    [House Report 111-299]
    [From the U.S. Government Publishing Office]

    111th Congress                                            Rept. 111-299
                            HOUSE OF REPRESENTATIVES
     1st Session                                                     Part 3
    ======================================================================

                AMERICA'S AFFORDABLE HEALTH CHOICES ACT OF 2009

                                    _______

    October 14, 2009.--Committed to the Committee of the Whole House on the
                 State of the Union, and ordered to be printed.

                                    _______

     Mr. George Miller of California, from the Committee on Education and
                         Labor, submitted the following

                                  R E P O R T

                                 together with

                        MINORITY AND SUPPLEMENTAL VIEWS

                            [To accompany H.R. 3200]

      The Committee on Education and Labor, to whom was referred
    the bill (H.R. 3200) to provide affordable, quality health care
    for all Americans and reduce the growth in health care
    spending, and for other purposes, having considered the same,
    report favorably thereon with an amendment and recommend that
    the bill as amended do pass.

      The amendment is as follows:
      Strike all after the enacting clause (other than sections 161
    through 163, 322, and 323 and title IV of division A, division
    B, section 2002 and titles I through IV of division C, and
    subtitles A, B, C, and E of title V of division C) and insert
    the following:

    SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND SUBTITLES.

      (a) Table of Divisions, Titles, and Subtitles.--This Act is divided
    into divisions, titles, and subtitles as follows:

                   DIVISION A--AFFORDABLE HEALTH CARE CHOICES

    TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
    Subtitle A--General Standards
    Subtitle B--Standards Guaranteeing Access to Affordable Coverage
    Subtitle C--Standards Guaranteeing Access to Essential Benefits
    Subtitle D--Additional Consumer Protections
    Subtitle E--Governance
    Subtitle F--Relation to other requirements; Miscellaneous
    Subtitle G--Early Investments
    TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
    Subtitle A--Health Insurance Exchange
    Subtitle B--Public health insurance option
    Subtitle C--Individual Affordability Credits
    Subtitle D--State innovation
    TITLE III--SHARED RESPONSIBILITY
    Subtitle A--Individual responsibility
    Subtitle B--Employer Responsibility

                 [For division B--See text of introduced bill]

              DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

    [For titles I through IV of division C, see text of introduced bill.]
    TITLE V--OTHER PROVISIONS
    [For subtitles A , B, and C of title V, see text of introduced bill.]
    Subtitle D--Grants for comprehensive programs to provide education to
    nurses and create a pipeline to nursing
    [For subtitle E of title V, see text of introduced bill.]
    Subtitle F--Standards for accessibility to medical equipment for
    individuals with disabilities.
    Subtitle G--Other grant programs
    Subtitle H--Long-term care and family caregiver support
    Subtitle I--Online resources
      (b) Short Title.--This Act may be cited as the ``America's Affordable
    Health Choices Act of 2009''.

                   DIVISION A--AFFORDABLE HEALTH CARE CHOICES

    SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.

      (a) Purpose.--
              (1) In general.--The purpose of this division is to provide
            affordable, quality health care for all Americans and reduce
            the growth in health care spending.
              (2) Building on current system.--This division achieves this
            purpose by building on what works in today's health care
            system, while repairing the aspects that are broken.
              (3) Insurance reforms.--This division--
                      (A) enacts strong insurance market reforms;
                      (B) creates a new Health Insurance Exchange, with a
                    public health insurance option alongside private plans;
                      (C) includes sliding scale affordability credits; and
                      (D) initiates shared responsibility among workers,
                    employers, and the government;
            so that all Americans have coverage of essential health
            benefits.
              (4) Health delivery reform.--This division institutes health
            delivery system reforms both to increase quality and to reduce
            growth in health spending so that health care becomes more
            affordable for businesses, families, and government.
      (b) Table of Contents of Division.--The table of contents of this
    division is as follows:

    Sec. 100. Purpose; table of contents of division; general definitions.

     TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

                         Subtitle A--General Standards

    Sec. 101. Requirements reforming health insurance marketplace.
    Sec. 102. Protecting the choice to keep current coverage.

        Subtitle B--Standards Guaranteeing Access to Affordable Coverage

    Sec. 111. Prohibiting pre-existing condition exclusions.
    Sec. 112. Guaranteed issue and renewal for insured plans.
    Sec. 113. Insurance rating rules.
    Sec. 114. Nondiscrimination in benefits; parity in mental health and
    substance abuse disorder benefits.
    Sec. 115. Ensuring adequacy of provider networks.
    Sec. 116. Ensuring value and lower premiums.
    Sec. 117. Consistency of costs and coverage under qualified health
    benefits plans during plan year.

        Subtitle C--Standards Guaranteeing Access to Essential Benefits

    Sec. 121. Coverage of essential benefits package.
    Sec. 122. Essential benefits package defined.
    Sec. 123. Health Benefits Advisory Committee.
    Sec. 124. Process for adoption of recommendations; adoption of benefit
    standards.
    Sec. 125. Prohibition of discrimination in health care services based
    on religious or spiritual content.

                  Subtitle D--Additional Consumer Protections

    Sec. 131. Requiring fair marketing practices by health insurers.
    Sec. 132. Requiring fair grievance and appeals mechanisms.
    Sec. 133. Requiring information transparency and plan disclosure.
    Sec. 134. Application to qualified health benefits plans not offered
    through the Health Insurance Exchange.
    Sec. 135. Timely payment of claims.
    Sec. 136. Standardized rules for coordination and subrogation of
    benefits.
    Sec. 137. Application of administrative simplification.
    Sec. 138. Records relative to prescription information.

                             Subtitle E--Governance

    Sec. 141. Health Choices Administration; Health Choices Commissioner.
    Sec. 142. Duties and authority of Commissioner.
    Sec. 143. Consultation and coordination.
    Sec. 144.  Health Insurance Ombudsman.

           Subtitle F--Relation to Other Requirements; Miscellaneous

    Sec. 151. Relation to other requirements.
    Sec. 152. Prohibiting discrimination in health care.
    Sec. 153. Whistleblower protection.
    Sec. 154. Construction regarding collective bargaining.
    Sec. 155. Severability.
    Sec. 156. Rule of construction regarding Hawaii Prepaid Health Care
    Act.
    Sec. 157. Increasing meaningful use of electronic health records.
    Sec. 158. Private right of contract with health care providers.

                         Subtitle G--Early Investments

    [For sections 161-163. See text of introduced bill.]
    Sec. 164. Reinsurance program for retirees.
    Sec. 165. Prohibition against post-retirement reductions of retiree
    health benefits by group health plans.
    Sec. 166. Limitations on preexisting condition exclusions in group
    health plans in advance of applicability of new prohibition of
    preexisting condition exclusions.
    Sec. 167. Extension of COBRA continuation coverage.

           TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

                     Subtitle A--Health Insurance Exchange

    Sec. 201. Establishment of Health Insurance Exchange; outline of
    duties; definitions.
    Sec. 202. Exchange-eligible individuals and employers.
    Sec. 203. Benefits package levels.
    Sec. 204. Contracts for the offering of Exchange-participating health
    benefits plans.
    Sec. 205. Outreach and enrollment of Exchange-eligible individuals and
    employers in Exchange-participating health benefits plan.
    Sec. 206. Other functions.
    Sec. 207. Health Insurance Exchange Trust Fund.
    Sec. 208. Optional operation of State-based health insurance exchanges.
    Sec. 209. Participation of small employer benefit arrangements.

                   Subtitle B--Public Health Insurance Option

    Sec. 221. Establishment and administration of a public health insurance
    option as an Exchange-qualified health benefits plan.
    Sec. 222. Premiums and financing.
    Sec. 223. Payment rates for items and services.
    Sec. 224. Modernized payment initiatives and delivery system reform.
    Sec. 225. Provider participation.
    Sec. 226. Application of fraud and abuse provisions.
    Sec. 227. Sense of the House regarding enrollment of Members in the
    public option.

                  Subtitle C--Individual Affordability Credits

    Sec. 241. Availability through Health Insurance Exchange.
    Sec. 242. Affordable credit eligible individual.
    Sec. 243. Affordable premium credit.
    Sec. 244. Affordability cost-sharing credit.
    Sec. 245. Income determinations.
    Sec. 246. No Federal payment for undocumented aliens.

                          Subtitle D--State Innovation

    Sec. 251. Waiver of ERISA limitation; application instead of state
    single payer system.
    Sec. 252. Requirements.
    Sec. 253. Definitions.

                        TITLE III--SHARED RESPONSIBILITY

                     Subtitle A--Individual Responsibility

    Sec. 301. Individual responsibility.

                      Subtitle B--Employer Responsibility

               Part 1--Health Coverage Participation Requirements

    Sec. 311. Health coverage participation requirements.
    Sec. 312. Employer responsibility to contribute towards employee and
    dependent coverage.
    Sec. 313. Employer contributions in lieu of coverage.
    Sec. 314. Authority related to improper steering.

       Part 2--Satisfaction of Health Coverage Participation Requirements

    Sec. 321. Satisfaction of health coverage participation requirements
    under the Employee Retirement Income Security Act of 1974.
    Sec. 324. Additional rules relating to health coverage participation
    requirements.

                  [FOR TITLE IV, SEE TEXT OF INTRODUCED BILL.]

      (c) General Definitions.--Except as otherwise provided, in this
    division:
              (1) Acceptable coverage.--The term ``acceptable coverage''
            has the meaning given such term in section 202(d)(2).
              (2) Basic plan.--The term ``basic plan'' has the meaning
            given such term in section 203(c).
              (3) Commissioner.--The term ``Commissioner'' means the Health
            Choices Commissioner established under section 141.
              (4) Cost-sharing.--The term ``cost-sharing'' includes
            deductibles, coinsurance, copayments, and similar charges but
            does not include premiums or any network payment differential
            for covered services or spending for non-covered services.
              (5) Dependent.--The term ``dependent'' has the meaning given
            such term by the Commissioner and includes a spouse.
              (6) Employment-based health plan.--The term ``employment-
            based health plan''--
                      (A) means a group health plan (as defined in section
                    733(a)(1) of the Employee Retirement Income Security
                    Act of 1974);
                      (B) includes such a plan that is the following:
                              (i) Federal, state, and tribal governmental
                            plans.--A governmental plan (as defined in
                            section 3(32) of the Employee Retirement Income
                            Security Act of 1974), including a health
                            benefits plan offered under chapter 89 of title
                            5, United States Code; or
                              (ii) Church plans.--A church plan (as defined
                            in section 3(33) of the Employee Retirement
                            Income Security Act of 1974); and
                      (C) excludes coverage described in section
                    202(d)(2)(E) (relating to TRICARE).
              (7) Enhanced plan.--The term ``enhanced plan'' has the
            meaning given such term in section 203(c).
              (8) Essential benefits package.--The term ``essential
            benefits package'' is defined in section 122(a).
              (9) Family.--The term ``family'' means an individual and
            includes the individual's dependents.
              (10) Federal poverty level; fpl.--The terms ``Federal poverty
            level'' and ``FPL'' have the meaning given the term ``poverty
            line'' in section 673(2) of the Community Services Block Grant
            Act (42 U.S.C. 9902(2)), including any revision required by
            such section.
              (11) Health benefits plan.--The terms ``health benefits
            plan'' means health insurance coverage and an employment-based
            health plan and includes the public health insurance option.
              (12) Health insurance coverage; health insurance issuer.--The
            terms ``health insurance coverage'' and ``health insurance
            issuer'' have the meanings given such terms in section 2791 of
            the Public Health Service Act.
              (13) Health insurance exchange.--The term ``Health Insurance
            Exchange'' means the Health Insurance Exchange established
            under section 201.
              (14) Medicaid.--The term ``Medicaid'' means a State plan
            under title XIX of the Social Security Act (whether or not the
            plan is operating under a waiver under section 1115 of such
            Act).
              (15) Medicare.--The term ``Medicare'' means the health
            insurance programs under title XVIII of the Social Security
            Act.
              (16) Plan sponsor.--The term ``plan sponsor'' has the meaning
            given such term in section 3(16)(B) of the Employee Retirement
            Income Security Act of 1974.
              (17) Plan year.--The term ``plan year'' means--
                      (A) with respect to an employment-based health plan,
                    a plan year as specified under such plan; or
                      (B) with respect to a health benefits plan other than
                    an employment-based health plan, a 12-month period as
                    specified by the Commissioner.
              (18) Premium plan; premium-plus plan.--The terms ``premium
            plan'' and ``premium-plus plan'' have the meanings given such
            terms in section 203(c).
              (19) QHBP offering entity.--The terms ``QHBP offering
            entity'' means, with respect to a health benefits plan that
            is--
                      (A) a group health plan (as defined, subject to
                    subsection (d), in section 733(a)(1) of the Employee
                    Retirement Income Security Act of 1974), the plan
                    sponsor in relation to such group health plan, except
                    that, in the case of a plan maintained jointly by 1 or
                    more employers and 1 or more employee organizations and
                    with respect to which an employer is the primary source
                    of financing, such term means such employer;
                      (B) health insurance coverage, the health insurance
                    issuer offering the coverage;
                      (C) the public health insurance option, the Secretary
                    of Health and Human Services;
                      (D) a non-Federal governmental plan (as defined in
                    section 2791(d) of the Public Health Service Act), the
                    State or political subdivision of a State (or agency or
                    instrumentality of such State or subdivision) which
                    establishes or maintains such plan; or
                      (E) a Federal governmental plan (as defined in
                    section 2791(d) of the Public Health Service Act), the
                    appropriate Federal official.
              (20) Qualified health benefits plan.--The term ``qualified
            health benefits plan'' means a health benefits plan that meets
            the requirements for such a plan under title I and includes the
            public health insurance option.
              (21) Public health insurance option.--The term ``public
            health insurance option'' means the public health insurance
            option as provided under subtitle B of title II.
              (22) Service area; premium rating area.--The terms ``service
            area'' and ``premium rating area'' mean with respect to health
            insurance coverage--
                      (A) offered other than through the Health Insurance
                    Exchange, such an area as established by the QHBP
                    offering entity of such coverage in accordance with
                    applicable State law; and
                      (B) offered through the Health Insurance Exchange,
                    such an area as established by such entity in
                    accordance with applicable State law and applicable
                    rules of the Commissioner for Exchange-participating
                    health benefits plans.
              (23) State.--The term ``State'' means the 50 States and the
            District of Columbia.
              (24) State medicaid agency.--The term ``State Medicaid
            agency'' means, with respect to a Medicaid plan, the single
            State agency responsible for administering such plan under
            title XIX of the Social Security Act.
              (25) Y1, y2, etc..--The terms ``Y1'' , ``Y2'', ``Y3'',
            ``Y4'', ``Y5'', and similar subsequently numbered terms, mean
            2013 and subsequent years, respectively.
              (26) Employee premium.--The term ``employee premium'' does
            not include a collectively bargained premium in the case of a
            group health plan (as defined in section 733(a)(1) of the
            Employee Retirement Income Security Act of 1974) that is a
            multiemployer plan (as defined in section 3(37) of such Act).

     TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

                         Subtitle A--General Standards

    SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.

      (a) Purpose.--The purpose of this title is to establish standards to
    ensure that new health insurance coverage and employment-based health
    plans that are offered meet standards guaranteeing access to affordable
    coverage, essential benefits, and other consumer protections.
      (b) Requirements for Qualified Health Benefits Plans.--On or after
    the first day of Y1, a health benefits plan shall not be a qualified
    health benefits plan under this division unless the plan meets the
    applicable requirements of the following subtitles for the type of plan
    and plan year involved:
              (1) Subtitle B (relating to affordable coverage).
              (2) Subtitle C (relating to essential benefits).
              (3) Subtitle D (relating to consumer protection).
      (c) Terminology.--In this division:
              (1) Enrollment in employment-based health plans.--An
            individual shall be treated as being ``enrolled'' in an
            employment-based health plan if the individual is a participant
            or beneficiary (as such terms are defined in section 3(7) and
            3(8), respectively, of the Employee Retirement Income Security
            Act of 1974) in such plan.
              (2) Individual and group health insurance coverage.--The
            terms ``individual health insurance coverage'' and ``group
            health insurance coverage'' mean health insurance coverage
            offered in the individual market or large or small group
            market, respectively, as defined in section 2791 of the Public
            Health Service Act.
      (d) Sense of Congress on Health Care Needs of United States
    Territories.--It is the sense of the Congress that the reforms made by
    H.R. 3200, as introduced, must be strengthened to meaningfully address
    the health care needs of residents of American Samoa, the Commonwealth
    of the Northern Mariana Islands, Guam, Puerto Rico, and the United
    States Virgin Islands and Congress is committed to working with the
    representatives of these territories to ensure that residents of these
    territories have access to high-quality and affordable health care in
    such a way that best serves their unique needs.

    SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

      (a) Grandfathered Health Insurance Coverage Defined.--Subject to the
    succeeding provisions of this section, for purposes of establishing
    acceptable coverage under this division, the term ``grandfathered
    health insurance coverage'' means individual health insurance coverage
    that is offered and in force and effect before the first day of Y1 if
    the following conditions are met:
              (1) Limitation on new enrollment.--
                      (A) In general.--Except as provided in this
                    paragraph, the individual health insurance issuer
                    offering such coverage does not enroll any individual
                    in such coverage if the first effective date of
                    coverage is on or after the first day of Y1.
                      (B) Dependent coverage permitted.--Subparagraph (A)
                    shall not affect the subsequent enrollment of a
                    dependent of an individual who is covered as of such
                    first day.
              (2) Limitation on changes in terms or conditions.--Subject to
            paragraph (3) and except as required by law, the issuer does
            not change any of its terms or conditions, including benefits
            and cost-sharing, from those in effect as of the day before the
            first day of Y1.
              (3) Restrictions on premium increases.--The issuer cannot
            vary the percentage increase in the premium for a risk group of
            enrollees in specific grandfathered health insurance coverage
            without changing the premium for all enrollees in the same risk
            group at the same rate, as specified by the Commissioner.
      (b) Grace Period for Current Employment-based Health Plans.--
              (1) Grace period.--
                      (A) In general.--The Commissioner shall establish a
                    grace period whereby, for plan years beginning after
                    the end of the 5-year period beginning with Y1, an
                    employment-based health plan in operation as of the day
                    before the first day of Y1 must meet the same
                    requirements as apply to a qualified health benefits
                    plan under section 101, including the essential benefit
                    package requirement under section 121.
                      (B) Exception for limited benefits plans.--
                    Subparagraph (A) shall not apply to an employment-based
                    health plan in which the coverage consists only of one
                    or more of the following:
                              (i) Any coverage described in section
                            3001(a)(1)(B)(ii)(IV) of division B of the
                            American Recovery and Reinvestment Act of 2009
                            (PL 111-5).
                              (ii) Excepted benefits (as defined in section
                            733(c) of the Employee Retirement Income
                            Security Act of 1974), including coverage under
                            a specified disease or illness policy described
                            in paragraph (3)(A) of such section.
                              (iii) Such other limited benefits as the
                            Commissioner may specify.
                    In no case shall an employment-based health plan in
                    which the coverage consists only of one or more of the
                    coverage or benefits described in clauses (i) through
                    (iii) be treated as acceptable coverage under this
                    division
              (2) Transitional treatment as acceptable coverage.--During
            the grace period specified in paragraph (1)(A), an employment-
            based health plan that is described in such paragraph shall be
            treated as acceptable coverage under this division.
              (3) Exception for consumer-directed health plans and
            arrangements.--In the case of a group health plan which
            consists of a consumer-directed health plan or arrangement
            (including a high deductible health plan, within the meaning of
            section 223(c)(2) of the Internal Revenue Code of 1986), such
            group health plan shall be treated as acceptable coverage under
            a current group health plan for purposes of this division.
      (c) Limitation on Individual Health Insurance Coverage.--
              (1) In general.--Individual health insurance coverage that is
            not grandfathered health insurance coverage under subsection
            (a) may only be offered on or after the first day of Y1 as an
            Exchange-participating health benefits plan.
              (2) Separate, excepted coverage permitted.--Excepted benefits
            (as defined in section 2791(c) of the Public Health Service
            Act) are not included within the definition of health insurance
            coverage. Nothing in paragraph (1) shall prevent the offering,
            other than through the Health Insurance Exchange, of excepted
            benefits so long as it is offered and priced separately from
            health insurance coverage.

        Subtitle B--Standards Guaranteeing Access to Affordable Coverage

    SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.

      A qualified health benefits plan may not impose any pre-existing
    condition exclusion (as defined in section 2701(b)(1)(A) of the Public
    Health Service Act) or otherwise impose any limit or condition on the
    coverage under the plan with respect to an individual or dependent
    based on any health status-related factors (as defined in section
    2791(d)(9) of the Public Health Service Act) in relation to the
    individual or dependent.

    SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.

      The requirements of sections 2711 (other than subsections (c) and
    (e)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and
    subsection (e)) of the Public Health Service Act, relating to
    guaranteed availability and renewability of health insurance coverage,
    shall apply to individuals and employers in all individual and group
    health insurance coverage, whether offered to individuals or employers
    through the Health Insurance Exchange, through any employment-based
    health plan, or otherwise, in the same manner as such sections apply to
    employers and health insurance coverage offered in the small group
    market, except that such section 2712(b)(1) shall apply only if, before
    nonrenewal or discontinuation of coverage, the issuer has provided the
    enrollee with notice of non-payment of premiums and there is a grace
    period during which the enrollees has an opportunity to correct such
    nonpayment. Rescissions of such coverage shall be prohibited except in
    cases of fraud as defined in sections 2712(b)(2) of such Act.

    SEC. 113. INSURANCE RATING RULES.

      (a) In General.--The premium rate charged for an insured qualified
    health benefits plan may not vary except as follows:
              (1) Limited age variation permitted.--By age (within such age
            categories as the Commissioner shall specify) so long as the
            ratio of the highest such premium to the lowest such premium
            does not exceed the ratio of 2 to 1.
              (2) By area.--By premium rating area (as permitted by State
            insurance regulators or, in the case of Exchange-participating
            health benefits plans, as specified by the Commissioner in
            consultation with such regulators).
              (3) By family enrollment.--By family enrollment (such as
            variations within categories and compositions of families) so
            long as the ratio of the premium for family enrollment (or
            enrollments) to the premium for individual enrollment is
            uniform, as specified under State law and consistent with rules
            of the Commissioner.
      (b) Study and Reports.--
              (1) Study.--The Commissioner, in coordination with the
            Secretary of Health and Human Services and the Secretary of
            Labor, shall conduct a study of the large group insured and
            self-insured employer health care markets. Such study shall
            examine the following:
                      (A) The types of employers by key characteristics,
                    including size, that purchase insured products versus
                    those that self-insure.
                      (B) The similarities and differences between typical
                    insured and self-insured health plans.
                      (C) The financial solvency and capital reserve levels
                    of employers that self-insure by employer size.
                      (D) The risk of self-insured employers not being able
                    to pay obligations or otherwise becoming financially
                    insolvent.
                      (E) The extent to which rating rules are likely to
                    cause adverse selection in the large group market or to
                    encourage small and mid size employers to self-insure
              (2) Reports.--Not later than 18 months after the date of the
            enactment of this Act, the Commissioner shall submit to
            Congress and the applicable agencies a report on the study
            conducted under paragraph (1). Such report shall include any
            recommendations the Commissioner deems appropriate to ensure
            that the law does not provide incentives for small and mid-size
            employers to self-insure or create adverse selection in the
            risk pools of large group insurers and self-insured employers.
            Not later than 18 months after the first day of Y1, the
            Commissioner shall submit to Congress and the applicable
            agencies an updated report on such study, including updates on
            such recommendations.

    SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND
                        SUBSTANCE ABUSE DISORDER BENEFITS.

      (a) Nondiscrimination in Benefits.--A qualified health benefits plan
    shall comply with standards established by the Commissioner to prohibit
    discrimination in health benefits or benefit structures for qualified
    health benefits plans, building from sections 702 of Employee
    Retirement Income Security Act of 1974, 2702 of the Public Health
    Service Act, and section 9802 of the Internal Revenue Code of 1986.
      (b) Parity in Mental Health and Substance Abuse Disorder Benefits.--
    To the extent such provisions are not superceded by or inconsistent
    with subtitle C, the provisions of section 2705 (other than subsections
    (a)(1), (a)(2), and (c)) of section 2705 of the Public Health Service
    Act shall apply to a qualified health benefits plan, regardless of
    whether it is offered in the individual or group market, in the same
    manner as such provisions apply to health insurance coverage offered in
    the large group market.

    SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.

      (a) In General.--A qualified health benefits plan that uses a
    provider network for items and services shall meet such standards
    respecting provider networks as the Commissioner may establish to
    assure the adequacy of such networks in ensuring enrollee access to
    such items and services and transparency in the cost-sharing
    differentials between in-network coverage and out-of-network coverage.
      (b) Internet Access to Information.--A qualified health benefits plan
    that uses a provider network shall provide a current listing of all
    providers in its network on its website and such data shall be
    available on the Health Insurance Exchange website as a `click through'
    from the basic information on that plan. The Commissioner shall also
    establish an on-line system whereby an individual may select by name
    any medical provider (as defined by the Commissioner) and be informed
    of the plan or plans with which that provider is contracting.
      (c) Provider Network Defined.--In this division, the term ``provider
    network'' means the providers with respect to which covered benefits,
    treatments, and services are available under a health benefits plan.

    SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.

      The QHBP offering entity shall provide that for any plan year in
    which a qualified health benefits plan that the entity offers has a
    medical loss ratio (expressed as a percentage) that is less than a
    percentage (not less than 85 percent) specified by the Commissioner,
    the QHBP offering entity offering such plan shall provide for rebates
    to enrollees of payment sufficient to meet such loss ratio. The
    Commissioner shall establish a uniform definition of medical loss ratio
    and methodology for determining how to calculate the medical loss
    ratio. Such methodology shall be designed to take into account the
    special circumstances of smaller and newer plans.

    SEC. 117. CONSISTENCY OF COSTS AND COVERAGE UNDER QUALIFIED HEALTH
                        BENEFITS PLANS DURING PLAN YEAR.

      In the case of health insurance coverage offered under a qualified
    health benefits plan, the coverage and cost of coverage may not be
    changed during the course of a plan year except to increase coverage to
    the enrollee or to lower costs to the enrollee.

        Subtitle C--Standards Guaranteeing Access to Essential Benefits

    SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

      (a) In General.--A qualified health benefits plan shall provide
    coverage that at least meets the benefit standards adopted under
    section 124 for the essential benefits package described in section 122
    for the plan year involved.
      (b) Choice of Coverage.--
              (1) Non-exchange-participating health benefits plans.--In the
            case of a qualified health benefits plan that is not an
            Exchange-participating health benefits plan, such plan may
            offer such coverage in addition to the essential benefits
            package as the QHBP offering entity may specify.
              (2) Exchange-participating health benefits plans.--In the
            case of an Exchange-participating health benefits plan, such
            plan is required under section 203 to provide specified levels
            of benefits and, in the case of a plan offering a premium-plus
            level of benefits, provide additional benefits.
              (3) Continuation of offering of separate excepted benefits
            coverage.--Nothing in this division shall be construed as
            affecting the offering of health benefits in the form of
            excepted benefits (described in section 102(b)(1)(B)(ii)) if
            such benefits are offered under a separate policy, contract, or
            certificate of insurance.
      (c) No Restrictions on Coverage Unrelated to Clinical
    Appropriateness.--A qualified health benefits plan may not impose any
    restriction (other than cost-sharing) unrelated to clinical
    appropriateness on the coverage of the health care items and services.

    SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.

      (a) In General.--In this division, the term ``essential benefits
    package'' means health benefits coverage, consistent with standards
    adopted under section 124 to ensure the provision of quality health
    care and financial security, that--
              (1) provides payment for the items and services described in
            subsection (b) in accordance with generally accepted standards
            of medical or other appropriate clinical or professional
            practice;
              (2) limits cost-sharing for such covered health care items
            and services in accordance with such benefit standards,
            consistent with subsection (c);
              (3) does not impose any annual or lifetime limit on the
            coverage of covered health care items and services;
              (4) complies with section 115(a) (relating to network
            adequacy); and
              (5) is equivalent, as certified by Office of the Actuary of
            the Centers for Medicare & Medicaid Services, to the average
            prevailing employer-sponsored coverage.
      (b) Minimum Services to Be Covered.--The items and services described
    in this subsection are the following:
              (1) Hospitalization.
              (2) Outpatient hospital and outpatient clinic services,
            including emergency department services.
              (3) Professional services of physicians and other health
            professionals.
              (4) Such services, equipment, and supplies incident to the
            services of a physician's or a health professional's delivery
            of care in institutional settings, physician offices, patients'
            homes or place of residence, or other settings, as appropriate.
              (5) Prescription drugs.
              (6) Rehabilitative and habilitative services.
              (7) Mental health and substance use disorder services.
              (8) Preventive services, including those services recommended
            with a grade of A or B by the Task Force on Clinical Preventive
            Services and including mental health and substance abuse
            services recommended by the Task Force on Clinical Preventive
            Services and those mental health and substance abuse services
            with compelling research or evidence, including Screening,
            Brief Intervention and Referral to Treatment (SBIRT), and those
            vaccines recommended for use by the Director of the Centers for
            Disease Control and Prevention.
              (9) Maternity care.
              (10) Well baby and well child care and early and periodic
            screening, diagnostic, and treatment services (as defined in
            section 1905(r) of the Social Security Act) at least for
            children under 21 years of age.
              (11) Durable medical equipment, prosthetics, orthotics and
            related supplies.
      (c) Requirements Relating to Cost-sharing and Minimum Actuarial
    Value.--
              (1) No cost-sharing for preventive services.--There shall be
            no cost-sharing under the essential benefits package for
            preventive items and services (as specified under the benefit
            standards), including well baby and well child care.
              (2) Annual limitation.--
                      (A) Annual limitation.--The cost-sharing incurred
                    under the essential benefits package with respect to an
                    individual (or family) for a year does not exceed the
                    applicable level specified in subparagraph (B).
                      (B) Applicable level.--The applicable level specified
                    in this subparagraph for Y1 is $5,000 for an individual
                    and $10,000 for a family. Such levels shall be
                    increased (rounded to the nearest $100) for each
                    subsequent year by the annual percentage increase in
                    the Consumer Price Index (United States city average)
                    applicable to such year.
                      (C) Use of copayments.--In establishing cost-sharing
                    levels for basic, enhanced, and premium plans under
                    this subsection, the Secretary shall, to the maximum
                    extent possible, use only copayments and not
                    coinsurance.
              (3) Minimum actuarial value.--
                      (A) In general.--The cost-sharing under the essential
                    benefits package shall be designed to provide a level
                    of coverage that is designed to provide benefits that
                    are actuarially equivalent to approximately 70 percent
                    of the full actuarial value of the benefits provided
                    under the reference benefits package described in
                    subparagraph (B).
                      (B) Reference benefits package described.--The
                    reference benefits package described in this
                    subparagraph is the essential benefits package if there
                    were no cost-sharing imposed.

    SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.

      (a) Establishment.--
              (1) In general.--There is established a private-public
            advisory committee which shall be a panel of medical and other
            experts to be known as the Health Benefits Advisory Committee
            to recommend covered benefits and essential, enhanced, and
            premium plans.
              (2) Chair.--The Surgeon General shall be a member and the
            chair of the Health Benefits Advisory Committee.
              (3) Membership.--The Health Benefits Advisory Committee shall
            be composed of the following members, in addition to the
            Surgeon General:
                      (A) 9 members who are not Federal employees or
                    officers and who are appointed by the President.
                      (B) 9 members who are not Federal employees or
                    officers and who are appointed by the Comptroller
                    General of the United States in a manner similar to the
                    manner in which the Comptroller General appoints
                    members to the Medicare Payment Advisory Commission
                    under section 1805(c) of the Social Security Act.
                      (C) Such even number of members (not to exceed 8) who
                    are Federal employees and officers, as the President
                    may appoint.
            The membership of the Committee shall include one or more
            experts in scientific evidence and clinical practice of
            integrative health care services. Such initial appointments
            shall be made not later than 60 days after the date of the
            enactment of this Act.
              (4) Terms.--Each member of the Health Benefits Advisory
            Committee shall serve a 3-year term on the Committee, except
            that the terms of the initial members shall be adjusted in
            order to provide for a staggered term of appointment for all
            such members.
              (5) Participation.--The membership of the Health Benefits
            Advisory Committee shall at least reflect providers, employers,
            labor, health insurance issuers, experts in health care
            financing and delivery, experts in racial and ethnic
            disparities, experts in care for those with disabilities,
            representatives of relevant governmental agencies. and at least
            one practicing physician or other health professional and an
            expert on children's health and shall represent a balance among
            various sectors of the health care system so that no single
            sector unduly influences the recommendations of such Committee.
            The membership of the Committee shall also include educated
            patients, consumer advocates, or both, who shall include
            persons who represent individuals affected by a specific
            disease or medical condition, are knowledgeable about the
            health care system, and have received training regarding
            health, medical, and scientific matters.
      (b) Duties.--
              (1) Recommendations on benefit standards.--The Health
            Benefits Advisory Committee shall recommend to the Secretary of
            Health and Human Services (in this subtitle referred to as the
            ``Secretary'') benefit standards (as defined in paragraph (4)),
            and periodic updates to such standards. In developing such
            recommendations, the Committee shall--
                      (A) take into account innovation in health care,
                      (B) consider how such standards could reduce health
                    disparities,
                      (C) take into account integrative health care
                    services, and
                      (D) take into account typical multiemployer plan
                    benefit structures and the impact of the essential
                    benefit package on such plans.
              (2) Deadline.--The Health Benefits Advisory Committee shall
            recommend initial benefit standards to the Secretary not later
            than 1 year after the date of the enactment of this Act.
              (3) State input.--The Health Benefits Advisory Committee
            shall examine the health coverage laws and benefits of each
            State in developing recommendations under this subsection and
            may incorporate such coverage and benefits as the Committee
            determines to be appropriate and consistent with this Act. The
            Health Benefits Advisory Committee shall also seek input from
            the States and consider recommendations on how to ensure that
            the quality of health coverage does not decline in any State.
              (4) Public input.--The Health Benefits Advisory Committee
            shall allow for public input as a part of developing
            recommendations under this subsection.
              (5) Benefit standards defined.--In this subtitle, the term
            ``benefit standards'' means standards respecting--
                      (A) the essential benefits package described in
                    section 122, including categories of covered
                    treatments, items and services within benefit classes,
                    and cost-sharing; and
                      (B) the cost-sharing levels for enhanced plans and
                    premium plans (as provided under section 203(c))
                    consistent with paragraph (5).
              (6) Levels of cost-sharing for enhanced and premium plans.--
                      (A) Enhanced plan.--The level of cost-sharing for
                    enhanced plans shall be designed so that such plans
                    have benefits that are actuarially equivalent to
                    approximately 85 percent of the actuarial value of the
                    benefits provided under the reference benefits package
                    described in section 122(c)(3)(B).
                      (B) Premium plan.--The level of cost-sharing for
                    premium plans shall be designed so that such plans have
                    benefits that are actuarially equivalent to
                    approximately 95 percent of the actuarial value of the
                    benefits provided under the reference benefits package
                    described in section 122(c)(3)(B).
              (7) Recommendations of integrative health care services task
            force.--
                      (A) Inclusion in committee's recommendations.--The
                    Health Benefits Advisory Committee shall include in its
                    recommendations under paragraph (1) the recommendations
                    made by the Integrative Health Care Services Task Force
                    established under subparagraph (B).
                      (B) Establishment of task force.--The Health Benefits
                    Advisory Committee shall establish an Integrative
                    Health Care Services Task Force. Such Task Force shall
                    consist of 5 experts with expertise in research in, and
                    practice of, integrative health care. Such experts
                    shall be appointed by the Committee from among experts
                    nominated by the Secretary, in consultation with the
                    National Center for Complementary and Alternative
                    Medicine at the National Institutes of Health. The duty
                    of the Task Force shall be to make recommendations to
                    the Committee on evidence-based, clinically effective,
                    and safe integrative care services.
      (c) Operations.--
              (1) Per diem pay.--Each member of the Health Benefits
            Advisory Committee shall receive travel expenses, including per
            diem in accordance with applicable provisions under subchapter
            I of chapter 57 of title 5, United States Code, and shall
            otherwise serve without additional pay.
              (2) Members not treated as federal employees.--Members of the
            Health Benefits Advisory Committee shall not be considered
            employees of the Federal government solely by reason of any
            service on the Committee.
              (3) Application of faca.--The Federal Advisory Committee Act
            (5 U.S.C. App.), other than section 14, shall apply to the
            Health Benefits Advisory Committee.
      (d) Publication.--The Secretary shall provide for publication in the
    Federal Register and the posting on the Internet website of the
    Department of Health and Human Services of all recommendations made by
    the Health Benefits Advisory Committee under this section.

    SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT
                        STANDARDS.

      (a) Process for Adoption of Recommendations.--
              (1) Review of recommended standards.--Not later than 45 days
            after the date of receipt of benefit standards recommended
            under section 123 (including such standards as modified under
            paragraph (2)(B)), the Secretary shall review such standards
            and shall determine whether to propose adoption of such
            standards as a package.
              (2) Determination to adopt standards.--If the Secretary
            determines--
                      (A) to propose adoption of benefit standards so
                    recommended as a package, the Secretary shall, by
                    regulation under section 553 of title 5, United States
                    Code, propose adoption such standards; or
                      (B) not to propose adoption of such standards as a
                    package, the Secretary shall notify the Health Benefits
                    Advisory Committee in writing of such determination and
                    the reasons for not proposing the adoption of such
                    recommendation and provide the Committee with a further
                    opportunity to modify its previous recommendations and
                    submit new recommendations to the Secretary on a timely
                    basis.
              (3) Contingency.--If, because of the application of paragraph
            (2)(B), the Secretary would otherwise be unable to propose
            initial adoption of such recommended standards by the deadline
            specified in subsection (b)(1), the Secretary shall, by
            regulation under section 553 of title 5, United States Code,
            propose adoption of initial benefit standards by such deadline.
              (4) Publication.--The Secretary shall provide for publication
            in the Federal Register of all determinations made by the
            Secretary under this subsection.
      (b) Adoption of Standards.--
              (1) Initial standards.--Not later than 18 months after the
            date of the enactment of this Act, the Secretary shall, through
            the rulemaking process consistent with subsection (a), adopt an
            initial set of benefit standards.
              (2) Periodic updating standards.--Under subsection (a), the
            Secretary shall provide for the periodic updating of the
            benefit standards previously adopted under this section.
              (3) Requirement.--The Secretary may not adopt any benefit
            standards for an essential benefits package or for level of
            cost-sharing that are inconsistent with the requirements for
            such a package or level under sections 122 and 123(b)(5).

    SEC. 125 PROHIBITION OF DISCRIMINATION IN HEALTH CARE SERVICES BASED ON
                        RELIGIOUS OR SPIRITUAL CONTENT.

      Neither the Commissioner nor any health insurance issuer offering
    health insurance coverage through the Exchange shall discriminate in
    approving or covering a health care service on the basis of its
    religious or spiritual content if expenditures for such a health care
    service are allowable as a deduction under 213(d) of the Internal
    Revenue Code of 1986, as in effect on January 1, 2009.

                  Subtitle D--Additional Consumer Protections

    SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.

      The Commissioner shall establish uniform marketing standards that all
    insured QHBP offering entities shall meet.

    SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

      (a) In General.--A QHBP offering entity shall provide for timely
    grievance and appeals mechanisms that the Commissioner shall establish.
      (b) Internal Claims and Appeals Process.--Under a qualified health
    benefits plan the QHBP offering entity shall provide an internal claims
    and appeals process that initially incorporates the claims and appeals
    procedures (including urgent claims) set forth at section 2560.503-1 of
    title 29, Code of Federal Regulations, as published on November 21,
    2000 (65 Fed. Reg. 70246) and shall update such process in accordance
    with any standards that the Commissioner may establish.
      (c) External Review Process.--
              (1) In general.--The Commissioner shall establish an external
            review process (including procedures for expedited reviews of
            urgent claims) that provides for an impartial, independent, and
            de novo review of denied claims under this division.
              (2) Requiring fair grievance and appeals mechanisms.--A
            determination made, with respect to a qualified health benefits
            plan offered by a QHBP offering entity, under the external
            review process established under this subsection shall be
            binding on the plan and the entity.
      (d) Construction.--Nothing in this section shall be construed as
    affecting the availability of judicial review under State law for
    adverse decisions under subsection (b) or (c), subject to section 151.

    SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

      (a) Accurate and Timely Disclosure.--
              (1) In general.--A qualified health benefits plan shall
            comply with standards established by the Commissioner for the
            accurate and timely disclosure of plan documents, plan terms
            and conditions, claims payment policies and practices, periodic
            financial disclosure, data on enrollment, data on
            disenrollment, data on the number of claims denials, data on
            rating practices, information on cost-sharing and payments with
            respect to any out-of-network coverage, and other information
            as determined appropriate by the Commissioner. The Commissioner
            shall require that such disclosure be provided in plain
            language.
              (2) Plain language.--In this subsection, the term ``plain
            language'' means language that the intended audience, including
            individuals with limited English proficiency, can readily
            understand and use because that language is clean, concise,
            well-organized, and follows other best practices of plain
            language writing.
              (3) Guidance.--The Commissioner shall develop and issue
            guidance on best practices of plain language writing.
      (b) Contracting Reimbursement.--A qualified health benefits plan
    shall comply with standards established by the Commissioner to ensure
    transparency to each health care provider relating to reimbursement
    arrangements between such plan and such provider.
      (c) Advance Notice of Plan Changes.--A change in a qualified health
    benefits plan shall not be made without such reasonable and timely
    advance notice to enrollees of such change.
      (d) Identification of Providers Trained and Accredited in Integrative
    Medicine.--A qualified health benefit plan shall include in the
    disclosure required under subsection (a) identification to enrollees of
    any providers of services under the plan that are trained and
    accredited in integrative health medicine.

    SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED
                        THROUGH THE HEALTH INSURANCE EXCHANGE.

      The requirements of the previous provisions of this subtitle shall
    apply to qualified health benefits plans that are not being offered
    through the Health Insurance Exchange only to the extent specified by
    the Commissioner.

    SEC. 135. TIMELY PAYMENT OF CLAIMS.

      A QHBP offering entity shall comply with the requirements of section
    1857(f) of the Social Security Act with respect to a qualified health
    benefits plan it offers in the same manner an Medicare Advantage
    organization is required to comply with such requirements with respect
    to a Medicare Advantage plan it offers under part C of Medicare.

    SEC. 136. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF
                        BENEFITS.

      The Commissioner shall establish standards for the coordination and
    subrogation of benefits and reimbursement of payments in cases
    involving individuals and multiple plan coverage.

    SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.

      A QHBP offering entity is required to comply with standards for
    electronic financial and administrative transactions under section
    1173A of the Social Security Act, added by section 163(a).

    SEC. 138. RECORDS RELATIVE TO PRESCRIPTION INFORMATION.

      (a) In General.--A qualified health benefits plan shall ensure that
    its records relative to prescription information containing patient
    identifiable and prescriber-identifiable data are maintained in
    accordance with this section.''
      (b) Requirements.--
              (1) In general.--Records described in subsection (a) may not
            be licensed, transferred, used, or sold by any pharmacy
            benefits manager, insurance company, electronic transmission
            intermediary, retail, mail order, or Internet pharmacy or other
            similar entity, for any commercial purpose, except for the
            limited purposes of--
                      (A) pharmacy reimbursement;
                      (B) formulary compliance;
                      (C) care management;
                      (D) utilization review by a health care provider, the
                    patient's insurance provider or the agent of either;
                      (E) health care research; or
                      (F) as otherwise provided by law.
              (2) Commercial purpose.--For purposes of paragraph (1), the
            term ``commercial purpose'' includes, but is not limited to,
            advertising, marketing, promotion, or any activity that could
            be used to influence sales or market share of a pharmaceutical
            product, influence or evaluate the prescribing behavior of an
            individual health care professional, or evaluate the
            effectiveness of a professional pharmaceutical detailing sales
            force.
      (c) Construction.--
              (1) Permitted practices.--Nothing in this section shall
            prohibit--
                      (A) the dispensing of prescription medications to a
                    patient or to the patient's authorized representative;
                      (B) the transmission of prescription information
                    between an authorized prescriber and a licensed
                    pharmacy;
                      (C) the transfer of prescription information between
                    licensed pharmacies;
                      (D) the transfer of prescription records that may
                    occur in the event a pharmacy ownership is changed or
                    transferred;
                      (E) care management educational communications
                    provided to a patient about the patient's health
                    condition, adherence to a prescribed course of therapy,
                    or other information about the drug being dispensed,
                    treatment options, or clinical trials.
              (2) De-identified data.--Nothing in this section shall
            prohibit the collection, use, transfer, or sale of patient and
            prescriber de-identified data by zip code, geographic region,
            or medical specialty for commercial purposes.

                             Subtitle E--Governance

    SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.

      (a) In General.--There is hereby established, as an independent
    agency in the executive branch of the Government, a Health Choices
    Administration (in this division referred to as the
    ``Administration'').
      (b) Commissioner.--
              (1) In general.--The Administration shall be headed by a
            Health Choices Commissioner (in this division referred to as
            the ``Commissioner'') who shall be appointed by the President,
            by and with the advice and consent of the Senate.
              (2) Compensation; etc.--The provisions of paragraphs (2), (5)
            and (7) of subsection (a) (relating to compensation, terms,
            general powers, rulemaking, and delegation) of section 702 of
            the Social Security Act (42 U.S.C. 902) shall apply to the
            Commissioner and the Administration in the same manner as such
            provisions apply to the Commissioner of Social Security and the
            Social Security Administration.

    SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.

      (a) Duties.--The Commissioner is responsible for carrying out the
    following functions under this division:
              (1) Qualified plan standards.--The establishment of qualified
            health benefits plan standards under this title, including the
            enforcement of such standards in coordination with State
            insurance regulators and the Secretaries of Labor and the
            Treasury.
              (2) Health insurance exchange.--The establishment and
            operation of a Health Insurance Exchange under subtitle A of
            title II.
              (3) Individual affordability credits.--The administration of
            individual affordability credits under subtitle C of title II,
            including determination of eligibility for such credits.
              (4) Additional functions.--Such additional functions as may
            be specified in this division.
      (b) Promoting Accountability.--
              (1) In general.--The Commissioner shall undertake activities
            in accordance with this subtitle to promote accountability of
            QHBP offering entities in meeting Federal health insurance
            requirements, regardless of whether such accountability is with
            respect to qualified health benefits plans offered through the
            Health Insurance Exchange or outside of such Exchange.
              (2) Compliance examination and audits.--
                      (A) In general.--The commissioner shall, in
                    coordination with States, conduct audits of qualified
                    health benefits plan compliance with Federal
                    requirements.   Such audits may include random
                    compliance audits and targeted audits in response to
                    complaints or other suspected non-compliance.
                      (B) Recoupment of costs in connection with
                    examination and audits.--The Commissioner is authorized
                    to recoup from qualified health benefits plans
                    reimbursement for the costs of such examinations and
                    audit of such QHBP offering entities.
      (c) Data Collection.--The Commissioner shall collect data for
    purposes of carrying out the Commissioner's duties, including for
    purposes of promoting quality and value, protecting consumers, and
    addressing disparities in health and health care and may share such
    data with the Secretary of Health and Human Services.
      (d) Sanctions Authority.--
              (1) In general.--In the case that the Commissioner determines
            that a QHBP offering entity violates a requirement of this
            title, the Commissioner may, in coordination with State
            insurance regulators and the Secretary of Labor, provide, in
            addition to any other remedies authorized by law, for any of
            the remedies described in paragraph (2).
              (2) Remedies.--The remedies described in this paragraph, with
            respect to a qualified health benefits plan offered by a QHBP
            offering entity, are--
                      (A) civil money penalties of not more than the amount
                    that would be applicable under similar circumstances
                    for similar violations under section 1857(g) of the
                    Social Security Act;
                      (B) suspension of enrollment of individuals under
                    such plan after the date the Commissioner notifies the
                    entity of a determination under paragraph (1) and until
                    the Commissioner is satisfied that the basis for such
                    determination has been corrected and is not likely to
                    recur;
                      (C) in the case of an Exchange-participating health
                    benefits plan, suspension of payment to the entity
                    under the Health Insurance Exchange for individuals
                    enrolled in such plan after the date the Commissioner
                    notifies the entity of a determination under paragraph
                    (1) and until the Secretary is satisfied that the basis
                    for such determination has been corrected and is not
                    likely to recur; or
                      (D) working with State insurance regulators to
                    terminate plans for repeated failure by the offering
                    entity to meet the requirements of this title.
      (e) Standard Definitions of Insurance and Medical Terms.--The
    Commissioner shall provide for the development of standards for the
    definitions of terms used in health insurance coverage, including
    insurance-related terms.
      (f) Efficiency in Administration.--The Commissioner shall issue
    regulations for the effective and efficient administration of the
    Health Insurance Exchange and affordability credits under subtitle C,
    including, with respect to the determination of eligibility for
    affordability credits, the use of personnel who are employed in
    accordance with the requirements of title 5, United States Code, to
    carry out the duties of the Commissioner or, in the case of sections
    208 and 241(b)(2), the use of State personnel who are employed in
    accordance with standards prescribed by the Office of Personnel
    Management pursuant to section 208 of the Intergovernmental Personnel
    Act of 1970 (42 U.S.C. 4728).

    SEC. 143. CONSULTATION AND COORDINATION.

      (a) Consultation.--In carrying out the Commissioner's duties under
    this division, the Commissioner, as appropriate, shall consult with at
    least with the following:
              (1) The National Association of Insurance Commissioners,
            State attorneys general, and State insurance regulators,
            including concerning the standards for insured qualified health
            benefits plans under this title and enforcement of such
            standards.
              (2) Appropriate State agencies, specifically concerning the
            administration of individual affordability credits under
            subtitle C of title II and the offering of Exchange-
            participating health benefits plans, to Medicaid eligible
            individuals under subtitle A of such title.
              (3) Other appropriate Federal agencies.
              (4) Indian tribes and tribal organizations.
              (5) The National Association of Insurance Commissioners for
            purposes of using model guidelines established by such
            association for purposes of subtitles B and D.
      (b) Coordination.--
              (1) In general.--In carrying out the functions of the
            Commissioner, including with respect to the enforcement of the
            provisions of this division, the Commissioner shall work in
            coordination with existing Federal and State entities to the
            maximum extent feasible consistent with this division and in a
            manner that prevents conflicts of interest in duties and
            ensures effective enforcement.
              (2) Uniform standards.--The Commissioner, in coordination
            with such entities, shall seek to achieve uniform standards
            that adequately protect consumers in a manner that does not
            unreasonably affect employers and insurers.

    SEC. 144. HEALTH INSURANCE OMBUDSMAN.

      (a) In General.--The Commissioner shall appoint within the Health
    Choices Administration a Qualified Health Benefits Plan Ombudsman who
    shall have expertise and experience in the fields of health care and
    education of (and assistance to) individuals.
      (b) Duties.--The Qualified Health Benefits Plan Ombudsman shall, in a
    linguistically appropriate manner--
              (1) receive complaints, grievances, and requests for
            information submitted by individuals;
              (2) provide assistance with respect to complaints,
            grievances, and requests referred to in paragraph (1),
            including--
                      (A) helping individuals determine the relevant
                    information needed to seek an appeal of a decision or
                    determination;
                      (B) assistance to such individuals with any problems
                    arising from disenrollment from such a plan;
                      (C) assistance to such individuals in choosing a
                    qualified health benefits plan in which to enroll; and
                      (D) assistance to such individuals in presenting
                    information under subtitle C (relating to affordability
                    credits);
              (3) consult with educated patients and consumer advocates
            (described in section 123(a)(5)); and
              (4) submit annual reports to Congress and the Commissioner
            that describe the activities of the Ombudsman and that include
            such recommendations for improvement in the administration of
            this division as the Ombudsman determines appropriate. The
            Ombudsman shall not serve as an advocate for any increases in
            payments or new coverage of services, but may identify issues
            and problems in payment or coverage policies.

           Subtitle F--Relation to Other Requirements; Miscellaneous

    SEC. 151. RELATION TO OTHER REQUIREMENTS.

      (a) Coverage Not Offered Through Exchange.--
              (1) In general.--In the case of health insurance coverage not
            offered through the Health Insurance Exchange (whether or not
            offered in connection with an employment-based health plan),
            and in the case of employment-based health plans, the
            requirements of this title do not supercede any requirements
            applicable under titles XXII and XXVII of the Public Health
            Service Act, parts 6 and 7 of subtitle B of title I of the
            Employee Retirement Income Security Act of 1974, or State law,
            except insofar as such requirements prevent the application of
            a requirement of this division, as determined by the
            Commissioner.
              (2) Construction.--Nothing in paragraph (1) shall be
            construed as affecting the application of section 514 of the
            Employee Retirement Income Security Act of 1974.
      (b) Coverage Offered Through Exchange.--
              (1) In general.--In the case of health insurance coverage
            offered through the Health Insurance Exchange--
                      (A) the requirements of this title do not supercede
                    any requirements (including requirements relating to
                    genetic information nondiscrimination and mental
                    health) applicable under title XXVII of the Public
                    Health Service Act or under State law, except insofar
                    as such requirements prevent the application of a
                    requirement of this division, as determined by the
                    Commissioner; and
                      (B) individual rights and remedies under State laws
                    shall apply.
              (2) Construction.--In the case of coverage described in
            paragraph (1), nothing in such paragraph shall be construed as
            preventing the application of rights and remedies under State
            laws with respect to any requirement referred to in paragraph
            (1)(A).

    SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE.

      (a) In General.--Except as otherwise explicitly permitted by this Act
    and by subsequent regulations consistent with this Act, all health care
    and related services (including insurance coverage and public health
    activities) covered by this Act shall be provided without regard to
    personal characteristics extraneous to the provision of high quality
    health care or related services.
      (b) Implementation.--To implement the requirement set forth in
    subsection (a), the Secretary of Health and Human Services shall, not
    later than 18 months after the date of the enactment of this Act,
    promulgate such regulations as are necessary or appropriate to insure
    that all health care and related services (including insurance coverage
    and public health activities) covered by this Act are provided (whether
    directly or through contractual, licensing, or other arrangements)
    without regard to personal characteristics extraneous to the provision
    of high quality health care or related services.

    SEC. 153. WHISTLEBLOWER PROTECTION.

      (a) Retaliation Prohibited.--No employer may discharge any employee
    or otherwise discriminate against any employee with respect to his
    compensation, terms, conditions, or other privileges of employment
    because the employee (or any person acting pursuant to a request of the
    employee)--
              (1) provided, caused to be provided, or is about to provide
            or cause to be provided to the employer, the Federal
            Government, or the attorney general of a State information
            relating to any violation of, or any act or omission the
            employee reasonably believes to be a violation of any provision
            of this Act or any order, rule, or regulation promulgated under
            this Act;
              (2) testified or is about to testify in a proceeding
            concerning such violation;
              (3) assisted or participated or is about to assist or
            participate in such a proceeding; or
              (4) objected to, or refused to participate in, any activity,
            policy, practice, or assigned task that the employee (or other
            such person) reasonably believed to be in violation of any
            provision of this Act or any order, rule, or regulation
            promulgated under this Act.
      (b) Enforcement Action.--An employee covered by this section who
    alleges discrimination by an employer in violation of subsection (a)
    may bring an action governed by the rules, procedures, legal burdens of
    proof, and remedies set forth in section 40(b) of the Consumer Product
    Safety Act (15 U.S.C. 2087(b)).
      (c) Employer Defined.--As used in this section, the term ``employer''
    means any person (including one or more individuals, partnerships,
    associations, corporations, trusts, professional membership
    organization including a certification, disciplinary, or other
    professional body, unincorporated organizations, nongovernmental
    organizations, or trustees) engaged in profit or nonprofit business or
    industry whose activities are governed by this Act, and any agent,
    contractor, subcontractor, grantee, or consultant of such person.
      (d) Rule of Construction.--The rule of construction set forth in
    section 20109(h) of title 49, United States Code, shall also apply to
    this section.

    SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.

      Nothing in this division shall be construed to alter or supercede any
    statutory or other obligation to engage in collective bargaining over
    the terms and conditions of employment related to health care.

    SEC. 155. SEVERABILITY.

      If any provision of this Act, or any application of such provision to
    any person or circumstance, is held to be unconstitutional, the
    remainder of the provisions of this Act and the application of the
    provision to any other person or circumstance shall not be affected.

    SEC. 156. RULE OF CONSTRUCTION REGARDING HAWAII PREPAID HEALTH CARE
                        ACT.

      (a) In General.--Subject to this section--
              (1) nothing in this division (or an amendment made by this
            division) shall be construed to modify or limit the application
            of the exemption for the Hawaii Prepaid Health Care Act (Haw.
            Rev. Stat. Sec. Sec.  393-1 et seq.) as provided for under
            section 514(b)(5) of the Employee Retirement Income Security
            Act of 1974 (29 U.S.C. 1144(b)(5)), and such exemption shall
            also apply with respect to the provisions of this division, and
              (2) for purposes of this division (and the amendments made by
            this division), coverage provided pursuant to the Hawaii
            Prepaid Health Care Act shall be treated as a qualified health
            benefits plan providing acceptable coverage so long as the
            Secretary of Labor determines that such coverage for employees
            (taking into account the benefits and the cost to employees for
            such benefits) is substantially equivalent to or greater than
            the coverage provided for employees pursuant to the essential
            benefits package.
      (b) Coordination With State Law of Hawaii.--The Commissioner shall,
    based on ongoing consultation with the appropriate officials of the
    State of Hawaii, make adjustments to rules and regulations of the
    Commissioner under this division as may be necessary, as determined by
    the Commissioner, to most effectively coordinate the provisions of this
    division with the provisions of the Hawaii Prepaid Health Care Act,
    taking into account any changes made from time to time to the Hawaii
    Prepaid Health Care Act and related laws of such State.

