015, and 2.5% of taxable income in 2016. After 2016, the penalty will be increased annually by the cost-of-living adjustment. Exemptions will be granted for those for whom the lowest cost plan option exceeds 8% of an individual’s income, and those with incomes below the tax filing threshold (in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples).

Health Benefit Exchanges. Effective in 2014, state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges are established, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage. States are permitted to allow businesses with more than 100 employees to purchase coverage in the SHOP Exchange beginning in 2017. States may form regional Exchanges or allow more than one Exchange to operate in a state as long as each Exchange serves a distinct geographic area.

Individual subsidies. Refundable and advanceable premium credits are made available to eligible individuals and families with incomes between 133 and 400% of the federal poverty level to purchase insurance through the Health Insurance Exchanges. The premium credits will be tied to the second lowest cost silver plan in the area and will be set on a sliding scale.

Employer subsidies. Small employers with no more than 25 employees and average annual wages of less than $40,000 that purchase health insurance for employees are provided with a tax credit.

For 2010 through 2013, a tax credit of up to 35% of the employer’s contribution toward the employee’s health insurance premium is provided if the employer contributes at least 50% of the total premium cost or 50% of a benchmark premium.

For 2014 and later, for eligible small businesses that purchase coverage through the state Exchange, a tax credit is provided of up to 50% of the employer’s contribution toward the employee’s health insurance premium if the employer contributes at least 50% of the total premium cost. The credit will be available for two years. The full credit will be available to employers with 10 or fewer employees and average annual wages of less than $25,000.

Effective 90 days after enactment and extending until Jan. 1, 2014, a temporary reinsurance program is established for employers providing health insurance coverage to retirees over age 55 who are not eligible for Medicare. The program will reimburse employers or insurers for 80% of retiree claims between $15,000 and $90,000

Financing of health reform. Beginning in 2014, a tax on individuals without qualifying coverage is imposed that is the greater of $695 per year up to a maximum of three times that amount or 2.5% of household income.

Effective in 2018, an excise tax is imposed on insurers of employer-sponsored health plans with aggregate values that exceed $10,200 for individual coverage and $27,500 for family coverage. The tax is equal to 40% 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 supplementary health insurance coverage, excluding dental and vision coverage.

Benefit design. Effective in 2014, an essential health benefits package is established that provides a comprehensive set of services, covers at least 60% of the actuarial value of the covered benefits, limits annual cost-sharing to the current law HSA limits ($5,950/individual and $11,900/family in 2010), and is not more extensive than the typical employer plan. Require the Secretary to define and annually update the benefit package through a transparent and public process.

Abortion coverage is prohibited from being required as part of the essential health benefits package.

Effective in 2014, all qualified health benefits plans, including those offered through the Exchanges and those offered in the individual and small group markets (except grandfathered plans) are required  to offer at least an essential health benefits package.

Private Insurance. Effective within 90 days of enactment and extending through Jan. 1, 2014, a temporary national high-risk pool is established to provide health coverage to individuals with pre-existing medical conditions. Individuals who have a pre-existing medical condition and who have been uninsured for at least six months will be eligible to enroll in the high-risk pool and receive subsidized premiums. Premiums for the pool will be established for a standard population and may vary by no more than 4 to 1 due to age; maximum cost-sharing will be limited to the current law HSA limit ($5,950/individual and $11,900/family in 2010). Appropriate $5 billion to finance the program

Effective in 2010, health insurance plans are required to report the proportion of premium dollars spent on clinical services, quality, and other costs. Effective in 2011, insurers must provide rebates to consumers for the amount of the premium spent on clinical services and quality that is less than 85% for plans in the large group market and 80% for plans in the individual and small group markets. A process is established for reviewing increases in health plan premiums and requiring plans to justify increases. States are required to report on trends in premium increases and recommend whether certain plan should be excluded from the Exchange based on unjustified premium increases.

Effective six months after enactment, all individual and group policies must provide dependent coverage for children through age 26; individual and group health plans are prohibited from placing lifetime limits on the dollar value of coverage and insurers are prohibited from rescinding coverage except in cases of fraud; plans are prohibited from imposing pre-existing condition exclusions for children

Beginning in January 2014, individual and group health plans are prohibited from placing annual limits on the dollar value of coverage. Prior to January 2014, plans may only impose annual limits on coverage as determined by the Secretary.