    SEC. 157. INCREASING MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS.

      (a) Study.--The Commissioner shall conduct a study on methods that
    QHBP offering entities can use to encourage increased meaningful use of
    electronic health records by health care providers, including--
              (1) qualified health benefits plans offering higher
            reimbursement rates for such meaningful use; and
              (2) promoting the use by health care providers of low-cost
            available electronic health record software packages, such as
            software made available to health care providers by the
            Veterans Administration.
      (b) Report.--Not later than 2 years after the date of the enactment
    of this Act, the Commissioner shall submit to the Congress a report
    containing--
              (1) the results of the study under subsection (a); and
              (2) recommendations concerning whether qualified health
            benefits plans should increase reimbursement rates to health
            care providers to increase meaningful use of electronic health
            records by such providers.
      (c) Requirements.--
              (1) In general.--Not later than one year after the date the
            report is submitted to the Congress under subsection (b), if,
            under subsection (b)(2), the Commissioner recommends increased
            reimbursement rates, the Commissioner shall require that
            qualified health benefits plans increase reimbursement rates
            for health care providers that show meaningful use of
            electronic health records.
              (2) Cost limitation.--An increase in rates under paragraph
            (1) shall not result in any increase in affordability premium
            or cost-sharing credits under subtitle C of title II of this
            division.

    SEC. 158. PRIVATE RIGHT OF CONTRACT WITH HEALTH CARE PROVIDERS.

      Nothing in this Act shall be construed to preclude any participant or
    beneficiary in a group health plan from entering into any contract or
    arrangement for health care with any health care provider.

                         Subtitle G--Early Investments

    SEC. 161-163. [FOR SECTIONS 161 THROUGH 163, SEE THE TEXT OF H.R.3200,
                        AS INTRODUCED.]

    SEC. 164. REINSURANCE PROGRAM FOR RETIREES.

      (a) Establishment.--
              (1) In general.--Not later than 90 days after the date of the
            enactment of this Act, the Secretary of Health and Human
            Services shall establish a temporary reinsurance program (in
            this section referred to as the ``reinsurance program'') to
            provide reimbursement to assist participating employment-based
            plans with the cost of providing health benefits to retirees
            and to eligible spouses, surviving spouses and dependents of
            such retirees.
              (2) Definitions.--For purposes of this section:
                      (A) The term ``eligible employment-based plan'' means
                    a group health benefits plan that--
                              (i) is maintained by one or more employers,
                            former employers or employee associations, or a
                            voluntary employees' beneficiary association,
                            or a committee or board of individuals
                            appointed to administer such plan, and
                              (ii) provides health benefits to retirees.
                      (B) The term ``health benefits'' means medical,
                    surgical, hospital, prescription drug, and such other
                    benefits as shall be determined by the Secretary,
                    whether self-funded or delivered through the purchase
                    of insurance or otherwise.
                      (C) The term ``participating employment-based plan''
                    means an eligible employment-based plan that is
                    participating in the reinsurance program.
                      (D) The term ``retiree'' means, with respect to a
                    participating employment-benefit plan, an individual
                    who--
                              (i) is 55 years of age or older;
                              (ii) is not eligible for coverage under title
                            XVIII of the Social Security Act; and
                              (iii) is not an active employee of an
                            employer maintaining the plan or of any
                            employer that makes or has made substantial
                            contributions to fund such plan.
                      (E) The term ``Secretary'' means Secretary of Health
                    and Human Services.
      (b) Participation.--To be eligible to participate in the reinsurance
    program, an eligible employment-based plan shall submit to the
    Secretary an application for participation in the program, at such
    time, in such manner, and containing such information as the Secretary
    shall require.
      (c) Payment.--
              (1) Submission of claims.--
                      (A) In general.--Under the reinsurance program, a
                    participating employment-based plan shall submit claims
                    for reimbursement to the Secretary which shall contain
                    documentation of the actual costs of the items and
                    services for which each claim is being submitted.
                      (B) Basis for claims.--Each claim submitted under
                    subparagraph (A) shall be based on the actual amount
                    expended by the participating employment-based plan
                    involved within the plan year for the appropriate
                    employment based health benefits provided to a retiree
                    or to the spouse, surviving spouse, or dependent of a
                    retiree. In determining the amount of any claim for
                    purposes of this subsection, the participating
                    employment-based plan shall take into account any
                    negotiated price concessions (such as discounts, direct
                    or indirect subsidies, rebates, and direct or indirect
                    remunerations) obtained by such plan with respect to
                    such health benefits. For purposes of calculating the
                    amount of any claim, the costs paid by the retiree or
                    by the spouse, surviving spouse, or dependent of the
                    retiree in the form of deductibles, co-payments, and
                    co-insurance shall be included along with the amounts
                    paid by the participating employment-based plan.
              (2) Program payments and limit.--If the Secretary determines
            that a participating employment-based plan has submitted a
            valid claim under paragraph (1), the Secretary shall reimburse
            such plan for 80 percent of that portion of the costs
            attributable to such claim that exceeds $15,000, but is less
            than $90,000. Such amounts shall be adjusted each year based on
            the percentage increase in the medical care component of the
            Consumer Price Index (rounded to the nearest multiple of
            $1,000) for the year involved.
              (3) Use of payments.--Amounts paid to a participating
            employment-based plan under this subsection shall be used to
            lower the costs borne directly by the participants and
            beneficiaries for health benefits provided under such plan in
            the form of premiums, co-payments, deductibles, co-insurance,
            or other out-of-pocket costs. Such payments shall not be used
            to reduce the costs of an employer maintaining the
            participating employment-based plan. The Secretary shall
            develop a mechanism to monitor the appropriate use of such
            payments by such plans.
              (4) Appeals and program protections.--The Secretary shall
            establish--
                      (A) an appeals process to permit participating
                    employment-based plans to appeal a determination of the
                    Secretary with respect to claims submitted under this
                    section; and
                      (B) procedures to protect against fraud, waste, and
                    abuse under the program.
              (5) Audits.--The Secretary shall conduct annual audits of
            claims data submitted by participating employment-based plans
            under this section to ensure that they are in compliance with
            the requirements of this section.
      (d) Retiree Reserve Trust Fund.--
              (1) Establishment.--
                      (A) In general.--There is established in the Treasury
                    of the United States a trust fund to be known as the
                    ``Retiree Reserve Trust Fund'' (referred to in this
                    section as the ``Trust Fund''), that shall consist of
                    such amounts as may be appropriated or credited to the
                    Trust Fund as provided for in this subsection to enable
                    the Secretary to carry out the reinsurance program.
                    Such amounts shall remain available until expended.
                      (B) Funding.--There are hereby appropriated to the
                    Trust Fund, out of any moneys in the Treasury not
                    otherwise appropriated, an amount requested by the
                    Secretary as necessary to carry out this section,
                    except that the total of all such amounts requested
                    shall not exceed $10,000,000,000.
                      (C) Appropriations from the trust fund.--
                              (i) In general.--Amounts in the Trust Fund
                            are appropriated to provide funding to carry
                            out the reinsurance program and shall be used
                            to carry out such program.
                              (ii) Budgetary implications.--Amounts
                            appropriated under clause (i), and outlays
                            flowing from such appropriations, shall not be
                            taken into account for purposes of any budget
                            enforcement procedures including allocations
                            under section 302(a) and (b) of the Balanced
                            Budget and Emergency Deficit Control Act and
                            budget resolutions for fiscal years during
                            which appropriations are made from the Trust
                            Fund.
                              (iii) Limitation to available funds.--The
                            Secretary has the authority to stop taking
                            applications for participation in the program
                            or take such other steps in reducing
                            expenditures under the reinsurance program in
                            order to ensure that expenditures under the
                            reinsurance program do not exceed the funds
                            available under this subsection.

    SEC. 165. PROHIBITION AGAINST POST-RETIREMENT REDUCTIONS OF RETIREE
                        HEALTH BENEFITS BY GROUP HEALTH PLANS.

      (a) In General.--Part 7 of subtitle B of title I of the Employee
    Retirement Income Security Act of 1974 is amended by inserting after
    section 714 the following new section:

    ``SEC. 715. PROTECTION AGAINST POST-RETIREMENT REDUCTION OF RETIREE
                        HEALTH BENEFITS.

      ``(a) In General.--Every group health plan shall contain a provision
    which expressly bars the plan, or any fiduciary of the plan, from
    reducing the benefits provided under the plan to a retired participant,
    or beneficiary of such participant, if such reduction affects the
    benefits provided to the participant or beneficiary as of the date the
    participant retired for purposes of the plan and such reduction occurs
    after the participant's retirement unless such reduction is also made
    with respect to active participants.
      ``(b) No Reduction.--Notwithstanding that a group health plan
    described in subsection (a) may contain a provision reserving the
    general power to amend or terminate the plan or a provision
    specifically authorizing the plan to make post-retirement reductions in
    retiree health benefits, it shall be prohibited for any group health
    plan, whether through amendment or otherwise, to reduce the benefits
    provided to a retired participant or his or her beneficiary under the
    terms of the plan if such reduction of benefits occurs after the date
    the participant retired for purposes of the plan and reduces benefits
    that were provided to the participant, or his or her beneficiary, as of
    the date the participant retired unless such reduction is also made
    with respect to active participants.''.
      (b) Conforming Amendment.--The table of contents in section 1 of such
    Act is amended by inserting after the item relating to section 714 the
    following new item:

    ``Sec. 715. Protection against post-retirement reduction of retiree
    health benefits.''.
      (c) Effective Date.--The amendments made by this section shall take
    effect on the date of the enactment of this Act.

    SEC. 166. LIMITATIONS ON PREEXISTING CONDITION EXCLUSIONS IN GROUP
                        HEALTH PLANS IN ADVANCE OF APPLICABILITY OF NEW
                        PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS.

      (a) Amendments to the Employee Retirement Income Security Act of
    1974.--
              (1) Reduction in look-back period.--Section 701(a)(1) of the
            Employee Retirement Income Security Act of 1974 (29 U.S.C.
            1181(a)(1)) is amended by striking ``6-month period'' and
            inserting ``30-day period''.
              (2) Reduction in permitted preexisting condition limitation
            period.--Section 701(a)(2) of such Act (29 U.S.C. 1181(a)(2))
            is amended by striking ``12 months'' and inserting ``3
            months'', and by striking ``18 months'' and inserting ``9
            months''.
              (3) Inapplicability of interim limitations upon applicability
            of total prohibition of exclusion.--Section 701 of such Act
            shall cease to be effective in the case of any group health
            plan as of the date on which such plan becomes subject to the
            requirements of section 111 of this Act (relating to
            prohibiting preexisting condition exclusions).
      (b) Effective Date.--
              (1) In general.--Except as provided in subparagraph (B), the
            amendments made by paragraphs (1) and (2) of subsection (a)
            shall apply with respect to group health plans for plan years
            beginning after the end of the 6th calendar month following the
            date of the enactment of this Act.
              (2) Special rule for collective bargaining agreements.--In
            the case of a group health plan maintained pursuant to one or
            more collective bargaining agreements between employee
            representatives and one or more employers ratified before the
            date of the enactment of this Act, the amendments made by
            paragraphs (1) and (2) of subsection (a) shall not apply to
            plan years beginning before the earlier of--
                      (A) the date on which the last of the collective
                    bargaining agreements relating to the plan terminates
                    (determined without regard to any extension thereof
                    agreed to after the date of the enactment of this Act),
                    or
                      (B) 3 years after the date of the enactment of this
                    Act.
            For purposes of subparagraph (A), any plan amendment made
            pursuant to a collective bargaining agreement relating to the
            plan which amends the plan solely to conform to any requirement
            added by the amendments made by paragraphs (1) and (2) of
            subsection (a) shall not be treated as a termination of such
            collective bargaining agreement.

    SEC. 167. EXTENSION OF COBRA CONTINUATION COVERAGE.

      (a) Extension of Current Periods of Continuation Coverage.--
              (1) In general.--In the case of any individual who is, under
            a COBRA continuation coverage provision, covered under COBRA
            continuation coverage on or after the date of the enactment of
            this Act, the required period of any such coverage which has
            not subsequently terminated under the terms of such provision
            for any reason other than the expiration of a period of a
            specified number of months shall, notwithstanding such
            provision and subject to subsection (b), extend to the earlier
            of the date on which such individual becomes eligible for
            coverage under an employment-based health plan or the date on
            which such individual becomes eligible for health insurance
            coverage through the Health Insurance Exchange (or a State-
            based Health Insurance Exchange operating in a State or group
            of States).
              (2) Notice.--As soon as practicable after the date of the
            enactment of this Act, the Secretary of Labor, in consultation
            with the Secretary of the Treasury and the Secretary of Health
            and Human Services, shall, in consultation with administrators
            of the group health plans (or other entities) that provide or
            administer the COBRA continuation coverage involved, provide
            rules setting forth the form and manner in which prompt notice
            to individuals of the continued availability of COBRA
            continuation coverage to such individuals under paragraph (1).
      (b) Continued Effect of Other Terminating Events.--Notwithstanding
    subsection (a), any required period of COBRA continuation coverage
    which is extended under such subsection shall terminate upon the
    occurrence, prior to the date of termination otherwise provided in such
    subsection, of any terminating event specified in the applicable
    continuation coverage provision other than the expiration of a period
    of a specified number of months.
      (c) Access to State Health Benefits Risk Pools.--This section shall
    supersede any provision of the law of a State or political subdivision
    thereof to the extent that such provision has the effect of limiting or
    precluding access by a qualified beneficiary whose COBRA continuation
    coverage has been extended under this section to a State health
    benefits risk pool recognized by the Commissioner for purposes of this
    section solely by reason of the extension of such coverage beyond the
    date on which such coverage otherwise would have expired.
      (d) Definitions.--For purposes of this section--
              (1) COBRA continuation coverage.--The term ``COBRA
            continuation coverage'' means continuation coverage provided
            pursuant to part 6 of subtitle B of title I of the Employee
            Retirement Income Security Act of 1974 (other than under
            section 609), title XXII of the Public Health Service Act,
            section 4980B of the Internal Revenue Code of 1986 (other than
            subsection (f)(1) of such section insofar as it relates to
            pediatric vaccines), or section 905a of title 5, United States
            Code, or under a State program that provides comparable
            continuation coverage. Such term does not include coverage
            under a health flexible spending arrangement under a cafeteria
            plan within the meaning of section 125 of the Internal Revenue
            Code of 1986.
              (2) COBRA continuation provision.--The term ``COBRA
            continuation provision'' means the provisions of law described
            in paragraph (1).

           TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

                     Subtitle A--Health Insurance Exchange

    SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF
                        DUTIES; DEFINITIONS.

      (a) Establishment.--There is established within the Health Choices
    Administration and under the direction of the Commissioner a Health
    Insurance Exchange in order to facilitate access of individuals and
    employers, through a transparent process, to a variety of choices of
    affordable, quality health insurance coverage, including a public
    health insurance option.
      (b) Outline of Duties of Commissioner.--In accordance with this
    subtitle and in coordination with appropriate Federal and State
    officials as provided under section 143(b), the Commissioner shall--
              (1) under section 204 establish standards for, accept bids
            from, and negotiate and enter into contracts with, QHBP
            offering entities for the offering of health benefits plans
            through the Health Insurance Exchange, with different levels of
            benefits required under section 203, and including with respect
            to oversight and enforcement;
              (2) under section 205 facilitate outreach and enrollment in
            such plans of Exchange-eligible individuals and employers
            described in section 202; and
              (3) conduct such activities related to the Health Insurance
            Exchange as required, including establishment of a risk pooling
            mechanism under section 206 and consumer protections under
            subtitle D of title I.
      (c) Exchange-participating Health Benefits Plan Defined.--In this
    division, the term ``Exchange-participating health benefits plan''
    means a qualified health benefits plan that is offered through the
    Health Insurance Exchange.

    SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

      (a) Access to Coverage.--In accordance with this section, all
    individuals are eligible to obtain coverage through enrollment in an
    Exchange-participating health benefits plan offered through the Health
    Insurance Exchange unless such individuals are enrolled in another
    qualified health benefits plan or other acceptable coverage.
      (b) Definitions.--In this division:
              (1) Exchange-eligible individual.--The term ``Exchange-
            eligible individual'' means an individual who is eligible under
            this section to be enrolled through the Health Insurance
            Exchange in an Exchange-participating health benefits plan and,
            with respect to family coverage, includes dependents of such
            individual.
              (2) Exchange-eligible employer.--The term ``Exchange-eligible
            employer'' means an employer that is eligible under this
            section to enroll through the Health Insurance Exchange
            employees of the employer (and their dependents) in Exchange-
            eligible health benefits plans.
              (3) Employment-related definitions.--The terms ``employer'',
            ``employee'', ``full-time employee'', and ``part-time
            employee'' have the meanings given such terms by the
            Commissioner for purposes of this division.
      (c) Transition.--Individuals and employers shall only be eligible to
    enroll or participate in the Health Insurance Exchange in accordance
    with the following transition schedule:
              (1) First year.--In Y1 (as defined in section 100(c))--
                      (A) individuals described in subsection (d)(1),
                    including individuals described in paragraphs (3), (4),
                    and (5) of subsection (d); and
                      (B) smallest employers described in subsection
                    (e)(1).
              (2) Second year.--In Y2--
                      (A) individuals and employers described in paragraph
                    (1); and
                      (B) smaller employers described in subsection (e)(2).
              (3)  Third year.--In Y3--
                      (A) individuals and employers described in paragraph
                    (2);
                      (B) larger employers described in subsection (e)(3);
                    and
                      (C) largest employers as permitted by the
                    Commissioner under subsection (e)(4).
              (4) Fourth and subsequent years.--In Y4 and subsequent
            years--
                      (A) individuals and employers described in paragraph
                    (3); and
                      (B) largest employers as permitted by the
                    Commissioner under subsection (e)(4).
      (d) Individuals.--
              (1) Individual described.--Subject to the succeeding
            provisions of this subsection, an individual described in this
            paragraph is an individual who--
                      (A) is not enrolled in coverage described in
                    subparagraphs (C) through (F) of paragraph (2); and
                      (B) is not enrolled in coverage as a full-time
                    employee (or as a dependent of such an employee) under
                    a group health plan if the coverage and an employer
                    contribution under the plan meet the requirements of
                    section 312.
            For purposes of subparagraph (B), in the case of an individual
            who is self-employed, who has at least 1 employee, and who
            meets the requirements of section 312, such individual shall be
            deemed a full-time employee described in such subparagraph.
              (2) Acceptable coverage.--For purposes of this division, the
            term ``acceptable coverage'' means any of the following:
                      (A) Qualified health benefits plan coverage.--
                    Coverage under a qualified health benefits plan.
                      (B) Grandfathered health insurance coverage; coverage
                    under current group health plan.--Coverage under a
                    grandfathered health insurance coverage (as defined in
                    subsection (a) of section 102) or under a current group
                    health plan (described in subsection (b) of such
                    section).
                      (C) Medicare.--Coverage under part A of title XVIII
                    of the Social Security Act.
                      (D) Medicaid.--Coverage for medical assistance under
                    title XIX of the Social Security Act, excluding such
                    coverage that is only available because of the
                    application of subsection (u), (z), or (aa) of section
                    1902 of such Act
                      (E) Members of the armed forces and dependents
                    (including tricare).--Coverage under chapter 55 of
                    title 10, United States Code, including similar
                    coverage furnished under section 1781 of title 38 of
                    such Code.
                      (F) VA.--Coverage under the veteran's health care
                    program under chapter 17 of title 38, United States
                    Code, but only if the coverage for the individual
                    involved is determined by the Commissioner in
                    coordination with the Secretary of Treasury to be not
                    less than a level specified by the Commissioner and
                    Secretary of Veteran's Affairs, in coordination with
                    the Secretary of Treasury, based on the individual's
                    priority for services as provided under section 1705(a)
                    of such title.
                      (G) Other coverage.--Such other health benefits
                    coverage, such as a State health benefits risk pool, as
                    the Commissioner, in coordination with the Secretary of
                    the Treasury, recognizes for purposes of this
                    paragraph.
            The Commissioner shall make determinations under this paragraph
            in coordination with the Secretary of the Treasury.
              (3) Treatment of certain non-traditional medicaid eligible
            individuals.--An individual who is a non-traditional Medicaid
            eligible individual (as defined in section 205(e)(4)(C)) in a
            State may be an Exchange-eligible individual if the individual
            was enrolled in a qualified health benefits plan, grandfathered
            health insurance coverage, or current group health plan during
            the 6 months before the individual became a non-traditional
            Medicaid eligible individual. During the period in which such
            an individual has chosen to enroll in an Exchange-participating
            health benefits plan, the individual is not also eligible for
            medical assistance under Medicaid.
              (4) Continuing eligibility permitted.--
                      (A) In general.--Except as provided in subparagraph
                    (B), once an individual qualifies as an Exchange-
                    eligible individual under this subsection (including as
                    an employee or dependent of an employee of an Exchange-
                    eligible employer) and enrolls under an Exchange-
                    participating health benefits plan through the Health
                    Insurance Exchange, the individual shall continue to be
                    treated as an Exchange-eligible individual until the
                    individual is no longer enrolled with an Exchange-
                    participating health benefits plan.
                      (B) Exceptions.--
                              (i) In general.--Subparagraph (A) shall not
                            apply to an individual once the individual
                            becomes eligible for coverage--
                                      (I) under part A of the Medicare
                                    program;
                                      (II) under the Medicaid program as a
                                    Medicaid eligible individual, except as
                                    permitted under paragraph (3) or clause
                                    (ii); or
                                      (III) in such other circumstances as
                                    the Commissioner may provide.
                              (ii) Transition period.--In the case
                            described in clause (i)(II), the Commissioner
                            shall permit the individual to continue
                            treatment under subparagraph (A) until such
                            limited time as the Commissioner determines it
                            is administratively feasible, consistent with
                            minimizing disruption in the individual's
                            access to health care.
              (5) Adversely affected retiree health benefits group
            participants and beneficiaries.--
                      (A) In general.--Beginning in Y1, an individual who
                    is a participant or beneficiary in an adversely
                    affected retiree health benefits group who does not
                    have coverage described in paragraph (2)(C) is an
                    Exchange eligible individual, whether or not such an
                    individual has other acceptable coverage.
                      (B) Adverage affected retiree health benefit group
                    defined.--In this paragraph, the term ``adversely
                    affected retiree health benefits group'' means the
                    retired participants and their beneficiaries of a group
                    health plan that cancelled or substantially reduced the
                    amount, type, level, or form of health benefit or
                    option provided prior January 1, 2008.
      (e) Employers.--
              (1)  Smallest employers.--Subject to paragraph (5), smallest
            employers described in this paragraph are employers with 15 or
            fewer employees.
              (2) Smaller employers.--Subject to paragraph (5), smaller
            employers described in this paragraph are employers that are
            not smallest employers described in paragraph (1) and that have
            25 or fewer employees.
              (3) Larger employers.--Subject to paragraph (5), larger
            employers described in this paragraph are employers that are
            not smallest employers described in paragraph (1) or smaller
            employers described in paragraph (2) and that have 50 or fewer
            employees.
              (4) Largest employers.--
                      (A) In general.--Beginning with Y3, the Commissioner
                    may permit employers not described in paragraphs (1)
                    (2), or (3) to be Exchange-eligible employers.
                      (B) Phase-in.--In applying subparagraph (A), the
                    Commissioner may phase-in the application of such
                    subparagraph based on the number of full-time employees
                    of an employer and such other considerations as the
                    Commissioner deems appropriate.
              (5) Continuing eligibility.--Once an employer is permitted to
            be an Exchange-eligible employer under this subsection and
            enrolls employees through the Health Insurance Exchange, the
            employer shall continue to be treated as an Exchange-eligible
            employer for each subsequent plan year regardless of the number
            of employees involved unless and until the employer meets the
            requirement of section 311(a) through paragraph (1) of such
            section by offering a group health plan and not through
            offering Exchange-participating health benefits plan.
              (6) Employer participation and contributions.--
                      (A) Satisfaction of employer responsibility.--For any
                    year in which an employer is an Exchange-eligible
                    employer, such employer may meet the requirements of
                    section 312 with respect to employees of such employer
                    by offering such employees the option of enrolling with
                    Exchange-participating health benefits plans through
                    the Health Insurance Exchange consistent with the
                    provisions of subtitle B of title III.
                      (B) Employee choice.--Any employee offered Exchange-
                    participating health benefits plans by the employer of
                    such employee under subparagraph (A) may choose
                    coverage under any such plan. That choice includes,
                    with respect to family coverage, coverage of the
                    dependents of such employee.
              (7) Affiliated groups.--Any employer which is part of a group
            of employers who are treated as a single employer under
            subsection (b), (c), (m), or (o) of section 414 of the Internal
            Revenue Code of 1986 shall be treated, for purposes of this
            subtitle, as a single employer.
              (8) Other counting rules.--The Commissioner shall establish
            rules relating to how employees are counted for purposes of
            carrying out this subsection.
              (9) Treatment of multiemployer plans.--The plan sponsor of a
            group health plan (as defined in section 733(a) of the Employee
            Retirement Income Security Act of 1974) that is multiemployer
            plan (as defined in section 3(37) of such Act) may obtain
            health insurance coverage with respect to participants in the
            plan through the Exchange to the same extent as an employer not
            described in paragraph (1) or (2) is permitted by the
            Commissioner to obtain health insurance coverage through the
            Exchange as an Exchange-eligible employer
      (f) Special Situation Authority.--The Commissioner shall have the
    authority to establish such rules as may be necessary to deal with
    special situations with regard to uninsured individuals and employers
    participating as Exchange-eligible individuals and employers, such as
    transition periods for individuals and employers who gain, or lose,
    Exchange-eligible participation status, and to establish grace periods
    for premium payment.
      (g) Surveys of Individuals and Employers.--The Commissioner shall
    provide for periodic surveys of Exchange-eligible individuals and
    employers concerning satisfaction of such individuals and employers
    with the Health Insurance Exchange and Exchange-participating health
    benefits plans.
      (h) Exchange Access Study.--
              (1) In general.--The Commissioner shall conduct a study of
            access to the Health Insurance Exchange for individuals and for
            employers, including individuals and employers who are not
            eligible and enrolled in Exchange-participating health benefits
            plans. The goal of the study is to determine if there are
            significant groups and types of individuals and employers who
            are not Exchange eligible individuals or employers, but who
            would have improved benefits and affordability if made eligible
            for coverage in the Exchange.
              (2) Items included in study.--Such study also shall examine--
                      (A) the terms, conditions, and affordability of group
                    health coverage offered by employers and QHBP offering
                    entities outside of the Exchange compared to Exchange-
                    participating health benefits plans; and
                      (B) the affordability-test standard for access of
                    certain employed individuals to coverage in the Health
                    Insurance Exchange.
              (3) Report.--Not later than January 1 of Y3, in Y6, and
            thereafter, the Commissioner shall submit to Congress on the
            study conducted under this subsection and shall include in such
            report recommendations regarding changes in standards for
            Exchange eligibility for for individuals and employers.

    SEC. 203. BENEFITS PACKAGE LEVELS.

      (a) In General.--The Commissioner shall specify the benefits to be
    made available under Exchange-participating health benefits plans
    during each plan year, consistent with subtitle C of title I and this
    section.
      (b) Limitation on Health Benefits Plans Offered by Offering
    Entities.--The Commissioner may not enter into a contract with a QHBP
    offering entity under section 204(c) for the offering of an Exchange-
    participating health benefits plan in a service area unless the
    following requirements are met:
              (1) Required offering of basic plan.--The entity offers only
            one basic plan for such service area.
              (2) Optional offering of enhanced plan.--If and only if the
            entity offers a basic plan for such service area, the entity
            may offer one enhanced plan for such area.
              (3) Optional offering of premium plan.--If and only if the
            entity offers an enhanced plan for such service area, the
            entity may offer one premium plan for such area.
              (4) Optional offering of premium-plus plans.--If and only if
            the entity offers a premium plan for such service area, the
            entity may offer one or more premium-plus plans for such area.
    All such plans may be offered under a single contract with the
    Commissioner.
      (c) Specification of Benefit Levels for Plans.--
              (1) In general.--The Commissioner shall establish the
            following standards consistent with this subsection and title
            I:
                      (A) Basic, enhanced, and premium plans.--Standards
                    for 3 levels of Exchange-participating health benefits
                    plans: basic, enhanced, and premium (in this division
                    referred to as a ``basic plan'', ``enhanced plan'', and
                    ``premium plan'', respectively).
                      (B) Premium-plus plan benefits.--Standards for
                    additional benefits that may be offered, consistent
                    with this subsection and subtitle C of title I, under a
                    premium plan (such a plan with additional benefits
                    referred to in this division as a ``premium-plus
                    plan'') .
              (2) Basic plan.--
                      (A) In general.--A basic plan shall offer the
                    essential benefits package required under title I for a
                    qualified health benefits plan.
                      (B) Tiered cost-sharing for affordable credit
                    eligible individuals.--In the case of an affordable
                    credit eligible individual (as defined in section
                    242(a)(1)) enrolled in an Exchange-participating health
                    benefits plan, the benefits under a basic plan are
                    modified to provide for the reduced cost-sharing for
                    the income tier applicable to the individual under
                    section 244(c).
              (3) Enhanced plan.--A enhanced plan shall offer, in addition
            to the level of benefits under the basic plan, a lower level of
            cost-sharing as provided under title I consistent with section
            123(b)(5)(A).
              (4) Premium plan.--A premium plan shall offer, in addition to
            the level of benefits under the basic plan, a lower level of
            cost-sharing as provided under title I consistent with section
            123(b)(5)(B).
              (5) Premium-plus plan.--A premium-plus plan is a premium plan
            that also provides additional benefits, such as adult oral
            health and vision care, approved by the Commissioner. The
            portion of the premium that is attributable to such additional
            benefits shall be separately specified.
              (6) Range of permissible variation in cost-sharing.--The
            Commissioner shall establish a permissible range of variation
            of cost-sharing for each basic, enhanced, and premium plan,
            except with respect to any benefit for which there is no cost-
            sharing permitted under the essential benefits package. Such
            variation shall permit a variation of not more than plus (or
            minus) 10 percent in cost-sharing with respect to each benefit
            category specified under section 122.
      (d) Treatment of State Benefit Mandates.--Insofar as a State requires
    a health insurance issuer offering health insurance coverage to include
    benefits beyond the essential benefits package, such requirement shall
    continue to apply to an Exchange-participating health benefits plan, if
    the State has entered into an arrangement satisfactory to the
    Commissioner to reimburse the Commissioner for the amount of any net
    increase in affordability premium credits under subtitle C as a result
    of an increase in premium in basic plans as a result of application of
    such requirement.

    SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE-PARTICIPATING HEALTH
                        BENEFITS PLANS.

      (a) Contracting Duties.--In carrying out section 201(b)(1) and
    consistent with this subtitle:
              (1) Offering entity and plan standards.--The Commissioner
            shall--
                      (A) establish standards necessary to implement the
                    requirements of this title and title I for--
                              (i) QHBP offering entities for the offering
                            of an Exchange-participating health benefits
                            plan; and
                              (ii) for Exchange-participating health
                            benefits plans; and
                      (B) certify QHBP offering entities and qualified
                    health benefits plans as meeting such standards and
                    requirements of this title and title I for purposes of
                    this subtitle.
              (2) Soliciting and negotiating bids; contracts.--The
            Commissioner shall--
                      (A) solicit bids from QHBP offering entities for the
                    offering of Exchange-participating health benefits
                    plans;
                      (B) based upon a review of such bids, negotiate with
                    such entities for the offering of such plans; and
                      (C) enter into contracts with such entities for the
                    offering of such plans through the Health Insurance
                    Exchange under terms (consistent with this title)
                    negotiated between the Commissioner and such entities.
              (3) FAR not applicable.--The provisions of the Federal
            Acquisition Regulation shall not apply to contracts between the
            Commissioner and QHBP offering entities for the offering of
            Exchange-participating health benefits plans under this title.
      (b) Standards for QHBP Offering Entities to Offer Exchange-
    participating Health Benefits Plans.--The standards established under
    subsection (a)(1)(A) shall require that, in order for a QHBP offering
    entity to offer an Exchange-participating health benefits plan, the
    entity must meet the following requirements:
              (1) Licensed.--The entity shall be licensed to offer health
            insurance coverage under State law for each State in which it
            is offering such coverage.
              (2) Data reporting.--The entity shall provide for the
            reporting of such information as the Commissioner may specify,
            including information necessary to administer the risk pooling
            mechanism described in section 206(b) and information to
            address disparities in health and health care.
              (3) Implementing affordability credits.--The entity shall
            provide for implementation of the affordability credits
            provided for enrollees under subtitle C, including the
            reduction in cost-sharing under section 244(c).
              (4) Enrollment.--The entity shall accept all enrollments
            under this subtitle, subject to such exceptions (such as
            capacity limitations) in accordance with the requirements under
            title I for a qualified health benefits plan. The entity shall
            notify the Commissioner if the entity projects or anticipates
            reaching such a capacity limitation that would result in a
            limitation in enrollment.
              (5) Risk pooling participation.--The entity shall participate
            in such risk pooling mechanism as the Commissioner establishes
            under section 206(b).
              (6) Essential community providers.--With respect to the basic
            plan offered by the entity, the entity shall contract for
            outpatient services with covered entities (as defined in
            section 340B(a)(4) of the Public Health Service Act, as in
            effect as of July 1, 2009). The Commissioner shall specify the
            extent to which and manner in which the previous sentence shall
            apply in the case of a basic plan with respect to which the
            Commissioner determines provides substantially all benefits
            through a health maintenance organization, as defined in
            section 2791(b)(3) of the Public Health Service Act.
              (7) Culturally and linguistically appropriate services and
            communications.--The entity shall provide for culturally and
            linguistically appropriate communication and health services.
              (8) Additional requirements.--The entity shall comply with
            other applicable requirements of this title, as specified by
            the Commissioner, which shall include standards regarding
            billing and collection practices for premiums and related grace
            periods and which may include standards to ensure that the
            entity does not use coercive practices to force providers not
            to contract with other entities offering coverage through the
            Health Insurance Exchange.
      (c) Contracts.--
              (1) Bid application.--To be eligible to enter into a contract
            under this section, a QHBP offering entity shall submit to the
            Commissioner a bid at such time, in such manner, and containing
            such information as the Commissioner may require.
              (2) Term.--Each contract with a QHBP offering entity under
            this section shall be for a term of not less than one year, but
            may be made automatically renewable from term to term in the
            absence of notice of termination by either party.
              (3) Enforcement of network adequacy.--In the case of a health
            benefits plan of a QHBP offering entity that uses a provider
            network, the contract under this section with the entity shall
            provide that if--
                      (A) the Commissioner determines that such provider
                    network does not meet such standards as the
                    Commissioner shall establish under section 115; and
                      (B) an individual enrolled in such plan receives an
                    item or service from a provider that is not within such
                    network;
            then any cost-sharing for such item or service shall be equal
            to the amount of such cost-sharing that would be imposed if
            such item or service was furnished by a provider within such
            network.
              (4) Oversight and enforcement responsibilities.--The
            Commissioner shall establish processes, in coordination with
            State insurance regulators, to oversee, monitor, and enforce
            applicable requirements of this title with respect to QHBP
            offering entities offering Exchange-participating health
            benefits plans and such plans, including the marketing of such
            plans. Such processes shall include the following:
                      (A) Grievance and complaint mechanisms.--The
                    Commissioner shall establish, in coordination with
                    State insurance regulators, a process under which
                    Exchange-eligible individuals and employers may file
                    complaints concerning violations of such standards.
                      (B) Enforcement.--In carrying out authorities under
                    this division relating to the Health Insurance
                    Exchange, the Commissioner may impose one or more of
                    the intermediate sanctions described in section 142(c).
                      (C) Termination.--
                              (i) In general.--The Commissioner may
                            terminate a contract with a QHBP offering
                            entity under this section for the offering of
                            an Exchange-participating health benefits plan
                            if such entity fails to comply with the
                            applicable requirements of this title. Any
                            determination by the Commissioner to terminate
                            a contract shall be made in accordance with
                            formal investigation and compliance procedures
                            established by the Commissioner under which--
                                      (I) the Commissioner provides the
                                    entity with the reasonable opportunity
                                    to develop and implement a corrective
                                    action plan to correct the deficiencies
                                    that were the basis of the
                                    Commissioner's determination; and
                                      (II) the Commissioner provides the
                                    entity with reasonable notice and
                                    opportunity for hearing (including the
                                    right to appeal an initial decision)
                                    before terminating the contract.
                              (ii) Exception for imminent and serious risk
                            to health.--Clause (i) shall not apply if the
                            Commissioner determines that a delay in
                            termination, resulting from compliance with the
                            procedures specified in such clause prior to
                            termination, would pose an imminent and serious
                            risk to the health of individuals enrolled
                            under the qualified health benefits plan of the
                            QHBP offering entity.
                      (D) Construction.--Nothing in this subsection shall
                    be construed as preventing the application of other
                    sanctions under subtitle E of title I with respect to
                    an entity for a violation of such a requirement.

    SEC. 205. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND
                        EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS
                        PLAN.

      (a) In General.--
              (1) Outreach.--The Commissioner shall conduct outreach
            activities consistent with subsection (c), including through
            use of appropriate entities as described in paragraph (4) of
            such subsection, to inform and educate individuals and
            employers about the Health Insurance Exchange and Exchange-
            participating health benefits plan options. Such outreach shall
            include outreach specific to vulnerable populations, such as
            children, individuals with disabilities, individuals with
            mental illness, and individuals with other cognitive
            impairments.
              (2) Eligibility.--The Commissioner shall make timely
            determinations of whether individuals and employers are
            Exchange-eligible individuals and employers (as defined in
            section 202).
              (3) Enrollment.--The Commissioner shall establish and carry
            out an enrollment process for Exchange-eligible individuals and
            employers, including at community locations, in accordance with
            subsection (b).
      (b) Enrollment Process.--
              (1) In general.--The Commissioner shall establish a process
            consistent with this title for enrollments in Exchange-
            participating health benefits plans. Such process shall provide
            for enrollment through means such as the mail, by telephone,
            electronically, and in person.
              (2) Enrollment periods.--
                      (A) Open enrollment period.--The Commissioner shall
                    establish an annual open enrollment period during which
                    an Exchange-eligible individual or employer may elect
                    to enroll in an Exchange-participating health benefits
                    plan for the following plan year and an enrollment
                    period for affordability credits under subtitle C. Such
                    periods shall be during September through November of
                    each year, or such other time that would maximize
                    timeliness of income verification for purposes of such
                    subtitle. The open enrollment period shall not be less
                    than 30 days.
                      (B) Special enrollment.--The Commissioner shall also
                    provide for special enrollment periods to take into
                    account special circumstances of individuals and
                    employers, such as an individual who--
                              (i) loses acceptable coverage;
                              (ii) experiences a change in marital or other
                            dependent status;
                              (iii) moves outside the service area of the
                            Exchange-participating health benefits plan in
                            which the individual is enrolled; or
                              (iv) experiences a significant change in
                            income.
                      (C) Enrollment information.--The Commissioner shall
                    provide for the broad dissemination of information to
                    prospective enrollees on the enrollment process,
                    including before each open enrollment period. In
                    carrying out the previous sentence, the Commissioner
                    may work with other appropriate entities to facilitate
                    such provision of information.
              (3) Automatic enrollment for non-medicaid eligible
            individuals.--
                      (A) In general.--The Commissioner shall provide for a
                    process under which individuals who are Exchange-
                    eligible individuals described in subparagraph (B) are
                    automatically enrolled under an appropriate Exchange-
                    participating health benefits plan. Such process may
                    involve a random assignment or some other form of
                    assignment that takes into account the health care
                    providers used by the individual involved or such other
                    relevant factors as the Commissioner may specify.
                      (B) Subsidized individuals described.--An individual
                    described in this subparagraph is an Exchange-eligible
                    individual who is either of the following:
                              (i) Affordability credit eligible
                            individuals.--The individual--
                                      (I) has applied for, and been
                                    determined eligible for, affordability
                                    credits under subtitle C;
                                      (II) has not opted out from receiving
                                    such affordability credit; and
                                      (III) does not otherwise enroll in
                                    another Exchange-participating health
                                    benefits plan.
                              (ii) Individuals enrolled in a terminated
                            plan.--The individual is enrolled in an
                            Exchange-participating health benefits plan
                            that is terminated (during or at the end of a
                            plan year) and who does not otherwise enroll in
                            another Exchange-participating health benefits
                            plan.
              (4) Direct payment of premiums to plans.--Under the
            enrollment process, individuals enrolled in an Exchange-
            partcipating health benefits plan shall pay such plans
            directly, and not through the Commissioner or the Health
            Insurance Exchange.
      (c) Coverage Information and Assistance.--
              (1) Coverage information.--The Commissioner shall provide for
            the broad dissemination of information on Exchange-
            participating health benefits plans offered under this title.
            Such information shall be provided in a comparative manner, and
            shall include information on benefits, premiums, cost-sharing,
            quality, provider networks, and consumer satisfaction.
              (2) Consumer assistance with choice.--To provide assistance
            to Exchange-eligible individuals and employers, the
            Commissioner shall--
                      (A) provide for the operation of a toll-free
                    telephone hotline to respond to requests for assistance
                    and maintain an Internet website through which
                    individuals may obtain information on coverage under
                    Exchange-participating health benefits plans and file
                    complaints;
                      (B) develop and disseminate information to Exchange-
                    eligible enrollees on their rights and
                    responsibilities;
                      (C) assist Exchange-eligible individuals in selecting
                    Exchange-participating health benefits plans and
                    obtaining benefits through such plans; and
                      (D) ensure that the Internet website described in
                    subparagraph (A) and the information described in
                    subparagraph (B) is developed using plain language (as
                    defined in section 133(a)(2)).
              (3) Use of other entities.--In carrying out this subsection,
            the Commissioner may work with other appropriate entities to
            facilitate the dissemination of information under this
            subsection and to provide assistance as described in paragraph
            (2).
      (d) Special Duties Related to Medicaid and CHIP.--
              (1) Coverage for certain newborns.--
                      (A) In general.--In the case of a child born in the
                    United States who at the time of birth is not otherwise
                    covered under acceptable coverage, for the period of
                    time beginning on the date of birth and ending on the
                    date the child otherwise is covered under acceptable
                    coverage (or, if earlier, the end of the month in which
                    the 60-day period, beginning on the date of birth,
                    ends), the child shall be deemed--
                              (i) to be a non-traditional Medicaid eligible
                            individual (as defined in subsection (e)(5))
                            for purposes of this division and Medicaid; and
                              (ii) to have elected to enroll in Medicaid
                            through the application of paragraph (3).
                      (B) Extended treatment as traditional medicaid
                    eligible individual.--In the case of a child described
                    in subparagraph (A) who at the end of the period
                    referred to in such subparagraph is not otherwise
                    covered under acceptable coverage, the child shall be
                    deemed (until such time as the child obtains such
                    coverage or the State otherwise makes a determination
                    of the child's eligibility for medical assistance under
                    its Medicaid plan pursuant to section 1943(c)(1) of the
                    Social Security Act) to be a traditional Medicaid
                    eligible individual described in section 1902(l)(1)(B)
                    of such Act.
              (2) CHIP transition.--A child who, as of the day before the
            first day of Y1, is eligible for child health assistance under
            title XXI of the Social Security Act (including a child
            receiving coverage under an arrangement described in section
            2101(a)(2) of such Act) is deemed as of such first day to be an
            Exchange-eligible individual unless the individual is a
            traditional Medicaid eligible individual as of such day.
              (3) Automatic enrollment of medicaid eligible individuals
            into medicaid.--The Commissioner shall provide for a process
            under which an individual who is described in section 202(d)(3)
            and has not elected to enroll in an Exchange-participating
            health benefits plan is automatically enrolled under Medicaid.
              (4) Notifications.--The Commissioner shall notify each State
            in Y1 and for purposes of section 1902(gg)(1) of the Social
            Security Act (as added by section 1703(a)) whether the Health
            Insurance Exchange can support enrollment of children described
            in paragraph (2) in such State in such year.
      (e) Medicaid Coverage for Medicaid Eligible Individuals.--
              (1) In general.--
                      (A) Choice for limited exchange-eligible
                    individuals.--As part of the enrollment process under
                    subsection (b), the Commissioner shall provide the
                    option, in the case of an Exchange-eligible individual
                    described in section 202(d)(3), for the individual to
                    elect to enroll under Medicaid instead of under an
                    Exchange-participating health benefits plan. Such an
                    individual may change such election during an
                    enrollment period under subsection (b)(2).
                      (B) Medicaid enrollment obligation.--An Exchange
                    eligible individual may apply, in the manner described
                    in section 241(b)(1), for a determination of whether
                    the individual is a Medicaid-eligible individual. If
                    the individual is determined to be so eligible, the
                    Commissioner, through the Medicaid memorandum of
                    understanding, shall provide for the enrollment of the
                    individual under the State Medicaid plan in accordance
                    with the Medicaid memorandum of understanding under
                    paragraph (4). In the case of such an enrollment, the
                    State shall provide for the same periodic
                    redetermination of eligibility under Medicaid as would
                    otherwise apply if the individual had directly applied
                    for medical assistance to the State Medicaid agency.
              (2) Non-traditional medicaid eligible individuals.--In the
            case of a non-traditional Medicaid eligible individual
            described in section 202(d)(3) who elects to enroll under
            Medicaid under paragraph (1)(A), the Commissioner shall provide
            for the enrollment of the individual under the State Medicaid
            plan in accordance with the Medicaid memorandum of
            understanding under paragraph (4).
              (3) Coordinated enrollment with state through memorandum of
            understanding.--The Commissioner, in consultation with the
            Secretary of Health and Human Services, shall enter into a
            memorandum of understanding with each State (each in this
            division referred to as a ``Medicaid memorandum of
            understanding'') with respect to coordinating enrollment of
            individuals in Exchange-participating health benefits plans and
            under the State's Medicaid program consistent with this section
            and to otherwise coordinate the implementation of the
            provisions of this division with respect to the Medicaid
            program. Such memorandum shall permit the exchange of
            information consistent with the limitations described in
            section 1902(a)(7) of the Social Security Act. Nothing in this
            section shall be construed as permitting such memorandum to
            modify or vitiate any requirement of a State Medicaid plan.
              (4) Medicaid eligible individuals.--For purposes of this
            division:
                      (A) Medicaid eligible individual.--The term
                    ``Medicaid eligible individual'' means an individual
                    who is eligible for medical assistance under Medicaid.
                      (B) Traditional medicaid eligible individual.--The
                    term ``traditional Medicaid eligible individual'' means
                    a Medicaid eligible individual other than an individual
                    who is--
                              (i) a Medicaid eligible individual by reason
                            of the application of subclause (VIII) of
                            section 1902(a)(10)(A)(i) of the Social
                            Security Act; or
                              (ii) a childless adult not described in
                            section 1902(a)(10)(A) or (C) of such Act (as
                            in effect as of the day before the date of the
                            enactment of this Act).
                      (C) Non-traditional medicaid eligible individual.--
                    The term ``non-traditional Medicaid eligible
                    individual'' means a Medicaid eligible individual who
                    is not a traditional Medicaid eligible individual.
      (f) Effective Culturally and Linguistically Appropriate
    Communication.--In carrying out this section, the Commissioner shall
    establish effective methods for communicating in plain language and a
    culturally and linguistically appropriate manner.

    SEC. 206. OTHER FUNCTIONS.

      (a) Coordination of Affordability Credits.--The Commissioner shall
    coordinate the distribution of affordability premium and cost-sharing
    credits under subtitle C to QHBP offering entities offering Exchange-
    participating health benefits plans.
      (b) Coordination of Risk Pooling.--The Commissioner shall establish a
    mechanism whereby there is an adjustment made of the premium amounts
    payable among QHBP offering entities offering Exchange-participating
    health benefits plans of premiums collected for such plans that takes
    into account (in a manner specified by the Commissioner) the
    differences in the risk characteristics of individuals and employers
    enrolled under the different Exchange-participating health benefits
    plans offered by such entities so as to minimize the impact of adverse
    selection of enrollees among the plans offered by such entities.
      (c) Special Inspector General for the Health Insurance Exchange.--
              (1) Establishment; appointment.--There is hereby established
            the Office of the Special Inspector General for the Health
            Insurance Exchange, to be headed by a Special Inspector General
            for the Health Insurance Exchange (in this subsection referred
            to as the ``Special Inspector General'') to be appointed by the
            President, by and with the advice and consent of the Senate.
            The nomination of an individual as Special Inspector General
            shall be made as soon as practicable after the establishment of
            the program under this subtitle.
              (2) Duties.--The Special Inspector General shall--
                      (A) conduct, supervise, and coordinate audits,
                    evaluations and investigations of the Health Insurance
                    Exchange to protect the integrity of the Health
                    Insurance Exchange, as well as the health and welfare
                    of participants in the Exchange;
                      (B) report both to the Commissioner and to the
                    Congress regarding program and management problems and
                    recommendations to correct them;
                      (C) have other duties (described in paragraphs (2)
                    and (3) of section 121 of division A of Public Law 110-
                    343) in relation to the duties described in the
                    previous subparagraphs; and
                      (D) have the authorities provided in section 6 of the
                    Inspector General Act of 1978 in carrying out duties
                    under this paragraph.
              (3) Application of other special inspector general
            provisions.--The provisions of subsections (b) (other than
            paragraphs (1) and (3)), (d) (other than paragraph (1)), and
            (e) of section 121 of division A of the Emergency Economic
            Stabilization Act of 2009 (Public Law 110-343) shall apply to
            the Special Inspector General under this subsection in the same
            manner as such provisions apply to the Special Inspector
            General under such section.
              (4) Reports.--Not later than one year after the confirmation
            of the Special Inspector General, and annually thereafter, the
            Special Inspector General shall submit to the appropriate
            committees of Congress a report summarizing the activities of
            the Special Inspector General during the one year period ending
            on the date such report is submitted.
              (5) Termination.--The Office of the Special Inspector General
            shall terminate five years after the date of the enactment of
            this Act.
      (d)  Assistance for Small Employers.--
              (1) In general.--The Commissioner, in consultation with the
            Small Business Administration, shall establish and carry out a
            program to provide to small employers counseling and technical
            assistance with respect to the provision of health insurance to
            employees of such employers through the Health Insurance
            Exchange.
              (2) Duties.--The program established under paragraph (1)
            shall include the following services:
                      (A) Educational activities to increase awareness of
                    the Health Insurance Exchange and available small
                    employer health plan options.
                      (B) Distribution of information to small employers
                    with respect to the enrollment and selection process
                    for health plans available under the Health Insurance
                    Exchange, including standardized comparative
                    information on the health plans available under the
                    Health Insurance Exchange.
                      (C) Distribution of information to small employers
                    with respect to available affordability credits or
                    other financial assistance.
                      (D) Referrals to appropriate entities of complaints
                    and questions relating to the Health Insurance
                    Exchange.
                      (E) Enrollment and plan selection assistance for
                    employers with respect to the Health Insurance
                    Exchange.
                      (F) Responses to questions relating to the Health
                    Insurance Exchange and the program established under
                    paragraph (1).
              (3) Authority to provide services directly or by contract.--
            The Commissioner may provide services under paragraph (2)
            directly or by contract with nonprofit entities that the
            Commissioner determines capable of carrying out such services.
              (4) Small employer defined.--In this subsection, the term
            ``small employer'' means an employer with less than 100
            employees.

    SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.

      (a) Establishment of Health Insurance Exchange Trust Fund.--There is
    created within the Treasury of the United States a trust fund to be
    known as the ``Health Insurance Exchange Trust Fund'' (in this section
    referred to as the ``Trust Fund''), consisting of such amounts as may
    be appropriated or credited to the Trust Fund under this section or any
    other provision of law.
      (b) Payments From Trust Fund.--The Commissioner shall pay from time
    to time from the Trust Fund such amounts as the Commissioner determines
    are necessary to make payments to operate the Health Insurance
    Exchange, including payments under subtitle C (relating to
    affordability credits).
      (c) Transfers to Trust Fund.--
              (1) Dedicated payments.--There is hereby appropriated to the
            Trust Fund amounts equivalent to the following:
                      (A) Taxes on individuals not obtaining acceptable
                    coverage.--The amounts received in the Treasury under
                    section 59B of the Internal Revenue Code of 1986
                    (relating to requirement of health insurance coverage
                    for individuals).
                      (B) Employment taxes on employers not providing
                    acceptable coverage.--The amounts received in the
                    Treasury under section 3111(c) of the Internal Revenue
                    Code of 1986 (relating to employers electing to not
                    provide health benefits).
                      (C) Excise tax on failures to meet certain health
                    coverage requirements.--The amounts received in the
                    Treasury under section 4980H(b) (relating to excise tax
                    with respect to failure to meet health coverage
                    participation requirements).
              (2) Appropriations to cover government contributions.--There
            are hereby appropriated, out of any moneys in the Treasury not
            otherwise appropriated, to the Trust Fund, an amount equivalent
            to the amount of payments made from the Trust Fund under
            subsection (b) plus such amounts as are necessary reduced by
            the amounts deposited under paragraph (1).
      (d) Application of Certain Rules.--Rules similar to the rules of
    subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall
    apply with respect to the Trust Fund.

    SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES.

      (a) In General.--If--
              (1) a State (or group of States, subject to the approval of
            the Commissioner) applies to the Commissioner for approval of a
            State-based Health Insurance Exchange to operate in the State
            (or group of States); and
              (2) the Commissioner approves such State-based Health
            Insurance Exchange,
    then, subject to subsections (c) and (d), the State-based Health
    Insurance Exchange shall operate, instead of the Health Insurance
    Exchange, with respect to such State (or group of States). The
    Commissioner shall approve a State-based Health Insurance Exchange if
    it meets the requirements for approval under subsection (b).
      (b) Requirements for Approval.--The Commissioner may not approve a
    State-based Health Insurance Exchange under this section unless the
    following requirements are met:
              (1) The State-based Health Insurance Exchange must
            demonstrate the capacity to and provide assurances satisfactory
            to the Commissioner that the State-based Health Insurance
            Exchange will carry out the functions specified for the Health
            Insurance Exchange in the State (or States) involved,
            including--
                      (A) negotiating and contracting with QHBP offering
                    entities for the offering of Exchange-participating
                    health benefits plan, which satisfy the standards and
                    requirements of this title and title I;
                      (B) enrolling Exchange-eligible individuals and
                    employers in such State in such plans;
                      (C) the establishment of sufficient local offices to
                    meet the needs of Exchange-eligible individuals and
                    employers;
                      (D) administering affordability credits under
                    subtitle B using the same methodologies (and at least
                    the same income verification methods) as would
                    otherwise apply under such subtitle and at a cost to
                    the Federal Government which does exceed the cost to
                    the Federal Government if this section did not apply;
                    and
                      (E) enforcement activities consistent with federal
                    requirements.
              (2) There is no more than one Health Insurance Exchange
            operating with respect to any one State.
              (3) The State provides assurances satisfactory to the
            Commissioner that approval of such an Exchange will not result
            in any net increase in expenditures to the Federal Government.
              (4) The State provides for reporting of such information as
            the Commissioner determines and assurances satisfactory to the
            Commissioner that it will vigorously enforce violations of
            applicable requirements.
              (5) Such other requirements as the Commissioner may specify.
      (c) Ceasing Operation.--
              (1) In general.--A State-based Health Insurance Exchange may,
            at the option of each State involved, and only after providing
            timely and reasonable notice to the Commissioner, cease
            operation as such an Exchange, in which case the Health
            Insurance Exchange shall operate, instead of such State-based
            Health Insurance Exchange, with respect to such State (or
            States).
              (2) Termination; health insurance exchange resumption of
            functions.--The Commissioner may terminate the approval (for
            some or all functions) of a State-based Health Insurance
            Exchange under this section if the Commissioner determines that
            such Exchange no longer meets the requirements of subsection
            (b) or is no longer capable of carrying out such functions in
            accordance with the requirements of this subtitle. In lieu of
            terminating such approval, the Commissioner may temporarily
            assume some or all functions of the State-based Health
            Insurance Exchange until such time as the Commissioner
            determines the State-based Health Insurance Exchange meets such
            requirements of subsection (b) and is capable of carrying out
            such functions in accordance with the requirements of this
            subtitle.
              (3) Effectiveness.--The ceasing or termination of a State-
            based Health Insurance Exchange under this subsection shall be
            effective in such time and manner as the Commissioner shall
            specify.
      (d) Retention of Authority.--
              (1) Authority retained.--Enforcement authorities of the
            Commissioner shall be retained by the Commissioner.
              (2) Discretion to retain additional authority.--The
            Commissioner may specify functions of the Health Insurance
            Exchange that--
                      (A) may not be performed by a State-based Health
                    Insurance Exchange under this section; or
                      (B) may be performed by the Commissioner and by such
                    a State-based Health Insurance Exchange.
      (e) References.--In the case of a State-based Health Insurance
    Exchange, except as the Commissioner may otherwise specify under
    subsection (d), any references in this subtitle to the Health Insurance
    Exchange or to the Commissioner in the area in which the State-based
    Health Insurance Exchange operates shall be deemed a reference to the
    State-based Health Insurance Exchange and the head of such Exchange,
    respectively.
      (f) Funding.--In the case of a State-based Health Insurance Exchange,
    there shall be assistance provided for the operation of such Exchange
    in the form of a matching grant with a State share of expenditures
    required.

    SEC. 209. PARTICIPATION OF SMALL EMPLOYER BENEFIT ARRANGEMENTS.

      (a) In General.--The Commissioner may enter into contracts with small
    employer benefit arrangements to provide consumer information,
    outreach, and assistance in the enrollment of small employers (and
    their employees) who are members of such an arrangement under Exchange
    participating health benefits plans.
      (b) Small Employer Benefit Arrangement Defined.--In this section, the
    term ``small employer benefit arrangement'' means a not-for-profit
    agricultural or other cooperative that--
              (1) consists solely of its members and is operated for the
            primary purpose of providing affordable employee benefits to
            its members;
              (2) only has as members small employers in the same industry
            or line of business;
              (3) has no member that has more than a 5 percent voting
            interest in the cooperative; and
              (4) is governed by a board of directors elected by its
            members.

                   Subtitle B--Public Health Insurance Option

    SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH INSURANCE
                        OPTION AS AN EXCHANGE-QUALIFIED HEALTH BENEFITS
                        PLAN.

      (a) Establishment.--For years beginning with Y1, the Secretary of
    Health and Human Services (in this subtitle referred to as the
    ``Secretary'') shall provide for the offering of an Exchange-
    participating health benefits plan (in this division referred to as the
    ``public health insurance option'') that ensures choice, competition,
    and stability of affordable, high quality coverage throughout the
    United States in accordance with this subtitle. In designing the
    option, the Secretary's primary responsibility is to create a low-cost
    plan without comprimising quality or access to care.
      (b) Offering as an Exchange-participating Health Benefits Plan.--
              (1) Exclusive to the exchange.--The public health insurance
            option shall only be made available through the Health
            Insurance Exchange.
              (2) Ensuring a level playing field.--Consistent with this
            subtitle, the public health insurance option shall comply with
            requirements that are applicable under this title to an
            Exchange-participating health benefits plan, including
            requirements related to benefits, benefit levels, provider
            networks, notices, consumer protections, and cost sharing.
              (3) Provision of benefit levels.--The public health insurance
            option--
                      (A) shall offer basic, enhanced, and premium plans;
                    and
                      (B) may offer premium-plus plans.
      (c) Administrative Contracting.--The Secretary may enter into
    contracts for the purpose of performing administrative functions
    (including functions described in subsection (a)(4) of section 1874A of
    the Social Security Act) with respect to the public health insurance
    option in the same manner as the Secretary may enter into contracts
    under subsection (a)(1) of such section. The Secretary has the same
    authority with respect to the public health insurance option as the
    Secretary has under subsections (a)(1) and (b) of section 1874A of the
    Social Security Act with respect to title XVIII of such Act. Contracts
    under this subsection shall not involve the transfer of insurance risk
    to such entity.
      (d) Ombudsman.--The Secretary shall establish an office of the
    ombudsman for the public health insurance option which shall have
    duties with respect to the public health insurance option similar to
    the duties of the Medicare Beneficiary Ombudsman under section
    1808(c)(2) of the Social Security Act.
      (e) Data Collection.--The Secretary shall collect such data as may be
    required to establish premiums and payment rates for the public health
    insurance option and for other purposes under this subtitle, including
    to improve quality and to reduce disparities in health and health care
    based on race, ethnicity, primary language, sex, sexual orientation,
    gender identity, disability, socioeconomic status, rural, urban, or
    other geographic setting, and any other population or subpopulation as
    determined appropriate by the Secretary, but only if the data
    collection is conducted on a voluntary basis and consistent with the
    standards, including privacy protections, established pursuant to
    section 1709 of the Public Health Service Act.
      (f) Treatment of Public Health Insurance Option.--With respect to the
    public health insurance option, the Secretary shall be treated as a
    QHBP offering entity offering an Exchange-participating health benefits
    plan.
      (g) Access to Federal Courts.--The provisions of Medicare (and
    related provisions of title II of the Social Security Act) relating to
    access of Medicare beneficiaries to Federal courts for the enforcement
    of rights under Medicare, including with respect to amounts in
    controversy, shall apply to the public health insurance option and
    individuals enrolled under such option under this title in the same
    manner as such provisions apply to Medicare and Medicare beneficiaries.

    SEC. 222. PREMIUMS AND FINANCING.

      (a) Establishment of Premiums.--
              (1) In general.--The Secretary shall establish
            geographically-adjusted premium rates for the public health
            insurance option in a manner--
                      (A) that complies with the premium rules established
                    by the Commissioner under section 113 for Exchange-
                    participating health benefit plans; and
                      (B) at a level sufficient to fully finance the costs
                    of--
                              (i) health benefits provided by the public
                            health insurance option; and
                              (ii) administrative costs related to
                            operating the public health insurance option.
              (2) Contingency margin.--In establishing premium rates under
            paragraph (1), the Secretary shall include an appropriate
            amount for a contingency margin.
      (b) Account.--
              (1) Establishment.--There is established in the Treasury of
            the United States an Account for the receipts and disbursements
            attributable to the operation of the public health insurance
            option, including the start-up funding under paragraph (2).
            Section 1854(g) of the Social Security Act shall apply to
            receipts described in the previous sentence in the same manner
            as such section applies to payments or premiums described in
            such section.
              (2) Start-up funding.--
                      (A) In general.--In order to provide for the
                    establishment of the public health insurance option
                    there is hereby appropriated to the Secretary, out of
                    any funds in the Treasury not otherwise appropriated,
                    $2,000,000,000. In order to provide for initial claims
                    reserves before the collection of premiums, there is
                    hereby appropriated to the Secretary, out of any funds
                    in the Treasury not otherwise appropriated, such sums
                    as necessary to cover 90 days worth of claims reserves
                    based on projected enrollment.
                      (B) Amortization of start-up funding.--The Secretary
                    shall provide for the repayment of the startup funding
                    provided under subparagraph (A) to the Treasury in an
                    amortized manner over the 10-year period beginning with
                    Y1.
                      (C) Limitation on funding.--Nothing in this section
                    shall be construed as authorizing any additional
                    appropriations to the Account, other than such amounts
                    as are otherwise provided with respect to other
                    Exchange-participating health benefits plans.

    SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.

      (a) Rates Established by Secretary.--
              (1) In general.--The Secretary shall establish payment rates
            for the public health insurance option for services and health
            care providers consistent with this section and may change such
            payment rates in accordance with section 224.
              (2) Initial payment rules.--
                      (A) In general.--Except as provided in subparagraph
                    (B) and subsection (b)(1), during Y1, Y2, and Y3, the
                    Secretary shall base the payment rates under this
                    section for services and providers described in
                    paragraph (1) on the payment rates for similar services
                    and providers under parts A and B of Medicare.
                      (B) Exceptions.--
                              (i) Practitioners' services.--Payment rates
                            for practitioners' services otherwise
                            established under the fee schedule under
                            section 1848 of the Social Security Act shall
                            be applied without regard to the provisions
                            under subsection (f) of such section and the
                            update under subsection (d)(4) under such
                            section for a year as applied under this
                            paragraph shall be not less than 1 percent.
                              (ii) Adjustments.--The Secretary may
                            determine the extent to which Medicare
                            adjustments applicable to base payment rates
                            under parts A and B of Medicare shall apply
                            under this subtitle.
              (3) For new services.--The Secretary shall modify payment
            rates described in paragraph (2) in order to accommodate
            payments for services, such as well-child visits, that are not
            otherwise covered under Medicare.
              (4) Prescription drugs.--Payment rates under this section for
            prescription drugs that are not paid for under part A or part B
            of Medicare shall be at rates negotiated by the Secretary.
      (b) Incentives for Participating Providers.--
              (1) Initial incentive period.--
                      (A) In general.--The Secretary shall provide, in the
                    case of services described in subparagraph (B)
                    furnished during Y1, Y2, and Y3, for payment rates that
                    are 5 percent greater than the rates established under
                    subsection (a).
                      (B) Services described.--The services described in
                    this subparagraph are items and professional services,
                    under the public health insurance option by a physician
                    or other health care practitioner who participates in
                    both Medicare and the public health insurance option.
                      (C) Special rules.--A pediatrician and any other
                    health care practitioner who is a type of practitioner
                    that does not typically participate in Medicare (as
                    determined by the Secretary) shall also be eligible for
                    the increased payment rates under subparagraph (A).
              (2) Subsequent periods.-- Beginning with Y4 and for
            subsequent years, the Secretary shall continue to use an
            administrative process to set such rates in order to promote
            payment accuracy, to ensure adequate beneficiary access to
            providers, and to promote affordablility and the efficient
            delivery of medical care consistent with section 221(a). Such
            rates shall not be set at levels expected to increase overall
            medical costs under the option beyond what would be expected if
            the process under subsection (a)(2) and paragraph (1) of this
            subsection were continued.
              (3) Establishment of a provider network.--Health care
            providers participating under Medicare are participating
            providers in the public health insurance option unless they opt
            out in a process established by the Secretary.
      (c) Administrative Process for Setting Rates.--Chapter 5 of title 5,
    United States Code shall apply to the process for the initial
    establishment of payment rates under this section but not to the
    specific methodology for establishing such rates or the calculation of
    such rates.
      (d) Construction.--Nothing in this subtitle shall be construed as
    limiting the Secretary's authority to correct for payments that are
    excessive or deficient, taking into account the provisions of section
    221(a) and the amounts paid for similar health care providers and
    services under other Exchange-participating health benefits plans.
      (e) Construction.--Nothing in this subtitle shall be construed as
    affecting the authority of the Secretary to establish payment rates,
    including payments to provide for the more efficient delivery of
    services, such as the initiatives provided for under section 224.
      (f) Limitations on Review.--There shall be no administrative or
    judicial review of a payment rate or methodology established under this
    section or under section 224.

    SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.

      (a) In General.--For plan years beginning with Y1, the Secretary may
    utilize innovative payment mechanisms and policies to determine
    payments for items and services under the public health insurance
    option. The payment mechanisms and policies under this section may
    include patient-centered medical home and other care management
    payments, accountable care organizations, value-based purchasing,
    bundling of services, differential payment rates, performance or
    utilization based payments, partial capitation, and direct contracting
    with providers.
      (b) Requirements for Innovative Payments.--The Secretary shall design
    and implement the payment mechanisms and policies under this section in
    a manner that--
              (1) seeks to--
                      (A) improve health outcomes;
                      (B) reduce health disparities (including racial,
                    ethnic, and other disparities);
                      (C) provide efficent and affordable care;
                      (D) address geographic variation in the provision of
                    health services; or
                      (E) prevent or manage chronic illness; and
              (2) promotes care that is integrated, patient-centered,
            quality, and efficient.
      (c) Encouraging the Use of High Value Services.--To the extent
    allowed by the benefit standards applied to all Exchange-participating
    health benefits plans, the public health insurance option may modify
    cost sharing and payment rates to encourage the use of services that
    promote health and value.
      (d) Non-uniformity Permitted.--Nothing in this subtitle shall prevent
    the Secretary from varying payments based on different payment
    structure models (such as accountable care organizations and medical
    homes) under the public health insurance option for different
    geographic areas.

    SEC. 225. PROVIDER PARTICIPATION.

      (a) In General.--The Secretary shall establish conditions of
    participation for health care providers under the public health
    insurance option.
      (b) Licensure or Certification.--The Secretary shall not allow a
    health care provider to participate in the public health insurance
    option unless such provider is appropriately licensed, certified, or
    otherwise permitted to practice under State law.
      (c) Payment Terms for Providers.--
              (1) Physicians.--The Secretary shall provide for the annual
            participation of physicians under the public health insurance
            option, for which payment may be made for services furnished
            during the year, in one of 2 classes:
                      (A) Preferred physicians.--Those physicians who agree
                    to accept the payment rate established under section
                    223 (without regard to cost-sharing) as the payment in
                    full.
                      (B) Participating, non-preferred physicians.--Those
                    physicians who agree not to impose charges (in relation
                    to the payment rate described in section 223 for such
                    physicians) that exceed the ratio permitted under
                    section 1848(g)(2)(C) of the Social Security Act.
              (2) Other providers.--The Secretary shall provide for the
            participation (on an annual or other basis specified by the
            Secretary) of health care providers (other than physicians)
            under the public health insurance option under which payment
            shall only be available if the provider agrees to accept the
            payment rate established under section 223 (without regard to
            cost-sharing) as the payment in full.
      (d) Exclusion of Certain Providers.--The Secretary shall exclude from
    participation under the public health insurance option a health care
    provider that is excluded from participation in a Federal health care
    program (as defined in section 1128B(f) of the Social Security Act).

    SEC. 226. APPLICATION OF FRAUD AND ABUSE PROVISIONS.

      Provisions of law (other than criminal law provisions) identified by
    the Secretary by regulation, in consultation with the Inspector General
    of the Department of Health and Human Services, that impose sanctions
    with respect to waste, fraud, and abuse under Medicare, such as the
    False Claims Act (31 U.S.C. 3729 et seq.), shall also apply to the
    public health insurance option.

    SEC. 227. SENSE OF THE HOUSE REGARDING ENROLLMENT OF MEMBERS IN THE
                        PUBLIC OPTION.

      It is the sense of the House of Representatives that Members who vote
    in favor of the establishment of a public, Federal Government run
    health insurance option, and senior members of the President's
    administration, are urged to forgo their right to participate in the
    Federal Employees Health Benefits Program (FEHBP) and agree to enroll
    under that public option.

                  Subtitle C--Individual Affordability Credits

    SEC. 241. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.

      (a) In General.--Subject to the succeeding provisions of this
    subtitle, in the case of an affordable credit eligible individual
    enrolled in an Exchange-participating health benefits plan--
              (1) the individual shall be eligible for, in accordance with
            this subtitle, affordability credits consisting of--
                      (A) an affordability premium credit under section 243
                    to be applied against the premium for the Exchange-
                    participating health benefits plan in which the
                    individual is enrolled; and
                      (B) an affordability cost-sharing credit under
                    section 244 to be applied as a reduction of the cost-
                    sharing otherwise applicable to such plan; and
              (2) the Commissioner shall pay the QHBP offering entity that
            offers such plan from the Health Insurance Exchange Trust Fund
            the aggregate amount of affordability credits for all
            affordable credit eligible individuals enrolled in such plan.
      (b) Application.--
              (1) In general.--An Exchange eligible individual may apply to
            the Commissioner through the Health Insurance Exchange or
            through another entity under an arrangement made with the
            Commissioner, in a form and manner specified by the
            Commissioner. The Commissioner through the Health Insurance
            Exchange or through another public entity under an arrangement
            made with the Commissioner shall make a determination as to
            eligibility of an individual for affordability credits under
            this subtitle.The Commissioner shall establish a process
            whereby, on the basis of information otherwise available,
            individuals may be deemed to be affordable credit eligible
            individuals. In carrying this subtitle, the Commissioner shall
            establish effective methods that ensure that individuals with
            limited English proficiency are able to apply for affordability
            credits.
              (2) Use of state medicaid agencies.--If the Commissioner
            determines that a State Medicaid agency has the capacity to
            make a determination of eligibility for affordability credits
            under this subtitle and under the same standards as used by the
            Commissioner, under the Medicaid memorandum of understanding
            (as defined in section 205(c)(4))--
                      (A) the State Medicaid agency is authorized to
                    conduct such determinations for any Exchange-eligible
                    individual who requests such a determination; and
                      (B) the Commissioner shall reimburse the State
                    Medicaid agency for the costs of conducting such
                    determinations.
              (3) Medicaid screen and enroll obligation.--In the case of an
            application made under paragraph (1), there shall be a
            determination of whether the individual is a Medicaid-eligible
            individual. If the individual is determined to be so eligible,
            the Commissioner, through the Medicaid memorandum of
            understanding, shall provide for the enrollment of the
            individual under the State Medicaid plan in accordance with the
            Medicaid memorandum of understanding. In the case of such an
            enrollment, the State shall provide for the same periodic
            redetermination of eligibility under Medicaid as would
            otherwise apply if the individual had directly applied for
            medical assistance to the State Medicaid agency.
      (c) Use of Affordability Credits.--
              (1) In general.--In Y1 and Y2 an affordable credit eligible
            individual may use an affordability credit only with respect to
            a basic plan.
              (2) Flexibility in plan enrollment authorized.--Beginning
            with Y3, the Commissioner shall establish a process to allow an
            affordability credit to be used for enrollees in enhanced or
            premium plans. In the case of an affordable credit eligible
            individual who enrolls in an enhanced or premium plan, the
            individual shall be responsible for any difference between the
            premium for such plan and the affordable credit amount
            otherwise applicable if the individual had enrolled in a basic
            plan.
      (d) Access to Data.--In carrying out this subtitle, the Commissioner
    shall request from the Secretary of the Treasury consistent with
    section 6103 of the Internal Revenue Code of 1986 such information as
    may be required to carry out this subtitle.
      (e) No Cash Rebates.--In no case shall an affordable credit eligible
    individual receive any cash payment as a result of the application of
    this subtitle.

    SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.

      (a) Definition.--
              (1) In general.--For purposes of this division, the term
            ``affordable credit eligible individual'' means, subject to
            subsection (b), an individual who is lawfully present in a
            State in the United States (other than as a nonimmigrant
            described in a subparagraph (excluding subparagraphs (K), (T),
            (U), and (V)) of section 101(a)(15) of the Immigration and
            Nationality Act)--
                      (A) who is enrolled under an Exchange-participating
                    health benefits plan and is not enrolled under such
                    plan as an employee (or dependent of an employee)
                    through an employer qualified health benefits plan that
                    meets the requirements of section 312;
                      (B) with family income below 400 percent of the
                    Federal poverty level for a family of the size
                    involved; and
                      (C) who is not a Medicaid eligible individual, other
                    than an individual described in section 202(d)(3) or an
                    individual during a transition period under section
                    202(d)(4)(B)(ii).
              (2) Treatment of family.--Except as the Commissioner may
            otherwise provide, members of the same family who are
            affordable credit eligible individuals shall be treated as a
            single affordable credit individual eligible for the applicable
            credit for such a family under this subtitle.
      (b) Limitations on Employee and Dependent Disqualification.--
              (1) In general.--Subject to paragraph (2), the term
            ``affordable credit eligible individual'' does not include a
            full-time employee of an employer if the employer offers the
            employee coverage (for the employee and dependents) as a full-
            time employee under a group health plan if the coverage and
            employer contribution under the plan meet the requirements of
            section 312.
              (2) Exceptions.--
                      (A) For certain family circumstances.--The
                    Commissioner shall establish such exceptions and
                    special rules in the case described in paragraph (1) as
                    may be appropriate in the case of a divorced or
                    separated individual or such a dependent of an employee
                    who would otherwise be an affordable credit eligible
                    individual.
                      (B) For unaffordable employer coverage.--For years
                    beginning with Y2, in the case of full-time employees
                    for which the cost of the employee premium (plus, to
                    the extent specified by the Commissioner, out-of-pocket
                    cost-sharing for such year or the preceding year) for
                    coverage under a group health plan would exceed 11
                    percent of current family income (determined by the
                    Commissioner on the basis of verifiable documentation
                    and without regard to section 245), paragraph (1) shall
                    not apply.
      (c) Income Defined.--
              (1) In general.--In this title, the term ``income'' means
            modified adjusted gross income (as defined in section 59B of
            the Internal Revenue Code of 1986).
              (2) Study of income disregards.--The Commissioner shall
            conduct a study that examines the application of income
            disregards for purposes of this subtitle. Not later than the
            first day of Y2, the Commissioner shall submit to Congress a
            report on such study and shall include such recommendations as
            the Commissioner determines appropriate.
      (d) Clarification of Treatment of Affordability Credits.--
    Affordabilty credits under this subtitle shall not be treated, for
    purposes of title IV of the Personal Responsibility and Work
    Opportunity Reconciliation Act of 1996, to be a benefit provided under
    section 403 of such title.

    SEC. 243. AFFORDABLE PREMIUM CREDIT.

      (a) In General.--The affordability premium credit under this section
    for an affordable credit eligible individual enrolled in an Exchange-
    participating health benefits plan is in an amount equal to the amount
    (if any) by which the premium for the plan (or, if less, the reference
    premium amount specified in subsection (c)), exceeds the affordable
    premium amount specified in subsection (b) for the individual.
      (b) Affordable Premium Amount.--
              (1) In general.--The affordable premium amount specified in
            this subsection for an individual for monthly premium in a plan
            year shall be equal to \1/12\ of the product of--
                      (A) the premium percentage limit specified in
                    paragraph (2) for the individual based upon the
                    individual's family income for the plan year; and
                      (B) the individual's family income for such plan
                    year.
              (2) Premium percentage limits based on table.--The
            Commissioner shall establish premium percentage limits so that
            for individuals whose family income is within an income tier
            specified in the table in subsection (d) such percentage limits
            shall increase, on a sliding scale in a linear manner, from the
            initial premium percentage to the final premium percentage
            specified in such table for such income tier.
      (c) Reference Premium Amount.--The reference premium amount specified
    in this subsection for a plan year for an individual in a premium
    rating area is equal to the average premium for the 3 basic plans in
    the area for the plan year with the lowest premium levels. In computing
    such amount the Commissioner may exclude plans with extremely limited
    enrollments.
      (d) Table of Premium Percentage Limits and Actuarial Value
    Percentages Based on Income Tier.--
              (1) In general.--For purposes of this subtitle, the table
            specified in this subsection is as follows:

       In the case of family income
     (expressed as a percent of FPL)      The initial premium         The final premium        The actuarial value
    within the following income tier:       percentage is--            percentage is--           percentage is--

    133% through 150%                  1.5%                       3%                        97%
    150% through 200%                  3%                         5%                        93%
    200% through 250%                  5%                         7%                        85%
    250% through 300%                  7%                         9%                        78%
    300% through 350%                  9%                         10%                       72%
    350% through 400%                  10%                        11%                       70%

              (2) Special rules.--For purposes of applying the table under
            paragraph (1)--
                      (A) For lowest level of income.--In the case of an
                    individual with income that does not exceed 133 percent
                    of FPL, the individual shall be considered to have
                    income that is 133% of FPL.
                      (B) Application of higher actuarial value percentage
                    at tier transition points.--If two actuarial value
                    percentages may be determined with respect to an
                    individual, the actuarial value percentage shall be the
                    higher of such percentages.

    SEC. 244. AFFORDABILITY COST-SHARING CREDIT.

      (a) In General.--The affordability cost-sharing credit under this
    section for an affordable credit eligible individual enrolled in an
    Exchange-participating health benefits plan is in the form of the cost-
    sharing reduction described in subsection (b) provided under this
    section for the income tier in which the individual is classified based
    on the individual's family income.
      (b) Cost-sharing Reductions.--The Commissioner shall specify a
    reduction in cost-sharing amounts and the annual limitation on cost-
    sharing specified in section 122(c)(2)(B) under a basic plan for each
    income tier specified in the table under section 243(d), with respect
    to a year, in a manner so that, as estimated by the Commissioner, the
    actuarial value of the coverage with such reduced cost-sharing amounts
    (and the reduced annual cost-sharing limit) is equal to the actuarial
    value percentage (specified in the table under section 243(d) for the
    income tier involved) of the full actuarial value if there were no
    cost-sharing imposed under the plan.
      (c) Determination and Payment of Cost-sharing Affordability Credit.--
    In the case of an affordable credit eligible individual in a tier
    enrolled in an Exchange-participating health benefits plan offered by a
    QHBP offering entity, the Commissioner shall provide for payment to the
    offering entity of an amount equivalent to the increased actuarial
    value of the benefits under the plan provided under section
    203(c)(2)(B) resulting from the reduction in cost-sharing described in
    subsection (b).

    SEC. 245. INCOME DETERMINATIONS.

      (a) In General.--In applying this subtitle for an affordability
    credit for an individual for a plan year, the individual's income shall
    be the income (as defined in section 242(c)) for the individual for the
    most recent taxable year (as determined in accordance with rules of the
    Commissioner). The Federal poverty level applied shall be such level in
    effect as of the date of the application.
      (b) Program Integrity; Income Verification Procedures.--
              (1) Program integrity.--The Commissioner shall take such
            steps as may be appropriate to ensure the accuracy of
            determinations and redeterminations under this subtitle.
              (2) Income verification.--
                      (A) In general.--Upon an initial application of an
                    individual for an affordability credit under this
                    subtitle (or in applying section 242(b)) or upon an
                    application for a change in the affordability credit
                    based upon a significant change in family income
                    described in subparagraph (A)--
                              (i) the Commissioner shall request from the
                            Secretary of the Treasury the disclosure to the
                            Commissioner of such information as may be
                            permitted to verify the information contained
                            in such application; and
                              (ii) the Commissioner shall use the
                            information so disclosed to verify such
                            information.
                      (B) Alternative procedures.--The Commissioner shall
                    establish procedures for the verification of income for
                    purposes of this subtitle if no income tax return is
                    available for the most recent completed tax year.
      (c) Special Rules.--
              (1) Changes in income as a percent of fpl.--In the case that
            an individual's income (expressed as a percentage of the
            Federal poverty level for a family of the size involved) for a
            plan year is expected (in a manner specified by the
            Commissioner) to be significantly different from the income (as
            so expressed) used under subsection (a), the Commissioner shall
            establish rules requiring an individual to report, consistent
            with the mechanism established under paragraph (2), significant
            changes in such income (including a significant change in
            family composition) to the Commissioner and requiring the
            substitution of such income for the income otherwise
            applicable.
              (2) Reporting of significant changes in income.--The
            Commissioner shall establish rules under which an individual
            determined to be an affordable credit eligible individual would
            be required to inform the Commissioner when there is a
            significant change in the family income of the individual
            (expressed as a percentage of the FPL for a family of the size
            involved) and of the information regarding such change. Such
            mechanism shall provide for guidelines that specify the
            circumstances that qualify as a significant change, the
            verifiable information required to document such a change, and
            the process for submission of such information. If the
            Commissioner receives new information from an individual
            regarding the family income of the individual,the Commissioner
            shall provide for a redetermination of the individual's
            eligibility to be an affordable credit eligible individual.
              (3) Transition for chip.--In the case of a child described in
            section 202(d)(2), the Commissioner shall establish rules under
            which the family income of the child is deemed to be no greater
            than the family income of the child as most recently determined
            before Y1 by the State under title XXI of the Social Security
            Act.
              (4) Study of geographic variation in application of fpl.--The
            Commissioner shall examine the feasibility and implication of
            adjusting the application of the Federal poverty level under
            this subtitle for different geographic areas so as to reflect
            the variations in cost-of-living among different areas within
            the United States. If the Commissioner determines that an
            adjustment is feasible, the study should include a methodology
            to make such an adjustment. Not later than the first day of Y2,
            the Commissioner shall submit to Congress a report on such
            study and shall include such recommendations as the
            Commissioner determines appropriate.
      (d) Penalties for Misrepresentation.--In the case of an individual
    intentionally misrepresents family income or the individual fails
    (without regard to intent) to disclose to the Commissioner a
    significant change in family income under subsection (c) in a manner
    that results in the individual becoming an affordable credit eligible
    individual when the individual is not or in the amount of the
    affordability credit exceeding the correct amount--
              (1) the individual is liable for repayment of the amount of
            the improper affordability credit; ;and
              (2) in the case of such an intentional misrepresentation or
            other egregious circumstances specified by the Commissioner,
            the Commissioner may impose an additional penalty.

    SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.

      Nothing in this subtitle shall allow Federal payments for
    affordability credits on behalf of individuals who are not lawfully
    present in the United States.

                          Subtitle D--State Innovation

    SEC. 251. WAIVER OF ERISA LIMITATION; APPLICATION INSTEAD OF STATE
                        SINGLE PAYER SYSTEM.

      (a) In General.--A State may request from the Secretary, and the
    Secretary must grant except under extraordinary circumstances, a waiver
    of application of section 514 of the Employee Retirement Income
    Security Act of 1974 with respect to a state single payer system
    enacted into law by such State that would be structured and operate in
    a manner consistent with this subtitle. The Secretary shall provide for
    the revocation of any waiver granted under this section upon a
    determination made by the Secretary that the requirements of the
    preceding sentence are no longer being met.
      (b) Effect of Waiver.--During any period for which a waiver under
    subsection (a) is in effect--
              (1) the provisions of section 514 of the Employee Retirement
            Income Security Act of 1974 shall not apply with respect to the
            State single payer system; and
              (2) the State single payer system shall operate in the State
            instead of the public health insurance option or the National
            Health Exchange.
      (c) Construction.--Nothing in this subtitle shall be construed to
    limit or otherwise affect the transfer and allocation under this Act of
    funds to States with single payer systems.

    SEC. 252. REQUIREMENTS.

      A State single payer system shall--
              (1) ) provide benefits that meet or exceed the standards of
            coverage and quality of care set forth in this Act; and
              (2) ensure that the cost to the Federal Government resulting
            from the waiver granted under section 261 is neither
            substantially greater nor substantially less than would have
            been the case in the absence of such waiver, except that:
                      (A) the State may seek and benefit from planning and
                    start-up funds with respect to the system; and
                      (B) nothing in this paragraph shall be construed to
                    preclude allowance for normal variations in population
                    demographics, health status, and other factors
                    exogenous to the health care system that may affect
                    differences in costs.

    SEC. 253. DEFINITIONS.

      (a) State Single Payer System.--The term ``State single payer
    system'' means, in connection with a State, a non-profit program of the
    State for providing health care--
              (1) in which a single agency of the State is responsible for
            financing health care benefits for all residents of the State
            and for the administration or supervision of the administration
            of the program;
              (2) under which private insurance duplicating the benefits
            provided in the single payer program is prohibited;
              (3) which provides comprehensive health benefits to all
            residents of the State, and provides measures to assure free
            choice of providers for covered services, to promote quality,
            and to help resolve complaints and disputes between consumers
            and providers; and
              (4) under which participation by health maintenance
            organizations is limited to non-profit health maintenance
            organizations that own their own delivery facilities and employ
            physicians on salary, and funding is limited to services that
            the health maintenance organizations actually deliver; and
              (5) which may be maintained by such State together one or
            more other States in a geographic region.
      (b) Secretary.--The term ``Secretary'' means the Secretary of Labor,
    acting in consultation with the Secretary of Health and Human Services.

                        TITLE III--SHARED RESPONSIBILITY

                     Subtitle A--Individual Responsibility

    SEC. 301. INDIVIDUAL RESPONSIBILITY.

      For an individual's responsibility to obtain acceptable coverage, see
    section 59B of the Internal Revenue Code of 1986 (as added by section
    401 of this Act).

                      Subtitle B--Employer Responsibility

               PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS

    SEC. 311. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

      (a) In General.--An employer meets the requirements of this section
    if such employer does all of the following:
              (1) Offer of coverage.--The employer offers each employee
            individual and family coverage under a qualified health
            benefits plan (or under a current employment-based health plan
            (within the meaning of section 102(b))) in accordance with
            section 312.
              (2) Contribution towards coverage.--If an employee accepts
            such offer of coverage, the employer makes timely contributions
            towards such coverage in accordance with section 312.
              (3) Contribution in lieu of coverage.--Beginning with Y2, if
            an employee declines such offer but otherwise obtains coverage
            in an Exchange-participating health benefits plan (other than
            by reason of being covered by family coverage as a spouse or
            dependent of the primary insured), the employer shall make a
            timely contribution to the Health Insurance Exchange with
            respect to each such employee in accordance with section 313.
      (b)  Hardship Exemption.--Notwithstanding any other provision of this
    part, an employer may, in a form and manner which shall be prescribed
    by the Secretary, apply to the Secretary for a waiver from the health
    coverage participation requirements of this part for any 2-year period.
    The Secretary shall grant the waiver within 30 days after submission of
    the application if the application reasonably demonstrates to the
    Secretary that meeting the requirements of this part would result in
    job losses that would negatively impact the employer or the community
    in which the employer is located.

    SEC. 312. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARDS EMPLOYEE AND
                        DEPENDENT COVERAGE.

      (a) In General.--An employer meets the requirements of this section
    with respect to an employee if the following requirements are met:
              (1) Offering of coverage.--The employer offers the coverage
            described in section 311(1) either through an Exchange-
            participating health benefits plan or other than through such a
            plan.
              (2) Employer required contribution.--The employer timely pays
            to the issuer of such coverage an amount not less than the
            employer required contribution specified in subsection (b) for
            such coverage.
              (3) Provision of information.--The employer provides the
            Health Choices Commissioner, the Secretary of Labor, the
            Secretary of Health and Human Services, and the Secretary of
            the Treasury, as applicable, with such information as the
            Commissioner may require to ascertain compliance with the
            requirements of this section.
              (4) Autoenrollment of employees.--The employer provides for
            autoenrollment of the employee in accordance with subsection
            (c).
      (b) Reduction of Employee Premiums Through Minimum Employer
    Contribution.--
              (1) Full-time employees.--The minimum employer contribution
            described in this subsection for coverage of a full-time
            employee (and, if any, the employee's spouse and qualifying
            children (as defined in section 152(c) of the Internal Revenue
            Code of 1986) under a qualified health benefits plan (or
            current employment-based health plan) is equal to--
                      (A) in case of individual coverage, not less than
                    72.5 percent of the applicable premium (as defined in
                    section 4980B(f)(4) of such Code, subject to paragraph
                    (2)) of the lowest cost plan offered by the employer
                    that is a qualified health benefits plan (or is such
                    current employment-based health plan); and
                      (B) in the case of family coverage which includes
                    coverage of such spouse and children, not less 65
                    percent of such applicable premium of such lowest cost
                    plan.
              (2) Applicable premium for exchange coverage.--In this
            subtitle, the amount of the applicable premium of the lowest
            cost plan with respect to coverage of an employee under an
            Exchange-participating health benefits plan is the reference
            premium amount under section 243(c) for individual coverage
            (or, if elected, family coverage) for the premium rating area
            in which the individual or family resides.
              (3) Minimum employer contribution for employees other than
            full-time employees.--In the case of coverage for an employee
            who is not a full-time employee, the amount of the minimum
            employer contribution under this subsection shall be a
            proportion (as determined in accordance with rules of the
            Health Choices Commissioner, the Secretary of Labor, the
            Secretary of Health and Human Services, and the Secretary of
            the Treasury, as applicable) of the minimum employer
            contribution under this subsection with respect to a full-time
            employee that reflects the proportion of--
                      (A) the average weekly hours of employment of the
                    employee by the employer, to
                      (B) the minimum weekly hours specified by the
                    Commissioner for an employee to be a full-time
                    employee.
              (4) Salary reductions not treated as employer
            contributions.--For purposes of this section, any contribution
            on behalf of an employee with respect to which there is a
            corresponding reduction in the compensation of the employee
            shall not be treated as an amount paid by the employer.
      (c) Automatic Enrollment for Employer Sponsored Health Benefits.--
              (1) In general.--The requirement of this subsection with
            respect to an employer and an employee is that the employer
            automatically enroll suchs employee into the employment-based
            health benefits plan for individual coverage under the plan
            option with the lowest applicable employee premium.
              (2) Opt-out.--In no case may an employer automatically enroll
            an employee in a plan under paragraph (1) if such employee
            makes an affirmative election to opt out of such plan or to
            elect coverage under an employment-based health benefits plan
            offered by such employer. An employer shall provide an employee
            with a 30-day period to make such an affirmative election
            before the employer may automatically enroll the employee in
            such a plan.
              (3) Notice requirements.--
                      (A) In general.--Each employer described in paragraph
                    (1) who automatically enrolls an employee into a plan
                    as described in such paragraph shall provide the
                    employees, within a reasonable period before the
                    beginning of each plan year (or, in the case of new
                    employees, within a reasonable period before the end of
                    the enrollment period for such a new employee), written
                    notice of the employees' rights and obligations
                    relating to the automatic enrollment requirement under
                    such paragraph. Such notice must be comprehensive and
                    understood by the average employee to whom the
                    automatic enrollment requirement applies.
                      (B) Inclusion of specific information.--The written
                    notice under subparagraph (A) must explain an
                    employee's right to opt out of being automatically
                    enrolled in a plan and in the case that more than one
                    level of benefits or employee premium level is offered
                    by the employer involved, the notice must explain which
                    level of benefits and employee premium level the
                    employee will be automatically enrolled in the absence
                    of an affirmative election by the employee.

    SEC. 313. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.

      (a) In General.--A contribution is made in accordance with this
    section with respect to an employee if such contribution is equal to an
    amount equal to 8 percent of the average wages paid by the employer
    during the period of enrollment (determined by taking into account all
    employees of the employer and in such manner as the Commissioner
    provides, including rules providing for the appropriate aggregation of
    related employers). Any such contribution--
              (1) shall be paid to the Health Choices Commissioner for
            deposit into the Health Insurance Exchange Trust Fund, and
              (2) shall not be applied against the premium of the employee
            under the Exchange-participating health benefits plan in which
            the employee is enrolled.
      (b) Special Rules for Small Employers.--
              (1) In general.--In the case of any employer who is a small
            employer for any calendar year, subsection (a) shall be applied
            by substituting the applicable percentage determined in
            accordance with the following table for ``8 percent'':

    If the annual payroll of such employer   The applicable percentage is:
     for the preceding calendar year:
      Does not exceed $250,000.............  0 percent
      Exceeds $250,000, but does not exceed  2 percent
       $300,000.
      Exceeds $300,000, but does not exceed  4 percent
       $350,000.
      Exceeds $350,000, but does not exceed  6 percent
       $400,000.

              (2) Small employer.--For purposes of this subsection, the
            term ``small employer'' means any employer for any calendar
            year if the annual payroll of such employer for the preceding
            calendar year does not exceed $400,000.
              (3) Annual payroll.--For purposes of this paragraph, the term
            ``annual payroll'' means, with respect to any employer for any
            calendar year, the aggregate wages paid by the employer during
            such calendar year.
              (4) Aggregation rules.--Related employers and predecessors
            shall be treated as a single employer for purposes of this
            subsection.

    SEC. 314. AUTHORITY RELATED TO IMPROPER STEERING.

      The Health Choices Commissioner (in coordination with the Secretary
    of Labor, the Secretary of Health and Human Services, and the Secretary
    of the Treasury) shall have authority to set standards for determining
    whether employers or insurers are undertaking any actions to affect the
    risk pool within the Health Insurance Exchange by inducing individuals
    to decline coverage under a qualified health benefits plan (or current
    employment-based health plan (within the meaning of section 102(b))
    offered by the employer and instead to enroll in an Exchange-
    participating health benefits plan. An employer violating such
    standards shall be treated as not meeting the requirements of this
    section.

       PART 2--SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS

    SEC. 321. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
                        UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT
                        OF 1974.

      (a) In General.--Subtitle B of title I of the Employee Retirement
    Income Security Act of 1974 is amended by adding at the end the
    following new part:

         ``PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS

    ``SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL HEALTH
                        COVERAGE PARTICIPATION REQUIREMENTS.

      ``(a) In General.--An employer may make an election with the
    Secretary to be subject to the health coverage participation
    requirements.
      ``(b) Time and Manner.--An election under subsection (a) may be made
    at such time and in such form and manner as the Secretary may
    prescribe.

    ``SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.

      ``(a) In General.--If an employer makes an election to the Secretary
    under section 801--
              ``(1) such election shall be treated as the establishment and
            maintenance of a group health plan (as defined in section
            733(a)) for purposes of this title, subject to section 151 of
            the America's Affordable Health Choices Act of 2009, and
              ``(2) the health coverage participation requirements shall be
            deemed to be included as terms and conditions of such plan.
      ``(b) Periodic Investigations to Discover Noncompliance.--The
    Secretary shall regularly audit a representative sampling of employers
    and group health plans and conduct investigations and other activities
    under section 504 with respect to such sampling of plans so as to
    discover noncompliance with the health coverage participation
    requirements in connection with such plans. The Secretary shall
    communicate findings of noncompliance made by the Secretary under this
    subsection to the Secretary of the Treasury and the Health Choices
    Commissioner. The Secretary shall take such timely enforcement action
    as appropriate to achieve compliance.
      ``(c) Recordkeeping.--To facilitate the audits described in
    subsection (b), the Secretary shall promulgate recordkeeping
    requirements for employers to account for both employees of the
    employer and individuals whom the employer has not treated as employees
    of the employer but with whom the employer, in the course of the trade
    or business in which the employer is engaged, has engaged for the
    performance of labor or services.

    ``SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

      ``For purposes of this part, the term `health coverage participation
    requirements' means the requirements of part 1 of subtitle B of title
    III of division A of America's Affordable Health Choices Act of 2009
    (as in effect on the date of the enactment of such Act).

    ``SEC. 804. RULES FOR APPLYING REQUIREMENTS.

      ``(a) Affiliated Groups.--In the case of any employer which is part
    of a group of employers who are treated as a single employer under
    subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue
    Code of 1986, the election under section 801 shall be made by such
    employer as the Secretary may provide. Any such election, once made,
    shall apply to all members of such group.
      ``(b) Separate Elections.--Under regulations prescribed by the
    Secretary, separate elections may be made under section 801 with
    respect to--
              ``(1) separate lines of business, and
              ``(2) full-time employees and employees who are not full-time
            employees.

    ``SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL
                        NONCOMPLIANCE.

      ``The Secretary may terminate the election of any employer under
    section 801 if the Secretary (in coordination with the Health Choices
    Commissioner) determines that such employer is in substantial
    noncompliance with the health coverage participation requirements and
    shall refer any such determination to the Secretary of the Treasury as
    appropriate.

    ``SEC. 806. REGULATIONS.

      ``The Secretary may promulgate such regulations as may be necessary
    or appropriate to carry out the provisions of this part, in accordance
    with section 324(a) of the America's Affordable Health Choices Act of
    2009. The Secretary may promulgate any interim final rules as the
    Secretary determines are appropriate to carry out this part.''.
      (b) Enforcement of Health Coverage Participation Requirements.--
    Section 502 of such Act (29 U.S.C. 1132) is amended--
              (1) in subsection (a)(6), by striking ``paragraph'' and all
            that follows through ``subsection (c)'' and inserting
            ``paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11) of
            subsection (c)''; and
              (2) in subsection (c), by redesignating the second paragraph
            (10) as paragraph (12) and by inserting after the first
            paragraph (10) the following new paragraph:
              ``(11) Health coverage participation requirements.--
                      ``(A) Civil penalties.--In the case of any employer
                    who fails (during any period with respect to which an
                    election under section 801(a) is in effect) to satisfy
                    the health coverage participation requirements with
                    respect to any employee, the Secretary may assess a
                    civil penalty against the employer of $100 for each day
                    in the period beginning on the date such failure first
                    occurs and ending on the date such failure is
                    corrected.
                      ``(B) Health coverage participation requirements.--
                    For purposes of this paragraph, the term `health
                    coverage participation requirements' has the meaning
                    provided in section 803.
                      ``(C) Limitations on amount of penalty.--
                              ``(i) Penalty not to apply where failure not
                            discovered exercising reasonable diligence.--No
                            penalty shall be assessed under subparagraph
                            (A) with respect to any failure during any
                            period for which it is established to the
                            satisfaction of the Secretary that the employer
                            did not know, or exercising reasonable
                            diligence would not have known, that such
                            failure existed.
                              ``(ii) Penalty not to apply to failures
                            corrected within 30 days.--No penalty shall be
                            assessed under subparagraph (A) with respect to
                            any failure if--
                                      ``(I) such failure was due to
                                    reasonable cause and not to willful
                                    neglect, and
                                      ``(II) such failure is corrected
                                    during the 30-day period beginning on
                                    the 1st date that the employer knew, or
                                    exercising reasonable diligence would
                                    have known, that such failure existed.
                              ``(iii) Overall limitation for unintentional
                            failures.--In the case of failures which are
                            due to reasonable cause and not to willful
                            neglect, the penalty assessed under
                            subparagraph (A) for failures during any 1-year
                            period shall not exceed the amount equal to the
                            lesser of--
                                      ``(I) 10 percent of the aggregate
                                    amount paid or incurred by the employer
                                    (or predecessor employer) during the
                                    preceding 1-year period for group
                                    health plans, or
                                      ``(II) $500,000.
                      ``(D) Advance notification of failure prior to
                    assessment.--Before a reasonable time prior to the
                    assessment of any penalty under this paragraph with
                    respect to any failure by an employer, the Secretary
                    shall inform the employer in writing of such failure
                    and shall provide the employer information regarding
                    efforts and procedures which may be undertaken by the
                    employer to correct such failure.
                      ``(E) Coordination with excise tax.--Under
                    regulations prescribed in accordance with section 324
                    of the America's Affordable Health Choices Act of 2009,
                    the Secretary and the Secretary of the Treasury shall
                    coordinate the assessment of penalties under this
                    section in connection with failures to satisfy health
                    coverage participation requirements with the imposition
                    of excise taxes on such failures under section 4980H(b)
                    of the Internal Revenue Code of 1986 so as to avoid
                    duplication of penalties with respect to such failures.
                      ``(F) Deposit of penalty collected.--Any amount of
                    penalty collected under this paragraph shall be
                    deposited as miscellaneous receipts in the Treasury of
                    the United States.''.
      (c) Clerical Amendments.--The table of contents in section 1 of such
    Act is amended by inserting after the item relating to section 734 the
    following new items:

         ``Part 8--National Health Coverage Participation Requirements

    ``Sec. 801. Election of employer to be subject to national health
    coverage participation requirements.
    ``Sec. 802. Treatment of coverage resulting from election.
    ``Sec. 803. Health coverage participation requirements.
    ``Sec. 804. Rules for applying requirements.
    ``Sec. 805. Termination of election in cases of substantial
    noncompliance.
    ``Sec. 806. Regulations.''.

      (d) Effective Date.--The amendments made by this section shall apply
    to periods beginning after December 31, 2012.

      [For sections 322 and 323, see text of bill as introduced on June 14,
    2009.]

    SEC. 324. ADDITIONAL RULES RELATING TO HEALTH COVERAGE PARTICIPATION
                        REQUIREMENTS.

      (a) Assuring Coordination.--The officers consisting of the Secretary
    of Labor, the Secretary of the Treasury, the Secretary of Health and
    Human Services, and the Health Choices Commissioner shall ensure,
    through the execution of an interagency memorandum of understanding
    among such officers, that--
              (1) regulations, rulings, and interpretations issued by such
            officers relating to the same matter over which two or more of
            such officers have responsibility under subpart B of part 6 of
            subtitle B of title I of the Employee Retirement Income
            Security Act of 1974, section 4980H of the Internal Revenue
            Code of 1986, and section 2793 of the Public Health Service Act
            are administered so as to have the same effect at all times;
            and
              (2) coordination of policies relating to enforcing the same
            requirements through such officers in order to have a
            coordinated enforcement strategy that avoids duplication of
            enforcement efforts and assigns priorities in enforcement.
      (b) Multiemployer Plans.--In the case of a group health plan that is
    a multiemployer plan (as defined in section 3(37) of the Employee
    Retirement Income Security Act of 1974), the regulations prescribed in
    accordance with subsection (a) by the officers referred to in
    subsection (a) shall provide for the application of the health coverage
    participation requirements to the plan sponsor and contributing
    sponsors of such plan.

                 DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

      [For division B, see text of bill as introduced on July 14, 2009.]

              DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

    SEC. 2001. TABLE OF CONTENTS; REFERENCES.

      (a) Table of Contents.--The table of contents of this division is as
    follows:

    Sec. 2001. Table of contents; references.
    [For section 2002, see text of introduced bill.]

        [FOR TEXT OF TITLES I THROUGH IV, SEE TEXT OF INTRODUCED BILL.]

                           TITLE V--OTHER PROVISIONS

           [For Subtitles A, B, and C, See Text of Introduced Bill.]

     Subtitle D--Grants for Comprehensive Programs to Provide Education to
                    Nurses and Create a Pipeline to Nursing

                 [For Subtitle E, See Text of Introduced Bill.]

    Sec. 2531. Establishment of grant program.

       Subtitle F--Standards for Accessibility to Medical Equipment for
                         Individuals With Disabilities.

    Sec. 2541. Access for individuals with disabilities.

                        Subtitle G--Other Grant Programs

    Sec. 2551. Reducing student-to-school nurse ratios.
    Sec. 2552. Wellness program grants.
    Sec. 2553. Health professions training for diversity programs.

            Subtitle H--Long-term Care and Family Caregiver Support

    Sec. 2561. Long-term care and family caregiver support.

                          Subtitle I--Online Resources

    Sec. 2571. Web site on health care labor market and related educational
    and training opportunities.
    Sec. 2572. Online health workforce training programs.

      (b) References.--Except as otherwise specified, whenever in this
    division an amendment is expressed in terms of an amendment to a
    section or other provision, the reference shall be considered to be
    made to a section or other provision of the Public Health Service Act
    (42 U.S.C. 201 et seq.).

      [For section 2002 and titles I through IV of division C, see text of
    bill as introduced on July 14, 2009.]

                           TITLE V--OTHER PROVISIONS

      [For subtitles A through C of title V of division C, see text of bill
    as introduced on July 14, 2009.]

     Subtitle D--Grants for Comprehensive Programs to Provide Education to
                    Nurses and Create a Pipeline to Nursing

    SEC. 2531. ESTABLISHMENT OF GRANT PROGRAM.

      (a) Purposes.--It is the purpose of this section to authorize grants
    to--
              (1) address the projected shortage of nurses by funding
            comprehensive programs to create a career ladder to nursing
            (including Certified Nurse Assistants, Licensed Practical
            Nurses, Licensed Vocational Nurses, and Registered Nurses) for
            incumbent ancillary health care workers;
              (2) increase the capacity for educating nurses by increasing
            both nurse faculty and clinical opportunities through
            collaborative programs between staff nurse organizations,
            health care providers, and accredited schools of nursing; and
              (3) provide training programs through education and training
            organizations jointly administered by health care providers and
            health care labor organizations or other organizations
            representing staff nurses and frontline health care workers,
            working in collaboration with accredited schools of nursing and
            academic institutions.
      (b) Grants.--Not later than 6 months after the date of the enactment
    of this Act, the Secretary of Labor (referred to in this section as the
    ``Secretary'') shall establish a partnership grant program to award
    grants to eligible entities to carry out comprehensive programs to
    provide education to nurses and create a pipeline to nursing for
    incumbent ancillary health care workers who wish to advance their
    careers, and to otherwise carry out the purposes of this section.
      (c) Eligibility.--To be eligible for a grant under this section, an
    entity shall be--
              (1) a health care entity that is jointly administered by a
            health care employer and a labor union representing the health
            care employees of the employer and that carries out activities
            using labor management training funds as provided for under
            section 302(c)(6) of the Labor Management Relations Act, 1947
            (29 U.S.C. 186(c)(6));
              (2) an entity that operates a training program that is
            jointly administered by--
                      (A) one or more health care providers or facilities,
                    or a trade association of health care providers; and
                      (B) one or more organizations which represent the
                    interests of direct care health care workers or staff
                    nurses and in which the direct care health care workers
                    or staff nurses have direct input as to the leadership
                    of the organization;
              (3) a State training partnership program that consists of
            nonprofit organizations that include equal participation from
            industry, including public or private employers, and labor
            organizations including joint labor-management training
            programs, and which may include representatives from local
            governments, worker investment agency one-stop career centers,
            community-based organizations, community colleges, and
            accredited schools of nursing; or
              (4) a school of nursing (as defined in section 801 of the
            Public Health Service Act (42 U.S.C. 296)).
      (d) Additional Requirements for Health Care Employer Described in
    Subsection (c).--To be eligible for a grant under this section, a
    health care employer described in subsection (c) shall demonstrate that
    it--
              (1) has an established program within their facility to
            encourage the retention of existing nurses;
              (2) provides wages and benefits to its nurses that are
            competitive for its market or that have been collectively
            bargained with a labor organization; and
              (3) supports programs funded under this section through 1 or
            more of the following:
                      (A) The provision of paid leave time and continued
                    health coverage to incumbent health care workers to
                    allow their participation in nursing career ladder
                    programs, including certified nurse assistants,
                    licensed practical nurses, licensed vocational nurses,
                    and registered nurses.
                      (B) Contributions to a joint labor-management
                    training fund which administers the program involved.
                      (C) The provision of paid release time, incentive
                    compensation, or continued health coverage to staff
                    nurses who desire to work full- or part-time in a
                    faculty position.
                      (D) The provision of paid release time for staff
                    nurses to enable them to obtain a bachelor of science
                    in nursing degree, other advanced nursing degrees,
                    specialty training, or certification program.
                      (E) The payment of tuition assistance which is
                    managed by a joint labor-management training fund or
                    other jointly administered program.
      (e) Other Requirements.--
              (1) Matching requirement.--
                      (A) In general.--The Secretary may not make a grant
                    under this section unless the applicant involved
                    agrees, with respect to the costs to be incurred by the
                    applicant in carrying out the program under the grant,
                    to make available non-Federal contributions (in cash or
                    in kind under subparagraph (B)) toward such costs in an
                    amount equal to not less than $1 for each $1 of Federal
                    funds provided in the grant. Such contributions may be
                    made directly or through donations from public or
                    private entities, or may be provided through the cash
                    equivalent of paid release time provided to incumbent
                    worker students.
                      (B) Determination of amount of non-federal
                    contribution.--Non-Federal contributions required in
                    subparagraph (A) may be in cash or in kind (including
                    paid release time), fairly evaluated, including
                    equipment or services (and excluding indirect or
                    overhead costs). Amounts provided by the Federal
                    Government, or services assisted or subsidized to any
                    significant extent by the Federal Government, may not
                    be included in determining the amount of such non-
                    Federal contributions.
              (2) Required collaboration.--Entities carrying out or
            overseeing programs carried out with assistance provided under
            this section shall demonstrate collaboration with accredited
            schools of nursing which may include community colleges and
            other academic institutions providing associate, bachelor's, or
            advanced nursing degree programs or specialty training or
            certification programs.
      (f) Use of Funds.--Amounts awarded to an entity under a grant under
    this section shall be used for the following:
              (1) To carry out programs that provide education and training
            to establish nursing career ladders to educate incumbent health
            care workers to become nurses (including certified nurse
            assistants, licensed practical nurses, licensed vocational
            nurses, and registered nurses). Such programs shall include one
            or more of the following:
                      (A) Preparing incumbent workers to return to the
                    classroom through English -as-a-second language
                    education, GED education, pre-college counseling,
                    college preparation classes, and support with entry
                    level college classes that are a prerequisite to
                    nursing.
                      (B) Providing tuition assistance with preference for
                    dedicated cohort classes in community colleges,
                    universities, accredited schools of nursing with
                    supportive services including tutoring and counseling.
                      (C) Providing assistance in preparing for and meeting
                    all nursing licensure tests and requirements.
                      (D) Carrying out orientation and mentorship programs
                    that assist newly graduated nurses in adjusting to
                    working at the bedside to ensure their retention
                    postgraduation, and ongoing programs to support nurse
                    retention.
                      (E) Providing stipends for release time and continued
                    health care coverage to enable incumbent health care
                    workers to participate in these programs.
              (2) To carry out programs that assist nurses in obtaining
            advanced degrees and completing specialty training or
            certification programs and to establish incentives for nurses
            to assume nurse faculty positions on a part-time or full-time
            basis. Such programs shall include one or more of the
            following:
                      (A) Increasing the pool of nurses with advanced
                    degrees who are interested in teaching by funding
                    programs that enable incumbent nurses to return to
                    school.
                      (B) Establishing incentives for advanced degree
                    bedside nurses who wish to teach in nursing programs so
                    they can obtain a leave from their bedside position to
                    assume a full- or part-time position as adjunct or
                    full-time faculty without the loss of salary or
                    benefits.
                      (C) Collaboration with accredited schools of nursing
                    which may include community colleges and other academic
                    institutions providing associate, bachelor's, or
                    advanced nursing degree programs, or specialty training
                    or certification programs, for nurses to carry out
                    innovative nursing programs which meet the needs of
                    bedside nursing and health care providers.
      (g) Preference.--In awarding grants under this section the Secretary
    shall give preference to programs that--
              (1) provide for improving nurse retention;
              (2) provide for improving the diversity of the new nurse
            graduates to reflect changes in the demographics of the patient
            population;
              (3) provide for improving the quality of nursing education to
            improve patient care and safety;
              (4) have demonstrated success in upgrading incumbent health
            care workers to become nurses or which have established
            effective programs or pilots to increase nurse faculty; or
              (5) are modeled after or affiliated with such programs
            described in paragraph (4).
      (h) Evaluation.--
              (1) Program evaluations.--An entity that receives a grant
            under this section shall annually evaluate, and submit to the
            Secretary a report on, the activities carried out under the
            grant and the outcomes of such activities. Such outcomes may
            include--
                      (A) an increased number of incumbent workers entering
                    an accredited school of nursing and in the pipeline for
                    nursing programs;
                      (B) an increasing number of graduating nurses and
                    improved nurse graduation and licensure rates;
                      (C) improved nurse retention;
                      (D) an increase in the number of staff nurses at the
                    health care facility involved;
                      (E) an increase in the number of nurses with advanced
                    degrees in nursing;
                      (F) an increase in the number of nurse faculty;
                      (G) improved measures of patient quality (which may
                    include staffing ratios of nurses, patient satisfaction
                    rates, patient safety measures); and
                      (H) an increase in the diversity of new nurse
                    graduates relative to the patient population.
              (2) General report.--Not later than 2 years after the date of
            the enactment of this Act, and annually thereafter, the
            Secretary of Labor shall, using data and information from the
            reports received under paragraph (1), submit to the Congress a
            report concerning the overall effectiveness of the grant
            program carried out under this section.
      (i) Authorization of Appropriations.--There are authorized to be
    appropriated to carry out this section such sums as may be necessary.