Six months following enactment, grandfathered plans are required to extend dependent coverage to age 26, prohibit rescissions of coverage, eliminate waiting periods for coverage of greater than 90 days, and eliminate pre-existing condition exclusions for children. Beginning in 2014, grandfathered group plans must eliminate lifetime limits on coverage and eliminate annual limits on coverage.

Effective in 2014, waiting periods for coverage are limited to 90 days and states have the option of merging the individual and small group markets.

Financing. The Congressional Budget Office estimates the cost of the coverage components of the reconciliation bill in combination with the Patient Protection and Affordable Care Act to be $940 billion over ten years. These costs are financed through a combination of savings from Medicare and Medicaid and new taxes and fees, including an excise tax on high-cost insurance, which CBO estimates will raise $32 billion over ten years. CBO estimates the proposal will reduce the deficit by $143 billion over ten years.

Reconciliation Is In The House

A nun, a bishop, and Doug Elmendorf (director of the Congressional Budget Office) walked into a bar just after the House Rules Committee released the 153-page text of H.R. 4872, the Health Care and Education Affordability Reconciliation Act of 2010, which makes budgetary changes to the already passed H.R. 3590, the Patient Protection and Affordable Care Act passed by the Senate in December 2009.

The Bishop, after ordering a double, spoke first: “The Senate bill expands federal funding and the role of the federal government in the provision of abortion procedures….In so doing, it forces all of us to become involved in an act that profoundly violates the conscience of many, the deliberate destruction of unwanted members of the human family still waiting to be born."

The nun, who had a small sherry, was undeterred by the Bishop’s lofty position, and she replied, “The Senate bill will not provide taxpayer funding for elective abortions. It will uphold longstanding conscience protections and it will make historic new investments – $250 million – in support of pregnant women. This is the REAL pro-life stance, and we as Catholics are all for it.”

Mr. Elmendorf, who had a ginger ale, did not address the abortion issue but noted that the proposed legislation would reduce the federal deficit by $138 billion over ten years.

The nun picked up the tab and left for the local homeless shelter. The bishop left to attend a conference with other clergy to discuss policy issues.  Mr. Elmendorf had an appointment to testify before the Congress on the cost of health care reform.

Now What?

The House, which has scheduled a vote on health reform for Sunday March 21, is likely to use a “deem and pass” strategy, through which passage of the reconciliation bill will also be deemed to be passage of the Senate legislation. If the legislation passes the House, the Senate bill would be sent to President Barack Obama for his signature and the reconciliation bill would go to the Senate for a vote.

Among the provisions in H.R. 4872 that are of interest to employer-based plans are the following:

Sec. 1001. Affordability. Changes the financing for premiums and cost sharing for individuals with incomes up to 400% of the federal poverty level. The bill improves tax credits to make premiums more affordable as a percent of income; and improves support for cost sharing, focusing on those with incomes below 250% of the federal poverty level. Starting in 2019, the bill constrains the growth in tax credits if premiums are growing faster than the consumer price index, unless spending is more than 10% below current Congressional Budget Office projections.

Sec. 1002. Individual responsibility. Modifies the assessment that individuals who choose to remain uninsured pay in three ways: (a) exempts the income below the filing threshold, (b) lowers the flat payment from $495 to $325 in 2015 and from $750 to $695 in 2016 and (c) raises the percent of income that is an alternative payment amount from 0.5 to 1.0% in 2014, 1.0 to 2.0% in 2015, and 2.0 to 2.5% for 2016 and subsequent years to make the assessment more progressive.

Sec. 1003. Employer responsibility. Improves the transition to the employer responsibility policy for employers with 50 or more full-time equivalent workers by subtracting the first 30 full time employees from the payment calculation (e.g., a firm with 51 workers that does not offer coverage will pay an amount equal to 51 minus 30, or 21 times the applicable per employee payment amount). The provision also changes the applicable payment amount for firms with more than 50 full-time workers that do not offer coverage to $2,000 per full-time employee. It also eliminates the assessment for workers in a waiting period, while maintaining the 90-day limit on the length of any waiting period beginning in 2014.