      [For subtitle E of title V of division C, see text of bill as
    introduced on July 14, 2009.]

       Subtitle F--Standards for Accessibility to Medical Equipment for
                         Individuals With Disabilities.

    SEC. 2541. ACCESS FOR INDIVIDUALS WITH DISABILITIES.

      Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et seq.) is
    amended by adding at the end of the following:

    ``SEC. 510. STANDARDS FOR ACCESSIBILITY OF MEDICAL DIAGNOSTIC
                        EQUIPMENT.

      ``(a) Standards.--Not later than 9 months after the date of enactment
    of the America's Affordable Health Choices Act of 2009, the
    Architectural and Transportation Barriers Compliance Board shall issue
    guidelines setting forth the minimum technical criteria for medical
    diagnostic equipment used in (or in conjunction with) physician's
    offices, clinics, emergency rooms, hospitals, and other medical
    settings. The guidelines shall ensure that such equipment is accessible
    to, and usable by, individuals with disabilities, including provisions
    to ensure independent entry to, use of, and exit from the equipment by
    such individuals to the maximum extent possible.
      ``(b) Medical Diagnostic Equipment Covered.--The guidelines issued
    under subsection (a) for medical diagnostic equipment shall apply to
    equipment that includes examination tables, examination chairs
    (including chairs used for eye examinations or procedures, and dental
    examinations or procedures), weight scales, mammography equipment, x-
    ray machines, and other equipment commonly used for diagnostic or
    examination purposes by health professionals.
      ``(c) Interim Standards.--Until the date on which final regulations
    are issued under subsection (d), purchases of examination tables,
    weight scales, and mammography equipment and used in (or in conjunction
    with) medical settings described in subsection (a), shall adhere to the
    following interim accessibility requirements:
              ``(1) Examination tables shall be height-adjustable between a
            range of at least 18 inches to 37 inches.
              ``(2) Weight scales shall be capable of weighing individuals
            who remain seated in a wheelchair or other personal mobility
            aid.
              ``(3) Mammography machines and equipment shall be capable of
            being used by individuals in a standing, seated, or recumbent
            position, including individuals who remain seated in a
            wheelchair or other personal mobility aid.
      ``(d) Regulations.--Not later than 6 months after the date of the
    issuance of the guidelines under subsection (a), each appropriate
    Federal agency authorized to promulgate regulations under this Act or
    under the Americans with Disabilities Act shall--
              ``(1) prescribe regulations in an accessible format as
            necessary to carry out the provisions of such Act and section
            504 of this Act that include accessibility standards that are
            consistent with the guidelines issued under subsection (a); and
              ``(2) ensure that health care providers and health care plans
            covered by the America's Affordable Health Choices Act of 2009
            meet the requirements of the Americans with Disabilities Act
            and section 504, including provisions ensuring that individuals
            with disabilities receive equal access to all aspects of the
            health care delivery system.
      ``(e) Review and Amend.--The Architectural and Transportation
    Barriers Compliance Board shall periodically review and, as
    appropriate, amend the guidelines as prescribed under subsection (a).
    Not later than 6 months after the date of the issuance of such revised
    guidelines, revised regulations consistent with such guidelines shall
    be promulgated in an accessible format by the appropriate Federal
    agencies described in subsection (d).''.

                        Subtitle G--Other Grant Programs

    SEC. 2551. REDUCING STUDENT-TO-SCHOOL NURSE RATIOS.

      (a) Demonstration Grants.--
              (1) In general.--The Secretary of Education, in consultation
            with the Secretary of Health and Human Services and the
            Director of the Centers for Disease Control and Prevention, may
            make demonstration grants to eligible local education agencies
            for the purpose of reducing the student-to-school nurse ratio
            in public elementary and secondary schools.
              (2) Special consideration.--In awarding grants under this
            section, the Secretary of Education shall give special
            consideration to applications submitted by high-need local
            educational agencies that demonstrate the greatest need for new
            or additional nursing services among children in the public
            elementary and secondary schools served by the agency, in part
            by providing information on current ratios of students to
            school nurses.
              (3) Matching funds.--The Secretary of Education may require
            recipients of grants under this subsection to provide matching
            funds from non-Federal sources, and shall permit the recipients
            to match funds in whole or in part with in-kind contributions.
      (b) Report.--Not later than 24 months after the date on which
    assistance is first made available to local educational agencies under
    this section, the Secretary of Education shall submit to the Congress a
    report on the results of the demonstration grant program carried out
    under this section, including an evaluation of the effectiveness of the
    program in improving the student-to-school nurse ratios described in
    subsection (a) and an evaluation of the impact of any resulting
    enhanced health of students on learning.
      (c) Definitions.--For purposes of this section:
              (1) The terms ``elementary school'', ``local educational
            agency'', and ``secondary school'' have the meanings given to
            those terms in section 9101 of the Elementary and Secondary
            Education Act of 1965 (20 U.S.C. 7801).
              (2) The term ``eligible local educational agency'' means a
            local educational agency in which the student-to-school nurse
            ratio in the public elementary and secondary schools served by
            the agency is 750 or more students to every school nurse.
              (3) The term ``high-need local educational agency'' means a
            local educational agency--
                      (A) that serves not fewer than 10,000 children from
                    families with incomes below the poverty line; or
                      (B) for which not less than 20 percent of the
                    children served by the agency are from families with
                    incomes below the poverty line.
              (4) The term ``nurse'' means a licensed nurse, as defined
            under State law.
      (d) Authorization of Appropriations.--To carry out this section,
    there are authorized to be appropriated such sums as may be necessary
    for each of the fiscal years 2010 through 2014.

    SEC. 2552. WELLNESS PROGRAM GRANTS.

      (a) Allowance of Grant.--
              (1) In general.--For purposes of this section, the Secretary
            of Labor shall award wellness grants as determined under this
            section. Wellness program grants shall be awarded to qualified
            employers for any plan year in an amount equal to 50 percent of
            the costs paid or incurred by the employer in connection with a
            qualified wellness program during the plan year. For purposes
            of the preceding sentence, in the case of any qualified
            wellness program offered as part of an employment-based health
            plan, only costs attributable to the qualified wellness program
            and not to the health plan, or health insurance coverage
            offered in connection with such a plan, may be taken into
            account.
              (2) Limitation.--The amount of the grant allowed under
            paragraph (1) for any plan year shall not exceed the sum of--
                      (A) the product of $200 and the number of employees
                    of the employer not in excess of 200 employees; plus
                      (B) the product of $100 and the number of employees
                    of the employer in excess of 200 employees.
            The wellness grants awarded to an employer under this section
            shall be for up to 3 years and shall not exceed $50,000.
      (b) Qualified Wellness Program.--For purposes of this section:
              (1) Qualified wellness program.--The term ``qualified
            wellness program'' means a program that --
                      (A) includes any 3 wellness components described in
                    subsection (c); and
                      (B) is be certified by the Secretary of Labor, in
                    coordination with the Health Choices Commissioner and
                    the Director of the Center for Disease Control and
                    Prevention, as a qualified wellness program under this
                    section.
              (2) Programs must be consistent with research and best
            practices.--
                      (A) In general.--The Secretary of Labor shall not
                    certify a program as a qualified wellness program
                    unless the program--
                              (i) is newly established or in existence on
                            the date of enactment of this Act but not yet
                            meeting the requirements of this section;
                              (ii) is consistent with evidenced-based
                            researched and best practices, as identified by
                            persons with expertise in employer health
                            promotion and wellness programs;
                              (iii) includes multiple, evidenced-based
                            strategies which are based on the existing and
                            emerging research and careful scientific
                            reviews, including the Guide to Community
                            Preventative Services, the Guide to Clinical
                            Preventative Services, and the National
                            Registry for Effective Programs, and
                              (iv) includes strategies which focus on
                            prevention and support for employee populations
                            at risk of poor health outcomes.
                      (B) Periodic updating and review.--The Secretary of
                    Labor, in consultation with other appropriate agencies
                    shall establish procedures for periodic review,
                    evaluation, and update of the programs under this
                    subsection.
              (3) Health literacy/accessibility.--The Secretary of Labor
            shall, as part of the certification process: --
                      (A) ensure that employers make the programs
                    culturally competent. physically and programmatically
                    accessible (including for individuals with
                    disabilities), and appropriate to the health literacy
                    needs of the employees covered by the programs;
                      (B) require a health literacy component to provide
                    special assistance and materials to employees with low
                    literacy skills, limited English and from under-served
                    populations; and
                      (C) require the Secretary of Labor, in consultation
                    with Secretary of Health and Human Services, to compile
                    and disseminate to employer health plans info on model
                    health literacy curricula, instructional programs, and
                    effective intervention strategies.
      (c) Wellness Program Components.--For purposes of this section, the
    wellness program components described in this subsection are the
    following:
              (1) Health awareness component.--A health awareness component
            which provides for the following:
                      (A) Health education.--The dissemination of health
                    information which addresses the specific needs and
                    health risks of employees.
                      (B) Health screenings.--The opportunity for periodic
                    screenings for health problems and referrals for
                    appropriate follow up measures.
              (2) Employee engagement component.--An employee engagement
            component which provides for the active engagement of employees
            in worksite wellness programs through worksite assessments and
            program planning, onsite delivery, evaluation, and improvement
            efforts.
              (3) Behavioral change component.--A behavioral change
            component which provides for altering employee lifestyles to
            encourage healthy living through counseling, seminars, on-line
            programs, or self-help materials which provide technical
            assistance and problem solving skills. such component may
            include programs relating to--
                      (A) tobacco use;
                      (B) obesity;
                      (C) stress management;
                      (D) physical fitness;
                      (E) nutrition;
                      (F) substance abuse;
                      (G) depression; and
                      (H) mental health promotion (including anxiety).
              (4) Supportive environment component.--A supportive
            environment component which includes the following:
                      (A) On-site policies.--Policies and services at the
                    worksite which promote a healthy lifestyle, including
                    policies relating to--
                              (i) tobacco use at the worksite;
                              (ii) the nutrition of food available at the
                            worksite through cafeterias and vending
                            options;
                              (iii) minimizing stress and promoting
                            positive mental health in the workplace; and
                              (iv) the encouragement of physical activity
                            before, during, and after work hours.
      (d) Participation Requirement.--No grant shall be allowed under
    subsection (a) unless the Secretary of Labor in consultation with other
    appropriate agencies, certifies, as a part of any certification
    described in subsection (b), that each wellness program component of
    the qualified wellness program--
              (1) shall be available to all employees of the employer;
              (2) shall not mandate participation by employees; and
              (3) shall not require participation by individual employees
            as a condition to obtain a premium discount, rebate, deductible
            reduction, or other financial reward.
      (e) Privacy Protections.--Any employee health information collected
    through participation in an employer wellness program shall be
    confidential and available only to appropriately trained health
    professions as defined by the Secretary of Labor. Employers or
    employees of the employer sponsoring a wellness program shall have no
    access to employee health data. All entities offering employer-
    sponsored wellness programs shall be considered ``business associates''
    pursuant to the American Reinvestment and Recovery Act and must comply
    with privacy protections restricting the release of personal medical
    information.
      (f) Definitions and Special Rules.--For purposes of this section:
              (1) Qualified employer.--The term ``qualified employer''
            means an employer that offers a qualified health benefits plan
            to every employee (including each employee required to be
            offered coverage under a qualified health benefits plan under
            subtitle B of title III of division A), and meets the health
            coverage participation requirements as defined in section 312.
              (2) Certain costs not included.--Costs paid or incurred by an
            employer for food or health insurance shall not be taken into
            account under subsection (a).
      (g) Outreach.--
              (1) In general.--The Secretary of the Labor, in conjunction
            with other appropriate agencies and members of the business
            community, shall institute an outreach program to inform
            businesses about the availability of the wellness program grant
            as well as to educate businesses on how to develop programs
            according to recognized and promising practices and on how to
            measure the success of implemented programs.
      (h) Effective Date.--This section shall take effect on January 1,
    2013.
      (i) Authorization of Appropriations.--There are authorized to be
    appropriated such sums as are necessary to carry out this section.

    SEC. 2553. HEALTH PROFESSIONS TRAINING FOR DIVERSITY PROGRAMS.

      Section 171 of the Workforce Investment Act of 1998 (29 U.S.C. 2916)
    is amended by adding at the end the following:
      ``(f) Health Professions Training for Diversity Program.--
              ``(1) In general.--The Secretary shall make available 20
            grants of no more than $1,000,000 annually to nonprofit
            organizations for the purposes of providing workforce
            development training program for those who are currently
            employed in the health care workforce.
              ``(2) Eligibility.--For the purposes of providing assistance
            and services under the program established in this subsection,
            grants are to be awarded to Area Health Education Centers or
            similar nonprofit organizations involved in the development and
            implementation of health care workforce development programs
            and that--
                      ``(A) have a formal affiliation with a hospital or
                    community health center, and institution of higher
                    education as defined by section 101 of the Higher
                    Education Act of 1965;
                      ``(B) have a history of providing program services to
                    minority populations; and
                      ``(C) provide workforce development programs to low-
                    income persons, veterans, or urban and rural
                    underserved communities.''.

            Subtitle H--Long-term Care and Family Caregiver Support

    SEC. 2561. LONG-TERM CARE AND FAMILY CAREGIVER SUPPORT.

      (a) Amendments to the Older Americans Act of 1965.--
              (1) Promotion of direct care workforce.--Section 202(b)(1) of
            the Older Americans Act of 1965 (42 U.S.C. 3012(b)(1)) is
            amended by inserting before the semicolon the following: ``,
            and, in carrying out the purposes of this paragraph, shall make
            recommendations to other Federal entities regarding appropriate
            and effective means of identifying, promoting, and implementing
            investments in the direct care workforce necessary to meet the
            growing demand for long-term health services and supports and
            assisting States in developing a comprehensive state workforce
            development plans with respect to such workforce including
            efforts to systematically assess, track, and report on
            workforce adequacy and capacity''.
              (2) Personal care attendant workforce advisory panel.--
            Section 202 of such Act (42 U.S.C. 3012) is amended by adding
            at the end the following new subsection:
      ``(g)(1) The Assistant Secretary shall establish a Personal Care
    Attendant Workforce Advisory Panel and pilot program to improve working
    conditions and training for long term care workers, including home
    health aides, certified nurse aides, and personal care attendants.
      ``(2) The Panel shall include representatives from--
              ``(A) relevant health care agencies and facilities (including
            personal or home care agencies, home health care agencies,
            nursing homes and residential care facilities);
              ``(B) the disability community;
              ``(C) the nursing community;
              ``(D) direct care workers (which may include unions and
            national organizations);
              ``(E) older individuals and family caregivers;
              ``(F) State and federal health care entities; and
              ``(G) experts in workforce development and adult learning.
      ``(3) Within one year after the establishment of the Panel, the Panel
    shall submit a report to the Assistant Secretary articulating core
    competencies for eligible personal or home care aides necessary to
    successfully provide long-term services and supports to eligible
    consumers, as well as recommended training curricula and resources.
      ``(4) Within 180 days after receipt by the Assistant Secretary of the
    report under paragraph (3), the Assistant Secretary shall establish a
    3-year demonstration program in 4 states to pilot and evaluate the
    effectiveness of the competencies articulated by the Panel and the
    training curricula and training methods recommended by the Panel.
      ``(5) Not later than 1 year after the completion of the demonstration
    program under paragraph (4), the Assistant Secretary shall submit to
    each House of the Congress a report containing the results of the
    evaluations by the Assistant Secretary pursuant to paragraph (4),
    together with such recommendations for legislation or administrative
    action as the Assistant Secretary determines appropriate.''.
      (b) Authorization of Additional Appropriations for the Family
    Caregiver Support Program Under the Older Americans Act of 1965.--
    Section 303(e)(2) of the Older Americans Act of 1965 (42 U.S.C.
    3023(e)(2)) is amended by striking ``$173,000,000'' and all that
    follows through ``2011'', and inserting ``and $250,000,000 for each of
    the fiscal years 2010, 2011, and 2012''.
      (c) Authorization of Additional Appropriations for the National
    Clearinghouse for Long-Term Care Information.--There is authorized to
    be appropriated $10,000,000 for each of the fiscal years 2010, 2011,
    and 2012 for the operation of the National Clearinghouse for Long-Term
    Care Information established by the Secretary of Health and Human
    Services under section 6021(d) of Public Law 109-171.

                          Subtitle I--Online Resources

    SEC. 2571. WEB SITE ON HEALTH CARE LABOR MARKET AND RELATED EDUCATIONAL
                        AND TRAINING OPPORTUNITIES.

      (a) In General.--The Secretary of Labor, in consultation with the
    National Center for Health Workforce Analysis, shall establish and
    maintain a Web site to serve as a comprehensive source of information,
    searchable by workforce region, on the health care labor market and
    related educational and training opportunities.
      (b) Contents.--The Web site maintained under this section shall
    include the following:
              (1) Information on the types of jobs that are currently or
            are projected to be in high demand in the health care field,
            including--
                      (A) salary information; and
                      (B) training requirements, such as requirements for
                    educational credentials, licensure, or certification.
              (2) Information on training and educational opportunities
            within each region for the type jobs described in paragraph
            (1), including by--
                      (A) type of provider or program (such as public,
                    private nonprofit, or private for-profit);
                      (B) duration;
                      (C) cost (such as tuition, fees, books, laboratory
                    expenses, and other mandatory costs);
                      (D) performance outcomes (such as graduation rates,
                    job placement, average salary, job retention, and wage
                    progression);
                      (E) Federal financial aid participation;
                      (F) average graduate loan debt;
                      (G) student loan default rates;
                      (H) average institutional grant aid provided;
                      (I) Federal and State accreditation information; and
                      (J) other information determined by the Secretary.
              (3) A mechanism for searching and comparing training and
            educational options for specific health care occupations to
            facilitate informed career and education choices.
              (4) Financial aid information, including with respect to loan
            forgiveness, loan cancellation, loan repayment, stipends,
            scholarships, and grants or other assistance authorized by this
            Act or other Federal or State programs.
      (c) Public Accessibility.--The Web site maintained under this section
    shall--
              (1) be publicly accessible;
              (2) be user friendly and convey information in a manner that
            is easily understandable; and
              (3) be in English and the second most prevalent language
            spoken based on the latest Census information.

    SEC. 2572. ONLINE HEALTH WORKFORCE TRAINING PROGRAMS.

      Section 171 of the Workforce Investment Act of 1998 (29 U.S.C. 2916)
    (as amended by section 2553) is further amended by adding at the end
    the following:
      ``(g) Online Health Workforce Training Program.--
              ``(1) Grant program.--
                      ``(A) In general.--The Secretary shall award National
                    Health Workforce Online Training Grants on a
                    competitive basis to eligible entities to enable such
                    entities to carry out training for individuals to
                    attain or advance in health care occupations. An entity
                    may leverage such grant with other Federal, State,
                    local, and private resources, in order to expand the
                    participation of businesses, employees, and individuals
                    in such training programs.
                      ``(B) Eligibility.--In order to receive a grant under
                    the program established under this paragraph--
                              ``(i) an entity shall be an educational
                            institution, community-based organization, non-
                            profit organization, workforce investment
                            board, or local or county government; and
                              ``(ii) an entity shall provide online
                            workforce training for individuals seeking to
                            attain or advance in health care occupations,
                            including nursing, nursing assistants,
                            dentistry, pharmacy, health care management and
                            administration, public health, health
                            information systems analysis, medical
                            assistants, and other health care practitioner
                            and support occupations.
                      ``(C) Priority.--Priority in awarding grants under
                    this paragraph shall be given to entities that--
                              ``(i) have demonstrated experience in
                            implementing and operating online worker skills
                            training and education programs;
                              ``(ii) have demonstrated experience
                            coordinating activities, where appropriate,
                            with the workforce investment system; and
                              ``(iii) conduct training for occupations with
                            national or local shortages.
                      ``(D) Data collection.--Grantees under this paragraph
                    shall collect and report information on--
                              ``(i) the number of participants;
                              ``(ii) the services received by the
                            participants;
                              ``(iii) program completion rates;
                              ``(iv) factors determined as significantly
                            interfering with program participation or
                            completion;
                              ``(v) the rate of job placement; and
                              ``(vi) other information as determined as
                            needed by the Secretary.
                      ``(E) Outreach.--Grantees under this paragraph shall
                    conduct outreach activities to disseminate information
                    about their program and results to workforce investment
                    boards, local governments, educational institutions,
                    and other workforce training organizations.
                      ``(F) Performance levels.--The Secretary shall
                    establish indicators of performance that will be used
                    to evaluate the performance of grantees under this
                    paragraph in carrying out the activities described in
                    this paragraph. The Secretary shall negotiate and reach
                    agreement with each grantee regarding the levels of
                    performance expected to be achieved by the grantee on
                    the indicators of performance.
                      ``(G) Authorization of appropriations.--There are
                    authorized to be appropriated to the Secretary to carry
                    out this subsection $50,000,000 for fiscal years 2011
                    through 2020.
              ``(2) Online health professions training program
            clearinghouse.--
                      ``(A) Description of grant.--The Secretary shall
                    award one grant to an eligible postsecondary
                    educational institution to provide the services
                    described in this paragraph.
                      ``(B) Eligibility.--To be eligible to receive a grant
                    under this paragraph, a postsecondary educational
                    institution shall--
                              ``(i) have demonstrated the ability to
                            disseminate research on best practices for
                            implementing workforce investment programs; and
                              ``(ii) be a national leader in producing
                            cutting-edge research on technology related to
                            workforce investment systems under subtitle B.
                      ``(C) Services.--The postsecondary educational
                    institution that receives a grant under this paragraph
                    shall use such grant--
                              ``(i) to provide technical assistance to
                            entities that receive grants under paragraph
                            (1);
                              ``(ii) to collect and nationally disseminate
                            the data gathered by entities that receive
                            grants under paragraph (1); and
                              ``(iii) to disseminate the best practices
                            identified by the National Health Workforce
                            Online Training Grant Program to other
                            workforce training organizations.
                      ``(D) Authorization of appropriations.--There are
                    authorized to be appropriated to the Secretary to carry
                    out this subsection $1,000,000 for fiscal years 2011
                    through 2020.''.

                                   I. Purpose

        The U.S. health care system is on an unsustainable course.
    Between 1999 and 2008, health insurance premiums more than
    doubled as wages largely stagnated.\1\ Over the past two
    decades, the cost of the average family health insurance policy
    has steadily drained larger and larger portions of families'
    income. In the United States, at least 47 million individuals
    are uninsured and millions more are underinsured.\2\ Even
    having insurance does not guarantee health care security, as
    families are forced to fight insurance companies that regularly
    deny coverage or delay treatment. In more than half of the
    medical bankruptcies filed, the household was insured.\3\
    Rising health care costs have had a negative impact on
    business, especially small employers.\4\ Over just the last 15
    years, the percentage of small businesses offering health
    insurance dropped from 61 percent to 38 percent.\5\ The number
    of uninsured Americans is expected to hit 61 million by
    2020.\6\ In no uncertain terms, the U.S. health care system is
    in crisis and has been for some time. Reform is needed.
    Inaction is not an option.
    ---------------------------------------------------------------------------
        \1\ Jacob Hacker, Testimony before the Committee on Education and
    Labor Committee, ``The Tri-Committee Draft for Health Care Reform,''
    (hereinafter Hacker)(Jun. 23, 2009) at 2.
        \2\ Alliance for Health Care Reform, ``Health Care Coverage in
    America: Understanding the Issues and Proposed Solutions.'' (Mar.
    2008).
        \3\ Id.
        \4\ U.S. Department of Health and Human Services, ``Helping the
    Bottom Line: Health Reform and Small Business,'' Prepared by Meena
    Seshamani, Director of Policy Analysis, Office of Health Reform,
    available at: http:\\www.healthreform.gov/reports/helpbottomline/
    helpbottomline.pdf.
        \5\ National Small Business Association, ``2008 NSBA Small & Mid-
    Sized Business Survey,'' Table at 14, available at:
    http:\\www.nsba.biz/docs/2008bizsurvey.pdf.
        \6\ The Commonwealth Fund Commission on a High Performance Health
    System, ``The Path to a High Performance U.S. Health System: A 2020
    Vision and the Policies to Pave the Way,'' Exhibit ES-2: Trend in the
    Number of Uninsured, 2009-2020 Under Current Law and Path Proposal,
    February 2009, available at: http:\\www.commonwealthfund.org//media/
    Files/Publications/Fund%20Report/2009/Feb/
    The%20Path%20to%20a%20High%20Performance%20US%20Health%20System/
    1237_Commission_path_high_perform_US_hlt_sys_WEB_rev_03052009.pdf.
    ---------------------------------------------------------------------------
        H.R. 3200, America's Affordable Health Choices Act, adopts
    the health care reform principles outlined by President Barack
    Obama. Specifically, the bill preserves and strengthens the
    employer-based health care system, includes protections for
    small businesses, creates a health insurance marketplace where
    individuals can choose between private insurance and the public
    health insurance option, ensures low and middle income
    Americans have access to affordability credits to help offset
    the costs of insurance and saves over $500 billion in future
    health outlays of Medicare and Medicaid through reforms to the
    system.
        Together, these critical reforms are fundamental to the
    long-term health and security of this country.

        II. Committee Action Including Legislative History and Votes in
                                   Committee

                              LEGISLATIVE HISTORY

        For more than 70 years, Congress and Presidents have
    attempted to reform the nation's health care system, most
    recently under President Clinton in 1993-94. The election of
    the Democratic majority in Congress in 2006 and President Obama
    in 2008 have led to renewed efforts toward national health care
    reform. The legislative history described in this report is
    limited to legislative action beginning in the 110th Congress.

                           110TH CONGRESS (2007-2008)

                    HEARINGS IN THE HOUSE OF REPRESENTATIVES

    Committee on Education and Labor

        On March 15, 2007, the Subcommittee on Health, Employment,
    Labor and Pensions of the Committee of Education and Labor held
    a hearing entitled ``Examining Innovative Approaches to
    Covering the Uninsured Through Employer-Provided Health
    Benefits.'' The panel included: Joan Alker, Deputy Executive
    Director, Center for Children and Families; Brian England,
    Owner, British American Auto Repair Columbia; Andrew Webber,
    President and Chief Executive Officer, National Business
    Coalition on Health; and Linda Blumberg, Ph.D., Economist and
    Principal Research Associate, Urban Institute.
        On May 22, 2007, the Subcommittee on Health, Employment,
    Labor and Pensions of the Committee of Education and Labor held
    a hearing entitled ``Health Care Reform: Recommendations to
    Improve Coordination of Federal and State Initiatives.'' The
    panel included: Congressman John Tierney (D-MA); Congressman
    Tom Price (R-GA); Congresswoman Tammy Baldwin (D-WI); Mila
    Kofman, J.D., Associate Research Professor, Health Policy
    Institute, Georgetown University; John Colmers, Secretary,
    State of Maryland Department of Health and Mental Hygiene;
    Steven Goldman, Commissioner, New Jersey Department of Banking
    and Insurance; John Morrison, Auditor and Commissioner, Montana
    Insurance and Securities; Amy Moore, Partner, Covington &
    Burling, LLP; and Kevin Covert, Board Member, American Benefits
    Council.
        On September 25, 2008, the Committee on Education and Labor
    held a hearing entitled ``Safeguarding Retiree Health
    Benefits.'' The panel included: C. William Jones, Chairman,
    ProtectSeniors.org; Bill Kadereit, President, National Retiree
    Legislative Network; David Lillie, Retiree, Raytheon Missile
    Systems; Scott Macey, Senior Vice President and Director of
    Government Affairs, Aon Consulting, Inc; Norman Stein, Douglas
    Arant Professor of Law, University of Alabama; and Dale
    Yamanoto, President and Founder, Red Quill Consulting.

    Committee on Energy & Commerce

        On September 18, 2008, the Subcommittee on Health of the
    Committee on Energy and Commerce held a hearing entitled
    ``America's Need for Health Reform.'' The panel included:
    Ronald E. Bachman, F.S.A., M.A.A.A., Senior Fellow, Center for
    Health Transformation; Governor Jon S. Corzine, State of New
    Jersey; Karen Davis, President, The Commonwealth Fund;
    Elizabeth Edwards, Senior Fellow, Center for American Progress;
    William J. Fox, F.S.A., M.A.A.A., Principal and Consulting
    Actuary, Milliman Inc.; E.J. ``Ned'' Holland, Jr., Senior Vice
    President, Human Resources and Communication, EMBARQ; Patricia
    Owen, President/Founder, FACES DaySpa; Stephen T. Parente,
    Ph.D., Director, Medical Industry Leadership Institute, and
    Associate Professor of Finance, Carlson School of Management,
    University of Minnesota; and Karen Pollitz, M.P.P., Research
    Professor, Health Policy Institute, Georgetown University.

    Committee on Ways and Means

        On November 17, 2007, the Subcommittee on Income Security
    and Family Support in the Committee on Ways and Means held a
    hearing entitled ``Impact of Gaps in Health Coverage on Income
    Security.'' The panel included: Sherena Johnson, former foster
    youth, Morrow, GA; Sara R. Collins, Ph.D., Assistant Vice
    President, Program on the Future of Health Insurance,
    Commonwealth Fund; Ron Pollack, Founding Executive Director,
    Families USA; Bruce Lesley, President, First Focus; and Brian
    J. Gottlob, Senior Fellow, Milton and Rose D. Friedman
    Foundation, Indianapolis, IN.
        On April 15, 2008, the Subcommittee on Health in the
    Committee on Ways and Means held a two-panel hearing entitled
    ``Instability of Health Coverage in America.'' The first panel
    included former Senator Dave Durenberger (R-MN). The second
    panel included: Diane Rowland, Sc.D., Executive Vice President,
    Kaiser Family Foundation; John Z. Ayanian, M.D., Professor of
    Medicine and Health Care Policy, Harvard Medical School;
    Michael O'Grady, Senior Fellow, National Opinion Research
    Center, University of Chicago; Stan Brock, Founder and
    Volunteer Director of Operations, Remote Area Medical,
    Knoxville, TN; and Stephen Finan, Associate Director of Policy,
    American Cancer Society.
        On May 14, 2008, the Subcommittee on Health in the
    Committee on Ways and Means held a hearing entitled ``Health
    Savings Accounts and Consumer Driven Health Care: Cost
    Containment or Cost-Shift.'' The panel included: John F.
    Dicken, Health Care Director, U.S. Government Accountability
    Office (GAO); Michael E. Chernew, Ph.D., Professor of Health
    Care Policy, Harvard Medical School; Linda J. Blumberg, Ph.D.,
    Principal Research Associate, Urban Institute; Judy Waxman,
    Vice President and Director of Health and Reproductive Rights,
    National Women's Law Center; and Wayne Sensor, CEO, Alegent
    Health.
        On June 10, 2008, the Subcommittee on Health in the
    Committee on Ways and Means held a two-panel hearing entitled
    ``Addressing Disparities in Health and Healthcare: Issues for
    Reform.'' The first panel included: Delegate Donna M.
    Christensen (D-USVI); former Congresswoman Hilda L. Solis (D-
    CA); Delegate Madeleine Z. Bordallo (D-GU); and Congressman
    Jerry Moran (R-KS). The second panel included: Marsha Little-
    Blanton, Dr.P.H., Senior Advisor on Race, Ethnicity and
    Healthcare, Kaiser Family Foundation; Mohammed Akhter, M.D.,
    M.P.H., Executive Director, National Medical Association; Deena
    Jang, J.D., Policy Director, Asian and Pacific Islander
    American Health Forum; Anthony B. Iton, M.D., J.D., M.P.H.,
    Director of Public Health and Health Officer, Alameda County,
    CA; Sally Satel, M.D., Resident Scholar, American Enterprise
    Institute; and Michael A. Rodriguez, M.D., M.P.H., Associate
    Professor and Vice Chair of Research, Department of Family
    Medicine, University of California, Los Angeles.
        On September 11, 2008, the Subcommittee on Health in the
    Committee on Ways and Means held a hearing entitled ``Reforming
    Medicare's Physician Payment System.'' The panel included:
    Bruce C. Vladeck, Ph.D., Senior Health Policy Advisor and
    Executive Director of Health Sciences, Ernst & Young, LLP; Gail
    Wilensky, Ph.D., Senior Fellow, Project Hope; Nancy H. Nielsen,
    M.D., Ph.D., President, American Medical Association; and
    Donald M. Crane, President and Chief Executive Officer,
    California Association of Physician Groups.
        On September 23, 2008, the Subcommittee on Health in the
    Committee on Ways and Means held a hearing entitled the
    ``Health of the Private Health Insurance Market.'' The panel
    included: Karen Davis, President, Commonwealth Fund; Bruce
    Bodaken, Chairman and Chief Executive Officer, Blue Shield of
    California; Roger Feldman, Ph.D., Blue Cross Professor of
    Health Insurance, University of Minnesota; and Mila Kofman,
    Superintendent of Insurance, Maine Bureau of Insurance.

                             HEARINGS IN THE SENATE

    Committee on Health, Education, Labor and Pension

        On January 10, 2007, the Senate Health, Education, Labor
    and Pensions (HELP) Committee held a hearing entitled ``Health
    Care Coverage and Access.'' The panel included: Peter Meade,
    Executive Vice President, Blue Cross Blue Shield of
    Massachusetts; John McDonough, Executive Director, Health Care
    for All; Karen Davis, President, Commonwealth Fund; Andy Stern,
    President, SEIU; Debra Ness, President, National Partnership
    for Women and Families; Larry Burton, Executive Vice President,
    Business Roundtable; Peter Harbage, New America Foundation;
    Joseph Antos, Wilson H. Taylor Scholar in Health Care and
    Retirement Policy, American Enterprise Institute; John Goodman,
    President, National Center for Policy Analysis; and Pat
    Vredevoogd Combs, National Association of Realtors, and owner,
    Coldwell-Banker-AJS Realty.
        On February 12, 2008, the Senate HELP Committee held a
    hearing entitled ``Addressing Healthcare Workforce Issues for
    the Future.'' The panel included: A. Bruce Steinwald, Director,
    Healthcare GAO; Kevin Grumbach, M.D., Director, Center for
    California Health Workforce Studies, University of California
    San Francisco, and Chair, Department of Family and Community
    Medicine; Roderick S. Hooker, Ph.D., P.A., Director of
    Research, Rheumatology Section, Medical Service Department of
    Veterans Affairs, Dallas VA Medical Center; Edward S. Salsberg,
    M.P.A., Director, Center for Workforce Studies, Association of
    American Medical Colleges; James Q. Swift, D.D.S., Board
    President, American Dental Education Association; Bruce
    Auerbach, M.D., President Elect, Massachusetts Medical Society,
    and Vice President and Chief of Emergency Medicine, Sturdy
    Memorial Hospital; Beth Landon, M.H.A., M.B.A., Director,
    Alaska Center for Rural Health, University of Alaska; Jennifer
    Laurent, M.S., FNP-BC, President, Vermont Nurse Practitioner
    Association; and John E. Maupin, Jr., D.D.S., M.B.A.,
    President, Morehouse School of Medicine.

    Committee on Finance

        On March 14, 2007, the Senate Committee on Finance held a
    hearing entitled ``Course for Health Care Reform: Moving Toward
    Universal Coverage.'' The panel included: James J. Mongan,
    M.D., President and Chief Executive Officer, Partners
    HealthCare; Stuart H. Altman, Ph.D., Dean, Sol C. Chaikin
    Professor of National Health Policy, The Heller School for
    Social Policy and Management, Brandeis University; John Sheils,
    Vice President, The Lewin Group; and Richard G. Frank, Ph.D.,
    Vice Chair, Citizens' Health Care Working Group.
        On May 6, 2008, the Senate Committee on Finance held a
    hearing entitled ``Seizing the New Opportunity for Health
    Reform.'' The panel included the Honorable Tommy Thompson and
    the Honorable Donna Shalala, both former Secretaries of Health
    and Human Services.
        On June 3, 2008, the Senate Committee on Finance held a
    hearing entitled ``Rising Costs, Low Quality in Health Care:
    The Necessity for Reform.'' The panel included: Paul B.
    Ginsburg, Ph.D., President, Center for Studying Health System
    Change; Elizabeth McGlynn, Ph.D., Associate Director, RAND
    Health, and Distinguished Chair in Health Quality; Arlene Holt
    Baker, Executive Vice President, AFL-CIO; and Felicia Fields,
    Group Vice President, Human Resources and Corporate Services,
    Ford Motor Company.
        On June 10, 2008, the Senate Committee on Finance held a
    hearing entitled ``47 Million and Counting: Why the Health Care
    Marketplace is Broken.'' The panel included: Lisa Kelly, cancer
    patient; Raymond Arth, President and CEO, Phoenix Faucets; Ron
    Williams, Chairman and Chief Executive Officer, Aetna, Inc.;
    and Mark Hall, Professor of Law and Public Health, Wake Forest
    University School of Law and School of Medicine.
        On September 9, 2008, the Senate Committee on Finance held
    a hearing entitled ``Improving Health Care Quality: An Integral
    Step Toward Health Reform.'' The panel included: Peter V. Lee,
    J.D., Executive Director of National Health Policy, Pacific
    Business Group on Health; Samuel Nussbaum, M.D., Executive Vice
    President for Clinical Health Policy and Chief Medical Officer,
    WellPoint, Inc.; Gregory Schoen, M.D., Regional Medical
    Director, Fairview Northland Health Services; Kevin B. Weiss,
    M.D., President and CEO, American Board of Medical Specialties;
    and William L. Roper, M.D., M.P.H., Dean, School of Medicine,
    University of North Carolina (UNC), and Vice Chancellor for
    Medical Affairs and CEO, UNC Health Care System.
        On September 23, 2008, the Senate Committee on Finance held
    a hearing entitled ``Covering the Uninsured: Making Health
    Insurance Markets Work.'' The panel included: John Bertko,
    F.S.A., M.A.A.A., Adjunct Staff, The RAND Corporation, and
    Former Chief Actuary, Humana, Inc., Flagstaff, AZ; Andrew
    Dreyfuss, Executive Vice President, Health Care Services, Blue
    Cross Blue Shield of Massachusetts; Pam MacEwan, Executive Vice
    President, Public Affairs and Governance, Group Health
    Cooperative; and Kim Holland, State of Oklahoma Insurance
    Commissioner.
        On November 19, 2008, the Senate Committee on Finance held
    a hearing entitled ``Health Care Reform: An Economic
    Perspective.'' The panel included: Ivan G. Seidenberg, Chairman
    and Chief Executive Officer, Verizon Communications, Inc.; Andy
    Stern, President, SEIU; Uwe E. Reinhardt, Ph.D., James Madison
    Professor of Political Economy, Woodrow Wilson School of Public
    and International Affairs, Princeton University; and Amitabh
    Chandra, Ph.D., Assistant Professor of Public Policy, John F.
    Kennedy School of Government, Harvard University.

                           111TH CONGRESS (2009-2010)

                    HEARINGS IN THE HOUSE OF REPRESENTATIVES

    Committee on Education and Labor

        On March 10, 2009, the Subcommittee on Health, Employment,
    Labor and Pensions of the Committee of Education and Labor held
    a panel entitled ``Strengthening Employer-Based Health Care.''
    The panel included: Mark Derbyshire, Small Business Owner;
    Bruce Pyenson, Principal and Consulting Actuary, Milliman,
    Inc.; John Sheridan, CEO, Cooper University Hospital; Kenneth
    Thorpe, Chair of the Health Policy and Management Department,
    Emory University; E. Neil Trautwein, Vice President, Employee
    Benefits Counsel, National Retail Federation; and Jim Winkler,
    Health Management Practice Leader, Hewitt Associates.
        On April 23, 2009, the Subcommittee on Health, Employment,
    Labor and Pensions of the Committee of Education and Labor held
    a panel entitled ``Ways to Reduce the Cost of Health Insurance
    for Employers, Employees and their Families.'' The panel
    included: Karen Davenport, Director of Health Policy, Center
    for American Progress; David Himmelstein, Associate Professor
    of Medicine, Harvard University; Michael Langan, Principal,
    Towers Perrin; William Oemichan, President and CEO, Cooperative
    Network; Ron Pollack, Executive Director, FamiliesUSA; Janet
    Trautwein, Executive Vice President and CEO, National
    Association of Health Underwriters; and William Vaughn, Senior
    Health Policy Analyst, Consumers Union.
        On June 10, 2009, the Subcommittee on Health, Employment,
    Labor and Pensions of the Committee of Education and Labor held
    a hearing entitled ``Examining the Single Payer Health Care
    Option.'' The panel included: Congressman John Conyers, Jr. (D-
    MI); Marcia Angell, M.D., Senior Lecturer in Social Medicine,
    Harvard Medical School; David Gratzer, Senior Fellow, Manhattan
    Institute; Geri Jenkins, R.N., Co-President, California Nurses
    Association/National Nurses Organizing Committee; and Walter
    Tsou M.D., M.P.H., National Board Advisor, Physicians for a
    National Health Program.

    Committee on Energy & Commerce

        On March 10, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a hearing entitled
    ``Making Health Care Work for American Families: Designing a
    High Performing Healthcare System.'' The panel included: Doug
    Elmendorf, Director, Congressional Budget Office; Glenn
    Hackbarth, Chairman, Medicare Payment Advisory Commission; Jack
    C. Ebeler, Vice Chair, Committee on Health Insurance Status and
    Its Consequences, Institute of Medicine; Alan Levine,
    Secretary, Louisiana Department of Health and Hospitals; Atul
    Gawande, M.D., Associate Professor of Surgery, Harvard Medical
    School, and Associate Professor, Department of Health Policy
    and Management, Harvard School of Public Health; and M. Todd
    Williamson, M.D., President, Medical Association of Georgia
    Policy Studies.
        On March 17, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a hearing entitled
    ``Making Health Care Work for American Families: Ensuring
    Affordable Coverage.'' The panel included: Uwe E. Reinhardt,
    Ph.D., Professor of Political Economy, Economics and Public
    Affairs, Princeton University; Sally C. Pipes, B.A., President
    and Chief Executive Officer, Pacific Research Institute; Judy
    Feder, Ph.D., Senior Fellow, Center for American Progress
    Action Fund; Mila Kofman, J.D., Superintendent of Insurance,
    State of Maine Bureau of Insurance; Jon Kingsdale, Ph.D.,
    Executive Director, Commonwealth Health Insurance Connector
    Authority, MA; Karen Pollitz, M.P.P., Research Professor,
    Health Policy Institute, Georgetown University; Katherine
    Baicker, Ph.D., Professor of Health Economics, Harvard School
    of Public Health; and Edmund F. Haislmaier, B.A., Senior
    Research Fellow, Center for Health, Heritage Foundation.
        On March 24, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a hearing entitled
    ``Making Health Care Work for American Families: Improving
    Access to Care.'' The panel included: Brian D. Smedley, Ph.D.,
    Vice President and Director, Health Policy Institute, Joint
    Center for Political and Economic Studies; Michael John
    Kitchell, M.D., President-Elect, Iowa Medical Society,
    McFarland Clinic PC; Michael A. Sitorius, M.D., Professor and
    Chairman, Department of Family Medicine, University of Nebraska
    Medical Center; Risa Lavizzo-Mourey, M.D., M.B.A., President
    and CEO, Robert Wood Johnson Foundation; Fitzhugh Mullan, M.D.,
    Murdock Head Professor of Medicine and Health Policy, Professor
    of Pediatrics, George Washington University; Jeffrey P. Harris,
    M.D., F.A.C.P., President, American College of Physicians;
    James R. Bean, M.D., President, American Association of
    Neurological Surgeons; and Diane Rowland, Sc.D., Executive
    Director, Kaiser Commission on Medicaid and the Uninsured.
        On March 27, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a hearing entitled
    ``Making Health Care Work for American Families: The Role of
    Public Health.'' The panel included: E. Besser, M.D., Acting
    Director, CDC, and Acting Administrator, Agency for Toxic
    Substances and Disease Registry; Jonathan E. Fielding, M.D.,
    M.P.H., Chair, Task Force on Community Preventive Services, and
    Director, L.A. County Department of Public Health and County
    Health Officer; Heather Howard, J.D., Commissioner, New Jersey
    Department of Health and Senior Services; David Satcher, M.D.,
    Ph.D., Former U.S. Surgeon General, and Director, Satcher
    Health Leadership Institute, Morehouse School of Medicine;
    Barbara Spivak, M.D., President, Mt. Auburn Cambridge
    Independent Practice Association, Inc.; Devon Herrick, Ph.D.,
    Senior Fellow, National Center for Policy Analysis; and Jeffrey
    Levi, Ph.D., Executive Director, Trust for Americas Health.
        On April 2, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a hearing entitled
    ``Making Health Care Work for American Families: Saving Money,
    Saving Lives.'' The panel included: Jonathan Skinner, Ph.D.,
    Professor of Economics, Dartmouth Institute for Health Policy
    and Clinical Practice; Christine K. Cassel, M.D., President and
    CEO, American Board of Internal Medicine and ABIM Foundation;
    John Goodman, Ph.D., President and CEO, National Center for
    Policy Analysis; Bruce Sigsbee, M.D., M.S., President Elect,
    American Academy of Neurology, and Medical Director, Pen Bay
    Physicians and Associates; Dennis Smith, M.P.A., Senior
    Research Fellow in Health Care Reform, Heritage Foundation;
    Jerry Avorn, M.D., Professor of Medicine, Harvard Medical
    School; Paul Ginsburg, Ph.D., President, Center for Studying
    Health System Change; Regina Herzlinger, Ph.D., Professor of
    Business Administration, Harvard Business School; Ronald
    Bachman, F.S.A., M.A.A.A., Senior Fellow, Center for Health
    Transformation; and Diane Archer, J.D., Director, Health Care
    Project, Institute for America's Future.
        On June 16, 2009, the Subcommittee on Oversight and
    Investigation of the Committee on Energy and Commerce held a
    hearing entitled ``Termination of Individual Health Policies by
    Insurance Companies.'' The panel included: Don Hamm, CEO,
    Assurant Health; Richard Collins, CEO, Golden Rule Insurance
    Company, UnitedHealth Group; Brian A. Sassi, President and CEO,
    Consumer Business, WellPoint, Inc.; Karen Pollitz, M.P.P.,
    Research Professor, Health Policy Institute, Georgetown
    University; Robin Beaton, Policyholder; Wittney Horton,
    Policyholder; and Peggy Raddatz, Relative of Policyholder.

    Committee on Ways & Means

        On March 11, 2009, the Committee on Ways and Means held a
    hearing entitled ``Expanding Coverage, Improving Quality and
    Controlling Costs.'' The panel included: John Z. Ayanian, M.D.,
    M.P.P., on behalf of the Institute of Medicine Committee on
    Health Insurance Status and Its Consequences; Karen Davis,
    President, Commonwealth Fund; and John M. Pickering, Principal,
    Consulting Actuary, Milliman, Inc.
        On March 17, 2009, the Subcommittee on Health in the
    Committee on Ways and Means held a hearing entitled ``MedPAC's
    Annual March Report to the Congress on Medicare Payment
    Policy.'' The panel featured Glenn M. Hackbarth, Chairman,
    Medicare Payment Advisory Commission.
        On April 1, 2009, the Committee of Ways and Means held a
    hearing entitled ``Reforming the Health Care Delivery System.''
    The hearing consisted of two panels. The first panel included:
    Glenn M. Hackbarth, Chairman, Medicare Payment Advisory
    Commission; Elliot S. Fisher, M.D., M.P.H., Director,
    Population Health and Policy, Dartmouth Institute for Health
    Policy and Clinical Practice, and Professor of Medicine and
    Community and Family Medicine, Dartmouth Medical School; and
    Robert A. Berenson, M.D., Senior Fellow, Urban Institute. The
    second panel included: Glenn D. Steele, Jr., M.D., Ph.D.,
    President and CMO, Geisinger Health System; L. Allen Dobson,
    Jr., M.D., F.A.A.F.P., Vice President for Clinical Practice
    Development, Carolinas Health System; and Brent C. James, M.D.,
    M.Stat., Chief Quality Officer and Chief Medical Officer,
    Institute for Health Care Delivery Research, Intermountain
    Healthcare.
        On April 22, 2009, the Committee on Ways and Means held a
    hearing entitled ``Insurance Market Reforms.'' The panel
    included: Uwe E. Reinhardt, Ph.D., James Madison Professor of
    Political Economy and Professor of Economics and Public
    Affairs, Princeton University; William Vaughn, Senior Policy
    Analyst, Consumers Union; William D. Hobson, Jr., M.S.,
    President and CEO, Watts Healthcare Corporation; David Borris,
    Owner, Hel's Kitchen Catering, Northbrook, Ill.; Kenneth L.
    Sperling, Global Health Management Leader, Hewitt Associates,
    on behalf of National Coalition on Benefits; and Linda
    Blumberg, Ph.D., Principal Research Associate, Urban Institute.
        On April 29, 2009, the Committee on Ways and Means held a
    hearing entitled ``Employer Sponsored Insurance.'' The panel
    included: Elise Gould, Ph.D., M.P.Aff., Director of Health
    Policy Research, Economic Policy Institute; J. Randal
    MacDonald, Senior Vice President for Human Resources, IBM
    Corporation; Kelly Conklin, Owner, Foley-Waite Associates;
    Denny Dennis, Senior Research Fellow, NFIB Research Foundation;
    John Shells, Senior Vice President, Lewin Group; and Gerald
    Shea, Special Assistant to the President, AFL-CIO.
        On May 6, 2009, the Committee on Ways and Means held a
    hearing on ``Health Care Reform'' with Kathleen Sebelius, the
    Secretary for Health and Human Services.

                             HEARINGS IN THE SENATE

    Committee on Health, Education, Labor and Pensions

        On January 29, 2009, the Senate HELP Committee held a
    hearing entitled ``Crossing the Quality Chasm in Health
    Reform.'' The panel included: Nancy Davenport-Ennis, CEO,
    National Patient Advocate Foundation; Karen Davis, President,
    Commonwealth Fund; Rhonda Robinson-Beale, M.D., Chief Medical
    Officer, Optum Health Behavioral Solutions, Golden Valley, MN;
    Elizabeth Teisberg, Ph.D., Associate Professor, University of
    Virginia's Darden School of Business; and Christine K. Cassel,
    M.D., President, American Board of Internal Medicine.
        On February 23, 2009, the Senate HELP Committee held a
    hearing entitled ``Principles of Integrative Health: A Path to
    Health Care Reform.'' The panel included: Cathy Baase, M.D.,
    Global Director Health Services, Dow Chemical Company; Robert
    M. Duggan, M.A., M.Ac., President, Tai Sophia Institute; James
    S. Gordon, M.D., Founder and Director, Center for Mind-Body
    Medicine; Wayne B. Jonas, M.D., President, Samueli Institute;
    Sister Charlotte Rose Kerr, R.S.M., R.N., B.S.N., M.P.H.,
    M.Ac., Practitioner and Professor Emeritus, Tai Sophia
    Institute; Mary Jo Kreitzer, Ph.D., R.N., Founder and Director,
    University of Minnesota Center for Spirituality & Healing;
    Herbert Benson, M.D., Director Emeritus, Benson-Henry Institute
    for Mind Body Medicine, Massachusetts General Hospital; Brian
    M. Berman, M.D., Director, Center for Integrative Medicine,
    University of Maryland School of Medicine; Susan Hartnoll
    Berman, Executive Director, Institute for Integrative Health;
    Ron Z. Goetzel, Ph.D., Research Professor and Director,
    Institute for Health and Productivity Studies, Rollins School
    of Public Health, Emory University; Kathi J. Kemper, M.D.,
    M.P.H., F.A.A.P., Caryl J. Guth Chair for Complementary and
    Integrative Medicine, Division of Health Sciences, Wake Forest
    University; and Simon Mills, Project Lead, United Kingdom
    Department of Health project: Integrated Self Care in Family
    Practice.
        On February 24, 2009, the Senate HELP Committee held a
    hearing entitled ``Addressing Underinsurance in National Health
    Reform.'' The panel included: Cathy Schoen, M.S., Senior Vice
    President, Commonwealth Fund; Gail Shearer, M.S., Director of
    Health Policy Analysis, Consumers Union; Diane Rowland, D.Sc.,
    Executive Vice President, Henry J. Kaiser Family Foundation,
    and Executive Director, Kaiser Commission on Medicaid and the
    Uninsured; and Grace-Marie Turner, President, Galen Institute.
        On March 24, 2009, the Senate HELP Committee held a hearing
    entitled ``Addressing Insurance Market Reform in National
    Health Reform.'' The panel included: Janet Trautwein, Executive
    Vice President and CEO, National Association of Health
    Underwriters; Ronald A. Williams, M.S., Chairman and Chief
    Executive Officer, Aetna, Inc.; Karen Pollitz, M.P.P., Research
    Professor, Health Policy Institute, Georgetown University;
    Karen Ignagni, M.B.A., President and CEO, America's Health
    Insurance Plans; Len Nichols, Ph.D., Director, Health Policy
    Program, New America Foundation; Katherine Baicker, Ph.D.,
    Professor of Health Economics, Department of Health Policy and
    Management, Harvard School of Public Health; and Sandy Praeger,
    Health Insurance Commissioner, State of Kansas.
        On April 28, 2009, the Senate HELP Committee held a hearing
    entitled ``Learning from the States: Individual State
    Experiences with Health Care Reform Coverage Initiatives in the
    Context of National Reform.'' The panel included: Jon
    Kingsdale, Ph.D., Executive Director, Commonwealth Health
    Insurance Connector Authority, MA; Susan Besio, Director,
    Office of Vermont Health Access, State of Vermont Human
    Services Agency; Harry Chen, M.D., Emergency Room Physician and
    Board Member, Vermont Program for Quality in Health Care; Brent
    James, Executive Director, IHC Institute for Health Care
    Delivery Research, Intermountain Health Care, Inc.; Honorable
    David Clark (R), Majority Leader, Utah House of
    Representatives; Ruth Liu, Senior Director for Health Policy,
    Legal and Government Relations, Kaiser Permanente; and Eileen
    McAnneny, Senior Vice-President of Government Affairs and
    Associate General Counsel, Associated Industries of
    Massachusetts.
        On April 30, 2009, the Senate HELP Committee held a hearing
    entitled ``Primary Health Care Access Reform: Community Health
    Centers and the National Health Service Corps.'' The panel
    included: Cynthia Bascetta, Director of Health Care, GAO; Dan
    Hawkins, Senior Vice President, National Association of
    Community Health Centers; Fitzhugh Mullan, M.D., Murdock Head
    Professor of Medicine and Health Policy, George Washington
    University School of Public Health; Caswell A. Evans, Jr.,
    D.D.S, M.P.H., Associate Dean for Prevention and Public Health
    Sciences, University of Illinois at Chicago College of
    Dentistry; Yvonne Davis, Board Member, Community Health Center;
    John Matthew, M.D., Health Center, Plainfield, VT; and Lisa
    Nichols, Executive Director, Midtown Community Center, Ogden,
    UT.
        On June 11, 2009, the Senate HELP Committee held a two-
    panel hearing entitled ``Health Care Reform.'' The first panel
    included: Margaret Flowers, M.D., Maryland Co-Chair, Physicians
    for a National Health Program; Ron Williams, CEO, Aetna, Inc;
    Randel Johnson, Vice President for Labor, Immigration, and
    Employee Benefits, U.S. Chamber of Commerce; William Dennis,
    Senior Research Fellow, National Federation of Independent
    Business; Mary Andrus, Co-Chair of the Health Care Taskforce,
    Consortium for Citizens with Disabilities; Samantha Rosman,
    M.D., Board of Trustees, American Medical Association; Ray
    Scheppach, Ph.D., Executive Director, National Governors'
    Association; Gerald Shea, Special Assistant to the President,
    AFL-CIO; Dennis Rivera, Chair, SEIU Healthcare; Katherine
    Baicker, Ph.D., Professor of Health Economics, Harvard School
    of Public Health; Jonathan Gruber, Ph.D., Associate Head, MIT
    Department of Economics; Janet Trautwein, Executive Vice-
    President and CEO, National Association of Health Underwriters;
    Sandy Praeger, Kansas Insurance Commissioner; Scott Gottlieb,
    M.D., Resident Fellow, American Enterprise Institute; and Steve
    Burd, President and CEO, Safeway, Inc. The second panel
    included: Gary Raskob, Ph.D., Dean, University of Oklahoma
    College of Public Health; Jeffrey Levi, Ph.D., Executive
    Director, Trust for America's Health; Fay Raines, Ph.D.,
    President, American Association of Colleges of Nursing; Wayne
    Jonas, M.D., President and CEO, Samueli Institute; Delos
    Cosgrove, M.D., CEO, Cleveland Clinic; Brent James, M.D.,
    M.Stat., Executive Director, Institute for Health Care Delivery
    Research, Intermountain Health Care, Inc.; Charles Kahn,
    M.P.H., President, Federation of American Hospitals; John
    Rother, J.D., Executive Vice President for Policy and Strategy,
    AARP; and Judith Palfrey, M.D., President-Elect, American
    Academy of Pediatric.

    Committee on Finance

        On February 25, 2009, the Senate Committee on Finance held
    a hearing entitled ``Scoring Health Care Reform: CBO's Budget
    Options'' with Douglas Elmendorf, Ph.D., Director of the
    Congressional Budget Office.
        On March 12, 2009, the Senate Committee on Finance held a
    hearing entitled ``Workforce Issues in Health Care Reform:
    Assessing the Present and Preparing for the Future.'' The panel
    included: David C. Goodman, M.D., M.S., Director of the Center
    for Health Policy Research, Dartmouth College; Allan H. Goroll,
    M.D., M.A.C.P., Professor of Medicine, Harvard Medical School;
    Fitzhugh Mullan, M.D., Murdock Head Professor of Medicine and
    Health Policy, George Washington University; and Steven A.
    Wartman, M.D., Ph.D., M.A.C.P., President and CEO, Association
    of Academic Health Centers.
        On March 25, 2009, the Senate Committee on Finance held a
    hearing entitled ``The Role of Long-Term Care in Health
    Reform.'' The panel included: Judy Feder, Ph.D., Senior Fellow,
    Center for American Progress Action Fund; Raymond C. Scheppach,
    Ph.D., Executive Director, National Governors Association;
    Dennis G. Smith, Senior Research Fellow in Health Care Reform,
    Heritage Foundation; and Joshua M. Wiener, Ph.D., Senior
    Fellow, RTI International.
        On April 21, 2009, the Senate Committee on Finance held a
    hearing entitled ``Reforming America's Health Care Delivery
    System.'' The panel included: Allan M. Korn, M.D., Senior Vice
    President, Chief Medical Officer, Office of Clinical Affairs,
    Blue Cross Blue Shield Association; Glenn M. Hackbarth, J.D.,
    Chairman, Medicare Payment Advisory Commission; Peter V. Lee,
    J.D., Executive Director of National Health Policy, Pacific
    Business Group on Health; Mark B. McClellan, M.D., Director,
    Engelberg Center for Health Care Reform, Brookings Institute;
    Lewis Morris, J.D., Chief Counsel to the Inspector General,
    Office of Counsel to the Inspector General; Mary D. Naylor,
    Ph.D., F.A.A.N., R.N., Marian S. Ware Professor in Gerontology,
    University of Pennsylvania School of Nursing; Debra Ness,
    President, National Partnership for Women and Families; Frank
    G. Opelka, M.D., F.A.C.S., Vice Chancellor for Clinical Affairs
    and Professor of Surgery, Office of the Chancellor, Louisiana
    State University Health Science Center; Glenn Steele, Jr.,
    M.D., Ph.D., President, Geisinger Health System; John Tooker,
    M.D., M.B.A., F.A.C.P., Executive Vice President and Chief
    Executive Officer, American College of Physicians; Richard J.
    Umbdenstock, F.A.C.H.E., President and CEO, American Hospital
    Association; Ron Williams, Chairman and CEO, Aetna, Inc.; and
    Paul J. Diaz, J.D., President and CEO, Kindred Healthcare, Inc.
        On May 5, 2009, the Senate Committee on Finance held a
    hearing entitled ``Expanding Health Care Coverage.'' The panel
    included: Stuart M. Butler, Ph.D., Vice President, Domestic and
    Economic Policy Studies, Heritage Foundation; John Castellani,
    President, Business Roundtable; Gary Claxton, Vice President
    and Director, Health Care Marketplace Project, Henry J. Kaiser
    Family Foundation; Donald A. Danner, President and CEO,
    National Federation of Independent Business; Jennie Chin
    Hansen, R.N., M.S., F.A.A.N., President, AARP; Karen Ignagni,
    President and CEO, America's Health Insurance Plan; R. Bruce
    Josten, Executive Vice President, Government Affairs, U.S.
    Chamber of Commerce; Len Nichols, Ph.D., Director, Health
    Policy Program, New America Foundation; Ron Pollack, J.D.,
    Executive Director, Families USA; Sandy Praeger, Chair, Health
    Insurance and Managed Care Committee, National Association of
    Insurance Commissioners; Sara Rosenbaum, J.D., Chair,
    Department of Health Policy, George Washington School of Public
    Health and Health Services; Diane Rowland, Sc.D., Executive
    Vice President, Henry J. Kaiser Family Foundation; Raymond C.
    Scheppach, Ph.D., Executive Director, National Governors
    Association; Scott Serota, President and Chief Executive
    Officer, Blue Cross and Blue Shield Association; and Andy
    Stern, President, SEIU.
        On May 12, 2009, the Senate Committee on Finance held a
    hearing entitled ``Financing Comprehensive Health Care
    Reform.'' The panel included: Stuart H. Altman, Ph.D., Sol C.
    Chaikin Professor of National Health Policy, Heller School for
    Social Policy and Management, Brandeis University; Joseph R.
    Antos, Ph.D., Wilson H. Taylor Scholar in Health Care and
    Retirement Policy, American Enterprise Institute; Katherine
    Baicker, Ph.D., Professor of Health Economics, Harvard School
    of Public Health; Leonard Burman, Ph.D., Director, Tax Policy
    Center, Urban Institute; Robert Greenstein, Ph.D., Executive
    Director, Center on Budget and Policy Priorities; Jonathan
    Gruber, Ph.D., Professor of Economics, Massachusetts Institute
    of Technology; Michael F. Jacobson, Ph.D., Executive Director,
    Center for Science in the Public Interest; James A. Klein,
    President, American Benefits Council; Edward Kleinbard, Chief
    of Staff, Joint Committee on Taxation; Gerald M. Shea, Special
    Assistant to the President, AFL-CIO; John Sheils, Senior Vice
    President, Lewin Group; Gail Wilensky, Ph.D., Senior Fellow,
    Project HOPE; and Steven Wojcik, Vice President of Public
    Policy, National Business Group on Health.

     INTRODUCTION AND CONSIDERATION OF AMERICA'S AFFORDABLE HEALTH CHOICES
                                 ACT, H.R. 3200

        On June 19, 2009, Congressman George Miller (D-CA), along
    with Congressmen Henry Waxman (D-CA), Charles Rangel (D-NY) and
    John Dingell (D-MI) released the Tri-Committee draft proposal
    for health care reform.

    Committee on Education & Labor Consideration of the Tri-Committee Draft
            Proposal for Health Care Reform

        On June 23, 2009, the House Education and Labor Committee
    held a hearing to discuss the draft proposal for health care
    reform that was jointly developed by the House Ways and Means,
    Energy and Commerce, and Education and Labor Committees. The
    draft was designed to achieve President Obama's goals of
    controlling health care cost, preserving health care choices,
    and ensuring quality, affordable health care for all Americans.
    The hearing entitled ``The Tri-Committee Draft Proposal for
    Health Care Reform'' consisted of three panels. The first panel
    included: Christina Romer, Ph.D., Chair, Council of Economic
    Advisers, Office of the President; Ron Pollack, Founding
    Executive Director, Families USA; Gerald Shea, Special
    Assistant to the President, AFL-CIO; Paul J. Speranza, Senior
    Vice President, General Counsel and Secretary, Wegmans Food
    Markets, Inc.; Jacob Hacker, Ph.D., Professor and Co-Director,
    Berkeley Center on Health, Economic, and Family Security,
    University of California Berkeley; Michael J. Stapley,
    President and Chief Executive Officer, Deseret Mutual; John
    Arensmeyer, Chief Executive Officer, Small Business Majority;
    and Fran Visco, President, National Breast Cancer Coalition.
    The second panel included: Karen Pollitz, Research Professor
    and Project Director, Health Policy Institute, Georgetown
    University; Celia Wcislo, Assistant Division Director, SEIU;
    James A. Klein, President, American Benefits Council; William
    Vaughan, Senior Health Policy Analyst, Consumers Union; Robert
    E. Moffit, Ph.D., Director, Center for Health Policy Studies,
    Heritage Foundation; ReShonda Young, Small Business Owner,
    Alpha Express, Inc. on behalf of the Main Street Alliance; and
    Fitzhugh Mullan, M.D., Murdock Head Professor of Medicine and
    Health Policy, George Washington University.

    Committee on Energy & Commerce Consideration of the Tri-Committee Draft
            Proposal for Health Care Reform

        On June 23, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a hearing entitled
    ``Comprehensive Health Reform Discussion, Day 1.'' The panel
    included: Richard Kirsch, National Campaign Manager, Health
    Care for America Now; Ralph G. Neas, Chief Executive Officer,
    National Coalition on Health Care; Stephen T. Parente, Ph.D.,
    Director, Medical Industry Leadership Institute; Marian Wright
    Edelman, President, Children's Defense Fund; Jennie Chin
    Hansen, President, AARP; David L. Shern, Ph.D., President and
    Chief Executive Officer, Mental Health America; Erik Novak,
    M.D., Orthopedic Surgeon, Patients United Now; Shona Robertson-
    Holmes, Patient at Mayo Clinic; Jeffrey Levi, Ph.D., Executive
    Director, Trust for America's Health; Brian D. Smedley, Ph.D.,
    Vice President and Director, Health Policy Institute, Joint
    Center for Political and Economic Studies; and Mark Kestner,
    M.D., Chief Medical Officer, Alegent Health.
        On June 24, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a three-panel hearing
    entitled ``Comprehensive Health Reform Discussion, Day 2.'' The
    first panel on single-payer health care included: Sidney M.
    Wolfe, M.D., Director, Health Research Group at Public Citizen;
    Steffie Woolhandler, M.D., Associate Professor of Medicine,
    Harvard Medical School, and Co-Founder, Physicians for a
    National Health Program; and John C. Goodman, Ph.D., President
    and CEO, National Center for Policy Analysis. The second panel
    on state, local and tribal views included: the Honorable
    Michael O. Leavitt, Former Secretary, U.S. Department of Health
    and Human Services; the Honorable Joseph Vitale (D), Chairman,
    Committee on Health, Human Services, and Senior Citizens, New
    Jersey State Senate; W. Ron Allen, Chairman, Jamestown
    S'Klallam Tribe; the Honorable Jay Webber (R), New Jersey State
    Assembly; Raymond C. Scheppach, Ph.D., Executive Director,
    National Governors Association; Robert S. Freeman, Deputy
    Executive Director, CenCal Health, California Association of
    Health Insuring Organizations; and Ron Pollack, Executive
    Director, Families USA. The third panel on drug and device
    manufacturer views included: Thomas Miller, CEO, Workflow and
    Solutions Division, Siemens Medical Solutions, USA; Kathleen
    Buto, Vice President for Health Policy, Johnson & Johnson;
    William Vaughan, Senior Health Policy Analyst, Consumers Union;
    Scott Gottlieb, M.D., Resident Fellow, American Enterprise
    Institute; and A. Kelly, Senior Vice President, Government
    Affairs and Public Policy, National Association of Chain Drug
    Stores.
        On June 25, 2009, the Subcommittee on Health of the
    Committee on Energy and Commerce held a four-panel hearing
    entitled ``Comprehensive Health Reform Discussion, Day 3.'' The
    first panel on Medicare payment included Glenn M. Hackbarth,
    Chair of the Medicare Payment Advisory Commission, and the
    Honorable Daniel R. Levinson, Inspector General of the U.S.
    Department of Health and Human Services. The second panel on
    doctor, nurse, hospital, and other provider views included: Ted
    D. Epperly, M.D., President, American Academy of Family
    Physicians; M. Todd Williamson, M.D., President, Medical
    Association of Georgia; Karl J. Ulrich, M.D., Clinic President
    and CEO, Marshfield Clinic; Janet Wright, M.D., Vice President,
    Science and Quality, American College of Cardiology; Kathleen
    M. White, Ph.D., Chair, Congress on Nursing Practice and
    Economics, American Nurses Association; Patricia Gabow, M.D.,
    Chief Executive Officer, Denver Health and Hospital Authority,
    National Association of Public Hospitals; Dan Hawkins, Senior
    Vice President, Public Policy and Research, National
    Association of Community Health Centers; Bruce T. Roberts,
    R.Ph., Executive Vice President and CEO, National Community
    Pharmacists Association; Bruce Yarwood, President and CEO,
    American Health Care Association; and Alissa Fox, Senior Vice
    President, Office of Policy and Representation, Blue Cross Blue
    Shield Association. The third panel on employer and employee
    views included: Kelly Conklin, Owner, Foley-Waite Custom
    Woodworking, Main Street Alliance; John Arensmeyer, Founder and
    CEO, Small Business Majority; Gerald M. Shea, Special Assistant
    to the President, AFL-CIO; Dennis Rivera, Health Care Chair,
    SEIU; John Castellani, President, Business Roundtable Institute
    for Corporate Ethics; John Sheils, Senior Vice President, Lewin
    Group; and Martin Reiser, Manager of Government Policy, Xerox
    Corporation, National Coalition on Benefits. The fourth panel
    on insurers' views included: Howard A. Kahn, Chief Executive
    Officer, L.A. Care Health Plan; Karen Pollitz, M.P.P., Research
    Professor, Health Policy Institute, Georgetown University;
    Karen Ignagni, President and CEO, America's Health Insurance
    Plans; and Janet Trautwein, Executive Vice President and CEO,
    National Association of Health Underwriters.

    Committee on Ways & Means Consideration of the Tri-Committee Draft
            Proposal for Health Care Reform

        On June 24, 2009, the Committee on Ways and Means had a
    hearing entitled ``Health Reform in the 21st Century: Proposals
    to Reform the Health System.'' The hearing consisted of three
    panels. The first panel included: Karen Pollitz, Policy
    Director, Health Policy Institute, Georgetown Public Policy
    Institute; John F. Holahan, Ph.D., Director, Health Policy
    Research Center, Urban Institute; and David Gratzer, M.D.,
    Senior Fellow, Manhattan Institute for Policy Research. The
    second panel included: Richard Kirsch, National Campaign
    Manager, Health Care for America NOW; Mike Draper, Owner,
    SMASH; Peter V. Lee, Executive Director for National Health
    Policy, Pacific Business Group on Health; Gerald Shea, Special
    Assistant to the President, AFL-CIO; Jennie Chin Hansen,
    President, AARP; and Randel K. Johnson, Senior Vice President,
    Labor, Immigration and Employee Benefits, U.S. Chamber of
    Commerce. The third panel included: Dan Baxter, Medical
    Director, William F. Ryan Community Health Network, NY; Ted
    Epperly, M.D., President, American Academy of Family
    Physicians; Donna Policastro, Executive Director, Rhode Island
    State Nurses Association on behalf of the American Nurses
    Association; Chip Kahn, President, Federation of American
    Hospitals; Larry Minnix, President and CEO, American
    Association of Homes and Services for the Aging; Ronald
    Williams, Chairman and CEO, Aetna, Inc.; and Richard Warner,
    M.D., Member, Kansas Medical Society House of Delegates, AMA
    Alternate Delegate, and past President, Kansas Medical Society.

    Introduction of America's Affordable Health Choices Act, H.R. 3200

        On July 15, 2009, after taking into consideration comments
    on the discussion draft from a very wide range of voices,
    Chairmen George Miller, Henry Waxman, Charles Rangel, and
    Congressman John Dingell introduced America's Affordable Health
    Choices Act, H.R. 3200. The bill seeks to control rising health
    care costs, strengthen the employer-based health care system,
    and ensure that all Americans have access to quality and
    affordable health care coverage.

    Committee on Education & Labor Mark-up of H.R. 3200

        The Full Committee met on July 15-17, 2009 to mark up H.R.
    3200. The Committee passed by voice vote an amendment in the
    nature of a substitute offered by Chairman George Miller (D-
    CA). There were 42 other amendments offered and debated. Of the
    amendments offered, 20 passed, 17 failed, 4 were withdrawn, and
    one was ruled not germane.

    America's Affordable Health Choices Act of 2009

        H.R. 3200 was reported favorably to the House with an
    amendment in the nature of a substitute. By a vote of 26-22,
    the Committee authorized the Chairman to transmit the bill,
    with an amendment in the nature of a substitute, to the
    Committee on the Budget in compliance with section 310 of the
    Congressional Budget Act of 1974 as the first part of the
    Committee's recommendations, pursuant to the reconciliation
    instruction in S. Con Res. 13.
        The Miller amendment in the nature of a substitute contains
    the following modifications to H.R. 3200:
        Recognizes the unique structures of multi-employer plans
    and how they interact with the Health Insurance Exchange (HIE).
    In Section 100(26), the health care contributions of
    multiemployer plans are to be treated as employer
    contributions. Section 123(b)(1)(D) directs the Health Benefits
    Advisory Committee to take into consideration the unique nature
    of the multiemployer plans in recommending the essential
    benefits package. Lastly, Section 202(e)(8) makes clear that
    multiemployer plans shall be treated as large employers in
    regard to joining the HIE.
        The Miller substitute also creates a new subsection (b) in
    Section 115 that requires qualified health benefits plans to
    make provider information available to consumers by publishing
    current listings of all providers within a plan network on
    their website. Amends the bill in Section 116 to provide that
    the medical loss ratio for qualified health benefits plans must
    be at least 85 percent.
        Creates Section 117 to prohibit insurance companies from
    changing the coverage or costs of a health plan mid-year except
    if the costs are lowered and/or the coverage is increased.
        Specifically includes in the essential benefits package
    ``durable medical equipment, prosthetics, orthotics, and
    supplies.'' (DMEPOS) The Committee is aware that Section 122
    (4) related to coverage of ``services, equipment, and supplies
    incident to the services of a physician's or a health
    professional's delivery of care in . . . patients' homes or
    places of residence'' encompasses coverage of such devices and
    related services, but opted to clarify that these are
    considered essential benefits. By separately listing the
    category of DMEPOS as an essential benefit, the Committee
    intends to underscore the importance of coverage for these
    devices and related services.
        Amends sections 122 and 133 to include three provisions
    related to integrative medicine: to require that the membership
    of the Health Benefits Advisory Committee include one or more
    integrative medicine providers; establish an Integrative Health
    Care Service Task Force that is to be comprised of five experts
    in integrative health care; and, ensure that HIE enrollees are
    provided with information to identify integrative medicine
    providers who are trained and accredited.
        Establishes Section 138 to ban the sales of physician
    prescribing data to the pharmaceutical industry when the
    physician serves patients enrolled in a qualified health
    benefit plan.
        Amends Section 202(d) to include that retirees who are
    participants or beneficiaries in an adversely affected health
    benefits group and are not enrolled in Medicare, are to be
    considered Exchange eligible individuals and may enter into the
    HIE in 2013, the first year of operation. Also limits post-
    retirement reductions of retiree health benefits by group
    health plans in Section 165.
        Creates a new provision, Section 209, to allow small
    employer benefit arrangements, which are defined as not-for-
    profit agricultural or other industry cooperatives, to work
    with the Commissioner to assist in the enrollment of small
    employers and their employees in the HIE. The small employer
    benefit arrangements are to operate for the primary purpose of
    providing affordable employee benefits to its members; that
    only consists of member employers that are in the same industry
    or line of business; ensure that no member has more than five
    percent voting interest in the cooperative, and are to be
    governed by a board of directors elected by its members.
        Adds an additional condition for providers eligible to
    participate in the public health insurance option in Section
    225(b) by permitting providers, such as Christian Science
    practitioners, who are ``otherwise permitted to practice under
    state law'' to also participate in the public health insurance
    option.
        Amends the affordability standard for access to the HIE in
    Section 242(b)(2)(B) by giving the Commissioner the authority
    to permit individuals and families who have received an
    employer offer of health care coverage to qualify for the HIE
    in Y2 of operation if their premium and cost sharing is greater
    than 11 percent of family income.
        Inserts language to protect against the misclassification
    of workers for purposes of the provisions within H.R. 3200. The
    language requires the Secretary of Labor to promulgate record-
    keeping requirements for both employees and certain individuals
    performing work for an employer but whom the employer has not
    treated as employees. The content and scope of these record-
    keeping requirements (both in terms of what data is needed and
    what non-employee individuals are covered) should be designed
    to assist the Secretary in the audits she performs to determine
    noncompliance with the bill's health coverage participation
    requirements.
        Requires the development of standards for accessible
    equipment, and requires relevant agencies to ensure that all
    entities covered by the legislation meet the requirements of
    the Americans with Disabilities Act and Section 504 of the
    Rehabilitation Act. The Committee recognizes that a critical
    component of providing health care to many individuals with
    disabilities is ensuring that diagnostic and treatment
    equipment is accessible to those with impairments which impede
    use of standard equipment. Inaccessible medical equipment often
    prevents people with disabilities from receiving the basic care
    others take for granted, such as getting weighed, preventative
    dental care, mammograms, pelvic exams, x-rays, physical
    examinations, colonoscopies, and vision screenings.
        Subtitle F of Division C adds a new provision to reduce the
    student-to-school nurse ratio. Section 2551 makes available
    demonstration grants to eligible local education agencies with
    the purpose of reducing the student-to-school nurse ratio in
    public elementary and secondary schools with special
    consideration given to high-need local educational agencies who
    demonstrate the greatest need for new or additional nursing
    services by providing information on the current ratios of
    students to school nurses.
        The last modification within the Miller substitute
    recognizes the importance of preventive approaches to health
    and wellness. Section 2552 authorizes the Secretary of Labor to
    offer incentives to employers who establish qualified wellness
    programs for their employees. The Committee believes these
    small grants will assist in improving the health of our
    nation's workforce and will reduce employer healthcare costs.
    Participating employers must offer the programs to all
    employees and cannot mandate participation nor use
    participation as a condition to receive any financial
    incentive.

                       AMENDMENTS CONSIDERED IN COMMITTEE

        The amendment offered by Representative Courtney (D-CT)
    amends Section 111 of the Miller substitute. The amendment
    reduces the pre-existing condition ``look-back'' period from
    six months to 30 days and shortens the amount of time during
    which a provider can exclude coverage for pre-existing
    conditions, during the period prior to the bill's effective
    date for the total prohibition on pre-existing condition
    exclusions. The amendment was passed by voice vote.
        The Representative Kline (R-MN) amendment would have struck
    Titles I and II of Division A which would include striking the
    protections and standards for qualified health benefits plans
    and also the HIE. The Kline amendment would have also struck
    Sections 311, 312, 313, 314, 321 and 324 which include striking
    employer mandate requirements and requirements for employer
    health coverage participation under ERISA. The amendment was
    defeated by a roll call vote of 19-29.
        The amendment offered by Representative Titus (D-NV) would
    increase the size of small businesses that can choose to enter
    the HIE. It specifies that in 2013 (Y1), the size of businesses
    eligible for the HIE would increase from 10 to 15; in 2014
    (Y2), the size of businesses eligible for the HIE would
    increase from 20 to 25; and, in 2015 (Y3), the Commissioner
    must allow additional small businesses to enter the HIE and
    would set the minimum size for an eligible small business as
    one with 50 employees or less. The amendment passed by a roll
    call vote of 29-19.
        The amendment offered by Representative Scott (D-VA) would
    add early periodic screening, diagnosis, and treatment (EPSDT)
    benefits to children up to age 21 to be included in the
    essential benefits package (Section 122(b)(10)). The amendment
    passed by a roll call vote of 32-17.
        The amendment offered by Representative Thompson (R-PA)
    would have struck Subtitle A of Title II of Division A, i.e.,
    the HIE. The amendment was defeated by a roll call vote of 19-
    29.
        The amendment offered by Representative Roe (R-TN) would
    have struck Subtitle B of Title II of Division A, i.e., the
    public health insurance option. The amendment was defeated by a
    roll call vote of 19-29.
        The amendment offered by Representative Davis (D-CA) would
    instruct the Health Benefits Advisory Committee to examine
    current state laws and to seek input from the states as it
    forms its recommendations for the federal benefits standards by
    inserting the aforementioned after paragraph (2) in Section
    123(b). The amendment was passed by voice vote.
        The amendment offered by Representative Guthrie (R-KY)
    would have struck Sections 311, 312, 313, 314, 321 and 324,
    i.e., the employer mandate requirements and requirements for
    employer health coverage participation under ERISA. The
    amendment was defeated by a roll call vote of 19-28.
        The second amendment offered by Representative Davis (D-CA)
    would end the current COBRA eligibility limit and allow those
    currently enrolled in COBRA to keep their insurance until they
    find another job offering coverage or until they become
    eligible to participate in the HIE. This amendment would be
    inserted after Subtitle G of Title I of Division A. The
    amendment was passed by voice vote.
        The amendment offered by Representative Biggert (R-IL) and
    Representative Price (R-GA) would have struck Section 102(b)
    and inserted that any group health plan operating under ERISA
    would be treated as already meeting the requirements of a
    qualified health benefits plan as listed in Title I. The
    amendment was defeated by a roll call vote of 18-29.
        The amendment offered by Representative Fudge (D-OH) and
    Representative Titus (D-NV) would help small employers select
    health plans. The amendment would require the Commissioner, in
    consultation with the Small Business Administration, to
    establish and carry out a program to provide health insurance
    counseling and technical assistance to small employers who
    provide their employees health care through the HIE. The
    amendment was passed by a roll call vote of 28-18.
        The amendment offered by Representative Wilson (R-SC) would
    exclude TRICARE from the definition of employment-based health
    care. The amendment was passed by voice vote.
        The amendment offered by Representative Hare (D-IL) would
    make a technical change in the Miller amendment regarding
    ``small employer benefit associations.'' The amendment would
    strike ``association(s)'' and instead insert
    ``arrangement(s).'' The amendment was passed by voice vote.
        The amendment offered by Representative Kline (R-MN) would
    have added to the end of Section 311 a provision to exempt
    employers from having to offer or maintain qualified health
    insurance coverage if an employer-initiated referendum calling
    for such an exemption was passed by a majority of employees.
    The amendment was defeated by a roll call vote of 18-28.
        The amendment offered by Representative Hirono (D-HI) would
    maintain Hawaii's Prepaid Health Care Act exemption under
    ERISA, including with respect to the provisions of H.R. 3200,
    where such state statute ensures health care benefits
    equivalent to or greater than those benefits that would be
    guaranteed by H.R. 3200. The amendment was passed by voice
    vote.
        The amendment offered by Representative Hoekstra (R-MI)
    would have suspended Sections 311, 312, 313, and 314, which
    pertain to H.R. 3200's employer mandate, in the event that the
    national unemployment rate as announced monthly by the Bureau
    of Labor Statistics at the Department of Labor equals or exceed
    eight percent for two consecutive months. The amendment was
    defeated by voice vote.
        The amendment offered by Representative Kucinich (D-OH)
    would create an ERISA waiver to permit States to enact single
    payer laws. The Department of Labor would determine whether the
    State plan meets certain requirements to obtain the waiver. The
    amendment was passed by a roll call vote of 27-19 with one
    member passing on the vote.
        The amendment offered by Representative Hunter (R-CA) would
    create a two-year employer hardship exemption that waives an
    employer's obligation to provide coverage or pay a penalty. The
    amendment was passed by voice vote.
        The second amendment offered by Representative Kucinich (D-
    OH) would have limited the total compensation of insurance
    company executives to not exceed the compensation of the
    President of the United States. The amendment was withdrawn and
    no further action was taken on it.
        The amendment offered by Mr. McClintock (R-CA) would have
    required that 30 days after H.R. 3200's enactment, the Director
    of the Office of Management and Budget submit a report to the
    House of Representatives determining whether Sections 311, 312,
    313, 314, 321, and 324 are deficit neutral for the applicable
    period of ten fiscal years. The report would be annually
    conducted prior at the end of each fiscal year and if a section
    was found to not be deficit neutral, then it would be suspended
    for two years following that fiscal year. The amendment was
    defeated by a roll call vote of 19-28.
        The en bloc amendment offered by Representative Holt (D-
    NJ), incorporating proposals by Representatives Loebsack, Wu,
    Courtney, Altmire, and Tonko, would add workforce development
    provisions for long-term care workers; add training for health
    care jobs for vulnerable populations; expand and clarify that
    mental health and substance abuse preventative services are
    covered in the essential benefits package; and create a health
    care labor market website and an online health professional
    training grant program. The amendment was passed by voice vote.
        The amendment offered by Representative Biggert (R-IL)
    would have established an annual report on the average waiting
    period for minimum health services and if an increase of five
    percent or more was reported, then Sections 311, 312, 313, 314,
    321, and 324 would not apply in the following year. The
    amendment was withdrawn and no further action was taken on it.
        The amendment offered by Representative Polis (D-CO) would
    expand the characteristics outlined in Section 221(e) on data
    collection to include race, ethnicity, primary language, sex,
    sexual orientation, gender identity, disability, socioeconomic
    status, rural, urban, or other geographic setting, and any
    other population or subpopulation as determined appropriate by
    the Secretary. The amendment was passed by voice vote.
        The amendment offered by Representative McMorris Rodgers
    (R-WA) would have prohibited any tax increases to families with
    an income of $250,000 or less. The amendment was ruled not
    germane as outside the jurisdiction of the Committee.
        The amendment offered by Representative Sablan (NMI),
    Representative Pierluisi (PR), and Representative Clarke (D-NY)
    would add to H.R. 3200 a Sense of Congress stating that the
    final bill must meaningfully address the health care needs of
    the territories. The amendment was passed by voice vote.
        The second amendment offered by Representative Kline (R-MN)
    would have prohibited any provision in H.R. 3200 from the
    application of state law remedies in connection to group health
    plans, maintaining that section 502 of ERISA will continue to
    supersede state law. The amendment was defeated by a roll call
    vote of 19-28.
        The amendment offered by Representative Sestak (D-PA) would
    require the presence of patient representatives on the Health
    Benefits Advisory Committee. It is the intent of the Committee
    that such educated patients or consumer advocates be free of
    conflicts of interest with any provider, insurer, or other
    interest in the health sector. The amendment was passed by
    voice vote.
        The amendment offered by Representative Price (R-GA) would
    have created a waiver that would exempt States from enacting
    Subtitle B in Title III if a State health plan was enacted into
    law by the legislature of that State. The amendment was
    defeated by a roll call vote of 19-28.
        The amendment offered by Representative Wu (D-OR) and
    Representative Altmire (D-PA) would require the Health Choices
    Commissioner to study how to increase the meaningful use of
    electronic health records and then use the results of that
    study to potentially require higher reimbursement rates for
    providers that use health information technology. The amendment
    was passed by voice vote.
        The amendment offered by Representative Souder (R-IN) would
    have prohibited any provision in H.R. 3200 from requiring a
    group health plan to provide coverage for abortion or access to
    an abortion. The amendment was defeated by roll call vote of
    19-29.
        The second amendment offered by Representative Souder (R-
    IN) would require that no funds appropriated under Titles I-III
    be used for abortion or to cover any part of the costs of any
    health benefits plan that includes coverage of abortion, except
    in the case where a woman suffers from a physical disorder,
    physical injury, or physical illness. The amendment was
    defeated by a roll call vote of 19-29.
        The second amendment offered by Representative Biggert (R-
    IL) would prohibit the Commissioner or any health insurance
    issuer offering health insurance coverage through the HIE from
    discriminating against approving or covering health care
    services based on religious or spiritual content if
    expenditures for such a health care service are allowable under
    213(d) of the Internal Revenue Code of 1986. The amendment was
    passed by voice vote.
        The second amendment offered by Representative Price (R-GA)
    would prohibit any provision in H.R. 3200 to be construed to
    preclude any participant or beneficiary in a group health plan
    from entering into any contract or arrangement for health care
    with any health care provider. The amendment was passed by
    voice vote.
        The second amendment offered by Representative Hoekstra (R-
    MI) would have designated a ``health care sharing ministry'' as
    an ``employer'' and the members of such a ministry would be
    designated as ``employees.'' The amendment was withdrawn and no
    further action was taken on it.
        The amendment offered by Representative Petri (R-WI) would
    permit group consumer directed health plans and arrangements
    (including a high deductible health plan with the meaning of
    section 223(c)(2) of the IRS Code) to be treated as acceptable
    coverage consistent with other employer group health plans
    subject to the grace period until Y5. The amendment was amended
    by unanimous consent to ensure that this exception was not
    permanent and passed by voice vote.
        The amendment offered by Representative McKeon (R-CA) would
    have created a new title at the end of Division A titled Title
    IV--Small Business Health Fairness. This title would include
    rules governing association health plans; clarification of
    treatment of single employer arrangements; enforcement
    provisions related to association health plans; and other
    provisions related to association health plans. The amendment
    was defeated by a roll call vote of 21-27.
        The amendment offered by Representative Castle (R-DE) would
    have allowed variation in cost-sharing and premiums charged by
    the qualified health benefits plans dependent upon participant
    participation in employer prevention and wellness programs. The
    amendment was withdrawn and no further action was taken on it.
        The second amendment offered by Representative Wilson (R-
    SC) would add to H.R. 3200 a Sense of the House of
    Representatives that any members who vote in support of the
    public health insurance option are urged to forgo their right
    to participate in the FEHBP and enroll under the public option.
    The amendment was passed by voice vote.
        The third amendment offered by Representative Price (R-GA)
    would have established provisions for defined contribution
    health plans. The amendment was defeated by a roll call vote of
    19-29.
        The fourth amendment offered by Representative Price (R-GA)
    would have struck the physician billing language in Section
    225(c). The amendment was defeated by a roll call vote of 19-
    29.
        The second amendment offered by Representative McMorris
    Rodgers (R-WA) would have exempted plans established and
    maintained by Indian tribal governments. The amendment was
    defeated by voice vote.

    Committee on Ways & Means Mark-up of H.R. 3200

        On July 16, 2009, the Committee on Ways and Means met to
    mark-up H.R. 3200, America's Affordable Health Choices Act and
    reported the bill as amended by a vote of 23-18.

    Committee on Energy & Commerce Mark-up of H.R. 3200

        Beginning on July 16, 2009, the Committee on Energy and
    Commerce met to mark-up H.R. 3200, America's Affordable Health
    Choices Act. In addition to July 16, 2009, the Committee
    considered H.R. 3200 on July 17, 20, 30 and 31. The Committee
    reported the bill as amended by a vote of 31-28.

           SENATE CONSIDERATION OF THE AFFORDABLE HEALTH CHOICES ACT

        Beginning on June 17, 2009 the HELP Committee met to mark-
    up the Affordable Health Choices Act. The Committee reported
    the bill as amended on July 15, 2009 by a vote of 13-10.

                            III. Summary of the Bill

        America's Affordable Health Choices Act makes critical
    reforms to this nation's broken health care system. It will
    lower costs, preserve choice, and expand access to quality,
    affordable care. To protect families struggling with health
    care costs and inadequate coverage, the bill ensures that
    health insurance companies can no longer compete based on risk
    selection. By prohibiting rate increases based on pre-existing
    conditions, gender and occupation, the bill requires that
    insurance companies instead compete based on quality and
    efficiency. In addition, H.R. 3200 will lower the cost of
    health care by eliminating co-pays and deductibles for
    preventive care, capping annual out-of-pocket expenses,
    prohibiting lifetime limits, and allowing the uninsured, part-
    time workers, and employees of some small businesses to obtain
    group rates by purchasing health care through the HIE.
        H.R. 3200 will expand choice of health insurance,
    especially in many parts of the country where families have
    very limited choices because of the nature of the insurance
    market. The HIE will serve as an organized and transparent
    ``marketplace for the purchase of health insurance'' \7\ where
    individuals and employees (phased-in over time) can shop and
    compare health insurance options. To participate in the HIE,
    insurers will be required to meet the insurance market reforms
    and consumer protections and offer the essential benefits
    package established by the new independent benefits advisory
    committee. Individuals and families under 400 percent of
    poverty who qualify for affordability credits will be able to
    use that money in the HIE to help offset the costs of their
    health care coverage.
    ---------------------------------------------------------------------------
        \7\ Linda Blumberg and Karen Pollitz, Health Insurance Exchanges:
    Organizing Health Insurance Marketplaces to Promote Health Reform
    Goals, the Urban Institute & Robert Wood Johnson Foundation (April
    2009).
    ---------------------------------------------------------------------------
        One health insurance choice within the HIE will be the
    public health insurance option. The public option will be
    required to operate on the same level as private insurance
    companies, adhering to the same market reforms and consumer
    protections, and it will be required to be financed from its
    premiums. Rates will vary geographically just as private
    insurers do. The public plan option will be able to utilize
    payment rates similar to Medicare with provider rates at
    Medicare plus 5 percent. However, beginning in Y4 the Secretary
    will have the authority to use an administrative process to set
    rates (at levels that do not increase costs) in order to
    promote payment accuracy and the delivery of affordable and
    efficient care.
        The inclusion of a public option in the HIE will help to
    rein in the costs of health insurance while preserving access.
    At all times, the Secretary retains the authority to utilize
    innovative payment mechanisms and policies to improve health
    outcomes, reduce health disparities, and promote quality and
    integrated care. Furthermore, the public option will represent
    choice in many communities where one insurer dominates the
    market. Consequently, the public health insurance option has
    the ability to increase competition and control costs. However,
    no one, including employers who put their employees into the
    HIE, can place or force anyone into the public option. The
    decision to enroll in a private plan or the public option is
    always left to individuals and families to decide for
    themselves.
        H.R. 3200 is built upon the premise of shared
    responsibility among individuals, employers and the government,
    so that everyone contributes and has access to affordable,
    quality health care. America's Affordable Health Choices Act
    gives employers the choice to either offer health insurance or
    pay a percentage of payroll for their employees to go into the
    HIE.
        Beginning in 2013, employers ``playing'' will be required
    to offer health coverage to all of their full-time employees
    and contribute 72.5 percent of the premium for an individual
    and 65 percent for a family premium. For part-time workers,
    employers will have the choice to either offer health coverage
    on a pro rata basis or pay the required penalty. There will be
    no minimum benefit requirement for existing employer-sponsored
    health plans until the end of 2018. At that time, employers who
    ``play'' will be required to offer coverage that is no less
    than the minimum benefit level within the Exchange and must
    include the insurance market reforms.
        Employers may also choose to ``pay'' instead of play. A
    ``pay'' employer would be required to make a contribution equal
    to 8 percent of their payroll to the HIE. However, recognizing
    the difficulties small businesses face, the bill includes a
    number of provisions to help small employers. For example, H.R.
    3200 exempts employers with payrolls of $250,000 or less from
    the pay or play requirements. For employers with payroll
    between $250,000 and $400,000 the contribution amount phases-up
    from 2 to 8 percent so that only employers with payrolls
    greater than $400,000 will pay the full 8 percent.
        Whether obtaining coverage through an employer, a spouse or
    the HIE, H.R. 3200 requires that individuals either enroll in
    health care coverage or pay 2.5 percent of their adjusted gross
    income capped at the total cost of the average cost premium
    offered in the HIE. Recognizing that high health care costs
    prevent many Americans from securing health care coverage, H.R.
    3200 provides for affordability credits to help eligible low-
    and middle-income individuals and families purchase coverage in
    the HIE. In addition, for those who can demonstrate that they
    are unable to afford health insurance, the Health Choices
    Commissioner (Commissioner) retains the authority to develop
    and grant hardship waivers.
        The affordability credits provided for under the bill will
    be available to individuals and families with incomes between
    133 to 400 percent of the federal poverty level. Medicaid will
    be expanded so that anyone below 133 percent of poverty will be
    Medicaid eligible and that expansion will be fully federally
    financed. Employees who are offered health insurance through an
    employer will be unable to go into the HIE and receive
    affordability credits unless that employer coverage is deemed
    unaffordable. An unaffordable employer offer is one where the
    employees' share of the premium and cost sharing are more than
    11 percent of family income.
        Finally, as millions of Americans gain coverage,
    investments in the health care workforce are critical to
    ensuring all Americans have access to needed care. H.R. 3200
    includes significant investments to help train more primary
    care and public health physicians as well as nurses. It puts
    into place incentives to encourage more people to become
    doctors and nurses (particularly in rural areas). Some of the
    workforce provisions include: (1) increased funding for the
    National Health Service Corp.; (2) expanded scholarships and
    loans for health professionals who work in shortage professions
    and areas; (3) steps to increase physician training outside of
    the hospital and redistribute unfilled graduate medical
    education residency slots so that more primary care physicians
    can be trained; and (4) grants through the Department of Labor
    to help train and retain nurses.

                              IV. Committee Views

        The Committee on Education and Labor of the 111th Congress
    is committed to containing the cost of health care and ensuring
    that every American has access to affordable, quality health
    care coverage. H.R. 3200 includes critical reforms to the
    health care system that are needed to reduce surging premium
    and health care costs that families, businesses and governments
    are struggling to afford. The bill cuts over a half trillion
    dollars from the health care system, ensures that no one is
    ever one illness away from bankruptcy and creates a system
    where 97 percent of Americans will have health care coverage by
    2015.

                                    Overview

        Health care reform is a critical issue in this country.
    There are 47 million people in the United States without health
    care coverage and almost nine million of them are children.\8\
    Meanwhile, health care costs are rising for nearly everyone.
    The United States spends over $2.4 trillion--more than 18
    percent of GDP--on health care services and products--far more
    than other industrialized countries.\9\ In addition, health
    care costs continue to grow faster than the economy as a whole,
    and individuals and families are burdened by the weight of
    these escalating expenses. Yet, for all this spending, the
    United States' scores are average or worse on many key
    indicators of health care quality. Health care reform is
    critical to restoring prosperity for our nation's families and
    H.R. 3200 will ensure that coverage is truly affordable and
    dependable for hard-working Americans.
    ---------------------------------------------------------------------------
        \8\ Supra note 2.
        \9\ National Coalition on Health Care, ``Facts on the Cost of
    Health Insurance and Health Care,'' (2007), available at:
    http:\\www.nchc.org/facts/cost.shtml
    ---------------------------------------------------------------------------

    The Uninsured

        The number of uninsured persons in the United States
    continues to grow, from 44.8 million in 2005 to 47.0 million in
    2006. The percentage of uninsured is also rising, from 15.3
    percent of the total population in 2005 to 15.8 percent in
    2006.\10\
    ---------------------------------------------------------------------------
        \10\ U.S. Census Bureau, ``Health Insurance Coverage: 2006--
    Highlights.'' (Aug. 27, 2007), available at: http:\\www.census.gov/
    hhes/www/hlthins/hlthin06/hlth06asc.html
    ---------------------------------------------------------------------------
        More than two-thirds of the uninsured live in a household
    with one full-time worker. These increasing numbers can be
    attributed to the rising cost of health care, a decline in
    manufacturing jobs and an increase in workers employed in the
    service industries and small businesses, which are less likely
    to provide insurance.\11\ Roughly two-thirds of Americans
    without health insurance have incomes 200 percent below the
    federal poverty level--or approximately $44,000 for a family of
    four.\12\ Not surprisingly, those in households with annual
    incomes below $25,000 are even less likely to be insured. In
    2006, twenty-five percent of these Americans were uninsured in
    comparison to 16 percent of the total population.\13\
    ---------------------------------------------------------------------------
        \11\ Robert Pear. ``Without Health Benefits, a Good Life Turns
    Fragile,'' N.Y. Times (Mar. 5, 2007).
        \12\ Kaiser Family Foundation, ``The Uninsured: A Primer,'' (Oct.
    2008). http:\\www.kff.org/uninsured/upload/7451-04.pdf.
        \13\ Carmen DeNavas-Walt, Bernadette D. Proctor and Jessica Smith,
    ``Income, Poverty, and Health Insurance Coverage in the United States:
    2006'' Current Population Reports (2006) at 60-233. See also, U.S.
    Department of Commerce, Economics and Statistics Administration, August
    2007.
    ---------------------------------------------------------------------------
        Approximately 162 million non-elderly workers and their
    dependents received health coverage through their employment-
    based health plans.\14\ However, millions of other working
    Americans are unable to participate in an employer-sponsored
    plan, either because the employer does not offer coverage or
    the employee is not eligible under the plan. In 2005, 20
    percent of ``wage and salary'' workers had an employer that did
    not offer any coverage to their workers. And 18 percent were
    not eligible for the health plan that was offered by their
    employer.\15\ For example, some firms do not offer coverage to
    part-time employees and some do not offer coverage to workers
    who have been employed for less than a specific amount of time.
    ---------------------------------------------------------------------------
        \14\ Elise Gould, ``The Erosion of Employer-Sponsored Health
    Insurance,'' Economic Policy Institute (Oct. 8, 2008).
        \15\ Supra note 9.
    ---------------------------------------------------------------------------
        While employer-sponsored plans still remain the dominant
    source of health coverage for most Americans, the percentage of
    people obtaining health coverage through these plans has been
    steadily shrinking. For example, 60 percent of employers
    offered benefits in 2007, compared with 69 percent in 2000.
    Most of this decline can be attributed to the decline in small
    businesses (less than 200 workers) offering coverage.\16\ Among
    firms with less than 10 workers, the offer rate dropped from 57
    percent in 2000 to 45 percent in 2007.\17\ For employers who
    have stopped offering coverage, almost three out of four say
    that premiums are too expensive.\18\
    ---------------------------------------------------------------------------
        \16\ Kaiser Commission on Medicaid and the Uninsured, ``2007
    Employer Health Benefits Survey--Summary of Findings,'' (Sept. 2007) at
    29, available at: http:\\www.kff.org/insurance/7672/index.cfm
        \17\ Paul Fronstin. ``Sources of Health Insurance and
    Characteristics of the Uninsured: Analysis of the March 2007 Current
    Population Survey.'' Employee Benefit Research Institute, October 2007.
        \18\ Kaiser Family Foundation/HRET, ``Employer Health Benefits 2007
    Annual Survey.'' (Sept. 2007).
    ---------------------------------------------------------------------------

    Unaffordable Health Care Coverage

        Employers and workers alike are increasingly concerned
    about the rising costs of health care and insurance. Premiums
    for employer-sponsored health coverage are rising much faster
    than workers' earnings and inflation. Between spring 2006 and
    spring 2007, premiums for coverage offered by employers across
    the United States increased by 6.1 percent--more than twice the
    growth in the Consumer Price Index (CPI). The average annual
    cost of employer-sponsored health insurance was nearing $13,000
    in 2008. In response to these steady premium hikes, many
    companies are asking their employees to cover some of the new
    costs. For instance, workers taking single coverage through an
    employer paid 12 percent more for their coverage in 2007 than
    in 2006. Premiums for a family of four paid by workers
    increased by 10 percent from 2006 to 2007.\19\
    ---------------------------------------------------------------------------
        \19\ Id.
    ---------------------------------------------------------------------------
        These increases are of great concern, and more and more
    workers believe that they may not be able to afford their share
    of the cost of coverage. In a recent poll by the Pew Research
    Center,\20\ forty-four percent of workers surveyed say that
    affording health insurance is difficult or very difficult. In
    addition, almost three out of four uninsured workers who chose
    not to participate in their employer's health plan in 2002 said
    the plan was too costly. Workers also know that if they lose
    their job, they are likely to lose access to affordable health
    care coverage.
    ---------------------------------------------------------------------------
        \20\ Pew Research Center for the People and the Press poll,
    conducted January 9-13, 2008, available at: http:\\people-press.org/
    reports/dispaly.php3?ReportID= 395.
    ---------------------------------------------------------------------------
        In addition, among those employers that offer benefits, a
    large percentage of firms report that in the next year not only
    are they very or somewhat likely to increase the amount workers
    contribute to premiums (45 percent), but they will also
    increase deductible amounts (37 percent), office visit cost
    sharing (42 percent) or the amount that employees have to pay
    for prescription drugs (41 percent).\21\
    ---------------------------------------------------------------------------
        \21\ Supra note 16.
    ---------------------------------------------------------------------------
        The problem of being ``underinsured'' has also become
    increasingly relevant. One recent study estimated that 29
    percent of individuals who have insurance are ``underinsured''
    and have coverage that is inadequate to secure them access to
    needed care or protect again catastrophic medical bills.\22\
    ---------------------------------------------------------------------------
        \22\ Consumer Reports, ``Health Insurance: CR Investigates Health
    Care,'' September 2007, available at: http:\\www.consumerreports.org/
    cro/health-fitness/health-care/health-insurance-9-07/overview/
    0709_health_ov.htm
    ---------------------------------------------------------------------------
        The Commonwealth Fund found that 25 million adults who had
    health coverage in 2007 were underinsured \23\--a 60 percent
    increase from the 16 million Americans who were underinsured in
    2003.\24\ Another study found that while 16 percent of adults
    spent more than 10 percent of their family income on health
    care service in 1996. By 2003 the proportion of adults bearing
    these health-related ``catastrophic financial burdens'' had
    increased to 19 percent to about 49 million individuals.\25\
    Another study found that financial burdens had increased to the
    point that private health insurance coverage no longer provided
    adequate financial protection for low-income families.\26\
    ---------------------------------------------------------------------------
        \23\ According to the Commonwealth Fund study, families are
    identified as underinsured if they had out-of-pocket medical spending
    that absorbed at least 10 percent of family income, or for low-income
    adults (200 percent below the federal poverty level), medical spending
    consumed at least 5 percent of family income.
        \24\ Cathy Schoen et al, ``How Many are Underinsured? Trends Among
    U.S. Adults, 2003 and 2007,'' Health Affairs 27 no. 4 (2008).
        \25\ J. Banthin and D. Bernard, ``Changes in Financial Burdens for
    Health Care: National Estimates for the Population Younger than 65
    Years, 1996 to 2003,'' JAMA (2006).
        \26\ J. Banthin, P. Cunningham and D. Bernard. ``Financial Burdens
    of Health Care, 2001-2004,'' Health Affairs 27, no.1 (2008) at 188-195.
    ---------------------------------------------------------------------------
        In addition, many families have little room within their
    family budgets for large or unexpected out-of-pocket health
    care expenses. In 2003, an estimated 77 million Americans--
    nearly two out of five adults--had difficulty paying medical
    bills.\27\ Even working age adults who were continually insured
    had problems paying their medical bills and carried medical
    debt as a result. Nearly half of all bankruptcies in the United
    States are related, in part, to health care expenses. And of
    those facing medical bankruptcies, roughly three-quarters had
    health insurance at the onset of their bankrupting illness.\28\
    ---------------------------------------------------------------------------
        \27\ Michelle M. Doty, Jennifer N. Edwards, and Alyssa L. Holmgren,
    ``Seeing Red: Americans Driven into Debt by Medical Bills,'' The
    Commonwealth Fund (Aug. 2005).
        \28\ David Himmelstein, Elizabeth Warren, D. Thorne, and S.
    Woolhandler, ``Illness and Injury as Contributors to Bankruptcy,''
    Health Affairs (2005).
    ---------------------------------------------------------------------------
        The risk of being underinsured or experiencing financial
    problems due to health spending varies not only by family
    income, but also by health status. According to Judy Feder,
    Senior Fellow at the Center for American Progress, ``health
    care affordability is particularly elusive for individuals with
    chronic illness and other conditions that require on-going,
    often costly, medical care.'' \29\ Individuals who are older
    and have chronic conditions such as diabetes, heart disease, or
    arthritis, or have experienced a stroke, are more likely to
    spend a high proportion of their income on health expenses. If
    these individuals do not have an employer-sponsored health
    plan, or if they lose this coverage, their ability to purchase
    coverage in the non-group market is limited at best. The non-
    group market systematically denies coverage, limits benefits,
    and charges excessive premiums to individuals with pre-existing
    conditions or those who are perceived to be at high-risk.
    Ironically, the people who are more likely to become sick--the
    very population that insurance is supposed to protect--are also
    more likely to be underinsured and face grave financial
    problems.
    ---------------------------------------------------------------------------
        \29\ Judy Feder, Testimony before the Committee on Energy and
    Commerce Committee (hereinafter Feder) (Mar. 17, 2009).
    ---------------------------------------------------------------------------

    The Consequences of being Uninsured or Underinsured

        Being uninsured makes it more likely that a person will not
    receive adequate medical care. Individuals without insurance
    often go without or delay care, and the care they do receive is
    likely to be lower quality than the care received by insured
    individuals. An estimated 18,000 to 22,000 Americans die each
    year because they do not have health coverage.\30\ The length
    of time a person goes without health insurance also makes a
    difference--people who are uninsured for at least a year report
    being in worse health than those uninsured for a shorter period
    of time.\31\ Finally, lack of coverage and coverage stability
    is particularly burdensome on the seriously and chronically
    ill, whose care is often delayed or denied when they cannot
    pay.\32\
    ---------------------------------------------------------------------------
        \30\ ``Insuring America's Health: Principles and Recommendations,''
    Institute of Medicine (Jan. 14, 2004).
        \31\ Id.
        \32\ Institute of Medicine, ``Care Without Coverage: Too Little,
    Too Late'' (May 2002), available at: http:\\www.iom.edu/Object.File/
    Master/4/160/Uninsured2FINAL.pdf
    ---------------------------------------------------------------------------

           HEALTH CARE COSTS AND SPENDING: THE COST OF DOING NOTHING

        H.R. 3200 ensures quality and affordable health care
    choices for all Americans while also controlling costs in a
    system in which costs have spiraled out of control. The United
    States spends over $2.4 trillion on health care each year.\33\
    As noted earlier, health care expenditures in the United States
    constitute approximately 18 percent of the current Gross
    Domestic Product (GDP).\34\ If health care costs continue to
    grow at historical rates, the share of GDP devoted to health
    care in the United States is projected to reach 34 percent by
    2040.\35\
    ---------------------------------------------------------------------------
        \33\ Supra note 9.
        \34\ Executive Office of the President, Council of Economic
    Advisors, ``The Economic Case for Health Care Reform,'' available at
    http:\\www.whitehouse.gov/administration/eop/cea/
    TheEconomicCaseforHealthCareReform/ (June 2009).
        \35\ Id.
    ---------------------------------------------------------------------------

    International Comparisons

        The United States devotes a far larger share of GDP to
    health care spending more than two times per person on health
    care than any other OECD (Organization for Economic Co-
    operation and Development) country.\36\ While health care
    expenditures in the United States are about 18 percent of GDP
    \37\ the OECD reports that the next highest country was
    Switzerland--with 11.3 percent--and in most other high-income
    countries, the share was less than 10 percent.\38\
    ---------------------------------------------------------------------------
        \36\ Marcia Angell Testimony before the Committee on Education and
    Labor Committee (hereinafter Angell) (Jun. 10, 2009).
        \37\ Supra note 34.
        \38\ Id.
    ---------------------------------------------------------------------------
        Despite outpacing other countries with investments in
    health care, the U.S. fails to produce better health outcomes
    in fundamental ways. OECD data shows that life expectancy in
    the United States is lower than in any other high-income
    country, as well as in many middle-income countries.\39\
    Similarly, the infant mortality rate in the United States is
    substantially higher than that of other developed countries.
    While many factors other than health care expenditures may
    affect life expectancy and infant mortality rates--for example,
    demographics, lifestyle behaviors, income inequality, non-
    health disparities, and measurement differences across
    countries \40\--the Council of Economic Advisors (CEA) has
    concluded that ``the fact that the United States lags behind
    lower spending countries is strongly suggestive of substantial
    inefficiency in our current system.'' \41\ Indeed, according to
    estimates by the CEA based on the spending and outcomes in
    other countries, efficiency improvements in the U.S. health
    care system potentially could free up resources equal to 5
    percent of U.S. GDP.\42\
    ---------------------------------------------------------------------------
        \39\ Id.
        \40\ Robert Wood Johnson Foundation, Commission to Build a
    Healthier America, ``Beyond Health Care: New Directions to a Healthier
    America'' (Apr. 2009).
        \41\ Supra note 34.
        \42\ Id.
    ---------------------------------------------------------------------------
        Analyzing health care spending over time, the CEA also
    notes that while health care spending has increased in other
    countries as well, the spending by the U.S. has not yielded the
    same outcomes as other countries. In 1970, the United States
    devoted only a moderately higher fraction of GDP to health care
    than other high-income countries, whereas in 2009 the United
    States spends dramatically more.\43\ Yet, during that same
    period, life expectancy has actually risen less in the United
    States than in other countries.\44\ This data suggests that
    much of the increased U.S. spending is inefficient.\45\
    ---------------------------------------------------------------------------
        \43\ Id.
        \44\ Garber, Alan M., and J. Skinner, ``Is American Health Care
    Uniquely Inefficient?'' Journal of Economic Perspectives (2008) at 27-
    50.
        \45\ Supra note 34.
    ---------------------------------------------------------------------------

    Cost of the Uninsured

        While the U.S. health care system currently leaves 47
    million Americans uninsured \46\ and approximately 25 million
    underinsured,\47\ the CEA projects that the number of uninsured
    could increase to 72 million by 2040.\48\ Such increases in the
    numbers of uninsured people will create additional
    uncompensated care costs, which include costs incurred by
    hospitals and physicians for the charity care they provide to
    the uninsured as well as bad debt such as unpaid bills.\49\
    Both the federal government and state governments use tax
    revenues to pay health care providers for a portion of these
    costs through programs such as Disproportionate Share Hospital
    (DSH) payments and grants to Community Health Centers.\50\ In
    2008, total government spending to reimburse uncompensated care
    costs incurred by medical providers was approximately $42.9
    billion.\51\ The CEA projects that if the U.S. does not slow
    the real growth rate of health spending and a subsequent rise
    in the uninsured, the real annual tax burden of uncompensated
    care for an average family of four will rise from $627 in 2008
    to $1,652 (in 2008 dollars) by 2030.\52\
    ---------------------------------------------------------------------------
        \46\ National Coalition on Health Care, available at: www.nchc.org/
    facts/cost.shtml (2009).
        \47\ ``How Many Are Underinsured? Trends Among U.S. Adults, 2003
    and 2007,'' Commonwealth Fund (2008)
        \48\ Supra note 34.
        \49\ American Hospital Association, ``Uncompensated Hospital Care
    Fact Sheet'' (Nov. 2005), available at http:\\www.aha.org/aha/content/
    2005/pdf/0511 UncompensatedCareFactSheet.pdf.
        \50\Hadley, Jack, J. Holahan, T. Coughlin, and D. Miller.
    ``Covering the Uninsured in 2008: Current Costs, Sources of Payment,
    and Incremental Costs,'' Health Affairs (2008).
        \51\ Id.
        \52\ Supra note 34.
    ---------------------------------------------------------------------------