Sec. 1005. Implementation funding. Provides $1 billion to the Secretary of Health and Human Services to finance the administrative costs of implementing health insurance reform.

Sec. 1004. Income definitions. The provision extends the exclusion from gross income for employer provided health coverage for adult children up to age 26.

Sec. 1101. Closing the Medicare prescription drug “donut hole”. Provides a $250 rebate for all Medicare Part D enrollees who enter the donut hole in 2010. Builds on pharmaceutical manufacturers' 50% discount on brand-name drugs beginning in 2011 to completely close the donut hole with 75% discounts on brand-name and generic drugs by 2020.

Sec. 1103. Savings from limits on MA plan administrative costs. Provides that Medicare Advantage plans spend at least 85% of revenue on medical costs or activities that improve quality of care, rather than profit and overhead.

Sec. 1401. High-cost plan excise tax. Reduces the revenue collected by the tax by 80%. This is achieved by: delaying the application of the tax until 2018, which gives the plans time to implement and realize the cost savings of reform; increasing the dollar thresholds to $10,200 for single coverage and $27,500 for family coverage ($11,850 and $30,950 for retirees and employees in high risk professions); excluding stand-alone dental and vision plans from the tax; and permitting an employer to reduce the cost of the coverage when applying the tax if the employer’s age and gender demographics are not representative of the age and gender demographics of a national risk pool.

Sec. 1402. Medicare tax. Modifies the tax to include net investment income in the taxable base. Currently, the Medicare tax does not apply to net investment income. The Medicare tax on net investment income does not apply if modified adjusted gross income is less than $250,000 in the case of a joint return, or $200,000 in the case of a single return. Net investment income is interest, dividends, royalties, rents, gross income from a trade or business involving passive activities, and net gain from disposition of property (other than property held in a trade or business). Net investment income is reduced by properly allocable deductions to such income.

Sec. 1403. Delay of the annual limitation on contributions to a health FSA. Delays the proposed $2,500 annual contribution by two years until 2013.

Sec. 1406. Health insurance providers. Delays the industry fee by three years to 2014 and modifies the annual industry fee for revenue neutrality. In the case of tax-exempt insurance providers, provides that only 50% of their net premiums that relate to their tax-exempt status are taken into account in calculating the fee. Provides exemptions for voluntary employee benefit associations (VEBAs) and nonprofit providers more than 80% of whose revenues is received from Social Security Act programs that target low income, elderly, or disabled populations.

CBO Preliminary Estimates

The federal government will provide up to $6,000 per year in subsidies for each eligible individual in health insurance exchanges established under health reform, according to a yesterday’s preliminary estimate by the Congressional Budget Office of the of the combined direct spending and revenue effects of H.R. 4872 and H.R. 3590.

According to the CBO, enacting both pieces of legislation, H.R. 3590 and the reconciliation proposal, would produce a net reduction in federal deficits of $138 billion over the 2010–2019 period as result of changes in direct spending and revenue. The proposal also would result in a increase of 32 million individuals covered by health insurance. The CBO estimates that by 2019 an additional 16 million individuals will be covered by Medicaid and the Children’s Health Insurance Program, 24 million will gain coverage through exchanges, 4 million fewer will be covered through employer plans, and 5 million fewer will be covered through individual plans

The health coverage provisions alone would cost $794 billion over a ten-year period, which would be offset by $913 billion in various revenue provisions, to produce a deficit reduction of $119 billion.

The average annual subsidy provided under a health insurance exchange in the combined legislation will be $5,200 in 2015, the first year of the subsidy, and is predicted to grow to $6,000 by 2019.

The CBO estimate also includes reconciliation amendments to the Higher Education Act of 1965, which authorizes most federal programs involving postsecondary education. These education amendments are predicted to reduce the deficit by $20 billion over a 10-year period.

Grading our diabetes care

As we refresh our memories about what’s in the Senate health reform bill, here’s a provision that you may not have heard about yet.