    Costs to Individuals and Families

        As the cost of health care skyrockets, families and
    employers offering health insurance struggle to absorb the
    increased costs. In 2008, employer-based premiums increased by
    5 percent. That growth was even greater for small firms. On
    average, they incurred a premium increase of 5.5 percent, and,
    for those with 24 or fewer workers, their respective increase
    was 6.8 percent.\53\ Much of the increase in health care costs
    has been shifted onto workers. In 2008, the average annual
    premium for a family of four was $12,700, and workers
    contributed approximately $3,400 of that total which was 12
    percent more than the year before. Workers are now paying
    $1,600 more for family coverage than they did 10 years ago.\54\
    Over the last decade, health care costs have risen on average
    four times faster than workers' earnings.\55\
    ---------------------------------------------------------------------------
        \53\ The Henry J. Kaiser Family Foundation. Employee Health
    Benefits: 2008 Annual Survey, (Sept. 2008).
        \54\ Angell.
        \55\ See, National Coalition on Health Care, available at:
    www.nchc.org/facts/cost.shtml (2009).
    ---------------------------------------------------------------------------
        These dramatic increases in health care costs have serious
    implications for American households. Some economists believe
    that, over the long run, workers pay for the rising cost of
    health insurance through lower wages.\56\ To illustrate this
    relationship, the CEA has analyzed historical and projected
    average annual total compensation (measured in 2008 dollars),
    which includes wages as well as non-wage benefits such as
    health insurance.\57\ Their analysis indicates that health
    insurance premiums are growing more rapidly than total
    compensation in percentage terms, and as a result, an
    increasing share of total compensation that a worker receives
    goes to cover health insurance premiums.\58\ Moreover, the CEA
    notes that households with employer-sponsored health insurance
    could also be affected by rapid cost growth as employers shift
    to less generous plans with higher annual deductibles.\59\ It
    is important to note, however, that the wage stagnation
    experienced by workers over recent decades cannot be attributed
    solely to rising health care costs. For example, low-wage
    workers have experienced real wage declines in recent years
    despite few such workers having access to or participating in
    employment-based health insurance coverage.\60\ More economic
    dynamics are at work in the wage squeeze on workers, but rising
    health costs contribute to the downward pressure.
    ---------------------------------------------------------------------------
        \56\ Pauly, Mark V., ``Health Benefits at Work: An Economic and
    Political Analysis of Employment-Based Health Insurance'' (1998).
        \57\ Supra note 34 (relying on the 1996 to 2006 Medical Expenditure
    Panel Survey-Insurance Component).
        \58\ Id.
        \59\ Id.
        \60\ Economic Policy Institute, ``Increasing Health Costs Can't
    Explain Earnings Dip for Low-Wage Workers,'' Economic Snapshot (April
    12, 2006).
    ---------------------------------------------------------------------------

    H.R. 3200 Will Increase Standards of Living and Create New Jobs

        By slowing the growth in health care costs, standards of
    living will improve and resources will be freed to improve and
    expand the health care system. The CEA projects that slowing
    growth by 1.5 percentage points per year will save a family
    $2,600 by 2020.\61\ By 2030 that savings would be increased to
    nearly $10,000.\62\
    ---------------------------------------------------------------------------
        \61\ Supra note 34.
        \62\ Id.
    ---------------------------------------------------------------------------
        Furthermore, the CEA estimates that the coverage expansions
    that will result from health reform will produce a net benefit
    of approximately $100 billion a year, or about two-thirds of a
    percent of GDP.\63\ According to its analysis, health care
    reform will lower the unemployment rate in the United States
    and could add as many as 500,000 jobs on an annual basis.\64\
    By producing a more healthy and productive workforce, health
    care reform will improve standards of living and help
    strengthen the U.S. economy.
    ---------------------------------------------------------------------------
        \63\ Id.
        \64\ Id.
    ---------------------------------------------------------------------------

    Shared Responsibility & Employment-Based Health Care Insurance

        In order to control costs and expand access to quality
    affordable health care, everyone must be covered and employers,
    individuals and the government must share in this
    responsibility. Consistent with the minimum wage and overtime
    laws, H.R. 3200 creates a fundamental right to a minimum level
    of health care contribution and/or coverage through an
    employer. As noted earlier, two-thirds of Americans receive
    health coverage through an employer, and H.R. 3200 builds upon
    the current employer-based system by implementing a `pay or
    play' requirement.
        The employer responsibility to provide and/or contribute to
    the health care of its workers will stabilize the employer-
    based health care system. Because the Employee Retirement
    Income Security Act of 1974 (ERISA) currently contains no
    requirement that an employer offer employee benefits, employers
    who do not offer health insurance to their workers gain an
    unfair economic advantage relative to those employers who do
    provide coverage, and millions of hard-working Americans and
    their families are left without health insurance. It is a
    vicious cycle because these uninsured workers turn to emergency
    rooms for health care which in turn increases costs for
    employers and families with health insurance. It is estimated
    that in 2008 premiums were about 8 percent or $1,100 higher due
    to this hidden cost shift.\65\
    ---------------------------------------------------------------------------
        \65\ Ben Furnas and Peter Harbage, ``The Cost Shift from the
    Uninsured,'' The Center for American Progress (Mar. 2009).
    ---------------------------------------------------------------------------

    Strengthening the Employer-Based System

        Millions of employers voluntarily decide to offer health
    benefits because it is in their economic interest. Employers
    are not taxed on their contributions to employees' health care,
    and these costs are deductible as a business expense.\66\ In
    addition, large employers can offer health care coverage at a
    much lower cost because they can negotiate with insurers and
    have a larger pool of employees to spread the risk.
    Furthermore, employers recognize that investments in health
    care can produce gains in employee health which means fewer
    missed days, higher productivity and better overall job
    satisfaction.
    ---------------------------------------------------------------------------
        \66\ Paul Ginsburg, ``Employment-Based Health Benefits Under
    Universal Coverage,'' Health Affairs (May/June 2008) at 675.
    ---------------------------------------------------------------------------
        Despite the incentives to offer health coverage,
    skyrocketing health care costs make it difficult for employers,
    particularly small businesses, to offer comprehensive health
    insurance. As noted earlier, while approximately 63 percent of
    the under-65 population and their dependents have insurance
    through employment,\67\ the number of employers offering health
    care coverage has been declining over the last decade. The
    number of people getting health coverage through an employer
    dropped by 3 million between 2000 and 2007,\68\ largely due to
    increasing costs. In addition, the Center for American Progress
    projects that as a result of layoffs, approximately 14,000
    Americans lose their employer-sponsored coverage each day.\69\
    Overall, since 1999 premiums have increased 120 percent and at
    a rate that is on average four times faster than workers'
    earnings.\70\
    ---------------------------------------------------------------------------
        \67\ Supra note 10.
        \68\ Id.
        \69\ Center for American Progress (Feb. 2009), available at:
    http:\\www.americanprogressaction.org/issues/2009/03/health--
    losses.html.
        \70\ National Coalition on Health Care, ``Health Insurance Costs,''
    (2009), available at: www.nchc.org/facts/cost.shtml
    ---------------------------------------------------------------------------
        However, even without an employer shared responsibility
    requirement, 86 percent of employers surveyed report that they
    will continue offering health care despite increasing
    costs.\71\ Many of these employers are large ones who use
    health care benefits as a means to recruit and retain
    employees. Health care benefits are ``highly valued by
    employees, and risk-averse employers may be reluctant to take
    advantage of the option of dropping coverage'' even though they
    can currently do so.\72\
    ---------------------------------------------------------------------------
        \71\ Supra note 61.
        \72\ Hacker at 10.
    ---------------------------------------------------------------------------
        H.R. 3200 generally will not change what many employers are
    already doing. Beginning in 2013, the bill requires employers
    already offering health insurance to make an offer to all full-
    time employees and contribute 72.5 percent of the cost toward
    an individual policy and 65 percent toward a family policy.
    Today, employers on average contribute 83 percent toward the
    coverage of individual premiums and 71 percent toward the
    coverage of family premiums.\73\
    ---------------------------------------------------------------------------
        \73\ ``Employee Benefits in the United States, March 2008,'' Bureau
    of Labor Statistics (Aug. 7, 2008).
    ---------------------------------------------------------------------------
        The second phase of requirements under H.R. 3200 for
    existing employer health plans does not take effect until the
    end of 2018. At that time, in addition to making the required
    contribution amount, every employer-sponsored health plan will
    have to, at a minimum meet the essential benefit standards
    defined by the benefits committee, as well as satisfy the
    insurance reform standards specified in the bill. Employer
    health insurance plans will be required to be equivalent to no
    less than 70 percent of the actuarial value minus the cost
    sharing components of the essential benefit package. The
    majority of employers already meet this standard. According to
    the Congressional Research Service, the typical employer-
    sponsored PPO has an estimated actuarial value between 80-84
    percent, while the typical employer-sponsored health savings
    account (HSA) and a qualified high deductible health plan
    (HDHP) has an estimated actuarial value of 76 percent,
    excluding contributions by an employer.\74\
    ---------------------------------------------------------------------------
        \74\ Chris Peterson, ``Setting and Valuing Health Insurance
    Benefits,'' Congressional Research Service (May 29, 2009) at 3-4.
    ---------------------------------------------------------------------------
        While many employer plans already meet the bill's
    requirements, there are some notable omissions. For example, 10
    percent of employer plans do not offer mental health and
    substance use disorder benefits and many include caps on
    lifetime limits and out of pocket expenses. In these cases,
    employers will have over 8 years to modify their plans and meet
    the requirements. Finally, H.R. 3200 extends the same benefit
    and insurance reform standards in all new employer and HIE
    plans, so that individuals and families have access in either
    case to affordable quality health coverage.

    Protecting Small Business

        For small business, health reform ``is their number one
    need.'' \75\ Forty-percent report that high costs have a
    ``negative effect on other parts of their business, such as
    high employee turnover or preventing business growth.'' \76\
    According to the Small Business Majority, a non-profit
    independent group representing 27 million small businesses,
    small businesses spend 18 percent more than large employers for
    health care coverage.\77\ The result is that in 2008, the
    percent of firms offering health insurance with three to nine
    employees dropped from 57 percent to 49 percent.\78\
    ---------------------------------------------------------------------------
        \75\ John Arensmeyer, Testimony before the Committee on Education
    and Labor Committee, ``The Tri-Committee Draft for Health Care
    Reform,'' (hereinafter Arensmeyer)(Jun. 23, 2009) at 1.
        \76\ Taking the Pulse on Main Street, ``Small Businesses, Health
    Insurance and Priorities for Reform (Jan. 2009).
        \77\ Arensmeyer at 2.
        \78\ Id.
    ---------------------------------------------------------------------------
        Small businesses have small purchasing pools and one of the
    biggest obstacles they face in securing affordable health
    coverage is the lack of bargaining power they have against the
    insurance companies. In addition, the administrative costs paid
    by small businesses can be up to 27 percent of premiums to pay
    for marketing and paperwork costs and underwriting.\79\
    ---------------------------------------------------------------------------
        \79\ ``The Economic Impact of Healthcare Reform on Small
    Business,'' Small Business Majority (Jun. 11, 2009) .
    ---------------------------------------------------------------------------
        LaShonda Young, a small business owner, testified to the
    Committee about the problems she has had in seeking coverage
    for her forty employees. She received eight bids and each was
    from the same insurance company. She testified her experience
    isn't unique, as there are only one or two health insurers in
    her area.\80\ She went on to testify that, ``it's been years
    since we've been able to afford group health insurance . . . we
    got quotes from a couple of different places, [the] quotes came
    in at about 13 percent of payroll. [We're] willing to pay our
    fair share but we just couldn't afford 13 percent . . . '' \81\
    Even if she was able to afford the coverage, she knew that it
    wouldn't cover the pre-existing conditions of her employees for
    up to 18 months and there was no guarantee the costs would
    remain stable.\82\ As a result, small employers like Young are
    looking to other ways to help their employees find coverage on
    their own. Young testified that her company offers small
    stipends to employees to buy insurance on their own.
    ---------------------------------------------------------------------------
        \80\ LaShonda Young, Testimony before the Committee on Education
    and Labor Committee, ``The Tri-Committee Draft for Health Care
    Reform,'' (hereinafter Young)(Jun. 23, 2009) at 2.
        \81\ Young at 2.
        \82\ Id.
    ---------------------------------------------------------------------------
        High health care costs also present an enormous obstacle
    for those trying to start or maintain a new business. While
    small businesses have traditionally played an essential role
    during prior economic recoveries, the high cost of health care
    is deterring entrepreneurs from starting a business in the
    first place. Louise Hardaway started her own business near
    Nashville, Tennessee. When attempting to get health care
    insurance she was quoted $12,800 a month to cover herself, her
    husband, business partner, and her business partner's spouse
    and child. Due to her inability to find affordable health care
    coverage Ms. Hardaway went out of business and went to work for
    another company where she could get health care.\83\
    ---------------------------------------------------------------------------
        \83\ Simona Covel, ``Sick and Getting Sicker,'' Wall St. Journal
    (Jul. 23, 2009).
    ---------------------------------------------------------------------------
        Recognizing the economic reality for many small businesses,
    in addition to driving down health care costs overall, H.R.
    3200 contains numerous provisions such as tax credits and
    access to the HIE to help these employers provide coverage and
    alleviate their costs. In addition, the bill exempts employers
    from the pay or play requirement if they have payrolls of
    $250,000 or less. For employers with payrolls above $250,000
    who choose not to offer coverage and would rather pay a
    penalty, that penalty is phased-up so that only employers with
    payrolls over $400,000 must pay the 8 percent penalty.
        The Small Business Majority reports that small businesses,
    workers and the economy stand to save billions of dollars with
    the enactment of health care reform.\84\ Absent health care
    reform small businesses will spend $2.4 trillion in health care
    costs over the next ten years. With health reform, small
    businesses will save 36 percent of those costs, as much as $855
    billion. Without health reform, small businesses stand to lose
    $52.1 billion in profits due to high health care costs over the
    next ten years. Health reform will decrease these losses and
    save $29.2 billion. Reduced health care costs will allow
    employers to reinvest in their business and their workers.
    Without health reform, individuals working for small businesses
    could lose up to $834 billion in lost wages as employers pass
    increased health care costs onto their employees over the next
    ten years. Health reform could save workers over $300 billion
    over the next ten years.\85\ Reduced health care costs will
    allow employers to reinvest in their business and their
    workers.
    ---------------------------------------------------------------------------
        \84\ Supra note 76.
        \85\ Id.
    ---------------------------------------------------------------------------

            THE HEALTH INSURANCE EXCHANGE WILL HELP SMALL EMPLOYERS

        H.R. 3200 creates a health insurance exchange (HIE) for the
    uninsured and employees of small businesses to purchase health
    insurance in the initial years after enactment. Due to the
    disadvantages small businesses face when trying to purchase
    health care coverage on their own, both proponents and
    opponents of the bill believe that a health insurance exchange
    is essential for small business: ``a broad, well-functioning
    marketplace offering consistency, fairness and healthy
    competition will vastly improve the availability and
    affordability of coverage to small businesses and the self-
    employed.'' \86\ Furthermore, it ``can be a vehicle that
    facilitates and monitors the movement of the system toward
    achievements of many national health care reform goals.''
    Eighty-percent of small business owners in a recent state
    survey stated they favor a health insurance pool that they can
    put their employees into to buy coverage.\87\
    ---------------------------------------------------------------------------
        \86\ Arensmeyer at 4.
        \87\ Id.
    ---------------------------------------------------------------------------
        A health insurance exchange is an organized marketplace
    where individuals and some employers can go to purchase health
    insurance. The HIE is advantageous to those looking to purchase
    insurance because it provides transparency when individuals and
    families shop for their health insurance. Currently, insurers
    are regulated by a patchwork of state laws. Beyond licensing
    requirements to sell insurance, private health insurance
    companies and health maintenance organizations (HMO) operate
    with considerable autonomy. The result is that policies can
    vary greatly and many policies leave people underinsured.
        The robust HIE will not only organize the marketplace but
    also include insurance reforms and consumer protections,
    administer affordability credits, and provide people with
    choice of plans. The HIE will require that insurers, both
    private and public, adhere to the same rules. To help consumers
    make educated decisions the Commissioner will conduct outreach
    and provide assistance to consumers. The Commissioner will
    ensure that information is readily available in plain language
    and is provided in a culturally and linguistically appropriate
    manner. Furthermore, qualified health benefits plans (QHBP)
    including those participating in the HIE will be required to
    comply with transparency requirements established by the
    Commissioner, including the accurate and timely disclosure of
    plan documents, plan terms and conditions, as well as
    information on cost-sharing and payments with respect to out-
    of-network coverage, claims denials and other information to
    help educate consumers.
        In addition to monitoring and streamlining the insurance
    industry, the HIE will play a significant role in containing
    health care costs. Health care costs are comprised of both the
    underlying costs of providing health care services as well as
    the administrative costs related to the provisions of
    coverage.\88\ The HIE will require participating plans to offer
    standardized benefit packages which will increase the ability
    to compare plans and ``reinforce incentives for insurers to
    price premiums as competitively as possible.'' \89\ Lower cost
    plans in the HIE will help those employers who ``play'' by
    putting their employees into HIE because they will be
    responsible for a set contribution amount regardless of the
    plan an employee choose. \90\ Furthermore, the affordability
    credits available to individuals in the HIE who do not enter
    the exchange with an employer contribution are tied to the
    average of the lowest three plans which will then incentivize
    individuals to choose low-cost plans. By the same token,
    insurers will be incentivized to offer low-cost plans in order
    to get more business.\91\
    ---------------------------------------------------------------------------
        \88\ Linda Bloomberg and Karen Pollitz, ``Health Insurance
    Exchanges: Organizing Health Insurance Marketplaces to Promote Health
    Reform Goals'' (Apr. 2009).
        \89\ Id.
        \90\ However, an employer is always permitted to contribute an
    amount greater than the minimum should it choose.
        \91\ Id.
    ---------------------------------------------------------------------------

    Access & Cost Containment Through A Public Health Insurance Option

        The inclusion of a strong public health insurance option in
    the HIE will save over one hundred billion dollars and provide
    choice to millions of consumers who currently have little or no
    choice when looking for a health plan. Its inclusion in the HIE
    will promote value and innovation in the private health
    insurance industry by increasing competition. The result is
    that the public option will lower costs for consumers across
    the private market.
        The public health insurance option will provide access to
    meaningful choice, something many Americans have never had when
    searching for a health plan. Many areas only have one or two
    dominant insurance options that control the market and thus
    have no downward pressure on costs.\92\ Furthermore, ``it is
    often in [these insurers'] interest to pay higher rates to key
    doctors and hospitals because they can pass on these costs to
    individuals and employers.''\93\ For insurers trying to enter a
    market, this practice makes it difficult for them to compete
    and reduce costs.
    ---------------------------------------------------------------------------
        \92\ Hacker at 5.
        \93\ Id.
    ---------------------------------------------------------------------------
        While the public option will be subject to the same
    standards as private plans, the public option can use
    administrative efficiencies to control costs. On average,
    private insurance overhead was about 11.7 percent of premiums
    which is significantly higher when compared to public insurers
    (Medicare is estimated at 3.6 percent and Medicaid at 6.8
    percent).\94\ In addition, because the public option is a
    health plan available nationwide it will have a broad reach and
    be able to obtain larger volume discounts and will not operate
    for profit.\95\ Accordingly, the public option in H.R. 3200
    will serve as a ``benchmark for private plans, a backup to
    allow consumers access to a good plan with broad access to
    providers in all parts of the country, and to serve as a cost-
    control backstop.''\96\
    ---------------------------------------------------------------------------
        \94\ John Holahan and Linda Blumberg, ``Can a Public Insurance Plan
    Increase Competition and Lower the Costs of Health Reform,'' Urban
    Institute (2009).
        \95\ Hacker at 7.
        \96\ Id.
    ---------------------------------------------------------------------------
        Ultimately, it will be up to consumers in the HIE to decide
    whether to enroll in the public option or a private plan. H.R.
    3200 intends to create a level playing field for both to
    compete. Consumers will be able to compare what each plan
    offers--private plans or the public option--and decide which
    plan serves them and their families best.\97\
    ---------------------------------------------------------------------------
        \97\ Id.
    ---------------------------------------------------------------------------

    Ensuring Access to Health Care Through Insurance Market Reforms

        Comprehensive insurance reforms are another critical
    element of health reform. Guaranteeing access to health care
    and protecting against medical debt largely depends on
    implementing comprehensive insurance reforms. About ``20
    percent of the population accounts for 80 percent of health
    spending;'' the ``sickest one-percent accounting for nearly
    one-quarter of health expenditures.''\98\ This uneven
    distribution of medical care creates incentives for insurance
    companies to avoid risk altogether rather than trying to spread
    it among the insured population.\99\ As a result, health
    insurers--particularly in the individual market--have adopted
    discriminatory, but not illegal, practices to cherry-pick
    healthy people and to weed out those who are not as
    healthy.\100\ These practices include: denying health coverage
    based on pre-existing conditions or medical history,\101\ even
    minor ones; charging higher, and often unaffordable, rates
    based on one's health; excluding pre-existing medical
    conditions from coverage; charging different premiums based on
    gender;\102\ and rescinding policies after claims are made
    based on an assertion that an insured's original application
    was incomplete.\103\ In addition, while ``state and federal
    laws give individuals the right to renew their health insurance
    coverage, guaranteed renewability provides no protection
    against rate increases.''\104\
    ---------------------------------------------------------------------------
        \98\ Karen Pollitz, testimony before the Committee on Energy and
    Commerce, Subcommittee on Health (hereinafter Pollitz) (Mar. 17, 2009).
        \99\ Linda Blumberg, testimony before the Committee on Ways And
    Means (April 22, 2009).
        \100\ Mila Kofman, testimony before the Committee on Energy and
    Commerce, Subcommittee on ealth (hereinafter Koffman)(Mar. 17, 2009);
    Blumberg, supra 94.
        \101\ See Fran Visco, testimony before the Committee on Education
    and Labor (June 22, 2009). Ms Visco testifying on behalf of the
    National Breast Coalition, stressed how no insurance or inadequate
    insurance has had a devastating effect on women diagnosed with breast
    cancer.
        \102\ A 2008 report by the National Women's Law Center examined
    individual insurance policies in 47 states and the District of Columbia
    and found that most of the states engage in a practice called ``gender
    rating'' where insurance companies arbitrarily charge women and men
    different rates for individual insurance premiums. Specifically, they
    found that women under 55 are charged more for health insurance than
    men (at age 25, 4% to 45% more; at age 40, 4 to 48% more). In addition,
    the report discovered that the vast majority of individual policies do
    not cover maternity leave, and in 9 states and the District of
    Columbia, insurers can reject survivors of domestic violence and those
    who have had C-sections. See: Nowhere to Turn: How the Individual
    Insurance Market Fails Women, National Women's Law Center (2008).
        \103\ Id, Pollitz, supra 98.
        \104\ Id.
    ---------------------------------------------------------------------------
        Discrimination based on health, gender and other factors
    has severe economic consequences for those who have been unable
    to find affordable health coverage and for those who have
    coverage, but are under-insured.\105\ As noted earlier, these
    practices have resulted in about 57 million Americans having
    debt because of medical bills,\106\ and over 42 million of that
    number has some sort of medical coverage.\107\ Medical debt is
    now the leading cause of personal bankruptcy.\108\
    ---------------------------------------------------------------------------
        \105\ Id; Pollitz, supra 98. While 47 million Americans have no
    health insurance at all, almost as many are underinsured.
        \106\ Pollitz, supra 98, testified that ``when out-of-pocket
    spending for medical bills (not including premiums) exceeds just 2.5%
    of family income, patients become burdened by medical debt, face
    barriers to accessing care, and have problems paying other bills.''
        \107\ Pollitz, supra 98.
        \108\ David U. Himmelstein, Deborah Thorne, Elizabeth Warren,
    Steffie Woolhandler, Medical Bankruptcy in the United States, 2007, The
    American Journal of Medicine (2009) at 3, finding that in 2007, 62.1%
    of all bankruptcies in the United States were medical, compared with 8
    percent in 2001. See also: Pollitz, supra 98; Kofman, supra 100, both
    of whom testified that most medical bankruptcies are filed by insured
    people.
    ---------------------------------------------------------------------------
        A key element to health reform is to prohibit risk
    selection practices and to support those factors based on
    quality and efficiency. Where states have prohibited these
    discriminatory practices, consumers have benefitted. For
    example, since 1993, Maine requires insurers to provide health
    insurance to individuals or small businesses on a ``guarantee
    issue'' basis. In addition, it also has an ``adjusted community
    rating'' so that prices for policies are set based on ``the
    collective claims experience of anyone with a policy'' and not
    on any one individual's medical history.\109\
    ---------------------------------------------------------------------------
        \109\ Kofman, supra 100.
    ---------------------------------------------------------------------------
        H.R. 3200 includes insurance market reforms ending
    discriminatory practices conducted by insurance companies.
    These reforms will apply both inside and outside the HIE to end
    the discriminatory practices currently practiced by insurance
    companies. The bill requires that all policies be sold on a
    guaranteed issue basis; prohibits insurers from excluding
    coverage based on pre-existing conditions; and prohibits
    insurers from charging higher rates based on health status,
    gender, or other factors. It would allow premiums to vary based
    only on age (no more than 2:1),\110\ geography and family size.
    In addition, the bill prohibits lifetime and annual limits on
    benefits so that families no longer face bankruptcy as a result
    of a serious medical illness.
    ---------------------------------------------------------------------------
        \110\ Pollitz, supra 98, testified that age is ``a strong proxy for
    health status.''
    ---------------------------------------------------------------------------

                    STRENGTHENING THE HEALTH CARE WORKFORCE

        As millions of new people gain access to health care
    coverage, H.R. 3200 recognizes that significant investments in
    the health care workforce are needed. There is mounting
    evidence that the nationwide healthcare workforce shortage is
    accelerating. The Health Resources and Services Administration,
    within the Department of Health and Human Services, reported in
    January of this year that twenty states were experiencing
    scarcities of physicians and nurses.\111\ In particular,
    dramatic shortages in the health care workforce are seen in
    primary care and nursing.
    ---------------------------------------------------------------------------
        \111\ See, http:\\newsroom.hrsa.gov/insidehrsa/jan2009
    ---------------------------------------------------------------------------
        Indeed, demand for primary care physicians outpaces supply
    more than in other specialty group.\112\ Specifically, the
    Association of American Medical Colleges (AAMC) estimates that
    primary care accounts for 37 percent of the total projected
    shortage in 2025.\113\ Primary care physicians are leaving the
    practice of medicine sooner than other physician specialties at
    the same time that fewer medical students and residents are
    choosing to make the practice of general internal medicine and
    primary care their central career goal.\114\ For many students,
    the costs of medical education are so high that they feel
    compelled to specialize in more lucrative subspecialties in
    order to manage their debt.\115\
    ---------------------------------------------------------------------------
        \112\ ``The Complexities of Physician Supply and Demand:
    Projections Through 2025,'' Association of American Medical Colleges
    (AAMC) (Nov. 2008).
        \113\ Id.
        \114\ Lipner RS, Bylsma WH. Arnold GK, Fortna GS, Tooker J. Cassel
    CK. Who is maintaining certification in internal medicine-and why? A
    national survey 10 years after initial certification. Ann Intern Med.
    (2005)
        \115\ Pear, Robert. ``Shortage of Doctors an Obstacle to Obama
    Goals.'' The NY Times (Apr. 26, 2009).
    ---------------------------------------------------------------------------
        While registered nurses constitute the largest single
    healthcare profession in the United States, there is a
    worsening nursing shortage.\116\ In 2000, the national supply
    of full time registered nurses was estimated at 1.89 million
    while the demand was estimated at 2 million, a shortage of
    110,000 nurses.\117\ Studies published in both The New England
    Journal of Medicine and The Journal of the American Medical
    Association confirms that the shortage of registered nurses is
    influencing the delivery of health care in the United States
    and negatively affecting patient outcomes.\118\
    ---------------------------------------------------------------------------
        \116\ See, Henry J. Kaiser Family Foundation, ``Addressing the
    Nursing Shortage'' (Jun. 2008).
        \117\ Id.
        \118\ Id.
    ---------------------------------------------------------------------------
        The current nursing shortage is a product of several trends
    including: a diminishing pipeline of new students to nursing, a
    decline in RN earnings relative to other career options, an
    aging nursing workforce, low job satisfaction and poor working
    conditions that contribute to high attrition rates.\119\
    Compounding these problems is the fact that nursing colleges
    and universities across the country are struggling to expand
    enrollment to meet the rising demand for nursing care.
    According to an American Association of Colleges of Nursing
    report, nursing schools turned away 49,948 qualified applicants
    from baccalaureate and graduate nursing programs in 2008 due to
    insufficient number of faculty, clinical sites, classroom
    space, clinical preceptors, and budget constraints.\120\
    ---------------------------------------------------------------------------
        \119\ Id.
        \120\ See, American Association of Colleges of Nursing,
    ``Enrollment and Graduations in Baccalaureate and Graduate programs in
    Nursing (2008-2009), available at: www.acne.nche.edu/IDS.
    ---------------------------------------------------------------------------
        The shortage of health care workers in this country
    disproportionately impacts those Americans residing in rural
    areas. The National Health Service Corps (NHSC) was established
    in the Emergency Health Personnel Act of 1970 (P.L. 91-623) to
    improve the distribution of health workers in underserved rural
    areas by providing scholarship support to students in qualified
    medical professions in exchange for a period of service in a
    Health Professional Shortage Area (HPSA).
        Administered by the Health Resources and Services
    Administration, in 2008, 14,000 students applied to the program
    for financial assistance. However, the Agency was only budgeted
    to grant one of every seven requests.\121\
    ---------------------------------------------------------------------------
        \121\ See, http:\\newsroom.hrsa.gov/insidersa/jan2009.
    ---------------------------------------------------------------------------
        H.R. 3200 includes significant investments in the health
    care workforce to directly address the shortages outlined. The
    legislation provides resources to help train more primary care
    physicians as well as registered nurses. It puts into place
    incentives to encourage more people to become doctors and
    nurses, particularly in rural areas. Specifically, the bill
    increases funding for the National Health Service Corps in
    order to expand scholarships and loans for health professionals
    that work in shortage professions and areas. In addition, it
    creates an advisory committee on health workforce evaluation to
    assess the adequacy and appropriateness of the health
    workforce, and to make recommendations to the Secretary of
    Health and Human Services on federal workforce policies to
    ensure the health workforce is meeting the nation's needs.

                      V. Section-by-Section Summary \122\

    ---------------------------------------------------------------------------
        \122\ This section-by-section summary is based in part on a summary
    initially prepared by the Congressional Research Service elaborated
    upon to reflect the views of the Committee.
    ---------------------------------------------------------------------------

                                   Division I

     Title I--Protections and Standards for Qualified Health Benefits Plans

                         Subtitle A--General Standards

    Sec. 100. Purpose; Table of Contents of Division; General Definitions

                Purpose
        The purpose of this division is to provide affordable,
    quality health care for all Americans and reduce the growth in
    health care spending. In addition, this division achieves this
    purpose by building on what works in today's health care
    system, while repairing the aspects that are broken. Insurance
    reforms that this division encompasses are:
               Enacting insurance market reforms
               Creating a new Health Insurance Exchange,
            with a public health insurance option alongside private
            plans
               Including sliding scale affordability
            credits
               Initiating shared responsibility among
            workers, employers, and the government
        This division institutes health delivery system reforms
    both to increase quality and to reduce growth in health
    spending so that health care becomes more affordable for
    businesses, families, and government.
                General Definitions (Created within this Act)
         Acceptable Coverage--qualified health benefits
    plan coverage, coverage under a grandfathered health insurance
    coverage or current group health plan, Medicare Part A,
    Medicaid, Military Health System, coverage under Veteran's
    Health Care Program (VA), and other coverage's the Secretary of
    HHS in coordination with the Health Choices Commissioner sees
    fit.
         Basic Plan--a plan that offers the essential
    benefits package's minimum requirements to be a qualified
    health benefits plan.
         Cost-sharing--includes deductibles, coinsurance,
    copayments, and similar charges but does not include premiums
    or any network payment differential for covered services or
    spending for non-covered services.
          Employment-Based Health Plan--the term given to
    group health plans (as defined in section 733(a)(1) of ERISA--
    (as an employee welfare benefit plan to the extent that plan
    provides medical care to employees or their dependents, either
    directly, through insurance or otherwise)), and is comprised of
    federal and state government plans, tribal plans and church
    plans. Following an amendment at Committee, this term was also
    defined as excluding TRICARE.
          Enhanced Plan--a plan that offers, in addition to
    the level of benefits under a basic plan, a lower level of
    cost-sharing equivalent to approximately 85 percent of the
    actuarial value of the benefits provided.
         Essential Benefits Package--health benefits
    coverage, consistent with the standards set forth by the
    Secretary no later than 18 months after enactment of this bill.
         Health Benefits Plan--health insurance coverage
    and a group health plan, including the public health insurance
    option.
         Health Insurance Exchange--created by this bill to
    facilitate access of individuals and employers, through a
    transparent process, to a variety of choices of affordable,
    quality health insurance coverage, including a public health
    insurance option.
         Premium Plan--a plan that offers, in addition to
    the level of benefits under a basic plan, a lower level of
    cost-sharing equivalent to approximately 95 percent of the
    actuarial value of the benefits provided.
         Premium Plus Plan--a premium plan that also offers
    additional benefits, such as oral health and vision care, all
    of which is approved by the Commissioner.
         Qualified Health Benefits Plan (QHBP)--a health
    benefits plan that meets the requirements set forth in Title I
    (by the Secretary) including the public health insurance
    option.
         QHBP Offering Entity--an entity can be any of the
    following: a health benefits plan (that is a group health plan)
    in which the employer is the main source of financing, health
    insurance coverage which the insurance issuer is offering the
    coverage, the public health insurance option, a non-federal
    government plan established by the State or political
    subdivision of a State, and a federal government plan.
         Public Health Insurance Option--a public plan
    (only available through the Health Insurance Exchange) with
    payment rates established by the Secretary. The public option
    would be required to offer basic, enhanced, and premium plans,
    and would be allowed to offer premium-plus plans. Payment rates
    for prescription drugs not covered by Medicare part A or B will
    be covered by the public option at prices negotiated by the
    Secretary.
         Service Area, Premium Rating Area--with respect to
    health insurance coverage: (1) if not within the Health
    Insurance Exchange, an area established by a QHBP offering
    entity of such coverage in accordance with applicable state law
    or (2) within the Health Insurance Exchange, an area
    established by such entity in accordance with state law and
    applicable rules set forth by the Commissioner for exchange-
    participating health benefits plans.
         ``State''--given term for purposes of the Medicaid
    program, but only includes the 50 states and the District of
    Columbia.
         Y1, Y2, etc.--2013, 2014, etc.

    Sec. 101. Requirements Reforming Health Insurance Marketplace

                Current Law
        Regulation of the private health insurance market is
    primarily done at the state level. State regulatory authority
    is broad in scope and includes requirements related to the
    issuance and renewal of coverage, benefits, rating, consumer
    protections, and other issues. Federal regulation of the
    private market is more narrow in scope and applicable mostly to
    employer-sponsored health insurance (i.e., through the Employee
    Retirement Income Security Act of 1974 (ERISA)).
                Proposed Law
        This provision would require ``qualified health benefits
    plans'' (QHBPs) to meet the new federal health insurance
    standards specified in Subtitles B (relating to affordable
    coverage), C (relating to essential benefits) and D (relating
    to consumer protection) of Title I. The section also provides
    terminology for the phrases ``enrollment in employment-based
    health plans;'' and ``individual and group health insurance
    coverage.''
        This provision also includes a Sense of Congress that the
    final bill must meaningfully address the health care needs of
    the territories.

    Sec. 102. Protecting the Choice to Keep Current Coverage

                Current Law
        See description under Sec. 101.
                Proposed Law
        ``Grandfathered health insurance coverage'' would be
    defined as individual health insurance coverage that is in
    effect before the first day of 2013, as long as the insurance
    carrier does not (1) enroll new individuals on or after the
    first day of 2013 (would not affect subsequent enrollment of a
    dependent); (2) change any terms or conditions of the
    individual coverage, except as required by law; and (3) vary
    the percentage increase in premiums for a risk group of
    enrollees without changing the premium for all enrollees in the
    same risk group at the same rate, as specified by the
    Commissioner. The Commissioner would establish a five-year
    grace period beginning in 2013 for existing group health plans
    to transition to the new federal health insurance standards
    applied to QHBPs. The grace period would not apply to limited
    benefits plans specified in the provision, such as dental only,
    vision only, flexible spending arrangements, and others.
        Individual health insurance coverage that is not
    grandfathered, may only be offered after the first day of 2013
    as an Exchange-plan. Excepted benefits (e.g., accident or
    disability insurance) could be offered as long as they are
    offered and priced separately from health insurance coverage.
    New group health plans would have to comply with this Act on
    2013.
        For purposes of the individual mandate (established under
    title III of Division A), an individual would be required to
    have ``acceptable coverage.'' In order for an individual health
    insurance policy to be considered acceptable coverage, the
    policy would be either grandfathered health insurance coverage
    or offered through the HIE (established under title II of
    Division A) or otherwise deemed or determined to be acceptable
    coverage under the bill. Group health coverage, including group
    health coverage consisting of a consumer-directed plan,
    provided during the grace period would be considered acceptable
    coverage.
        Section 102(b)(3), providing an exception for treating
    consumer-directed health plans and arrangements as acceptable
    coverage, was added by an amendment which originally called for
    a ``permanent'' exception. The word ``permanent'' was dropped
    from the amendment by unanimous consent, as Members of the
    Committee agreed that such exception for treating consumer-
    directed health plans as acceptable coverage should only be
    effective during the five-year grace period, not permanently.

        Subtitle B--Standards Guaranteeing Access to Affordable Coverage

    Sec. 111. Prohibiting Pre-Existing Condition Exclusions

                Current Law
        The Health Insurance Portability and Accountability Act of
    1996 (HIPAA), which amended ERISA, limits the duration that
    issuers in the group market may exclude coverage for pre-
    existing health conditions for ``HIPAA eligible'' individuals,
    among other provisions. Group plans may impose pre-existing
    condition exclusions for no longer than 12 months (18 months in
    the case of a late enrollee), and must decrease that exclusion
    period by the number of months an enrollee had prior
    ``creditable coverage.'' HIPAA outright prohibits issuers in
    the individual market from excluding coverage for pre-existing
    conditions for HIPAA eligibles.
        All states require health issuers to reduce the period of
    time when coverage for pre-existing health conditions may be
    excluded, in compliance with HIPAA. As of January 2009 in the
    small group market, 21 states had pre-existing condition
    exclusion rules that provided consumer protection above the
    federal standard. And as of December 2008 in the individual
    market, 42 states limit the period of time when coverage for
    pre-existing health conditions may be excluded for non-HIPAA
    eligible enrollees in that market.
                Proposed Law
        This provision would create a uniform minimum standard
    prohibiting a qualified health benefits plan from excluding
    coverage for pre-existing health conditions, or otherwise
    limiting or conditioning such coverage with respect to an
    individual or dependent based on any health status-related
    factors. Such factors include health status, medical condition
    (including both physical and mental illnesses), claims
    experience, receipt of health care, medical history, genetic
    information, evidence of insurability (including conditions
    arising out of acts of domestic violence) and disability.

    Sec. 112. Guaranteed Issue and Renewal for Insured Plans

                Current Law
        HIPAA requires that coverage sold to small groups (2-50
    employees) must be sold on a guaranteed issue basis. That is,
    the issuer must accept every small employer that applies for
    coverage. (Guaranteed issue rules do not address premiums.)
    HIPAA also guarantees that each issuer in the individual market
    make at least two policies available (``guaranteed
    availability'') to all HIPAA eligible individuals. In addition,
    HIPAA guarantees renewal or continuation of group coverage at
    the option of the plan sponsor (e.g., employer) and individual
    coverage at the option of the individual, with some exceptions.
    Insurers may not renew coverage under specified circumstances,
    such as nonpayment of premiums or fraud.
        All states require issuers to offer policies to firms with
    2-50 workers on a guaranteed issue basis, in compliance with
    HIPAA. As of January 2009 in the small group market, 13 states
    also require issuers to offer policies on a guaranteed issue
    basis to self-employed ``groups of one.'' And as of December
    2008 in the individual market, 15 states require issuers to
    offer some or all of their insurance products on a guaranteed
    issue basis to non-HIPAA eligible individuals.
                Proposed Law
        This provision would require issuers to offer all health
    insurance coverage on a guaranteed issue and renewal basis
    beginning in 2013, whether offered through the HIE (established
    under Subtitle A of Title II), through any employment-based
    health plan, or otherwise. Rescissions of coverage would be
    prohibited, except in cases of fraud.

    Sec. 113. Insurance Rating Rules

                Current Law
        There are no federal rating rules applicable to the private
    health insurance market. Most states currently impose rating
    rules on insurance carriers in the small group and individual
    markets. Existing state rating rules restrict an insurer's
    ability to price insurance policies according to the risk of
    the person or group seeking coverage, and vary from state to
    state. Such restrictions may specify the case characteristics
    (or risk factors) that may or may not be considered when
    setting a premium, such as age. The spectrum of existing state
    rating limitations ranges from pure community rating, to
    adjusted (or modified) community rating, to rate bands, to no
    restrictions. Pure community rating means that premiums cannot
    vary based on any characteristic related to a person's or
    group's risk, including health. Adjusted community rating means
    that premiums cannot vary based on health, but may vary based
    on other key risk factors, such as gender. Rate bands allow
    premium variation based on health, but such variation is
    limited according to a range specified by the state. Moreover,
    both adjusted community rating and rate bands allow premium
    variation based on any other permitted case characteristic,
    such as industry. And for each characteristic, the state
    typically specifies the amount of allowable variation. As of
    January 2009 in the small group market, one state has pure
    community rating rules, eleven have adjusted community rating
    rules, and 35 have rate bands. As of December 2008 in the
    individual market, two states have pure community rating rules,
    five have adjusted community rating rules, and eleven have rate
    bands.
        There are no federally-established rating areas in the
    private health insurance market. However, some states have
    enacted rating rules in the individual and small group markets
    that include geographic location as a factor on which premiums
    may vary. In these cases, the state has established rating
    areas. Typically, states use counties or zip codes to define
    those areas.
                Proposed Law
        This provision would impose new federal rating rules on
    qualified health benefits plans. QHBP premiums would vary only
    by age (by no more than a 2:1 ratio within age categories
    specified by the Commissioner (established under Sec. 141)),
    premium rating area (as permitted by state regulators or, in
    the case of an Exchange plan, as specified by the
    Commissioner), and family enrollment (as specified under State
    law and consistent with Commissioner rules).
        The Commissioner, in coordination with the Secretaries of
    Health and Human Services (HHS) and Labor, would conduct a
    study of the large group market to examine (1) characteristics
    of employers who purchase fully-insured health insurance
    products and employers who self-fund health benefits, including
    characteristics related to bearing risk and solvency, and (2)
    the extent to which rating rules cause adverse selection in the
    large group market or encourage small and mid-size employers to
    self-insure health benefits. The Commissioner would submit this
    report to Congress and the applicable agencies no later than 18
    months after enactment, and include any recommendations to
    ensure that the law does not provide incentives for small and
    mid-size employers to self-insure or create adverse selection
    in the risk pools of large group insurers and self-insured
    employers.

    Sec. 114. Nondiscrimination in Benefits

                Current Law
        HIPAA established federal rules regarding non-
    discrimination based on health status-related factors. It
    prohibits group issuers from establishing rules for eligibility
    and premium contributions based on health status-related
    factors. Those factors include health status, medical condition
    (including both physical and mental illnesses), claims
    experience, receipt of health care, medical history, genetic
    information, evidence of insurability (including conditions
    arising out of acts of domestic violence) and disability. In
    addition, the Genetic Information Nondiscrimination Act of 2008
    prohibits issuers in the individual health insurance market
    from establishing eligibility rules (including continued
    eligibility) based on an individual's genetic information, and
    the Paul Wellstone and Pete Domenici Mental Health Parity and
    Addiction Equity Act of 2008 establishes that if an employer
    provides mental health benefits there must be parity with
    physical health benefits.
                Proposed Law
        This provision would require QHBPs to comply with non-
    discrimination standards regarding health benefits or benefit
    structures established by the Commissioner, building on
    existing federal non-discrimination rules in ERISA, the Public
    Health Service Act (PHSA), and the Internal Revenue Code of
    1986. Existing mental health parity rules, apply to QHBPs,
    regardless of whether coverage is offered in the individual or
    group market.

    Sec. 115. Ensuring Adequacy of Provider Networks

                Current Law
        HIPAA established special rules for network plans. It
    allows small group issuers to (1) limit the employers that
    apply for coverage to those firms with eligible individuals who
    live or work in the network service area, and (2) deny coverage
    to small employers if the issuer demonstrates (if required) to
    the State that it has limited provider capacity due to
    obligations to existing enrollees and it is applying this
    decision uniformly without regard to claims experience or
    health status-related factors. HIPAA also prohibits a small
    group issuer that has denied coverage in any service area to
    offer small group coverage in that area for 180 days after the
    denial.
                Proposed Law
        This provision would require QHBPs that use provider
    networks to meet provider network standards that may be
    established by the Commissioner to ensure the adequacy of
    networks, and transparency in the cost-sharing differences
    between in- and out-of-network coverage. The term ``provider
    network'' means the providers with respect to covered benefits,
    treatments, and services available under a health benefit plan.

    Sec. 116. Ensuring Value and Lower Premiums

                Current Law
        Medical loss ratio is the share of total premium revenue
    spent on medical claims. Medigap insurance policies are private
    supplemental health care policies that Medicare beneficiaries
    can purchase to help cover some items, services, and cost
    sharing not covered under Medicare. Medigap plans are required
    to have a minimum medical loss ratio of 65 percent for
    individual policies and 75 percent for group policies. In
    addition, most states impose medical loss ratios or related
    requirements on insurers in the individual and/or small group
    health insurance markets.
                Proposed Law
        This provision would require a QHBP to comply with a
    medical loss ratio standard to be determined by the
    Commissioner but not less than 85 percent. For any QHBP that
    does not meet such a standard, it would be required to provide
    rebates to enrollees, in a manner specified by the
    Commissioner, in sufficient amounts to meet such a loss ratio.
    To establish the medical loss ratio standard, the Commissioner
    would build on the definition and methodology, developed by the
    HHS Secretary under Section 161, for determining how to
    calculate such a ratio. The methodology would set the highest
    ratio possible to ensure adequate QHBP participation,
    competition both in and out of the HIE, and value for consumers
    so that their premium contributions are used for medical
    claims.

    Sec. 117. Consistency of costs and coverage under qualified health
            benefits plans during plan year

        This provision would prohibit insurance companies from
    changing the coverage or costs of a health plan mid-year except
    if the costs are lowered and/or the coverage is increased.

        Subtitle C--Standards Guaranteeing Access to Essential Benefits

    Sec. 121. Coverage of Essential Benefits Package

                Current Law
        There are limited federal benefit mandates for health
    insurance. These standards were added to the Health Insurance
    Portability and Accountability Act of 1996 (HIPAA), and are
    described in the discussion of Section 122, below.
                Proposed Law
        This provision would require a ``qualified health benefits
    plans (QHBP)'' to cover at least an ``essential benefit
    package.'' QHBPs could be offered in or outside of an Exchange.
    QHBPs offered outside of an Exchange would be allowed to offer
    additional benefits beyond those specified in the essential
    benefits package. For QHBPs offered through the Exchange, a
    plan offering a premium-plus level of benefits (established
    under Section 203) could provide additional benefits.
        The requirements under Division A would not affect the
    offering of limited-purpose benefit plans, including policies
    covering dental or vision treatment, long-term care, Medicare
    supplement policies, workers' compensation, and other similar
    benefits, if such benefit plans are offered under a separate
    policy, contract, or certificate of insurance.
        A QHBP would not be allowed to impose coverage restrictions
    (except cost sharing) unrelated to the clinical appropriateness
    of the health care items and services.

    Sec. 122. Essential Benefit Package Defined

                Current Law
        Federally mandated benefits. Laws are found in the Employee
    Retirement Income Security Act (ERISA--covering employer-
    sponsored plans), the Public Health Service Act (PHSA--covering
    insurance plans and state and local government plans), and the
    Internal Revenue Code (IRC--covers Church plans in certain
    circumstances).
        Those mandates include:
         The Paul Wellstone and Pete Domenici Mental Health
    Parity and Addiction Equity Act of 2008 established that
    employers who offer mental health and substance use disorder
    benefits must offer them in an equal manner as physical health
    benefits are offered. The Newborns' and Mothers' Health
    Protection Act of 1996 (NMHPA) requires plans that offer
    maternity coverage to pay for at least a 48-hour hospital stay
    following childbirth (96-hour stay in the case of a cesarean
    section).
         The Women's Health and Cancer Rights Act of 1998
    contains protections for patients who elect breast
    reconstruction in connection with a mastectomy. For plan
    participants and beneficiaries receiving benefits in connection
    with a mastectomy, plans offering coverage for a mastectomy
    must also cover reconstructive surgery and other benefits
    related to a mastectomy.
         The Genetic Information Nondiscrimination Act of
    2008 (GINA) prohibits discrimination based on genetic
    information by health insurers and employers. GINA strengthens
    and clarifies existing HIPAA nondiscrimination and portability
    provisions. Broadly, GINA prohibits health insurers from
    engaging in three practices: (1) using genetic information
    about an individual to adjust a group plan's premiums, or, in
    the case of individual plans, to deny coverage, adjust
    premiums, or impose a preexisting condition exclusion; (2)
    requiring or requesting genetic testing; and (3) requesting,
    requiring, or purchasing genetic information for underwriting
    purposes.
         Michelle's Law ensures that dependent post
    secondary education students who take a medically necessary
    leave of absence do not lose health insurance coverage. The law
    provides that a group health plan may not terminate a college
    student's health coverage simply because the student takes a
    medically necessary leave of absence from school or changes to
    part-time status. The leave of absence must be medically
    necessary, begin while the student is suffering from a serious
    illness or injury and would otherwise result in a loss of
    coverage.
        Similarly, the Advisory Committee on Immunization Practices
    (ACIP), administered by the Centers for Disease Control and
    Prevention (CDC), reviews scientific evidence and makes
    recommendations to the Secretary and the CDC Director for the
    routine administration of vaccines to children, adolescents,
    and adults in the U.S. civilian population. The ACIP is not
    explicitly authorized; rather, it is based in general
    authorities of the Secretary in Titles II and III of the PHSA.
                Proposed Law
        This provision would require the essential benefits package
    to cover specified items and services, limit cost sharing,
    prohibit annual and lifetime limits on covered services, ensure
    the adequacy of provider networks, and be equivalent (as
    certified by the Office of the Actuary of the Centers for
    Medicare and Medicaid Services) to the average prevailing
    employer-sponsored coverage.
        The essential benefits package would be required to cover
    the following items and services:
               Hospitalization;
               Outpatient hospital and clinic services,
            including emergency department services;
               Services of physicians and other health
            professionals;
               Services, equipment, and supplies incident
            to the services of a physician or health professional
            in appropriate settings;
               Prescription drugs;
               Rehabilitative and ``habilitative'' services
            (i.e., services to maintain the physical, intellectual,
            emotional, and social functioning of developmentally
            delayed individuals);
               Mental health and substance use disorder
            services;
               Preventive services, include those graded
            ``A'' or ``B'' by the Task Force on Clinical and
            Preventive Services, as well as certain other substance
            abuse and mental health services, and those vaccines
            recommended by the Director of the CDC;
               Maternity care;
               Well baby and well child care and oral
            health, vision, and hearing services, equipment, and
            supplies, as defined under Section 1905(r) of the
            Social Security Act, for those under age 21; and
               Durable medical equipment, prosthetics,
            orthotics and related supplies.
        The Committee recognizes that historically, insurers have
    not covered medical services addressing a range of women's
    health needs, resulting in high out-of-pocket costs for medical
    services, such as maternity care and preventive screenings.
    Women have a variety of essential health needs throughout their
    lifetimes. Therefore, the Committee intends that the bill
    require the basic benefits package include the full range of
    medical services for women's unique health needs, at all stages
    of life, including, but not limited to, maternity care,
    preventive screenings such as mammograms, annual gynecological
    exams, diagnostic, routine care, and recommended treatments.
        The Committee believes that medically necessary evidence-
    based behavioral intervention services, including those
    provided to individuals with autism, are included within the
    ambit of section 122(b) of the bill.
        The essential benefits package would be subject to various
    requirements concerning cost-sharing. The package would be
    required to provide preventive items and services without cost-
    sharing. The annual out-of-pocket limit in 2013 would be $5,000
    for an individual and $10,000 for a family. These limits would
    be annually adjusted for inflation using the Consumer Price
    Index (CPI). To the extent possible, the Commissioner would
    establish cost-sharing levels using copayments (a flat dollar
    fee) and not coinsurance (a percentage fee). Cost-sharing would
    result in coverage equal to approximately 70 percent of the
    actuarial value of the benefits if there were no cost-sharing
    imposed.

    Sec. 123. Health Benefits Advisory Committee

                Current Law
        None.
                Proposed Law
        A Health Benefits Advisory Committee (HBAC) would be
    established to recommend covered benefits and the essential,
    enhanced, and premium plans. The HBAC would be chaired by the
    Surgeon General. The HBAC membership would be comprised of
               Nine members, appointed by the President,
            who are neither federal employees nor officers;
               Nine members, appointed by the Comptroller
            General, who are neither federal employees nor
            officers; and
               An even number, up to eight members,
            appointed by the President, who are federal employees
            and officers.
        The initial appointments would be made within 60 days of
    enactment. Each HBAC member would serve a three-year term,
    except the terms of the initial appointments would be adjusted
    to provide for staggered years of appointment. The members
    would reflect the interests of the many diverse groups of
    stakeholders so that no single interest would unduly influence
    the HBAC's recommendations. At a minimum, committee membership
    would reflect educated patients or consumer advocates,
    providers, employers, labor, health insurance issuers, experts
    in health care and delivery, experts in health disparities, and
    government agencies. In addition, at least one HBAC member
    would be a practicing physician or health professional, and
    another member would be an expert on children's health. At
    least one member must be an expert on the scientific evidence
    and clinical practice of integrative medicine.
        The HBAC's recommendations to the Secretary on the
    essential benefits package (as defined in Section 122), cost-
    sharing levels for the enhanced plans and premium plans (as
    defined in Section 203), and periodic updates of the package
    would be required to incorporate innovation in health care. The
    HBAC members would also consider how the package would reduce
    health disparities, would take into account integrative
    medicine, and would allow for public input as part of
    developing its recommendations. The HBAC's initial benefit
    recommendations must be made to the Secretary within one year
    of enactment.
        In developing standards for the enhanced and premium plans,
    the HBAC would be required to calculate cost-sharing such that
    the enhanced plan would have benefits that are actuarially
    equivalent to about 85 percent of the actuarial value of the
    benefits provided in the essential benefits package, and the
    premium plans would have benefits that are actuarially
    equivalent to about 95 percent of the actuarial value of the
    benefits provided in the essential benefits package.
        The Committee intends that, in developing its
    recommendations regarding benefit standards, the Health
    Benefits Advisory Committee shall take into account the special
    characteristics of group health plans that are multiemployer
    plans as defined in section 3(37) of the Employee Retirement
    Income Security Act and the impact of the recommendations on
    such plans. Among the special characteristics to be considered
    is that these plans are funded, and their costs borne, by the
    workers who tradeoff wages for employer contributions, that a
    plan's income fluctuates with the availability of covered work,
    and that workers are equally represented on the plans' boards
    of trustees who design the rules and benefit programs.
        HBAC members would serve without pay, but would receive
    federal travel expenses, including per diem expenses. In
    addition, the HBAC would be subject to the Federal Advisory
    Committee Act although the members would not become Federal
    employees.
        The Secretary would be required to publish all
    recommendations developed pursuant to this Section in the
    Federal Register and on the HHS website.
        Following an amendment at Committee, this provision would
    also instruct the Health Benefits Advisory Committee to examine
    current state laws and to seek input from the states as it
    forms its recommendations for the federal benefits standards.

    Sec. 124. Process for Adoption of Recommendations; Adoption of Benefit
            Standards

                Current Law
        None.
                Proposed Law
        This Section proposes a timeline by which the Secretary
    must choose whether to adopt the recommendations of the HBAC
    established under Section 123 of this bill. Within 45 days of
    receiving the HBAC's recommendations regarding the essential
    benefits package, the Secretary would be required either to
    adopt the benefit standards as written or not adopt the benefit
    standards, notify the HBAC of the reasons for this decision,
    and provide an opportunity for the HBAC to revise and resubmit
    its recommendations.
        The Secretary would be required to adopt an initial set of
    benefit standards within 18 months of enactment either by
    adopting the recommendations (and any revisions) of the HBAC,
    or absent that, by proposing an initial set of benefit
    standards.
        The Secretary would be required to publish all
    determinations under this Section in the Federal Register.
        The Secretary would be required to periodically update the
    benefit standards. However, an essential benefits package that
    does not meet the essential benefits requirements specified in
    Section 122 could not be adopted.

    Sec. 125. Prohibition of Discrimination in Health Care Services Based
            on Religious or Spiritual Content

        This provision would prohibit the Commissioner or any
    health insurance issuer offering health insurance coverage
    through the HIE from discriminating against approving or
    covering health care services based on religious or spiritual
    content if expenditures for such a health care service are
    allowable under 213(d) of the Internal Revenue Code of 1986.

                  Subtitle D--Additional Consumer Protections

    Sec. 131. Requiring Fair Marketing Practices by Health Insurers

                Current Law
        States have established varying marketing standards to
    prohibit insurers from marketing their insurance products only
    to healthy risks.
                Proposed Law
        This provision would require the Commissioner to establish
    uniform marketing standards for QHBPs.