According to Act Section 10407 (scroll down to page 2281), biennially, the Secretary of Health and Human (HHS) Services and the Centers for Disease Control and Prevention (CDC) must prepare and publicly produce national and state-specific “diabetes report cards,” which discuss preventative care, risk factors, and aggregate health outcomes for diabetes patients. In connection with this reporting, the HHS and the CDC will encourage collection of additional diabetes-mortality data and state revision of standard birth and death certificates to contain any relevant information related to diabetes. The Secretary also must collaborate with medical groups and associations to conduct a study on the role diabetes-specific education should play in medical licensure and board certifications.

Means to collect additional information about diabetes. To enhance the collection of data and statistics related to diabetes and diabetes-related complications, the Secretary of Health and Human Services and the Director of the Centers for Disease Control and Prevention are required to gather data for and prepare national and state-specific “diabetes report cards.”

The report cards will discuss health information concerning individuals with diabetes on an aggregate basis and will report information on risk factors affecting patients and the public and general preventative care practices. Future reports also will address trends in the nation concerning diabetic care and related costs and will describe the policies and procedures implemented to meet the goals of improving diabetic care and decreasing prevalence of the disease. The report cards will be made available on the Internet.

Promoting state adoption of additional means to collect diabetes data. In connection with creating these report cards, the Secretary and CDC will promote the collection of additional consolidated diabetes-mortality data by encouraging states to revise their standard-form birth and death certificates. The revisions would include places in which to note the existence of or connections to diabetes. They also will work with physicians to provide education and training highlighting the importance of collecting this data and properly completing the documents.

The encouragement of these changes to states' birth and death certificates are intended to provide physicians with increased ability to recognize the prevalence of the disease and to consider its role
in patient death.

Another procedural twist possible for health reform

The clock on health reform is now ticking and some reports indicate that a vote could come by this weekend. However, potentially even bigger news is that House Speaker Nancy Pelosi is said to be considering using the “deemed without passage” or “self-executing rule” to get health reform legislation completed. At this point, Democratic leaders haven’t made the final decision on whether to use this legislative tactic but it is said to be one of three options they are considering.

Right about now, you might be wondering exactly what “deemed without passage” involves. Let me tell you, before I looked into it, I’d never heard of it either. I learned that some people call it the “Slaughter Rule,” named after New York Congresswoman Louise Slaughter, the chairperson of the House Rules Committee. I’m not sure that clarifies anything because, personally, I always thought the “slaughter rule” is what softball umpires invoke when one team is clobbering the other, say by a score of 15 to 5. In politics, however, that’s not the case. Still confused? You’re not alone.

Though some are claiming, erroneously, that “deemed without passage” means that the House does not need to vote, apparently, that is untrue. “Deemed without passage,” more formally known as the “self-executing rule” is a parliamentary procedure that does not require a direct vote, but rather an indirect vote. As MSNBC.com describes it, “the health-care bill would be voted on INDIRECTLY, tucked into what's known as `the rule.’ The rule essentially outlines the rules for an upcoming vote -- in this case, it would be the vote on the package of reconciliation fixes.”

Even though you may not have heard of it, surprisingly, “deemed without passage” is not some rarely-used rule. In fact, the self-executing rule has been around since the 1970s, according to the Woodrow Wilson International Center for Scholars, though it did not become more widely used until the 1980s and 1990s. During the 104th and 105th Congresses (1995 to 1998), for example, there were 38 and then 52 self-executing rules.

The “self-executing rule” has been used to “enact significant substantive and sometimes controversial propositions,” the Congressional Research Service (CRS) indicates. You might be somewhat familiar with the results. In 1989, the House used it to bar smoking on domestic flights of two hours or more. In 1996, it was used to incorporate a voluntary employee verification program, addressing the employment of illegal aliens. Then, in 1997, it was used to block the use of statistical sampling for the 2000 census.

That same CRS report on self-executing rules calls them “procedurally imaginative.” I’ll say they are. Just when we thought we’d seen everything in this year-long health reform debate, along comes something new to astonish us.

Stay tuned, the end really is in sight now.

CLASS Act Provision To Expand Personal Care Workforce

The health reform legislation includes a provision for Community Living Assistance Services and Supports (CLASS) which would implement a national, voluntary insurance program for purchasing long-term care, including community living assistance services and support.

Sec. 8002 of the CLASS Act requires the Department of Health and Human Services to establsih within 90 days after the law’s enactment a Personal Care Attendants (PCA) Workforce Advisory Panel to advise HHS and Congress on issues related to that workforce’s work circumstances. Among the workforce issues the PCA advisory panel would review are the following:
• Adequacy of the number of PCA workers;
• Compensation (salaries and wages);
• Benefits; and
• Access to PCA workers’ services.

Members of the advisory panel are to include...
• Persons with disabilities in all age groups;
• Elderly; and
• Representatives of the disabled, elderly, workforce and labor organizations, home and community-based service providers, and assisted living providers.

A PCA’s main responsibility is to help ill, weak or elderly clients with their personal needs such as hygiene, exercise, medication and communication, grocery shopping and meal preparation, and other activities of dailiy living.

Individuals can hire their own PCAs independently or through a home health agency. One benefit of hiring a PCA through an agency is convenience—presumably, the agency screens applicants for character and reliability, as well as for experience. Too often, however, training and experience are not required. Also, an agency often will provide back-up care in the PCA’s absence. Among the disadvantages of hiring a PCA through an agency are higher costs, and potential lack of control over choosing the caregiver.

Historically, there has been a shortage of qualified workers to care for disabled and elderly who need personal assistance to be able to remain in their homes. The shortage is primarily due to the fact that these workers typically are paid minimum wage and provided few, if any, benefits, including paid time off for sick days or other personal time, health insurance, or retirement.

Home health care agencies provide varied levels of care providers and their services are costly. State regulation of home care agencies and providers is highly varied as is the quality of service providers. Furthermore, few people buy long-term care insurance, also expensive, to help them cover these expenses should they need them’.

The CLASS Act’s required advisory panel, it is hoped, would help expand the qualified PCA workforce that will be necessary with the growth of the aging baby boomer population. That is, should it pass the health reform hhurdles.

Health reform: a timetable and a bellwether

Speaker Pelosi tells us that the House will vote on both the Senate bill and the sidecar reconciliation bill this week. A memo from Rep. Chris Van Hollen (D-MD), sent to House staffers and obtained by Chris Frates at politico.com, offers the rest of us a good timetable for how events may unfold this week. Here’s the timetable, according to the memo:

Monday:

---Congressional Budget Office publishes final "score" on legislative language (not yet, at this writing, but check here).
---House Budget Committee must approve use of reconciliation process (scheduled for Monday).

After those two steps are accomplished, here's what should come next:

---House Rules Committee approves the procedures that will be followed for the debate on the House floor.
--A Manager’s amendment will be posted online. After that, the plan is for 72 hours to pass without a vote.

Van Hollen predicts a vote may occur Friday or Saturday.

Looking for a bellwether as to how the ultimate vote will go? As good a sign as any might be Bart Stupak’s mood.


Rep. Stupak (D-MI), you recall, led a group of anti-abortion Democrats in demanding (and getting) what some would see as restrictive language in the House bill on abortion funding** via the health exchanges.

Stupak has been adamant that he can’t support the Senate’s approach to the contentious abortion issue.  On Friday afternoon, however, when talking to National Review Online, Stupak sounded down, like a man who thought it unlikely he could hold his coalition together. So, if Stupak’s still down in the dumps this week, it may mean the Democrats might actually pass the darn thing.

**You can’t use the reconciliation bill to address the abortion issue further; go here if you want to know why. Go here if you want every possible nuance and contingency as to why this is so. Go here if you want something just as complex but much more fun. Go Cats.

Three Barriers To An Individual Mandate

Virginia is poised to become the first state to make illegal an individual mandate for health insurance, and this highlights just one of three possible problems Congress may have in implementing an individual requirement to buy health insurance.

As my colleague already has pointed out, if Congress passes health reform with an individual mandate, there could be a constitutional challenge under the Commerce Clause.

Virginia’s action is another hurdle. On March 10, the State’s House of Delegates passed H.B. 10, a bill, previously passed in the state Senate, outlawing individual mandates. Gov. Bob McDonnell has indicated he will sign the legislation.

The bill states that no state resident "shall be required to obtain or maintain a policy of individual insurance coverage." In addition, H.B. 10 states that no resident shall be "liable for any penalty, assessment, fee, or fine as a result of his failure to procure or obtain health insurance coverage."