    Sec. 132. Requiring Fair Grievance and Appeals Mechanisms

                Current Law
        ERISA does mandate compliance to certain standards if an
    employer chooses to offer health benefits, such as procedures
    for appealing denied benefit claims. The Department of Labor
    has issued regulations for plan internal appeal processes but
    does not provide for external appeals other than through
    judicial review. In addition, as of February 2008, 44 states
    and the District of Columbia mandate the independent review of
    benefit denials by an entity outside of the health plan
    (``external review''). The Supreme Court has upheld the
    application of state external review laws to ERISA covered
    plans.
                Proposed Law
        This provision would require QHBPs to provide for a uniform
    timely grievance and appeals mechanisms as established by the
    Commissioner. QHBPs would provide an internal claims and
    appeals process that initially incorporates the claims and
    appeals procedures (including urgent claims) promulgated by the
    Labor Department and published in the Code of Federal
    Regulations on November 21, 2000 (65 Fed. Reg. 70246). Such a
    process would be updated in accordance with any relevant
    standards that may be established by the Commissioner. The
    Commissioner would establish standards for an external review
    process (including expedited review of urgent claims), and any
    determination made with respect to a QHBP under an external
    review process would be binding. Aggrieved individuals would
    have state law rights and remedies to appeal adverse QHBP
    decisions.

    Sec. 133. Requiring Information Transparency and Plan Disclosure

                Current Law
        ERISA requires applicable health plans (as well as other
    ``welfare benefit'' plans) to disclose and report certain plan
    information to enrollees and regulators. For example, plan
    administrators must provide to enrollees a written summary plan
    description (SPD) which contains the terms of the plan and the
    benefits offered, including any material modifications, and the
    SPD must be written in a manner that can be understood by the
    average enrollee. Certain plans must file an annual report with
    the Department of Labor, containing information about the
    operation, funding, assets, and investments of those plans.
                Proposed Law
        This provision would require QHBPs to comply with
    disclosure standards established by the Commissioner concerning
    plan terms and conditions, claims payment policies, plan
    finances, claims denials, and other information as determined
    appropriate by the Commissioner. One specified disclosure
    requirement would be a list of health care providers under the
    plan trained and accredited in integrative medicine. The
    Commissioner would require such disclosure to be provided in
    plain language. QHBPs would be required to comply with
    standards established by the Commissioner to ensure
    transparency regarding reimbursements between the plan and
    health care providers. A change in a QHBP could not be made
    without reasonable and timely advance notice to enrollees about
    the change.

    Sec. 134. Application to Qualified Health Benefits Plans Not Offered
            Through the Health Insurance Exchange

                Current Law
        None.
                Proposed Law
        The Committee intends that the Commissioner may make any or
    all of the requirements of Subtitle D applicable to qualified
    health benefits plans outside of the HIE if the Commissioner
    determines that such an extension is necessary to accomplish
    the fundamental purposes of this Act. The Commissioner may make
    the requirements applicable to only health insurance issuers,
    and not to self-funded plans or to multiemployer plans based
    upon the Commissioner's determination that such plans satisfy
    the consumer protections provided for in this Act.

    Sec. 135. Timely Payment of Claims

                Current Law
        Under Medicare Advantage (MA), private health plans are
    paid a per-person amount to provide all Medicare-covered
    benefits (except hospice) to beneficiaries who enroll in their
    plan. MA plans include health maintenance organizations and
    private fee-for-service (PFFS) plans. MA PFFS plans are
    required to pay 95 percent of ``clean claims'' within 30 days
    of receipt. The Centers for Medicare and Medicaid Services
    (CMS) defines a clean claim as a claim that has no defect or
    impropriety, and is submitted with all the required
    documentation. The 30-day rule also applies to claims submitted
    to any MA organization by a provider who does not have a
    written contract with the plan. MA organizations are required
    to pay interest on clean claims that are not paid within 30
    days. All other claims from non-contracted providers must be
    paid within 60 days. MA organizations that do contract with
    providers (i.e., HMOs and PPOs) must include a prompt payment
    provision in their contracts.
                Proposed Law
        This provision would require QHBPs to comply with the
    prompt pay requirements applicable to Medicare Advantage plans.

    Sec. 136. Standardized Rules for Coordination and Subrogation of
            Benefits

                Current Law
        While there are no federal statutes specifying primary and
    secondary payment rules for multiple insurers in the private
    market, the Medicare statutes can be cited as providing an
    example. Section 1862(b) of the Social Security Act authorizes
    the Medicare Secondary Payer (MSP) program, which identifies
    specific conditions under which another party pays first and
    Medicare is only responsible for qualified secondary payments.
    The statute authorizes several methods to identify cases when
    an insurer other than Medicare is the primary payer and to
    facilitate recoveries when incorrect Medicare payments have
    been made. Under certain conditions, the law makes Medicare the
    secondary payer to insurance plans and programs for
    beneficiaries covered through (1) a group health plan based on
    either their own or a spouse's current employment; (2) auto and
    other liability insurance; (3) no-fault liability insurance;
    and (4) workers' compensation situations, including the Black
    Lung program. The purpose of the MSP program is to shift costs
    from Medicare to private sources of payment, thus reducing
    Medicare expenditures. Additionally, the Medicare statutes
    exclude Medicare coverage for items and services paid for
    directly or indirectly by a government entity, subject to
    certain limitations. This includes the Department of Veterans
    Affairs, among others.
        The states have long established rules on coordination of
    benefits and subrogation of claims but in recent years, health
    plans have challenged aspects of the traditional rules leading
    to confusion and uncertainty in this area.
                Proposed Law
        The Commissioner would establish standards for the
    coordination of benefits and reimbursement of payments in cases
    involving individual and multiple plan coverage.

    Sec. 137. Application of Administrative Simplification

                Current Law
        To support the growth of electronic record keeping and
    claims processing, HIPAA's Administrative Simplification
    provisions instructed the Secretary to adopt electronic format
    and data standards for several routine administrative and
    financial transactions between health care providers and health
    plans/payers. The standards apply to health care providers (who
    transmit any health information in electronic form in
    connection with a HIPAA-specified transaction), health plans,
    and health care clearinghouses. Although providers have made
    significant progress in streamlining administrative processes,
    much work remains to achieve uniforms claims and billing
    processes.
                Proposed Law
        This provision would require QHBP offering entities (as
    defined in the bill) to comply with the new administrative
    simplification standards adopted under Sec. 163 (discussed
    below).

    Sec. 138. Records Relative to Prescription Information

        This provision would ban the sales of physician prescribing
    habits to the pharmaceutical industry when the physician serves
    patients enrolled in a qualified health benefit plan.

                             Subtitle E--Governance

    Sec. 141. Health Choices Administration; Health Choices Commissioner

                Current Law
        No specific provision in federal law.
                Proposed Law
        This provision would establish an independent agency in the
    Executive Branch of the United States called the Health Choices
    Administration, ``Administration.'' The Administration would be
    headed by a Health Choices Commissioner, ``Commissioner,'' who
    would be appointed by the President, by advice and consent of
    the Senate. Section 702 of the Social Security Act (detailing
    compensation, terms, general powers, rule-making, and
    delegation as applied to the Commissioner of Social Security
    and the Social Security Administration) would apply to the
    Commissioner.

    Sec. 142. Duties and Authority of Commissioner

                Current Law
        None.
                Proposed Law
        This provision would make the Commissioner responsible for
    carrying out the following functions:
         Qualified Plan Standards--Establishing qualified
    health benefits plan (``QHBP'') standards, including the
    enforcement of such standards in coordination with State
    insurance regulators and the Secretaries of Labor and the
    Treasury.
         Health Insurance Exchange--Establishing and
    operating the Health Insurance Exchange.
         Individual Affordability Credits--Administering
    individual affordability credits, including the determination
    of eligibility for such credits.
         Promoting Accountability--Undertaking activities
    in accordance with this section to promote accountability of
    QHBP offering entities in meeting Federal health insurance
    requirements, regardless of whether such accountability is with
    respect to qualified health benefits plans offered through or
    outside the Health Insurance Exchange.
         Compliance Examination and Audits--coordinating
    with States to conduct audits of qualified health benefits plan
    compliance with Federal requirements. These audits would
    include random compliance audits and targeted audits in
    response to complaints or other suspected non-compliance.
         Recoupment of Costs in Connection with Examination
    and Audits--authorizing to recoup from qualified health
    benefits plans reimbursement for costs of such examinations and
    audit of such QHBP offering entities.
         Data Collection--Collecting data for the purposes
    of carrying out the Commissioner's duties, including promoting
    quality, value, protecting consumers and addressing disparities
    in health care; the commissioner may share such data with
    Secretary of Health and Human Services. The Committee believes
    populations who experience disparities in health care include
    people with disabilities.
         Sanctions Authority--Providing any of the
    following remedies (in addition to any other authorized by law)
    in coordination with State insurance regulators and the
    Secretary of Labor if it is determined that a QHBP offering
    entity violates a requirement:
              1. Civil money penalties of not more than the amount
            applicable under similar circumstances for similar
            violations under Medicare;
              2. Suspension of plan enrollment of individuals under
            such plan after the date the Commissioner notifies the
            entity of a decision, until the Commissioner is
            satisfied with rectification;
              3. In the case of an Exchange-participating health
            benefits plan, suspension of payment under the Health
            Insurance Exchange for individuals enrolled in the plan
            after the date the Commissioner notifies the entity of
            such decision and until the Commissioner is satisfied
            with corrective action; or
              4. Work with State insurance regulators to terminate
            plans for repeated failure by the QHBP offering entity
            to meet this title's requirements.
        Standard Definitions of Insurance and Medical Terms--
    providing the development of standards for defining terms used
    in health insurance coverage, including insurance-related
    terms.

    Sec. 143. Consultation and Coordination

                Current Law
        None.
                Proposed Law
        The Commissioner, as appropriate, would be required to
    consult with, at a minimum, the National Association of
    Insurance Commissioners, State attorneys general, and State
    insurance regulators concerning the standards and enforcement
    for insured qualified health benefits plans described in this
    title. Concurrently, the Commissioner would be required to
    consult with, at a minimum, Indian tribes and tribal
    organizations, appropriate federal agencies, and appropriate
    State agencies concerning affordability credits and the
    offering of Exchange-participating health benefits plans
    (including Medicaid concerning standards for insured qualified
    health benefits plans).

    Sec. 144. Health Insurance Ombudsman

                Current Law
        The Department of Health and Human Services receives
    various complaint handling and client-assistance ombudsmen
    including:
        Long-term Care Ombudsman--mandated by Older Americans Act
    of 1965, consists of 1,000 paid and 14,000 volunteers who
    identify, investigate, and resolve complaints made by, or on
    the behalf, of residents. They have a blend of federal and
    state oversight.
        Medicare Beneficiary Ombudsman--Created by the Medicare
    Prescription Drug, Improvement, and Modernization Act of 2003
    (P.L. 108-173), it is intended to ensure those eligible for
    Medicare have reliable and current information about their
    benefits, rights and protections under the Medicare program,
    and the procedures for getting problems and disputes resolved.
    The Ombudsman is to aid Medicare recipients in filing appeals
    if their insurance did not pay proper amounts for their medical
    services or those services were denied.
        State Health Insurance Ombudsman--Several states (VT, MN,
    and IL to name a few) have created State health insurance
    ombudsmen, with the core responsibilities of rectifying
    concerns encompassing access to care, billing problems, and
    access to health insurance. The ombudsman provides information
    on state and federal programs that may be available, explains
    continuation rights under an existing health plan, provides
    help on how to shop for health insurance, and assists in
    appealing decisions made by their health insurance.
                Proposed Law
        The Commissioner would appoint within the Health Choices
    Administration a Qualified Health Benefits Ombudsman (with
    experience and expertise in the fields of health care and
    education). The Ombudsman would be required to perform the
    following duties:
         Receive and provide assistance with complaints,
    grievances, and requests for information submitted by
    individuals. The assistance would be provided more specifically
    in instances such as helping individuals determine relevant
    information for an appeal, assisting with any problems arising
    from disenrollment, choosing a qualified health benefits plan
    to enroll, and presenting information relevant to affordability
    credits.
         Submit annual reports to Congress and the
    Commissioner describing the activities of the Ombudsman,
    including recommendations for improvement in the Administration
    of this Division, as determined appropriate. The Ombudsman
    would not serve as an advocate for any increases in payments or
    new coverage of services, but would identify issues and
    problems in payment or coverage policies.

           Subtitle F--Relation to Other Requirements; Miscellaneous

    Sec. 151. Relation to Other Requirements

                Current Law
        None.
                Proposed Law
         Coverage Not Offered Through the Exchange--The
    requirements of this provision would not supersede specified
    provisions of federal and state laws with respect to the health
    insurance coverage not offered through the Health Insurance
    Exchange (whether or not offered in connection with an
    employment-based health plan).
         Coverage Offered Through the Exchange--The
    requirements under this title would not supersede any
    requirements relating to genetic information non-discrimination
    and mental health for such health insurance coverage (as long
    as those related do not prevent the application of requirements
    detailed in this division; as determined by the Commissioner).
    Concurrently, individual rights and remedies under State laws
    would apply. Nothing in this paragraph would be construed as
    preventing the application of rights and remedies under State
    laws.

    Sec. 152. Prohibiting Discrimination in Health Care

                Current Law
        HIPAA established federal rules regarding non-
    discrimination based on health status-related factors. It
    prohibits group issuers from establishing rules for eligibility
    and premium contributions based on health status-related
    factors. Those factors include health status, medical condition
    (including both physical and mental illnesses), claims
    experience, receipt of health care, medical history, genetic
    information, evidence of insurability (including conditions
    arising out of acts of domestic violence) and disability. In
    addition, the Genetic Information Nondiscrimination Act of 2008
    (GINA, P.L. 110-233) prohibits issuers in the individual health
    insurance market from establishing eligibility rules (including
    continued eligibility) based on an individual's genetic
    information. The Paul Wellstone and Pete Domenici Mental Health
    Parity and Addiction Equity Act of 2008 establishes parity by
    requiring an employer offering mental health and substance use
    disorder benefits in an equal manner as physical health
    benefits are offered.
        In addition, Title VI of the Civil Rights Act of 1964
    prohibits discrimination by the recipients of federal funds,
    which includes many hospitals, clinics and social service
    agencies. However, the Civil Rights Act's link to the receipt
    of federal funds has insulated many insurance companies from
    any obligation to comply with nondiscrimination protections.
                Proposed Law
        Unless explicitly permitted within this Act and subsequent
    related regulations, all health care and related services,
    (including insurance coverage and public health activities)
    covered by this Act would be provided regardless of personal
    characteristics extraneous to the provision of high quality
    health care or related services.
        Within 18 months of enactment, the Secretary would be
    required to ensure that all health care and related services
    would be provided without regard for extraneous personal
    characteristics.

    Sec. 153. Whistleblower Protection

                Current Law
        None.
                Proposed Law
        No employer may discharge any employee (or otherwise
    discriminate against) with respect to his compensation, terms,
    conditions, or other privileges of employment because the
    employee (or an individual acting at the request of the
    employee):
         Provides or causes to provide to the employer,
    Federal Government, the attorney general of a relevant State,
    information relating to any violation of, or any act or
    omission the employee reasonably believes to be a violation of
    any provision, order, rule, or regulation promulgated under
    this Act.
         Testifies or is about to testify in a proceeding
    concerning such violation.
         Assists, participates or about to assist and
    participate in such a proceeding.
         Objects to, or refused to participate in any
    activity, policy, practice, or assigned task that the employee
    reasonably believes to be in violation of any provision, order,
    rule and regulation promulgated under this Act.
        Enforcement Action--An employee covered by this section who
    alleges discrimination by an employer in violation may bring an
    action governed by the rules, procedures, legal burden of
    proof, and remedies detailed in section 40(b) of the Consumer
    Product Safety Act.
        Employer Defined--The term employer in this section means
    any person (including one or more individuals, partnerships,
    associations, corporations, trusts, professional membership
    organization including a certification, disciplinary, or other
    professional body, unincorporated organizations,
    nongovernmental organizations, or trustees) engaged in profit
    or nonprofit business or industry whose activities are governed
    by this Act, and any agent, contractor, subcontractor, grantee,
    or consultant of such person.
        Rule of Construction--The rule of construction set forth
    concerning employee protections in the United States Code would
    apply to this section.

    Sec. 154. Construction Regarding Collective Bargaining

                Current Law
        None.
                Proposed Law
        Nothing in this division may be construed to alter or
    supersede any statutory or other obligation to engage in
    collective bargaining over the terms and conditions of
    employment related to health care. This rule of construction
    clarifies that long-standing principles of law continue to
    apply in the context of this health reform legislation. Where a
    new law sets mandatory minimum labor standards, the parties in
    a collective bargaining relationship must abide by such
    standards. Where, however, a new law leaves some discretion to
    an employer with regard to how to achieve compliance, which
    this bill indeed does on many levels, an employer with
    collective bargaining obligations may not make unilateral
    changes to the terms and conditions of employment but must
    bargain with the employees' bargaining representative over
    those matters.\123\
    ---------------------------------------------------------------------------
        \123\ See, e.g., Murphy Oil USA, 286 N.L.R.B. 1039, 1042 (1987);
    Standard Candy Co., 147 N.L.R.B. 1070, 1073 (1964); Fort Halifax
    Packing Co. v. Coyne, 482 U.S. 1, 20 (1987).
    ---------------------------------------------------------------------------

    Sec. 155. Severability

                Current Law
        None.
                Proposed Law
        If any provision of this Act, or the application thereof
    towards any person or circumstance, is held unconstitutional,
    the application of the remaining provisions would not be
    affected.

    Sec. 156. Rule of Construction Regarding Hawaii Prepaid Health Care Act

        Added with an amendment at Committee, this provision would
    maintain Hawaii's Prepaid Health Care Act exemption under
    ERISA, including with respect to the provisions of H.R. 3200,
    where such state statute ensures health care benefits
    equivalent to or greater than those benefits that would be
    guaranteed by H.R. 3200.

    Sec. 157. Increasing Meaningful Use of Electronic Health Records

        This provision would require the Health Choices
    Commissioner to study how to increase the meaningful use of
    electronic health records and then use the results of that
    study to potentially require higher reimbursement rates for
    providers that use health information technology.

    Sec. 158. Private Right of Contract with Health Care Providers

        This provision forbids any other provision in this bill
    from being construed to preclude any participant or beneficiary
    in a group health plan from entering into any contract or
    arrangement for health care with any health care provider.

                         Subtitle G--Early Investments

    Sec. 161. Ensuring Value and Lower Premiums

        The Committee did not exercise jurisdiction over this
    provision.

    Sec. 162. Ending Health Insurance Rescission Abuse

        The Committee did not exercise jurisdiction over this
    provision.

    Sec. 163. Administrative Simplification

        The Committee did not exercise jurisdiction over this
    provision.

    Sec. 164. Reinsurance Program for Retirees

                Current Law
        No current law.
                Proposed Law
        No later than 90 days after enactment, the Secretary would
    establish a temporary reinsurance program, to provide
    reimbursement to assist participating private or public sector
    employment-based plans with the cost of providing health
    benefits to eligible retirees who are 55 and older and their
    dependents, including eligible and surviving spouses. Such
    plans include voluntary employee benefit associations (VEBAs)
    and multi-employer plans covering retirees. Health benefits
    would be required to include medical, surgical, hospital,
    prescription drug, and other benefits determined by the
    Secretary. An eligible employment-based plan would submit an
    application to the Secretary, as required. A participating
    employment-based program would submit claims for reimbursement
    to the Secretary, documenting the actual cost of items and
    services for each claim. Each claim would be based on the
    actual amount expended by the participant. The participating
    employment-based plan would take into account any negotiated
    price concessions, such as discounts, subsidies, and rebates.
    The cost of deductibles and cost-sharing would be included in
    the cost of the claim, along with the amounts paid by the plan.
    For any valid claim, the Secretary would reimburse the plan for
    80 percent of the portion of costs above $15,000 and below
    $90,000. This amount would be adjusted annually based on the
    percent increase in the medical care component of the Consumer
    Price Index, rounded to the nearest multiple of $1,000. Amounts
    paid to a participating employment-based plan would be used to
    lower cost directly to participants and beneficiaries in the
    form of premiums, co-payments, deductible, co-insurance, or
    other out-of-pocket costs, but would not be used to reduce the
    costs of an employer maintaining the employment-based plan. The
    Secretary would establish an appeals process for denied claims,
    procedures to protect against fraud, waste, and abuse, and
    would conduct annual audits of claims date.
        The Retiree Reserve Trust Fund would be established,
    consisting of such amounts as appropriated or credited to the
    Fund to enable the Secretary to carry out the reinsurance
    program. The Secretary could request such sums as necessary to
    carry out this section, not to exceed $10 billion. Amounts
    appropriated and outlays from such appropriation would not be
    taken into account for purpose of any budget enforcement
    procedures, thus exempting the Fund from the framework of the
    budget resolution and the points of order which enforce that
    framework. The Secretary would have the authority to stop
    taking applications or take other steps to reduce expenditures
    to ensure that expenditures did not exceed available funds.

    Sec. 165. Prohibition Against Post-Retirement Reductions of Retiree
            Health Benefits by Group Health Plans

        This provision would prohibit group health plans from
    reducing retirees' health benefits after those retirees have
    retired, unless the reduction is also made to benefits for
    active participants.

    Sec. 166. Limitations on Preexisting Condition Exclusions in Group
            Health Plans in Advance of Applicability of New Prohibition of
            Preexisting Condition Exclusions

        This provision would require that the limit on pre-existing
    conditions exclusions in the insurance market start immediately
    at the bill's passage instead of 2013 as the introduced version
    of H.R. 3200 instructs. The permitted ``look back'' period is
    reduced from six months to 30 days, and the amount of time
    during which a provider can exclude coverage for pre-existing
    conditions is shortened.

    Sec. 167. Extension of COBRA Continuation Coverage

        This section was added by amendment at Committee. This
    provision would end the current COBRA eligibility limit and
    allow those currently enrolled in COBRA to keep their insurance
    until they find another job offering coverage or until they
    become eligible to participate in the HIE.

           Title II--Health Insurance Exchange and Related Provisions

                     Subtitle A--Health Insurance Exchange

                Current Law
        No specific provision in federal law.
                Proposed Law
        Text.

    Sec. 201. Establishment of Health Insurance Exchange; Outline of
            Duties; Definitions

        A Health Insurance Exchange, ``Exchange'' would be
    established to facilitate access of individuals and employers
    to a variety of choices of affordable, quality health insurance
    coverage, including a public health insurance plan option. The
    HIE would exist within the Health Choices Administration under
    the direction of the Health Choices Commissioner (described
    above in Sections 141 and 142). As described in greater detail
    in the following sections, regarding the Exchange, the
    Commissioner would (1) establish standards for, accept bids
    from, and negotiate and enter into contracts with entities
    seeking to offer qualified health benefits plans (QHBPs)
    through the Exchange, (2) facilitate outreach and enrollment of
    Exchange-eligible individuals and employers, and (3) conduct
    appropriate activities related to the Exchange, including
    establishment of a risk pooling mechanism and consumer
    protections.

    Sec. 202. Exchange-eligible Individuals and Employers

        Beginning in 2013, all individuals generally would be
    eligible to obtain coverage through the Exchange, unless they
    were enrolled in the following (as determined by the
    Commissioner, in coordination with the Treasury Secretary):
               a group plan through a full-time employee
            (including a self-employed person with at least one
            employee) for which the employer makes an adequate
            contribution (described below in Section 312),
               Medicare,
               Medicaid (except in certain cases, discussed
            below), or
               military and VA coverage.
        Except for the Medicaid exception, individuals would lose
    eligibility for Exchange coverage once they become eligible for
    Medicare Part A, Medicaid (although in this case, the
    Commissioner could permit continued Exchange eligibility for
    such limited time as the Commissioner determines it is
    administratively feasible and consistent with minimizing
    disruption in the individual's access to health care), and
    other circumstances as the Commissioner provides. Besides those
    cases, once individuals enroll in an Exchange plan, they would
    continue to be eligible until they are no longer enrolled.
        Exchange-eligible employers could meet the requirements of
    the employer responsibility (Section 312) by offering and
    contributing adequately toward employees' enrollment through
    the Exchange. Those employees would be able to choose any of
    the available Exchange plans. Once employers are Exchange
    eligible and enroll their employees through the Exchange, they
    would continue to be Exchange eligible, unless they decided to
    then offer their own qualified health benefits plan(s).
        In 2013, employers with 15 or fewer employees would be
    Exchange-eligible. In 2014, employers with 25 or fewer
    employees would be Exchange-eligible. Beginning in 2015,
    employers with 50 or fewer employees would be Exchange-
    eligible, however the Commissioner could permit employers
    larger than 50 to participate in the Exchange. These additional
    employers could be phased in or made eligible based on the
    number of full-time employees or other considerations the
    Commissioner deems appropriate. (``Employer'' and other
    employment-related definitions would be defined by the
    Commissioner.)
        The Committee intends that if and when the Commissioner
    permits ``larger employers'' to become Exchange-eligible
    employers, the Commissioner will also permit a multiemployer
    plan (as defined in section 3(37) of the Employee Retirement
    Income Security Act) itself to become an Exchange-eligible
    employer on behalf of its contributing employers as if it were
    one employer.
        The Commissioner would have the authority to establish
    rules to deal with special situations with regard to uninsured
    individuals participating as Exchange-eligible individuals and
    employers, such as transition periods for individuals and
    employers who gain, or lose, Exchange-eligible participation
    status, and to establish grace periods for premium payment.
        The Commissioner would be required to provide for periodic
    surveys of Exchange-eligible individuals and employers
    concerning their satisfaction with the Exchange and its plans.
        The Commissioner would conduct an Exchange Access Study--a
    study of access to the Health Insurance Exchange for
    individuals and for employers, including individuals and
    employers who are not eligible and enrolled in HIE plans. The
    goal of the study would be to determine if there are
    significant groups and types of individuals and employers who
    are not Exchange eligible but who would have improved benefits
    and affordability if made eligible. The study also would
    examine the terms, conditions, and affordability of group
    health coverage offered by employers and QHBP-offering insurers
    outside of the Exchange compared to Exchange-participating
    health benefits plans, as well as the affordability-test
    standard for access of certain employed individuals to coverage
    in the Health Insurance Exchange. The Commissioner would submit
    the study to Congress by January 1 of 2015, 2018, and
    thereafter, and would include in the report recommendations
    regarding changes in standards for Exchange eligibility for
    individuals and employers.
        This provision would also give the Commissioner authority
    to define terms such as ``employer'' and ``employee'' for
    purposes of this division. The Commissioner should take care
    that such definitions minimize incentives to misclassify
    workers as non-employees. Moreover, the Commissioner should
    take into consideration any special employer or industry
    organizational structures such as ``employers of record'' in
    the home health industry and hour of service calculations for
    airline personnel in the airline industry in light of relevant
    federal rules and industry practices when defining these
    employment terms.

    Sec. 203. Benefits Package Levels

        The Commissioner would specify the benefits to be made
    available under HIE plans during each plan year, consistent
    with this section and Sections 121-134 above. The Commissioner
    could not enter into a contract with an entity wanting to offer
    coverage through the Exchange in a service area(s), unless the
    following requirements are met:
         The entity offers only one Basic plan in the
    service area.
         The entity may offer one Enhanced plan in the
    service area.
         If the entity offers an Enhanced plan in a service
    area, the entity may offer one Premium plan for the area.
         If the entity offers a Premium plan for a service
    area, the entity may offer one or more Premium-Plus plans for
    the area.
        All such plans could be offered under a single contract
    with the Commissioner.
        Consistent with the standards in Sections 101-164 above,
    the Commissioner would also establish the following standards
    for the three primary levels of Exchange plans--Basic,
    Enhanced, and Premium--and for additional benefits that may be
    offered in a Premium-Plus plan. Besides offering the essential
    benefits package (Section 122 above) for a QHBP, Basic plan
    benefit packages would be modified to provide for reduced cost-
    sharing for individuals eligible for the ``affordability cost-
    sharing credit,'' described below in Section 244. Excluding the
    credit, the benefit package of a Basic plan would have an
    actuarial value representing payment for approximately 70
    percent of all the covered items and services in the essential
    benefits package (Section 122 above). Enhanced plans would have
    lower cost-sharing than Basic plans, representing approximately
    85 percent of the actuarial value of all the covered items and
    services in the essential benefits package. Premium plans would
    have lower cost-sharing than Enhanced plans, representing
    approximately 95 percent of the actuarial value of all the
    covered items and services in the essential benefits package.
    Premium-Plus plans would be Premium plans that also provide
    additional benefits, such as adult oral health and vision care,
    approved by the Commissioner. The portion of the premium that
    is attributable to such additional benefits would be separately
    specified.
        The Commissioner would establish a permissible range of
    variation of cost-sharing for the Basic, Enhanced and Premium
    plans. Such variation would permit variations up to 10 percent
    in cost-sharing with respect to several benefit categories
    (Section 122).
        If a state requires health insurers to offer benefits
    beyond the essential benefits package, such requirements would
    continue to apply to Exchange plans, but only if the state has
    entered into an arrangement satisfactory to the Commissioner to
    reimburse the Commissioner for the amount of any resulting net
    increase in affordability premium credits (Section 243).

    Sec. 204. Contracts for the Offering of Exchange-participating Health
            Benefits Plans

        The Commissioner would establish standards, described
    below, for Exchange-participating entities and their health
    benefits plans. The Commissioner would certify entities and
    plans if the standards are met. The Commissioner would solicit
    and review bids from QHBP-offering entities for offering
    Exchange plans, negotiate with the entities, and enter into
    contracts with the entities for offering plans through the
    Exchange under terms negotiated between the Exchange and the
    entities.
        The Federal Acquisition Regulation (the principal set of
    rules that govern the contracting process for the federal
    government) would not apply to contracts between the
    Commissioner and QHBP-offering entities for offering Exchange
    plans.
        The standards for Exchange-participating entities would
    consist of the following requirements:
         The entity must be licensed or otherwise permitted
    to offer health insurance coverage under state law for each
    state in which it offers coverage.
         The entity must provide for reporting data/
    information specified by the Commissioner, including
    information necessary to administer the risk pooling mechanism
    in Section 206 and information to address disparities in health
    and health care.
         The entity must provide for implementation of the
    affordability credits provided for enrollees (described in
    Sections 241-246 below).
         The entity must accept all applicable enrollment
    via the Exchange, subject to such exceptions (such as capacity
    limitations) in accordance with the federal requirements for
    QHBPs (discussed under Title I), and would notify the
    Commissioner if it projects or anticipates reaching a capacity
    that would result in a limitation in enrollment.
         The entity must participate in the pooling
    mechanism as established by the Commissioner (described in
    Section 206 below).
         Regarding the Basic plan offered by the entity,
    the entity must contract for outpatient services with certain
    federally supported health care providers. The Commissioner
    would also specify how this requirement would apply to Health
    Maintenance Organizations (HMOs).
         The entity must provide culturally and
    linguistically appropriate communication and health services.
         The entity must comply with other applicable
    requirements of this title specified by the Commissioner, which
    would include standards regarding billing and collection
    practices for premiums and grace periods and which may include
    standards to ensure that the entity does not use coercive
    practices to force providers not to contract with other
    entities offering coverage through the Exchange.
        For the contracting process, entities' bids would have to
    contain the information required by the Commissioner. Contracts
    would last at least one year, but could be automatically
    renewed in the absence of notice of termination by either
    party. The contract would provide that if the Commissioner
    determines that a plan's provider network is not adequate, then
    the cost-sharing charged to a person who received out-of-
    network care would be the same as if the care had been provided
    in-network.
        In coordination with state insurance regulators, the
    Commissioner would establish processes to oversee, monitor, and
    enforce applicable requirements on Exchange-participating
    entities and QHBPs, including plan marketing. In conjunction
    with state insurance regulators, the Commissioner would
    establish a process for individuals and employers to file
    complaints concerning violations. The Commissioner could
    terminate a contract with an entity if it fails to comply with
    the requirements of this title; the Commissioner could also
    impose one or more intermediate sanctions.
        Any determination by the Commissioner to terminate a
    contract would be made in accordance with formal investigation
    and compliance procedures established by the Commissioner under
    which (a) the Commissioner provides the entity with the
    reasonable opportunity to develop and implement a corrective
    action plan to correct the deficiencies that were the basis of
    the Commissioner's determination; and (b) the Commissioner
    provides the entity with reasonable notice and opportunity for
    hearing (including the right to appeal an initial decision)
    before terminating the contract. However, these procedures need
    not apply if the Commissioner determined that a delay in
    termination would pose an imminent and serious risk to the
    health of individuals enrolled under the plan.

    Sec. 205. Outreach and Enrollment of Exchange-eligible Individuals and
            Employers in Exchange-participating Health Benefits Plan

        Outreach. The Commissioner would conduct outreach
    activities to inform and educate individuals and employers
    about the Exchange and its participating health plans. Such
    outreach would include outreach specific to vulnerable
    populations, such as children, individuals with disabilities,
    individuals with mental illness, and individuals with other
    cognitive impairments. The Commissioner's required outreach
    activities would include the following:
         broadly disseminate information on Exchange-
    participating plans, provided in a comparative manner and
    including information on benefits, premiums, cost-sharing,
    quality, provider networks, and consumer satisfaction;
         provide assistance to Exchange-eligible
    individuals and employers via a toll-free telephone hotline and
    an Internet website;
         develop and disseminate information to Exchange-
    eligible enrollees on their rights and responsibilities;
         assist Exchange-eligible individuals in selecting
    plans and obtaining benefits; and
         ensure the information is developed using plain
    language (described in Section 133 above).
        Enrollment. The Commissioner would be required to make
    timely determinations of whether individuals and employers are
    eligible for Exchange coverage and to establish and carry out
    an enrollment process, including at community locations.
    Enrollment would be permitted by mail, telephone,
    electronically, or in person.
        Open enrollment for individuals and employers to enroll in
    an Exchange plan and affordability credits (described in
    Sections 241-245 below) would be at least 30 days and would be
    during September through November of each year before benefits
    would begin, or such other time that would maximize the
    timeliness of income verification. However, the Commissioner
    would also provide for special enrollment periods to take into
    account special circumstances of individuals and employers,
    such as an individual who loses acceptable coverage,
    experiences a change in marital or other dependent status,
    moves outside the plan's service area, or experiences a
    significant change in income. The Commissioner, potentially
    with other appropriate entities, would be required to broadly
    disseminate information on the enrollment process, including
    before each enrollment period.
        The Commissioner would establish a process to automatically
    enroll the following individuals into an appropriate Exchange
    plan (potentially involving a random assignment or some other
    form of assignment that takes into account the health care
    providers used by the individual, or such other relevant
    factors specified by the Commissioner):
               those who have applied for affordability
            credits, been determined eligible, have not opted out
            from receiving such credit, and do not enroll in
            another Exchange plan; and
               those enrolled in an Exchange plan that is
            terminated (during or at the end of a plan year) who do
            not enroll in another Exchange plan.
        Under the enrollment process, individuals enrolled in an
    Exchange plan would pay such plans directly, not through the
    Commissioner or the Exchange.
        Special provisions apply to newborns born in the United
    States without acceptable coverage at birth. Until other
    acceptable coverage begins, the child would be considered a
    non-traditional Medicaid-eligible individual (for whom the
    state would be paid 100 percent federal reimbursement) and
    would be deemed as having elected Medicaid coverage. This
    coverage would end no later than the end of the month 60 days
    after the child's birth; at the end of that period, if the
    child still does not have acceptable coverage, the child is
    deemed a traditional Medicaid-eligible individual, for whom the
    state receives the regular Medicaid federal matching rate.
        As of the day before the first day of 2013, CHIP-eligible
    children, including targeted low-income children in a Medicaid-
    expansion CHIP program, would be deemed to be Exchange
    eligible. The Commissioner would notify each state in 2013
    whether the Exchange could support enrollment of these
    children.
        A ``traditional Medicaid eligible individual'' is a
    Medicaid-eligible individual excluding (1) those who are
    eligible because of the expansion of Medicaid in Section 1701
    of this legislation to individuals up to 133\1/3\ percent FPL
    and (2) a childless adult who would not otherwise be classified
    as categorically needy (as per current Medicaid statute,
    Section 1902(a)(10)(A)) or medically needy (as per current
    Medicaid statute, Section 1902(a)(10)(C)) as in effect as of
    the day before the date of enactment of this Act. A ``non-
    traditional Medicaid-eligible individual'' is a Medicaid-
    eligible individual who is not a traditional Medicaid-eligible
    individual. Section 202 of the legislation includes provisions
    so that a non-traditional Medicaid eligible individual could be
    Exchange-eligible if the individual was enrolled in a qualified
    health benefits plan, grandfathered health insurance coverage,
    or current group health plan during the six months before the
    individual became a non-traditional Medicaid eligible
    individual. Under this section, the Commissioner would provide
    these individuals with the option to enroll in Medicaid rather
    than an Exchange plan and to change that election during open
    enrollment periods described earlier in this section. The
    Commissioner would provide for a process to automatically
    enroll these individuals into Medicaid if they have not elected
    to enroll in any Exchange plan.
        An Exchange-eligible individual could apply for a Medicaid-
    eligibility determination. If the individual is determined to
    be eligible, the Commissioner would provide for the
    individual's enrollment under the state Medicaid plan in
    accordance with the Medicaid memorandum of understanding. In
    the case of such an enrollment, the state would provide for the
    same periodic redetermination of eligibility under Medicaid
    that would apply if the individual had directly applied to the
    state Medicaid agency. The legislation would require the
    Commissioner, in consultation with the HHS Secretary, to enter
    into a memorandum of understanding with each state with respect
    to coordinating enrollment of individuals in Exchange plans and
    under state Medicaid programs, and to otherwise coordinate the
    implementation of these provisions with respect to the Medicaid
    program. This memorandum would permit the exchange of
    information consistent with limitations specified in Medicaid
    statute with respect to providing safeguards that restrict the
    use or disclosure of information concerning applicants and
    recipients to purposes directly connected with the
    administration of the state Medicaid plan, and at state option,
    the exchange of information necessary to verify eligibility for
    other federal programs (e.g., for free and reduced price school
    lunches). None of these provisions could be construed as
    permitting such memorandum to modify or vitiate any requirement
    of a state Medicaid plan.
        In carrying out this section, the Commissioner would
    establish effective methods for communicating in plain language
    and a culturally and linguistically appropriate manner.

    Sec. 206. Other Functions

        The Commissioner would be required to coordinate the
    distribution of affordability premium and cost-sharing credits
    (described below in Sections 243-244) to the Exchange plans.
    The Commissioner would also be required to establish a risk-
    pooling mechanism, to adjust premium payments to Exchange plans
    to take into account (in a manner specified by the
    Commissioner) the differences in the risk characteristics of
    individuals and employers enrolled under the Exchange plans.
        An Office of the Special Inspector General for the Exchange
    would be established, headed by a Special Inspector General
    appointed by the President and confirmed by the Senate. The
    Special Inspector General's nomination would be made as soon as
    practicable after the establishment of the Exchange.
        The duties of the Special Inspector General would consist
    of the following:
               conduct, supervise, and coordinate audits,
            evaluations and investigations of the Health Insurance
            Exchange to protect the integrity of the Exchange as
            well as the health and welfare of participants in the
            Exchange;
               report both to the Commissioner and to the
            Congress regarding program and management problems and
            recommendations to correct them;
               related to the duties above, have other
            duties described as applying to the Special Inspector
            General of the Troubled Asset Relief Program (TARP),
            per paragraphs (2) and (3) of Section 121 of P.L. 110-
            343; and
               in carrying out these duties, have the
            authorities of inspectors general in Section 6 of the
            Inspector General Act of 1978.
        Other provisions of the TARP Special Inspector General
    would also be applied, regarding the basis of the Special
    Inspector General's appointment, how s/he might be removed,
    his/her salary, and available personnel, facilities and other
    resources.
        Not later than one year after the confirmation of the
    Special Inspector General, and annually thereafter, the Special
    Inspector General would submit to the appropriate committees of
    Congress a report summarizing the activities of the Special
    Inspector General during the one year period ending on the date
    the report is submitted.
        The Office of the Special Inspector General would terminate
    five years after the date of the enactment of this Act.
        Following an amendment at Committee, this provision would
    also require the Commissioner, in consultation with the Small
    Business Administration, to establish and carry out a program
    to provide health insurance counseling and technical assistance
    to small employers who provide their employees health care
    through the HIE.

    Sec. 207. Health Insurance Exchange Trust Fund

        A ``Health Insurance Exchange Trust Fund'' would be created
    within the U.S. Treasury, consisting of such amounts as may be
    appropriated or credited to the fund. The Commissioner would
    pay from the Trust Fund amounts as determined necessary to make
    payments to operate the Exchange, including affordability
    credits.
        Dedicated payments to the Trust Fund would include the
    following:
               tax on individuals not obtaining acceptable
            coverage (Section 401);
               tax on employers electing to not provide
            health benefits (Section 412); and
               tax on employers who fail to satisfy health
            coverage participation requirements (Section 411).
        Such additional sums as necessary would be appropriated.
    General provisions in the Internal Revenue Code regarding
    federal government trust funds would apply.

    Sec. 208. Optional Operation of State-based Health Insurance Exchanges

        If a state (or group of states, subject to the
    Commissioner's approval) applied to the Commissioner for
    approval of a state-based Health Insurance Exchange, and if the
    Commissioner approves such state-based Exchange, then the
    state-based Exchange would operate instead of the federal
    Exchange in that state(s).
        The Commissioner could not approve a state-based Exchange
    unless the following requirements were met (and would be
    required to approve it if the conditions were met):
         The state-based Exchange must demonstrate the
    capacity to and provide assurances satisfactory to the
    Commissioner that it could carry out the functions specified
    for the federal Exchange in the state(s) including:
               negotiating and contracting with qualified
            plans;
               enrolling Exchange-eligible individuals and
            employers in plans;
               establishing sufficient local offices to
            meet the needs of Exchange-eligible individuals and
            employers;
               administering premium and cost-sharing
            credits (described below in Sections 241-246) using the
            same methodologies, and at least the same income
            verification methods, as would otherwise apply and at a
            cost to the federal government that is not greater than
            what would otherwise apply; and
               enforcement activities consistent with
            federal requirements.
         There is no more than one Exchange in operation in
    any one state.
         The state provides assurances satisfactory to the
    Commissioner that approval of such an Exchange would not result
    in any net increase in expenditures to the federal government.
         The State provides for reporting of such
    information as the Commissioner determines and assurances
    satisfactory to the Commissioner that it will vigorously
    enforce violations of applicable requirements.
         Such other requirements as the Commissioner may
    specify.
        A state-based Exchange could, at the option of the state,
    and only after providing timely and reasonable notice to the
    Commissioner, cease operation. In this case, the federal
    Exchange would be operational in the state(s).
        The Commissioner could terminate the approval (for some or
    all functions) of a state-based Exchange if the Commissioner
    determined that it no longer met the requirements listed above
    or was no longer capable of carrying out such functions. In
    lieu of terminating the state-based Exchange's approval, the
    Commissioner could temporarily assume some or all functions of
    the state-based Exchange until the Commissioner determined that
    it met the applicable requirements and was capable of carrying
    out those functions. The ceasing or termination of a state-
    based Exchange would be effective in such time and manner as
    the Commissioner would specify.
        Enforcement authorities of the Commissioner would be
    retained by the Commissioner. The Commissioner could specify
    functions of the federal Exchange that may not be performed by
    a state-based Exchange or that could be performed by both the
    Commissioner and the state-based Exchange.
        In the case of a state-based Exchange, except as the
    Commissioner may otherwise specify, any references to the
    ``Exchange'' or to the ``Commissioner'' in the area in which
    the state-based Exchange operates would be deemed a reference
    to the state-based Exchange and the head of that Exchange.
        In the case of a state-based Exchange, funding assistance
    would be provided for its operation in the form of a matching
    grant, with a state share of expenditures required.

    Sec. 209. Participation of Small Employer Benefit Arrangements

        This provision would allow the Commissioner to enter into
    contracts with small business co-ops operating a small business
    benefit arrangement to facilitate their participation in the
    HIE.

                   Subtitle B--Public Health Insurance Option

    Sec. 221. Establishment and Administration of a Public Health Insurance
            Option As An Exchange-Qualified Health Benefits Plan

                Current Law
        Medicare is an example of a federal public health insurance
    program for the aged and disabled. Under Medicare, Congress and
    the Department of Health and Human Services (HHS), Centers for
    Medicare and Medicaid Services (CMS) determine many parameters
    of the program including eligibility rules, financing
    (including determination of payroll taxes, and premiums),
    required benefits, payments to health care providers, and cost
    sharing amounts.
                Proposed Law
        The provision would require the Secretary of Health and
    Human Services (Secretary) to provide for the offering of a
    public health insurance option through the Exchange starting
    2013. The Secretary would be required to ensure that the public
    option provided choice, competition and stability of
    affordable, high quality coverage throughout the United States.
    The Secretary's primary responsibility would be to create a
    low-cost plan without compromising quality or access to care.
        The public option would only be available through the
    Health Insurance Exchange. The public option would be required
    to comply with requirements applicable to Exchange-
    participating health benefit plans, including requirements
    related to benefits, benefit levels, provider networks,
    notices, consumer protections, and cost sharing. The public
    option would be required to offer basic, enhanced, and premium
    plans, and would be allowed to offer premium-plus plans.
        The Secretary would be allowed to enter into contracts for
    the administration of the public option in the same manner as
    the Secretary is allowed to enter into contracts for the
    administration of the Medicare program. These administrative
    functions include, subject to restrictions, determination of
    payment amounts, making payments, beneficiary education and
    assistance, provider consultative services, communication with
    providers, and provider education and technical assistance. The
    Secretary would have the same authority to enter into contracts
    for the public option, as the Secretary has with respect to the
    Medicare program. The provision would prohibit contracts that
    involve the transfer of insurance risk.
        The Secretary would be required to establish an office of
    the ombudsman for the public health insurance option which
    would have duties similar to those of the Medicare Beneficiary
    Ombudsman.
        The Secretary would be required to collect data necessary
    to establish premiums and payment rates and for other purposes,
    including improving quality and reducing disparities in health
    care based on race, ethnicity, primary language, sex, sexual
    orientation, gender identity, disability, socioeconomic status,
    rural, urban, or other geographic setting, and any other
    population or subpopulation as determined appropriate by the
    Secretary. Such data collection would be on a voluntary basis
    and consistent with certain privacy standards.
        With respect to the public health insurance option, the
    Secretary would be treated as an entity offering a Quality
    Health Benefit Plan through the Exchange.
        The provisions relating to access to Federal courts for
    enforcement of rights under Medicare would apply to the public
    option and individuals enrolled under the public option in the
    same manner that they apply to Medicare and Medicare
    beneficiaries.

    Sec. 222. Premiums and Financing

                Current Law
        No current law.
                Proposed Law
        The Secretary would be required to establish
    geographically-adjusted premiums for the public option in a
    manner that complies with the premium rules established by the
    Commissioner for Exchange-participating health benefit plans
    and at a level sufficient to fully finance the cost of health
    benefits and administration for the public option. Premiums
    would be required to include an appropriate amount for a
    contingency margin.
        The provision would establish an account in the Treasury
    for receipts and disbursements attributable to the public
    option, including start-up funding. The start-up funding would
    be equal to the sum of $2 billion for the establishment of the
    public option, and such sums as may be necessary to cover 90
    days worth of reserves based on projected enrollment. These
    amounts would be authorized to be appropriated to the Secretary
    out of any funds in the Treasury not otherwise appropriated.
    The Secretary would be required to provide for repayment of the
    start-up funding in an amortized manner over a 10 year period
    starting in 2013. The provision specifies that nothing in this
    section could be construed as authorizing any additional
    appropriations to the account, other than amounts otherwise
    provided with respect to other Exchange-participating plans. As
    under the Medicare Advantage program, states would be
    prohibited from imposing a premium tax or similar tax with
    respect to the public option.

    Sec. 223. Payment Rates for Items and Services

                Current Law
        No current law.
                Proposed Law
        The Secretary would be required to establish payment rates
    for services and health care providers under the public option.
        In general, during the first three years of the public
    option, the Secretary would be required to base payment rates
    on the rates for similar services and providers under Medicare.
    For services furnished in 2013, 2014 and 2015, physicians and
    other health care practitioners who participate in both
    Medicare and the public option would receive payment rates 5%
    greater than rates otherwise established by the Secretary for
    items and professional services. Pediatricians and other
    practitioners who do not typically participate in Medicare--as
    determined by the Secretary--would also be eligible for the
    increased payment rates. Beginning in 2016, the Secretary would
    be required to continue to use an administrative process to set
    payment rates to promote payment accuracy, to ensure adequate
    beneficiary access to providers, and to promote affordability
    and the efficient delivery of health care. The Secretary would
    be prohibited from setting rates at levels expected to increase
    overall medical costs for the public option beyond what would
    be expected if Medicare rates (plus the 5% addition) were to
    continue.
        The provision specifies that nothing would prevent the use
    of innovative payment methodologies such as those described in
    Section 224 in connection with the negotiation of payment
    rates. As introduced and reported, H.R. 3200 would allow the
    Secretary discretion to establish a prescription drug
    formulary, and use other methods, including those used by
    private sector pharmacy benefit managers, to reduce
    prescription drug costs under the public health insurance
    option, and the Committee expects that the Secretary would
    implement such a formulary.
        Health care providers participating in Medicare would be
    participating providers in the public health insurance option
    unless they opted out in a process established by the
    Secretary.
        The provision would prohibit administrative or judicial
    review of a payment rate or methodology established under this
    section, or Section 224.

    Sec. 224. Modernized Payment Initiatives and Delivery System Reform

                Current Law
        No current law.
                Proposed Law
        Beginning in the first year of the public option, the
    Secretary would be given the authority to use innovative
    payment mechanisms and policies to determine payments for items
    and services under the public option. The payment mechanisms
    and policies may include the following: patient-centered
    medical home, other care management payments, accountable care
    organizations, value-based purchasing, bundling of services,
    differential payment rates, performance or utilization based
    payments, partial capitation, and direct contracting with
    providers. The Secretary would be required to design and
    implement the payment mechanisms and policies in a way that
    promotes care that is integrated, patient-centered, efficient
    and of quality, and that seeks to either (a) improve health
    outcomes, (b) reduce health disparities, (c) address geographic
    variation in the provision of health services, (d) prevent or
    manage chronic illness, or (e) provide efficient and affordable
    care. To the extent allowed under the rules for Exchange-
    participating plans, the provision would allow cost sharing and
    payment rates under the public option to be modified to
    encourage the use of services that promote health and value.
    The provision specifies that nothing in the subtitle would
    prevent the Secretary from varying payments based on different
    payment structure models for different geographic areas.

    Sec. 225. Provider Participation

                Current Law
        No current law
                Proposed Law
        The Secretary would be required to establish conditions of
    participation for health care providers under the public
    option. The Secretary would be prohibited from allowing a
    health care provider to participate unless appropriately
    licensed or certified under State law. A health care provider
    that was excluded from participation in a Federal health care
    program (as defined in Section 1128(f) of the Social Security
    Act), would be prohibited from participating under the public
    option.
        Annually, the Secretary would be required to provide for
    physicians to participate in the public plan in one of two
    classes: (a) preferred physician, or (b) participating, non-
    preferred physician. A preferred physician would be one who
    agreed to accept the established rate as payment in full. A
    participating non-preferred physician would be one who could
    balance bill-impose charges that exceed the charges that may be
    imposed for such items and services (in relation to the payment
    rate for such items and services under Medicare). The
    participating non-preferred physician would agree not to impose
    charges that exceed 115 percent of the amount established under
    Sec. 223 (consisting of the Medicare rate and the 5 percent
    addition). The Secretary would be required to provide for the
    participation of non-physician providers. Non-physician
    providers would only be allowed to participate if they accepted
    the established rates as payment in full.

    Sec. 226. Application of Fraud and Abuse Provisions

                Current Law
        Title XVIII of the SSA, the Medicare statutes, requires
    activities that prevent, detect, investigate and prosecute
    health care fraud and abuse. In general, initiatives designed
    to fight fraud, waste, and abuse are considered program
    integrity activities. Program integrity is considered a
    component of the effective and efficient administration of
    government programs, which are entrusted with ensuring that
    taxpayer dollars are spent wisely. Efforts to ensure Medicare
    program integrity encompass a wide range of activities and
    require coordination among multiple private and public
    entities. This includes processes directed at reducing payment
    errors to Medicare providers, as well as activities to prevent,
    detect, investigate, and ultimately prosecute health care fraud
    and abuse.
                Proposed Law
        The provisions of law (other than criminal law) identified
    by the Secretary by regulation, in consultation with the
    Inspector General, that impose sanctions with respect to waste,
    fraud, and abuse under Medicare would also apply to the public
    health insurance option.

    Sec. 227. Sense of the House Regarding Enrollment of Members in the
            Public Option

        This provision would create a Sense of the House of
    Representatives that any members who vote in support of the
    public health insurance option are urged to forgo their right
    to participate in the FEHBP and enroll under the public option.

                  Subtitle C--Individual Affordability Credits

    Sec. 241. Availability Through Health Insurance Exchange

                Current Law
        None.
                Proposed Law
        This provision would provide premium and cost-sharing
    credits to ``affordable credit eligible individuals'' (defined
    in Section 242) for certain individuals enrolled in coverage
    through the Exchange. The Commissioner would pay each QHBP
    participating in the Exchange the aggregate amount of credits
    for all eligible individuals enrolled in that plan.
        An Exchange-eligible individual could apply to the
    Commissioner, through the Exchange or another entity under an
    arrangement made with the Commissioner, in a form and manner
    specified by the Commissioner. The Commissioner, through the
    Health Insurance Exchange or through another public entity
    under an arrangement made with the Commissioner, would make a
    determination as to eligibility of an individual for
    affordability credits. The Commissioner would establish a
    process whereby, on the basis of information otherwise
    available, individuals may be deemed eligible for credits. The
    Commissioner would also establish effective methods that ensure
    that individuals with limited English proficiency are able to
    apply for affordability credits.
        If the Commissioner determines that a state Medicaid agency
    has the capacity to make a determination of eligibility for
    affordability credits under the same standards as used by the
    Commissioner, under the Medicaid memorandum of understanding
    (described above in Section 205), the state Medicaid agency is
    authorized to conduct such determinations for any Exchange-
    eligible individual who requests such a determination, and the
    Commissioner would reimburse the state Medicaid agency for the
    costs of conducting such determinations.
        In addition, there would be a Medicaid screen-and-enroll
    obligation, that when individuals apply for affordability
    credits, a determination would be made as to whether they are
    eligible for Medicaid. If they are determined eligible for
    Medicaid, the Commissioner, through the Medicaid memorandum of
    understanding, would provide for their enrollment under the
    state Medicaid plan, and the state would provide for the same
    periodic redetermination of eligibility under Medicaid as would
    otherwise apply.
        During the first two years of implementation, credits would
    be allowed for coverage under a Basic plan only. Beginning in
    the third year, credits would be allowed for coverage under
    Enhanced or Premium plans by a process established by the
    Commissioner. The individual would be responsible for any
    difference between the premium for an Enhanced or Premium plan
    and the credit amount based on a Basic plan applicable to that
    enrollee.
        The Commissioner would be authorized to request from the
    Treasury Secretary information that may be required to carry
    out this subtitle (regarding individual affordability credits),
    consistent with existing rules regarding confidentiality and
    disclosure of tax return information. Individuals who are
    eligible to receive credits would not receive them in the form
    of cash payments.

    Sec. 242. Affordable Credit Eligible Individual

                Current Law
        None.
                Proposed Law
        This provision would define an ``affordable credit eligible
    individual'' as an individual who (1) is lawfully present in a
    state in the United States (other than those lawfully present
    as non-immigrants, with some exceptions), (2) is enrolled in an
    Exchange plan and is not enrolled through an employer plan that
    meets the employer responsibility to contribute toward employee
    and dependent coverage (described below in Section 312), (3)
    has family income below 400 percent FPL, and (4) who is not a
    Medicaid-eligible individual (other than some exceptions
    described above in Section 202). Family members who are
    eligible for credits will be treated as a single affordable
    credit eligible individual.
        Credits would not be available to full-time employees of an
    employer offering coverage consistent with the employer
    contribution rules described in Section 312. The Commissioner
    would make exceptions to this rule for divorced or separated
    individuals, or dependents of employees who would otherwise be
    eligible for credits. Exceptions would also be made, beginning
    in 2014, for full-time employees whose premium and cost sharing
    costs under a group health plan exceed 11 percent of family
    income.
        Income would be defined as ``modified adjusted gross
    income'' (MAGI), per the new 59B of the Internal Revenue Code,
    added in Sec. 401. The Commissioner would conduct a study to
    examine the application of income disregards for the purposes
    of the affordability credits. The Commissioner would submit a
    report to Congress of such a study, including recommendations
    as the Commissioner determines appropriate. Affordability
    credits would not be treated as a federal means-tested public
    benefit for eligibility purposes for qualified aliens under the
    Personal Responsibility and Work Opportunity Reconciliation Act
    of 1996.