In response to current national health reform proposals, at least 35 other states have begun legislative action to restrict or ban an individual mandate, according to the National Conference of State Legislatures.

Whether such a state challenge to a federal law can be sustained is in much dispute. On the one hand, the Constitution's federal supremacy clause appears to indicate that when federal and state law conflict, federal law takes precedence. Nevertheless the Supreme Court has upheld Oregon’s right to die law in the face of federal opposition.

Is Compliance The Highest Hurdle?

However the biggest hurdle to the individual mandate may be compliance. The Senate health reform bill, H.R. 3590, does impose penalties for not purchasing health insurance, but the legislation also lets those who do not pay the penalty off the hook:

“In the case of any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure” (Sec. 1501(b) of H.R. 3590).

In a review of all three possible barriers to the individual mandate, Timothy S. Jost writes in the New England Journal of Medicine,

“It is possible that the federal government will eventually conclude that it is not possible to enforce the individual mandate for health insurance. But if individuals successfully resist accepting responsibility for being insured, there will be no way of expanding affordable coverage in a system that depends on private insurers. If government funding of health care must therefore be increased, it may not be the result resisters want.”

Let's study pain

Have you ever been in pain? Of course you have. You’ve been riding this health care reform rollercoaster along with the rest of us, so I’m confident you’ve felt some pain during the past year (such as headaches from reading thousands of pages of legislative text!). And I’m sure there are other times in your life where you’ve been in pain for actual health-related reasons.

Pain is a significant health problem. Common pain conditions strike more than half of U.S. workers and cost employers $61 billion in lost productive time, according to one study. Untreated pain also affects quality of life and many aspects of daily living.

So, what’s this got to do with health care reform? Well, the Senate health reform bill (HR. 3590) contains a provision on research and treatment for pain care management.

Pursuant to Act Sec. 4305, the Secretary of Health and Human Services (HHS) must seek to enter into an agreement with the Institute of Medicine of the National Academies to convene a Conference on Pain (Conference). The Director of the National Institutes of Health is encouraged to continue and expand, through the Pain Consortium, a program of basic and clinical research on the causes of and potential treatments for pain. The HHS Secretary may award grants to foster pain care education and training programs for health care professionals.

Conference on pain. The purposes of the Conference are to:

• increase the recognition of pain as a significant public health problem in the United States;


• evaluate the adequacy of assessment, diagnosis, treatment, and management of acute and chronic pain in the general population, and in identified racial, ethnic, gender, age, and other demographic groups that may be disproportionately affected by inadequacies in the assessment, diagnosis, treatment, and management of pain;


• identify barriers to appropriate pain care; and


• establish an agenda for action in both the public and private sectors that will reduce such barriers and significantly improve the state of pain care research, education, and clinical care in the United States.

 So, how about we get started on managing pain by bringing this wild reform ride to an end?

What does health reform opposition look like?

It seems like hardly a day can go by without my seeing another poll saying that Americans are opposed to health reform. In my own everyday conversations, I don’t see quite that level of opposition. Are my family and friends out of the mainstream or is something else going on?

Whenever I see those polls, I always want to shout ”but why”? When people say that they oppose health reform, is it because the pending health reform bills do too much? Or do the bills do too little?

Well, I finally got my wish because, for the first time I’m aware of, a pollster finally asked the obvious follow-up question to those who say they oppose the bills. In an Ipsos/McClatchy poll conducted by Ipsos Public Affairs in late February, only 41 percent of respondents say they support the health reform proposals with 47 percent opposing them. On its face, that looks like just another health reform survey. Ho-hum.

But wait, there's more. The difference: This pollster asked the follow-up question. According to the survey, 54 percent of health reform opponents say they oppose the measures because they go too far and, somewhat surprisingly, 37 percent of opponents said they oppose the bills because they don’t go far enough to reform healthcare.

The follow-up completely changes the meaning of the survey. In effect, ignoring the undecideds, 66 percent (a super-majority, in fact) say that they favor the health reform bills being discussed or even stronger legislation (that is, at least this level of health reform) and only 34 percent oppose at least this level of health reform.

Now that sort of puts a whole different perspective on “health reform opposition,” doesn’t it?