    Sec. 243. Affordable Premium Credit

                Current Law
        None.
                Proposed Law
        This section would establish the rules for determining the
    amount of the premium credit provided to eligible individuals
    enrolled in an Exchange plan. The ``affordability premium
    credit'' would be an amount equal to the lesser of (1) the
    amount by which the enrollee's premium exceeds a specified
    level that is considered affordable (``affordable premium
    amount''), or (2) the amount by which the ``reference premium''
    (the average premium of the three least expensive Basic plans
    in the individual's premium rating area) exceeds the
    ``affordable premium amount.'' In calculating the reference
    premium, the Commissioner may exclude plans with extremely
    limited enrollments.
        The affordable premium credit amount would be calculated on
    a monthly basis, based on the following table, to limit
    individuals' premium payments to a percentage of family income
    (MAGI) relative to the poverty level, as specified in the table
    below.

    ------------------------------------------------------------------------
                                                            Premium payment
                 Federal poverty level (FPL)                  limit, as a
                                                           percent of income
    ------------------------------------------------------------------------
    133% or less.........................................               1.5%
    150%.................................................                 3%
    200%.................................................                 5%
    250%.................................................                 7%
    300%.................................................                 9%
    350%.................................................                10%
    400%.................................................                11%
    ------------------------------------------------------------------------

        The Commissioner would establish premium percentage limits
    so that for individuals whose family income is between the
    income tiers specified in the table, the percentage limits
    would increase on a linear sliding scale.

    Sec. 244. Affordability Cost-Sharing Credit

                Current Law
        None.
                Proposed Law
        The affordability cost-sharing credit under this section
    would be available to those enrolled in an Exchange plan whose
    income is less than 400 percent FPL. The Commissioner would
    specify reductions in cost-sharing amounts and the annual
    limitation (out-of-pocket maximum) on cost-sharing under a
    Basic plan so that the average percentage of covered benefits
    paid by the plan (as estimated by the Commissioner) is equal to
    the percentages (actuarial values) in the table for each income
    tier.

    ------------------------------------------------------------------------
                                                            Actuarial value
                 Federal poverty level (FPL)                   percentage
    ------------------------------------------------------------------------
    150% or less.........................................                97%
    200%.................................................                93%
    250%.................................................                85%
    300%.................................................                78%
    350%.................................................                72%
    400%.................................................                70%
    ------------------------------------------------------------------------

        The Commissioner would provide payments to QHBP-offering
    entities in an amount equivalent to the increased actuarial
    value of benefits resulting from the cost-sharing reductions.

    Sec. 245. Income Determinations

                Current Law
        None.
                Proposed Law
        This provision would use an individual's adjusted gross
    income in the most recent taxable year for determination of a
    credit under this Subtitle. The Commissioner would take steps
    as may be appropriate to ensure the accuracy of determinations
    and redeterminations under this subtitle. The Commissioner
    would request information from the Treasury Secretary as may be
    permitted to verify income information submitted in
    applications for credits. The Commissioner would establish
    procedures for verification of income if no tax return is
    available for the most recent completed tax year. The
    Commissioner would establish special rules for cases when an
    individual's income is expected (in a manner specified by the
    Commissioner) to be significantly different from the income
    submitted for application for and determination of a credit.
    The Commissioner would establish rules under which an
    individual would be required to inform the Commissioner when
    there is a significant change in income. Such mechanism would
    provide for guidelines that specify the circumstances that
    qualify as a significant change, the verifiable information
    required to document such a change, and the process for
    submission of such information. If the Commissioner receives
    new information from an individual regarding the family income
    of the individual, the Commissioner would provide for a
    redetermination of the individual's eligibility to be an
    affordable credit eligible individual.
        For a CHIP-eligible child deemed to be eligible for
    coverage through the Exchange, during the first year of
    implementation the Commissioner would establish rules under
    which family income of the child is deemed to be no greater
    than the family income of that child as most recently
    determined by the State under CHIP. The Commissioner would
    examine the feasibility and implication of adjusting the
    application of the federal poverty level in this Subtitle to
    take into account geographic differences, in order to reflect
    cost-of-living variations across the country. The Commissioner
    would submit a report to Congress, no later than the first day
    of the second year of implementation, on such a study and make
    recommendations as appropriate. An individual who intentionally
    misrepresents family income or fails to disclose to the
    Commissioner a significant change in family income would be
    liable for repayment of any improperly received credit and, in
    the case of intentional misrepresentation, may be required to
    pay an additional penalty as imposed by the Commissioner.

    Sec. 246. No Federal Payment for Undocumented Aliens

                Current Law
        None
                Proposed Law
        No credits would be given to individuals who are not
    lawfully present in the country.

                          Subtitle D--State Innovation

    Sec. 251. Waiver of ERISA Limitation; Application Instead of State
            Single Payer System

        Added by an amendment at Committee, this provision would
    create an ERISA waiver to permit States to enact single payer
    laws. The Department of Labor would determine whether the State
    plan meets certain requirements to obtain the waiver. With such
    a waiver, a state single payer system would operate in lieu of
    the HIE in such state.

                        Title III--Shared Responsibility

                     Subtitle A--Individual Responsibility

    Sec. 301. Individual Responsibility

        The Committee did not exercise jurisdiction over this
    section.

                      Subtitle B--Employer Responsibility

    Sec. 311. Health Coverage Participation Requirements,

    Sec. 312. Employer Responsibility to Contribute Towards Employee and
            Dependent Coverage,

    Sec. 313. Employer Contributions in Lieu of Coverage,

    Sec. 314. Authority Related to Improper Steering,

    Sec. 321. Satisfaction of Health Coverage Participation Requirements
            under the Employee Retirement Income Security Act of 1974,

    Sec. 322. Satisfaction of Health Coverage Participation Requirements
            under the Internal Revenue Code of 1986,

    Sec. 323. Satisfaction of Health Coverage Participation Requirements
            under the Public Health Service Act, and

    Sec. 324. Additional rules relating to health coverage participation
            requirements

                Current Law
        There is no federal requirement that employers offer health
    insurance coverage to employees or their families. As with
    other compensation, the cost of employer-provided health
    coverage is a deductible business expense under section 162 of
    the Code. In addition, employer-provided health insurance
    coverage is generally not included in an employee's gross
    income.
        ERISA \124\ preempts state law relating to certain
    employer-sponsored health plans. While ERISA specifically
    provides that its preemption rule does not exempt or relieve
    any person from any State law which regulates insurance, ERISA
    also provides that an employee benefit plan is not deemed to be
    engaged in the business of insurance for purposes of any State
    law regulating insurance companies or insurance contracts. As a
    result of this ERISA preemption, the courts have held that
    self-insured employer-sponsored health plans cannot be
    regulated under State insurance law.
    ---------------------------------------------------------------------------
        \124\ Pub. L. No. 93-406
    ---------------------------------------------------------------------------
        While ERISA does not require an employer to offer health
    benefits, it does require compliance with a few limited
    standards if an employer chooses to offer health benefits,
    mainly compliance with plan fiduciary standards, reporting and
    disclosure requirements, and procedures for appealing denied
    benefit claims. ERISA was amended (as well as the Public Health
    Service Act and the Internal Revenue Code) in the Consolidated
    Omnibus Budget Reconciliation Act of 1985 (COBRA) \125\ and the
    Health Insurance Portability and Accountability Act of 1996
    (``HIPAA'') \126\, adding other Federal requirements for health
    plans, including rules for health care continuation coverage,
    limitations on exclusions from coverage based on preexisting
    conditions, and a few benefit requirements such as minimum
    hospital stay requirements for mothers following the birth of a
    child.
    ---------------------------------------------------------------------------
        \125\ Pub. L. No. 99-272.
        \126\ Pub. L. No. 104-191.
    ---------------------------------------------------------------------------
                Proposed Law

    Section 311. Health Coverage Participation Requirements

        Section 311 of the bill sets forth the basic requirement
    for an employer to offer individual and family health care
    coverage, to make timely contributions to such coverage when
    accepted by the employee, and to make contributions to the HIE
    in lieu of such coverage when the employee declines the
    coverage but obtains coverage from an HIE plan.
        Additionally, employers that meet certain economic hardship
    qualifications could apply for a two-year employer hardship
    exemption that waives an employer's obligation to provide
    coverage required by this bill. The Secretary shall develop
    rules on the form and manner of such exemption applications and
    should take a robust approach to collecting information from an
    employer applicant and determining how significant and
    unavoidable such claimed hardship is. For example, employers
    should not be allowed to game or abuse this exemption through
    timed outlays, like executive bonuses, in order to create a
    balance sheet designed to demonstrate hardship when it comes to
    complying with health coverage requirements. The Committee
    expects the Secretary to require adequate documentation of the
    employer's financial circumstances to demonstrate whether it
    qualifies for this exemption.

    Section 312. Employer Responsibility to Contribute towards Employee and
            Dependent Coverage

        Section 312 specifies the minimum contribution amounts an
    employer must make to satisfy the coverage requirements for
    full-time and non-full-time employees. An employer may not
    satisfy the minimum contribution requirement through a salary
    reduction arrangement with the employee. This section also
    provides rules for the automatic enrollment of employees into
    employer plans and how employees may opt out of such automatic
    enrollment.
        Employers offering health benefit plans would be required
    to offer individual and family coverage under a qualified
    health benefits plan (or certain grandfathered health insurance
    plans) \127\ and to make contributions to help discharge the
    coverage costs of employees enrolled in the employer-provided
    plan. For full time employees, the employer would be required
    to contribute at least 72.5 percent of the lowest cost plan
    offered by the employer which meets the requirements of the
    essential benefits package \128\ (65 percent for eligible
    employees electing family coverage). For part time employees,
    the contribution amount from the employer would be a fraction
    of the minimum contributions made for full time employees, with
    such fraction being equal to a ratio of the average weekly
    hours worked by the employee compared to the minimum weekly
    hours specified by the Health Choices Commissioner. Employers
    would be required to provide information to the Secretaries of
    Labor, Health and Human Services, and the Treasury, to assist
    the Secretaries with ascertaining compliance with the
    proposal's requirements.
    ---------------------------------------------------------------------------
        \127\ For a plan to be a ``qualified health benefits plan'' it
    would need to meet certain minimum coverage requirements, but it need
    not be offered through the Exchange.
        \128\ The essential benefits package would include certain
    specified limits on required cost sharing, would ban annual or lifetime
    limit on covered health care items or services and certain specified
    minimum services, and would impose certain requirements as to network
    adequacy as determined by the Health Choices Commissioner.
    ---------------------------------------------------------------------------

    Sec. 313. Employer Contributions in Lieu of Coverage

        Employers that elect not to provide eligible health benefit
    plans to their employees would be subject to a contribution to
    the Health Insurance Exchange Trust Fund equal to 8 percent of
    wages (as defined in section 3121 for purposes of FICA). There
    is a special rule for an employer who is considered a small
    employer, defined as any employer with an annual payroll for
    the preceding calendar year which does not exceed $400,000.
        Employers with payrolls that do not exceed $250,000 would
    be exempt. Employers with payrolls that exceed $250,000 but do
    not exceed $300,000 would be subject to a contribution equal to
    2 percent of wages; employers with payrolls that exceed
    $300,000 but do not exceed $350,000 would be subject to a
    contribution of 4 percent of wages; and employers with an
    annual payroll that exceeds $350,000 but do not exceed $400,000
    would be subject to a contribution of 6 percent of wages.
        Related employers and predecessors would be treated as a
    single employer for purposes of determining whether an employer
    qualifies for the special rule for small employers.

    Section 314. Authority related to improper steering

        The Health Choices Commissioner (in coordination with the
    Secretaries of Labor, Health and Human Services, and the
    Treasury) would have the authority to set standards for
    determining whether employers were undertaking any actions to
    affect the risk pool within the Health Insurance exchange by
    inducing employees to enroll in Exchange-participating health
    plans rather than in employer-provided plans. An employer found
    to be violating these standards would be treated as not meeting
    the coverage requirements.

    Section 321. Satisfaction of Health Coverage Participation Requirements
            under the Employee Retirement Income Security Act of 1974

        Section 321 amends ERISA and sets forth the requirements
    for an employer to satisfy the health coverage participation
    requirements under the bill.

    Elections

        Under the proposal, employers would be required to make an
    affirmative election regarding whether to offer health benefit
    plans to employees. Those employers electing to offer health
    benefit plans would be required to have their plans meet
    certain minimum coverage requirements. Employers choosing not
    to offer health benefit plans, or that offered plans that did
    not meet the proposal's qualification requirements, would be
    subject to additional taxes or penalties. Employers with
    payrolls of $250,000 or less would be exempt from the pay or
    play requirements.
        The Secretaries of Labor, Health and Human Services, and
    the Treasury, would prescribe coordinated rules for employer
    elections regarding coverage, including rules for the time,
    manner and form of elections, and the treatment of affiliated
    groups of employers, separate lines of business, and full
    versus part time employees.\129\ Subject to Section 151,
    employers electing to offer health benefit plans would be
    treated as having established and maintained a group health
    plan for purposes of ERISA and the Public Health Service Act
    (``PHSA''),\130\ and the proposal's health coverage
    participation requirements would be deemed to be part of the
    terms and conditions of the employer-provided plan.
    ---------------------------------------------------------------------------
        \129\ The Commissioner and Secretaries would also be required to
    issue regulations applying the proposal's requirements to multiemployer
    plans (as defined in section 3(37) of ERISA).
        \130\ 42. U.S.C. 6A.
    ---------------------------------------------------------------------------
        Employers would be required to provide verification of
    their compliance with the proposal's health coverage
    participation requirement to the Health Choices Commissioner
    and to the Secretaries of Labor, Health and Human Services, and
    the Treasury.

    Aggregation Rules

        For affiliated groups of employers, the identity of the
    employer would generally be determined by applying the employer
    aggregation rules in section 414(b), (c), (m), and (o).\131\
    The same election would apply to all employers in the
    aggregated group. Employers would be able to make separate
    elections for employees in separate lines of business, or for
    full time employees and part time employees.
    ---------------------------------------------------------------------------
        \131\ Section 414(b) provides that, for specified employee benefit
    purposes, all employees of all corporations which are members of a
    controlled group of corporations are treated as employed by a single
    employer. There is a similar rule in section 414(c) under which all
    employees of trades or businesses (whether or not incorporated) which
    are under common control are treated under regulations as employed by a
    single employer, and, in section 414(m), under which employees of an
    affiliated service group (as defined in that section) are treated as
    employed by a single employer. Section 414(o) authorizes the Treasury
    to issue regulations to prevent avoidance of the certain requirements
    under section 414(m).
    ---------------------------------------------------------------------------

    Noncompliance with Coverage Requirements

        Employers who elected to provide coverage but whose health
    benefit plans failed to meet the proposal's minimum health
    coverage participation requirements would be subject to
    penalties of $100 per day for each employee to whom the failure
    applied.\132\ The penalties would not apply to (1) periods
    during which an employer used reasonable diligence but did not
    discover any failures, and (2) failures that were corrected
    within 30 days of discovery (but only if such failures were due
    to reasonable cause and not willful neglect). Penalties imposed
    on employers for unintentional failures (i.e., due to
    reasonable cause and not to willful neglect) would be limited
    to the lesser of: 10 percent of the aggregate amount paid or
    incurred by the employer during the preceding taxable year for
    group health plans, or $500,000.
    ---------------------------------------------------------------------------
        \132\ The proposal would permit the penalties to be assessed
    through an excise tax or a civil penalty under ERISA or PHSA. Penalties
    for any particular failure would not be duplicated, however. The
    Secretary of Labor or Health and Human Services, as appropriate, would
    be required to give advance written notification of failure to
    employers prior to the assessment of a penalty. The Secretary of Health
    and Human Services would be able to bring civil actions in Federal
    court to collect civil penalties assessed under PHSA.
    ---------------------------------------------------------------------------
        The Secretaries would also be able to terminate an
    employer's election (and thus subject them to the required
    contribution imposed on employers that do not offer coverage)
    if it was determined that the employer was substantially
    noncompliant with health coverage participation requirements.
        The Secretary of Labor would be required to conduct
    periodic audits of employers in order to discover noncompliance
    with health coverage participation requirements. The Secretary
    of the Treasury and the Health Choices Commissioner would be
    informed of audit results.
        To facilitate such audits, especially with respect to the
    problem of employers misclassifying employees as independent
    contractors, the Secretary of Labor would be authorized to
    issue regulations that would require employers to keep records
    on both employees and certain claimed independent contractors.
    The Secretary should craft such recordkeeping requirements to
    assist in uncovering and remedying any misclassification of
    workers.

    Sec. 322 Satisfaction of Health Coverage Participation Requirements
            under the Internal Revenue Code

        The Committee did not exercise jurisdiction over this
    section.

    Sec. 323. Satisfaction of Health Coverage Participation Requirements
            under the Public Health Service Act

        The Committee did not exercise jurisdiction over this
    section.

    Sec. 324. Additional Rules Relating to Health Coverage Participation
            Requirements

        The Health Choices Commissioner and the Secretaries of
    Labor, Health and Human Services, and the Treasury would be
    required to execute an interagency memorandum of understanding
    to ensure coordination with respect to regulations, rulings,
    interpretations, and enforcement of the proposal.

             TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

        The Committee does not have jurisdiction over Title IV of
    Division A.

                 Division B--Medicare and Medicaid Improvements

        The Committee does not have jurisdiction over Division B.

              Division C--Public Health and Workforce Development

        The Committee has jurisdiction over certain provisions in
    Division C, summarized below.

    Sec. 2502. Establishment of Grant Program

                Current Law
        PHSA Section 831 establishes a Nurse Education, Practice,
    and Retention Grants program. Under this program, the Secretary
    may award grants or enter into contracts with a school of
    nursing, health care facility, or a partnership of the two, to
    respond to the nursing shortage and increase the number of
    registered nurses in specific priority areas, as described.
    Funds may be used to promote career advancement for nurses.
    Appropriations authority for this grant program expired at the
    end of FY2007.
                Proposed Law
        This provision would establish a new partnership grant
    program, administered by the Secretary of Labor, to provide
    matching grants for nursing training programs that aim to
    increase the number and skill levels of nurses, and expand
    nurse training capacity, in order to address projected nursing
    shortages. The Secretary of Labor would be required to
    establish this partnership grant program within six months of
    enactment.
        Eligible entities would be: (1) a health care entity that
    is jointly administered by a health care employer and a labor
    union representing that organization's health care employees,
    and that carries out activities using training funds as
    provided under Section 302(c)(6) of the Labor Management
    Relations Act (relating to funds paid by an employer to a trust
    fund established by a union to provide specified benefits or
    defray the costs of apprenticeship or training programs); (2)
    an entity that operates a training program jointly administered
    by one or more health care providers, facilities, or a trade
    association of health care providers; and by organizations that
    represent the interests of direct care health care workers or
    staff nurses, and include their leadership input; or (3) a
    State training partnership program that consists of non-profit
    organizations that have equal participation from industry
    (including both public and private employers) and labor
    organizations (including joint labor-management training
    programs), which may include representatives from local
    governments, worker investment agency one-stop career centers,
    community-based organizations, community colleges, and
    accredited schools of nursing. Eligible entities would be
    required to submit an appropriate application to the Secretary
    of Labor.
        An eligible entity that is a health care employer would
    also be required to demonstrate that it: (1) has an established
    nursing retention program; (2) provides nursing wages and
    benefits that are competitive for its market or that have been
    collectively bargained with a labor organization; and (3)
    provides support for employees participating in the training
    program through one or more specified means, including paid
    leave time, or contributions to a training fund, among others.
        The Secretary of Labor would be prohibited from awarding
    grants unless the applicant agrees to provide non-Federal
    matching funds that are equal to or no less than one dollar for
    each Federal dollar received. Matching funds could be secured
    from donations or provided through the cash equivalent of paid
    release time provided to incumbent worker students
    participating in educational programs. In addition, eligible
    entities would be required to demonstrate collaboration with
    accredited schools of nursing.
        Awardees would be required to use funds to create training
    programs to allow incumbent health care workers to become
    nurses, to provide for the advanced training of nurses, or
    both. In each case, a number of specified program components
    would be required.
        In making awards, the Secretary of Labor would be required
    to give preference to programs that improve nurse retention;
    that improve the diversity of nursing graduates; that improve
    the quality of nursing education; that have demonstrated
    success for transitioning health care workers into nursing or
    have established pilot programs to increase nurse faculty; or
    that are modeled after or affiliated with established
    transitioning and pilot programs mentioned above.
        Awardees would be required annually to submit an evaluation
    to the Secretary of Labor, which must include a description of
    the grantee's activities and an evaluation of program outcomes.
    Several outcomes that may be reported are specified.
        The Secretary of Labor would be required, within two years
    of enactment and annually thereafter, to report to Congress on
    the overall effectiveness of the grant programs carried out
    under this provision. This provision would authorize to be
    appropriated such sums as may be necessary to carry out the
    partnership grant program.

       Subtitle F--Standards for Accessibility to Medical Equipment for
                         Individuals with Disabilities

    Sec. 2541. Access for Individuals with Disabilities

        This provision would require the development of standards
    for accessible equipment, and require relevant agencies to
    ensure that all entities covered by the legislation meet the
    requirements of the Americans with Disabilities Act and Section
    504 of the Rehabilitation Act.

                        Subtitle G--Other Grant Programs

    Sec. 2551. Reducing Student-to-School Nurse Ratios

        This provision would make available demonstration grants to
    eligible local education agencies with the purpose to reduce
    the student-to-school nurse ratio in public elementary and
    secondary schools with special consideration given to high-need
    local educational agencies who demonstrate the greatest need
    for new or additional nursing services by providing information
    on the current ratios of students to school nurses.

    Sec. 2552. Wellness Program Grants

        This provision would authorize the Secretary of Labor to
    offer incentives to employers who establish qualified wellness
    programs for their employees. Participating employers must
    offer the programs to all employees and cannot mandate
    participation nor use participation as a condition to receive
    any financial incentive. The Committee recognizes the success
    of workplace wellness programs in promoting health and well-
    being and in reducing medical expenditures. The Committee urges
    the Secretary to promote both public and private workplace
    wellness programs.

    Sec. 2553. Health Professions Training for Diversity Programs

        This provision would authorize the Secretary of Labor to
    make grants to certain health care workforce development
    programs, particularly those focused on low-income persons,
    veterans, or rural or urban underserved populations.

            Subtitle H--Long-Term Care and Family Caregiver Support

    Sec. 2561. Long-Term Care and Family Caregiver Support

        This provision would establish an advisory panel and a
    pilot program focused on improving the working conditions and
    training for the long-term care workforce.

                          Subtitle I--Online Resources

    Sec. 2571. Web Site on Health Care Labor Market and Related Educational
            and Training Opportunities

        This provision would require the Secretary of Labor to
    establish a web site that would serve as a clearinghouse of
    information on the health care labor market, including
    educational and training opportunities and financial aid
    information.

    Sec. 2572. Online Health Workforce Training Programs

        This provision would establish a grant program with the
    Secretary of Labor to award grants to qualifying entities
    providing health care workers with online training.

                         VI. Explanation of Amendments

        The Amendment in the Nature of a Substitute and amendments
    thereof are explained in the body of this report.

               VII. Application of Law to the Legislative Branch

        Section 102(b)(3) of Public Law 104-1, the Congressional
    Accountability Act, requires a description of the application
    of this bill to the legislative branch. The Committee has
    determined that the bill would apply to the legislative branch
    and its employees in the same way it would apply to employers
    and employees in the private sector.

                       VIII. Regulatory Impact Statement

        The Committee has determined that H.R. 3200 provides for a
    new Health Insurance Exchange, in which participation is
    voluntary, and that such Exchange will be governed by a new
    Health Choices Administration which will establish, among other
    things, standards for what constitutes a qualified health
    benefit plan. With several exceptions for other acceptable
    coverage, employers and individuals will be required to
    maintain coverage via a qualified health benefit plan or pay a
    fee for not doing so. This new health care policy
    infrastructure will have the impact of ensuring that 97% of
    Americans have meaningful health insurance coverage and reduce
    the cost of providing such coverage for both employers and
    individuals.

                         IX. Unfunded Mandate Statement

        Section 423 of the Congressional Budget and Impoundment
    Control Act (as amended by Section 101(a)(2) of the Unfunded
    Mandates Reform Act, P.L. 104-4) requires a statement of
    whether the provisions of the reported bill include unfunded
    mandates. The Committee anticipates that this issue will be
    addressed in a CBO cost estimate letter for the bill when it
    proceeds to consideration on the House floor, following the
    merger of the three versions of the bill reported by the three
    committees of jurisdiction.

                              X. Earmark Statement

        H.R. 3200 does not contain any congressional earmarks,
    limited tax benefits, or limited tariff benefits as defined in
    clause 9(d), 9(e) or 9(f) of rule XXI.

                                 XI. Roll Call

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        XII. Statement of Oversight Findings and Recommendations of the
                                   Committee

        In compliance with clause 3(c)(1) of rule XIII and clause
    2(b)(1) of rule X of the rules of the House of Representatives,
    the Committee's oversight findings and recommendations are
    reflected in the body of this report.

                XIII. New Budget Authority and CBO Cost Estimate

        With respect to the requirements of clause 3(c)(2) of rule
    XIII of the House of Representatives and section 308(a) of the
    Congressional Budget Act of 1974 and with respect to
    requirements of 3(c)(3) of rule XIII of the House of
    Representatives and section 402 of the Congressional Budget Act
    of 1974, the Committee anticipates that a CBO cost estimate
    letter on H.R. 3200 will address these issues when the bill
    proceeds to consideration on the House floor. CBO is unable to
    provide a cost estimate prior to the reconciliation of the
    versions of the bill as amended and reported by the three
    committees of jurisdiction.

           XIV. Statement of General Performance Goals and Objectives

        In accordance with clause 3(c) of House rule XIII, the goal
    of H.R. 3200 is to increase access to affordable quality health
    coverage and contain costs.

                     XV. Constitutional Authority Statement

        Under clause 3(d)(1) of rule XIII of the Rules of the House
    of Representatives, the Committee must include a statement
    citing the specific powers granted to Congress in the
    Constitution to enact the law proposed by H.R. 3200. The
    amendments and new law made by this bill are within Congress'
    authority under Article I, Section 8, Clauses 1, 3, and 18 of
    the Constitution.

                            XVI. Committee Estimate

        Clause 3(d)(2) of rule XIII of the Rules of the House of
    Representatives requires an estimate and a comparison of the
    costs that would be incurred in carrying out H.R. 3200.
        The Committee anticipates that, as noted earlier, a CBO
    cost estimate will address these issues when the bill proceeds
    to consideration on the House floor.

          XVII. Changes in Existing Law Made by the Bill, as Reported

        In compliance with clause 3(e) of rule XIII of the Rules of
    the House of Representatives, changes in existing law made by
    the bill, as reported, are shown as follows (existing law
    proposed to be omitted is enclosed in black brackets, new
    matter is printed in italic, existing law in which no change is
    proposed is shown in roman):

                EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974

                       SHORT TITLE AND TABLE OF CONTENTS

      Section 1. This Act may be cited as the ``Employee Retirement
    Income Security Act of 1974''.

                                TABLE OF CONTENTS

         * * * * * * *

                 TITLE I--PROTECTION OF EMPLOYEE BENEFIT RIGHTS

         * * * * * * *

                        Subtitle B--Regulatory Provisions

         * * * * * * *

                     Part 7--Group Health Plan Requirements

         * * * * * * *

                          Subpart B--Other Requirements

         * * * * * * *
    Sec. 715. Protection against post-retirement reduction of retiree health
              benefits.
         * * * * * * *

           Part 8--National Health Coverage Participation Requirements

    Sec. 801. Election of employer to be subject to national health coverage
              participation requirements.
    Sec. 802. Treatment of coverage resulting from election.
    Sec. 803. Health coverage participation requirements.
    Sec. 804. Rules for applying requirements.
    Sec. 805. Termination of election in cases of substantial noncompliance.
    Sec. 806. Regulations.
         * * * * * * *

    TITLE I--PROTECTION OF EMPLOYEE BENEFIT RIGHTS

               *       *       *       *       *       *       *

    Subtitle B--Regulatory Provisions

               *       *       *       *       *       *       *

    Part 5--Administration and Enforcement

               *       *       *       *       *       *       *

                               CIVIL ENFORCEMENT

      Sec. 502. (a) A civil action may be brought--
              (1) * * *

               *       *       *       *       *       *       *

              (6) by the Secretary to collect any civil penalty
            under [paragraph (2), (4), (5), (6), (7), (8), or (9)
            of subsection (c)] paragraph (2), (4), (5), (6), (7),
            (8), (9), (10), or (11) of subsection (c) or under
            subsection (i) or (l);

               *       *       *       *       *       *       *

      (c)(1) * * *

               *       *       *       *       *       *       *

      (11) Health coverage participation requirements.--
              (A) Civil penalties.--In the case of any employer who
            fails (during any period with respect to which an
            election under section 801(a) is in effect) to satisfy
            the health coverage participation requirements with
            respect to any employee, the Secretary may assess a
            civil penalty against the employer of $100 for each day
            in the period beginning on the date such failure first
            occurs and ending on the date such failure is
            corrected.
              (B) Health coverage participation requirements.--For
            purposes of this paragraph, the term ``health coverage
            participation requirements'' has the meaning provided
            in section 803.
              (C) Limitations on amount of penalty.--
                      (i) Penalty not to apply where failure not
                    discovered exercising reasonable diligence.--No
                    penalty shall be assessed under subparagraph
                    (A) with respect to any failure during any
                    period for which it is established to the
                    satisfaction of the Secretary that the employer
                    did not know, or exercising reasonable
                    diligence would not have known, that such
                    failure existed.
                      (ii) Penalty not to apply to failures
                    corrected within 30 days.--No penalty shall be
                    assessed under subparagraph (A) with respect to
                    any failure if--
                              (I) such failure was due to
                            reasonable cause and not to willful
                            neglect, and
                              (II) such failure is corrected during
                            the 30-day period beginning on the 1st
                            date that the employer knew, or
                            exercising reasonable diligence would
                            have known, that such failure existed.
                      (iii) Overall limitation for unintentional
                    failures.--In the case of failures which are
                    due to reasonable cause and not to willful
                    neglect, the penalty assessed under
                    subparagraph (A) for failures during any 1-year
                    period shall not exceed the amount equal to the
                    lesser of--
                              (I) 10 percent of the aggregate
                            amount paid or incurred by the employer
                            (or predecessor employer) during the
                            preceding 1-year period for group
                            health plans, or
                              (II) $500,000.
              (D) Advance notification of failure prior to
            assessment.--Before a reasonable time prior to the
            assessment of any penalty under this paragraph with
            respect to any failure by an employer, the Secretary
            shall inform the employer in writing of such failure
            and shall provide the employer information regarding
            efforts and procedures which may be undertaken by the
            employer to correct such failure.
              (E) Coordination with excise tax.--Under regulations
            prescribed in accordance with section 324 of the
            America's Affordable Health Choices Act of 2009, the
            Secretary and the Secretary of the Treasury shall
            coordinate the assessment of penalties under this
            section in connection with failures to satisfy health
            coverage participation requirements with the imposition
            of excise taxes on such failures under section 4980H(b)
            of the Internal Revenue Code of 1986 so as to avoid
            duplication of penalties with respect to such failures.
              (F) Deposit of penalty collected.--Any amount of
            penalty collected under this paragraph shall be
            deposited as miscellaneous receipts in the Treasury of
            the United States.
      [(10)] (12) The Secretary and the Secretary of Health and
    Human Services shall maintain such ongoing consultation as may
    be necessary and appropriate to coordinate enforcement under
    this subsection with enforcement under section 1144(c)(8) of
    the Social Security Act.

               *       *       *       *       *       *       *

                     Part 7--Group Health Plan Requirements

         Subpart A--Requirements Relating to Portability, Access, and
                                  Renewability

    SEC. 701. INCREASED PORTABILITY THROUGH LIMITATION ON PREEXISTING
                        CONDITION EXCLUSIONS.

      (a) Limitation on Preexisting Condition Exclusion Period;
    Crediting for Periods of Previous Coverage.--Subject to
    subsection (d), a group health plan, and a health insurance
    issuer offering group health insurance coverage, may, with
    respect to a participant or beneficiary, impose a preexisting
    condition exclusion only if--
              (1) such exclusion relates to a condition (whether
            physical or mental), regardless of the cause of the
            condition, for which medical advice, diagnosis, care,
            or treatment was recommended or received within the [6-
            month period] 30-day period ending on the enrollment
            date;
              (2) such exclusion extends for a period of not more
            than [12 months] 3 months (or [18 months] 9 months in
            the case of a late enrollee) after the enrollment date;
            and

               *       *       *       *       *       *       *

    Subpart B--Other Requirements

               *       *       *       *       *       *       *

    SEC. 715. PROTECTION AGAINST POST-RETIREMENT REDUCTION OF RETIREE
                        HEALTH BENEFITS.

      (a) In General.--Every group health plan shall contain a
    provision which expressly bars the plan, or any fiduciary of
    the plan, from reducing the benefits provided under the plan to
    a retired participant, or beneficiary of such participant, if
    such reduction affects the benefits provided to the participant
    or beneficiary as of the date the participant retired for
    purposes of the plan and such reduction occurs after the
    participant's retirement unless such reduction is also made
    with respect to active participants.
      (b) No Reduction.--Notwithstanding that a group health plan
    described in subsection (a) may contain a provision reserving
    the general power to amend or terminate the plan or a provision
    specifically authorizing the plan to make post-retirement
    reductions in retiree health benefits, it shall be prohibited
    for any group health plan, whether through amendment or
    otherwise, to reduce the benefits provided to a retired
    participant or his or her beneficiary under the terms of the
    plan if such reduction of benefits occurs after the date the
    participant retired for purposes of the plan and reduces
    benefits that were provided to the participant, or his or her
    beneficiary, as of the date the participant retired unless such
    reduction is also made with respect to active participants.

               *       *       *       *       *       *       *

          PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS

    SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL HEALTH
                        COVERAGE PARTICIPATION REQUIREMENTS.

      (a) In General.--An employer may make an election with the
    Secretary to be subject to the health coverage participation
    requirements.
      (b) Time and Manner.--An election under subsection (a) may be
    made at such time and in such form and manner as the Secretary
    may prescribe.

    SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.

      (a) In General.--If an employer makes an election to the
    Secretary under section 801--
              (1) such election shall be treated as the
            establishment and maintenance of a group health plan
            (as defined in section 733(a)) for purposes of this
            title, subject to section 151 of the America's
            Affordable Health Choices Act of 2009, and
              (2) the health coverage participation requirements
            shall be deemed to be included as terms and conditions
            of such plan.
      (b) Periodic Investigations to Discover Noncompliance.--The
    Secretary shall regularly audit a representative sampling of
    employers and group health plans and conduct investigations and
    other activities under section 504 with respect to such
    sampling of plans so as to discover noncompliance with the
    health coverage participation requirements in connection with
    such plans. The Secretary shall communicate findings of
    noncompliance made by the Secretary under this subsection to
    the Secretary of the Treasury and the Health Choices
    Commissioner. The Secretary shall take such timely enforcement
    action as appropriate to achieve compliance.
      (c) Recordkeeping.--To facilitate the audits described in
    subsection (b), the Secretary shall promulgate recordkeeping
    requirements for employers to account for both employees of the
    employer and individuals whom the employer has not treated as
    employees of the employer but with whom the employer, in the
    course of the trade or business in which the employer is
    engaged, has engaged for the performance of labor or services.

    SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

      For purposes of this part, the term ``health coverage
    participation requirements'' means the requirements of part 1
    of subtitle B of title III of division A of America's
    Affordable Health Choices Act of 2009 (as in effect on the date
    of the enactment of such Act).

    SEC. 804. RULES FOR APPLYING REQUIREMENTS.

      (a) Affiliated Groups.--In the case of any employer which is
    part of a group of employers who are treated as a single
    employer under subsection (b), (c), (m), or (o) of section 414
    of the Internal Revenue Code of 1986, the election under
    section 801 shall be made by such employer as the Secretary may
    provide. Any such election, once made, shall apply to all
    members of such group.
      (b) Separate Elections.--Under regulations prescribed by the
    Secretary, separate elections may be made under section 801
    with respect to--
              (1) separate lines of business, and
              (2) full-time employees and employees who are not
            full-time employees.

    SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL
                        NONCOMPLIANCE.

      The Secretary may terminate the election of any employer
    under section 801 if the Secretary (in coordination with the
    Health Choices Commissioner) determines that such employer is
    in substantial noncompliance with the health coverage
    participation requirements and shall refer any such
    determination to the Secretary of the Treasury as appropriate.

    SEC. 806. REGULATIONS.

      The Secretary may promulgate such regulations as may be
    necessary or appropriate to carry out the provisions of this
    part, in accordance with section 324(a) of the America's
    Affordable Health Choices Act of 2009. The Secretary may
    promulgate any interim final rules as the Secretary determines
    are appropriate to carry out this part.

               *       *       *       *       *       *       *

                                  ----------

                           REHABILITATION ACT OF 1973

               *       *       *       *       *       *       *
    TITLE V--RIGHTS AND ADVOCACY

               *       *       *       *       *       *       *

    SEC. 510. STANDARDS FOR ACCESSIBILITY OF MEDICAL DIAGNOSTIC EQUIPMENT.

      (a) Standards.--Not later than 9 months after the date of
    enactment of the America's Affordable Health Choices Act of
    2009, the Architectural and Transportation Barriers Compliance
    Board shall issue guidelines setting forth the minimum
    technical criteria for medical diagnostic equipment used in (or
    in conjunction with) physician's offices, clinics, emergency
    rooms, hospitals, and other medical settings. The guidelines
    shall ensure that such equipment is accessible to, and usable
    by, individuals with disabilities, including provisions to
    ensure independent entry to, use of, and exit from the
    equipment by such individuals to the maximum extent possible.
      (b) Medical Diagnostic Equipment Covered.--The guidelines
    issued under subsection (a) for medical diagnostic equipment
    shall apply to equipment that includes examination tables,
    examination chairs (including chairs used for eye examinations
    or procedures, and dental examinations or procedures), weight
    scales, mammography equipment, x-ray machines, and other
    equipment commonly used for diagnostic or examination purposes
    by health professionals.
      (c) Interim Standards.--Until the date on which final
    regulations are issued under subsection (d), purchases of
    examination tables, weight scales, and mammography equipment
    and used in (or in conjunction with) medical settings described
    in subsection (a), shall adhere to the following interim
    accessibility requirements:
              (1) Examination tables shall be height-adjustable
            between a range of at least 18 inches to 37 inches.
              (2) Weight scales shall be capable of weighing
            individuals who remain seated in a wheelchair or other
            personal mobility aid.
              (3) Mammography machines and equipment shall be
            capable of being used by individuals in a standing,
            seated, or recumbent position, including individuals
            who remain seated in a wheelchair or other personal
            mobility aid.
      (d) Regulations.--Not later than 6 months after the date of
    the issuance of the guidelines under subsection (a), each
    appropriate Federal agency authorized to promulgate regulations
    under this Act or under the Americans with Disabilities Act
    shall--
              (1) prescribe regulations in an accessible format as
            necessary to carry out the provisions of such Act and
            section 504 of this Act that include accessibility
            standards that are consistent with the guidelines
            issued under subsection (a); and
              (2) ensure that health care providers and health care
            plans covered by the America's Affordable Health
            Choices Act of 2009 meet the requirements of the
            Americans with Disabilities Act and section 504,
            including provisions ensuring that individuals with
            disabilities receive equal access to all aspects of the
            health care delivery system.
      (e) Review and Amend.--The Architectural and Transportation
    Barriers Compliance Board shall periodically review and, as
    appropriate, amend the guidelines as prescribed under
    subsection (a). Not later than 6 months after the date of the
    issuance of such revised guidelines, revised regulations
    consistent with such guidelines shall be promulgated in an
    accessible format by the appropriate Federal agencies described
    in subsection (d).

               *       *       *       *       *       *       *

                                  ----------

                        WORKFORCE INVESTMENT ACT OF 1998

               *       *       *       *       *       *       *
    TITLE I--WORKFORCE INVESTMENT SYSTEMS

               *       *       *       *       *       *       *

    Subtitle D--National Programs

               *       *       *       *       *       *       *

    SEC. 171. DEMONSTRATION, PILOT, MULTISERVICE, RESEARCH, AND MULTISTATE
                        PROJECTS.

      (a) * * *

               *       *       *       *       *       *       *

      (f) Health Professions Training for Diversity Program.--
              (1) In general.--The Secretary shall make available
            20 grants of no more than $1,000,000 annually to
            nonprofit organizations for the purposes of providing
            workforce development training program for those who
            are currently employed in the health care workforce.
              (2) Eligibility.--For the purposes of providing
            assistance and services under the program established
            in this subsection, grants are to be awarded to Area
            Health Education Centers or similar nonprofit
            organizations involved in the development and
            implementation of health care workforce development
            programs and that--
                      (A) have a formal affiliation with a hospital
                    or community health center, and institution of
                    higher education as defined by section 101 of
                    the Higher Education Act of 1965;
                      (B) have a history of providing program
                    services to minority populations; and
                      (C) provide workforce development programs to
                    low-income persons, veterans, or urban and
                    rural underserved communities.
      (g) Online Health Workforce Training Program.--
              (1) Grant program.--
                      (A) In general.--The Secretary shall award
                    National Health Workforce Online Training
                    Grants on a competitive basis to eligible
                    entities to enable such entities to carry out
                    training for individuals to attain or advance
                    in health care occupations. An entity may
                    leverage such grant with other Federal, State,
                    local, and private resources, in order to
                    expand the participation of businesses,
                    employees, and individuals in such training
                    programs.
                      (B) Eligibility.--In order to receive a grant
                    under the program established under this
                    paragraph--
                              (i) an entity shall be an educational
                            institution, community-based
                            organization, non-profit organization,
                            workforce investment board, or local or
                            county government; and
                              (ii) an entity shall provide online
                            workforce training for individuals
                            seeking to attain or advance in health
                            care occupations, including nursing,
                            nursing assistants, dentistry,
                            pharmacy, health care management and
                            administration, public health, health
                            information systems analysis, medical
                            assistants, and other health care
                            practitioner and support occupations.
                      (C) Priority.--Priority in awarding grants
                    under this paragraph shall be given to entities
                    that--
                              (i) have demonstrated experience in
                            implementing and operating online
                            worker skills training and education
                            programs;
                              (ii) have demonstrated experience
                            coordinating activities, where
                            appropriate, with the workforce
                            investment system; and
                              (iii) conduct training for
                            occupations with national or local
                            shortages.
                      (D) Data collection.--Grantees under this
                    paragraph shall collect and report information
                    on--
                              (i) the number of participants;
                              (ii) the services received by the
                            participants;
                              (iii) program completion rates;
                              (iv) factors determined as
                            significantly interfering with program
                            participation or completion;
                              (v) the rate of job placement; and
                              (vi) other information as determined
                            as needed by the Secretary.
                      (E) Outreach.--Grantees under this paragraph
                    shall conduct outreach activities to
                    disseminate information about their program and
                    results to workforce investment boards, local
                    governments, educational institutions, and
                    other workforce training organizations.
                      (F) Performance levels.--The Secretary shall
                    establish indicators of performance that will
                    be used to evaluate the performance of grantees
                    under this paragraph in carrying out the
                    activities described in this paragraph. The
                    Secretary shall negotiate and reach agreement
                    with each grantee regarding the levels of
                    performance expected to be achieved by the
                    grantee on the indicators of performance.
                      (G) Authorization of appropriations.--There
                    are authorized to be appropriated to the
                    Secretary to carry out this subsection
                    $50,000,000 for fiscal years 2011 through 2020.
              (2) Online health professions training program
            clearinghouse.--
                      (A) Description of grant.--The Secretary
                    shall award one grant to an eligible
                    postsecondary educational institution to
                    provide the services described in this
                    paragraph.
                      (B) Eligibility.--To be eligible to receive a
                    grant under this paragraph, a postsecondary
                    educational institution shall--
                              (i) have demonstrated the ability to
                            disseminate research on best practices
                            for implementing workforce investment
                            programs; and
                              (ii) be a national leader in
                            producing cutting-edge research on
                            technology related to workforce
                            investment systems under subtitle B.
                      (C) Services.--The postsecondary educational
                    institution that receives a grant under this
                    paragraph shall use such grant--
                              (i) to provide technical assistance
                            to entities that receive grants under
                            paragraph (1);
                              (ii) to collect and nationally
                            disseminate the data gathered by
                            entities that receive grants under
                            paragraph (1); and
                              (iii) to disseminate the best
                            practices identified by the National
                            Health Workforce Online Training Grant
                            Program to other workforce training
                            organizations.
                      (D) Authorization of appropriations.--There
                    are authorized to be appropriated to the
                    Secretary to carry out this subsection
                    $1,000,000 for fiscal years 2011 through 2020.

               *       *       *       *       *       *       *

                                  ----------

                          OLDER AMERICANS ACT OF 1965

               *       *       *       *       *       *       *
    TITLE II--ADMINISTRATION ON AGING

               *       *       *       *       *       *       *

                        FUNCTIONS OF ASSISTANT SECRETARY

      Sec. 202. (a) * * *
      (b) To promote the development and implementation of
    comprehensive, coordinated systems at Federal, State, and local
    levels that enable older individuals to receive long-term care
    in home and community-based settings, in a manner responsive to
    the needs and preferences of older individuals and their family
    caregivers, the Assistant Secretary shall, consistent with the
    applicable provisions of this title--
              (1) collaborate, coordinate, and consult with other
            Federal entities responsible for formulating and
            implementing programs, benefits, and services related
            to providing long-term care, and may make grants,
            contracts, and cooperative agreements with funds
            received from other Federal entities, and, in carrying
            out the purposes of this paragraph, shall make
            recommendations to other Federal entities regarding
            appropriate and effective means of identifying,
            promoting, and implementing investments in the direct
            care workforce necessary to meet the growing demand for
            long-term health services and supports and assisting
            States in developing a comprehensive state workforce
            development plans with respect to such workforce
            including efforts to systematically assess, track, and
            report on workforce adequacy and capacity;

               *       *       *       *       *       *       *

      (g)(1) The Assistant Secretary shall establish a Personal
    Care Attendant Workforce Advisory Panel and pilot program to
    improve working conditions and training for long term care
    workers, including home health aides, certified nurse aides,
    and personal care attendants.
      (2) The Panel shall include representatives from--
              (A) relevant health care agencies and facilities
            (including personal or home care agencies, home health
            care agencies, nursing homes and residential care
            facilities);
              (B) the disability community;
              (C) the nursing community;
              (D) direct care workers (which may include unions and
            national organizations);
              (E) older individuals and family caregivers;
              (F) State and federal health care entities; and
              (G) experts in workforce development and adult
            learning.
      (3) Within one year after the establishment of the Panel, the
    Panel shall submit a report to the Assistant Secretary
    articulating core competencies for eligible personal or home
    care aides necessary to successfully provide long-term services
    and supports to eligible consumers, as well as recommended
    training curricula and resources.
      (4) Within 180 days after receipt by the Assistant Secretary
    of the report under paragraph (3), the Assistant Secretary
    shall establish a 3-year demonstration program in 4 states to
    pilot and evaluate the effectiveness of the competencies
    articulated by the Panel and the training curricula and
    training methods recommended by the Panel.
      (5) Not later than 1 year after the completion of the
    demonstration program under paragraph (4), the Assistant
    Secretary shall submit to each House of the Congress a report
    containing the results of the evaluations by the Assistant
    Secretary pursuant to paragraph (4), together with such
    recommendations for legislation or administrative action as the
    Assistant Secretary determines appropriate.

               *       *       *       *       *       *       *

          TITLE III--GRANTS FOR STATE AND COMMUNITY PROGRAMS ON AGING

    Part A--General Provisions

               *       *       *       *       *       *       *

                 AUTHORIZATION OF APPROPRIATIONS; USES OF FUNDS

      Sec. 303. (a) * * *

               *       *       *       *       *       *       *

      (e)(1) * * *
      (2) There are authorized to be appropriated to carry out part
    E (relating to family caregiver support) $166,500,000 for
    fiscal year 2008, [$173,000,000 for fiscal year 2009,
    $180,000,000 for fiscal year 2010, and $187,000,000 for fiscal
    year 2011] and $250,000,000 for each of the fiscal years 2010,
    2011, and 2012.

               *       *       *       *       *       *       *

                        XVIII. Committee Correspondence

        None.

                              XIX. Minority Views

                                    ------

                                 MINORITY VIEWS

    Introduction
        Committee Republicans agree that health care reform
    legislation should make health care more affordable, improve
    quality, and reduce the number of uninsured Americans. As
    policymakers, we should be doing all that we can to make
    positive reforms to the health care system that would use
    private markets to lower the cost of health care insurance;
    improve affordability and accessibility for both employers and
    employees; give employers and employees the tools they need to
    encourage healthier behavior; change health care provider
    reimbursement structures to reward high-quality results; and
    address the long-term solvency of existing entitlement
    programs, like Medicare and Medicaid.
        Considering that the majority of Americans obtain health
    insurance coverage through their employers, the employment-
    based system plays a central role in the delivery of health
    care. Recognizing the importance of employment-based health
    coverage, Committee Republicans have led efforts in recent
    years to lower the cost and increase the affordability of
    employment-based health coverage. Committee Republicans
    continue to support efforts to assist employers and employees
    in obtaining cost-effective, high quality coverage.
        In assessing health care reform legislation, Committee
    Republicans bear in mind a number of important principles.
    Foremost, reform efforts should allow individuals who are
    satisfied with their current coverage to keep it, and give
    Americans the freedom to choose the health plans and medical
    providers that best fit their needs. Second, reforms should
    make quality health care coverage affordable and accessible for
    every American, regardless of pre-existing health conditions.
    Third, we must guard against a new government-run health care
    plan that would eliminate the health coverage that more than
    100 million Americans currently receive through their job, or
    limit their choice of doctors and medical treatment options.
    Fourth, reform efforts must ensure that medical decisions are
    made by patients and doctors, not government bureaucrats.
    Finally, reforms must improve Americans' lives through
    effective prevention, wellness, and disease management
    programs, while developing new treatments and cures for life-
    threatening diseases.
        Measured against these principles, H.R. 3200, as reported
    from the Committee on Education and Labor, wholly fails to meet
    the mark. For these reasons, and as set forth more fully below,
    Committee Republicans oppose the bill.
    H.R. 3200, Procedural History
        On the afternoon of Friday, June 19, 2009, House Democrats
    circulated the ``TriCommittee Draft Proposal for Health Care
    Reform,'' an 852-page health care plan crafted behind closed
    doors by the Democrat Chairmen of three House committees with
    jurisdiction over health care issues. The draft proposal was
    not formally introduced or assigned a legislative bill number.
    There were vast shortcomings and gaps in the draft proposal,
    including the lack of a cost estimate and the absence of
    several key provisions, including specific financing
    mechanisms. House Republicans were denied the opportunity to
    provide meaningful input on the ``draft proposal,'' and met for
    the first time with Committee Democrats only two days before
    the proposal was publicly circulated.
        On Tuesday, June 23, 2009, the Committee on Education and
    Labor held a hearing on the draft proposal. Although Committee
    Republicans and invited witnesses provided valuable commentary,
    the short time frame for review and the significant gaps in the
    draft proposal hindered the ability to comprehensively analyze
    the Democrat health care reform plan prior to the hearing on
    June 23.
        Thereafter, on July 14, 2009, House Democrat Leaders
    formally introduced their health care reform bill, H.R. 3200,
    the ``America's Affordable Health Choices Act of 2009.'' The
    introduced bill totaled 1,017 pages (an increase of 165 pages)
    and contained numerous technical and substantive changes. No
    formal estimate of the cost of H.R. 3200 has been provided;
    rather, prior to the Committee's consideration of the bill a
    ``preliminary,'' incomplete score of H.R. 3200 prepared by the
    Congressional Budget Office (CBO) was provided. This
    ``preliminary'' analysis was not based on H.R. 3200, but rather
    on ``technical specifications'' of the June 19 TriCommittee
    draft proposal that were provided to CBO by House Democrats.
        On the afternoon of July 15, 2009, the full Committee on
    Education and Labor commenced its markup of H.R. 3200 with
    Member opening statements. Late on that same afternoon,
    Committee Republicans were provided with the Chairman's
    Amendment in the Nature of a Substitute, which totaled 1,040
    pages (adding another 23 pages) and contained further
    substantive changes to H.R. 3200. Not one hearing was held on
    the Democrat-generated health care reform provisions of H.R.
    3200, or on the Chairman's Amendment in the Nature of a
    Substitute. On the morning of July 17, 2009, after
    consideration of 42 amendments, the Committee completed its
    consideration of H.R. 3200, and the bill was ordered favorably
    reported to the House of Representatives by a vote of 26-22.
    Three Democrats joined with all Committee Republicans in
    opposing the bill.
    General Concerns Regarding H.R. 3200
        Committee Republicans are concerned about the inexplicable
    rush to legislate on this important issue. The changes
    contemplated by H.R. 3200 will significantly impact more than
    one-sixth of the American economy, yet House Democrats drafted
    the partisan bill behind closed doors and without any
    meaningful participation by Republicans and even many
    Democrats. Committee Republicans have not been provided with an
    adequate amount of time to fully analyze the complex provisions
    of H.R. 3200. Further, we expect that the bill will change yet
    again following consideration by the three House Committees of
    jurisdiction, and prior to consideration by the full House, if
    it should occur. However, our review to date reveals numerous
    and significant policy concerns.
        In general, Committee Republicans are concerned that H.R.
    3200 fails to address the problems in the U.S. health care
    system, and in fact will only serve to exacerbate these
    problems through the adoption of misguided and historically
    ineffective policies. Moreover, the bill's true cost is
    unknown, but will likely be excessive. The cost will likely
    exceed $1.3 trillion over ten years, and the latest CBO
    estimate indicates that the bill will add more than $239
    billion to the federal deficit over a ten-year period. More
    troubling is the fact that under H.R. 3200, the federal
    government starts collecting new taxes and revenues within a
    year or two of enactment, but implementation of many of the
    programs (i.e., the creation of a new federal bureaucracy and
    insurance coverage subsidies) is delayed, which artificially
    lowers the ``cost'' of the legislation under consideration by
    CBO. Further, in the later years of the CBO ten-year estimate,
    the costs of the program significantly outstrip new revenues,
    meaning the true costs of the Democrat legislation are much
    higher over the long term (i.e., beyond CBO's limited ten-year
    period). This is a cost the country cannot afford to bear.
        The specific problems of the bill are numerous. For
    instance, Democrats attempt to pay for some of the cost through
    significantly higher taxes on individuals and businesses, with
    small business owners (those who create the majority of
    American jobs) appearing to shoulder a disproportionate share
    of the burden. It creates a massive new federal bureaucracy
    with unprecedented powers to determine ``acceptable'' health
    care coverage, and tax those who fail to comply with the bill's
    numerous legal mandates. The bill essentially eliminates
    current state-based private markets for health insurance. H.R.
    3200 creates a ``public health insurance option'' (i.e.,
    government-run health insurance plan) controlled by the new
    federal bureaucracy that is based on the flawed Medicare
    payment structure, and will undermine the private health
    insurance coverage currently enjoyed by millions of Americans.
    H.R. 3200 does little, if anything, to change the flawed health
    care delivery and payment structure, which is critical to
    control health care costs, increase affordability, and make
    coverage more accessible to Americans. The goal of H.R. 3200
    appears to be nothing less than centralization of the country's
    health care sector in the federal government. It should be
    rejected.

    Concerns Relating to ERISA Group Health Plans

        The 1,040-page bill is divided into three separate
    Divisions: Division A, entitled ``Affordable Health Care
    Choices''; Division B, ``Medicare and Medicaid Improvements'';
    and Division C, ``Public Health and Workforce Development''.
    The Committee on Education and Labor maintains jurisdiction
    over much of Division A, and a portion of Division C.
    Considering this Committee's jurisdiction over the Employee
    Retirement Income and Security Act of 1974 (ERISA) and the
    provision of employer-sponsored group health coverage, this
    Committee's consideration of H.R. 3200 focused primarily on
    Division A.
        Division A of H.R. 3200 contains several controversial
    Democrat proposals, including the establishment of a new
    federal bureaucracy which would be charged with defining
    ``acceptable'' health benefits, creating and regulating a new
    national health insurance exchange, distributing massive new
    federal subsidies for low and middle-income individuals to
    purchase ``acceptable'' health insurance through the exchange,
    and regulating the provision of insurance nationally. Also,
    Division A contains a provision creating a new government-run
    health insurance plan option, which would be a federally-
    created and administered government-run insurance plan based on
    Medicare, allegedly designed to ``compete'' with private
    insurance plans.
        Democrats attempt to pay for this new bureaucracy through a
    number of new tax provisions that affect all Americans. For
    instance, H.R. 3200 institutes a new mandate on every
    individual to obtain ``acceptable'' coverage or pay a 2.5
    percent tax. It creates a ``pay or play'' mandate on virtually
    all employers to provide ``acceptable'' insurance coverage or
    pay a new 8 percent payroll tax to the federal government. The
    introduced bill also provides some details left out of the June
    19 Tri-Committee draft proposal, such as a provision exempting
    only the very smallest businesses, and new tax increases that
    are intended to pay for this massive new federal entitlement
    program. Many of the new taxes set forth in H.R. 3200
    disproportionately impact small businesses and small business
    owners. Even so, Democrats' attempt to pay for the cost of this
    legislation falls far short as the bill's costs increase
    substantially over time and will likely result in at least a
    $239 billion increase in the federal deficit.\1\ The
    overwhelming cost of the Democrat bill, and its bevy of new
    taxes, has raised significant concerns among many Americans.
    Committee Republicans believe that the bill creates a massive
    new federal bureaucracy and places significant new liabilities
    and tax burdens on all Americans and virtually all American
    employers, even those that are not profitable, which will
    likely have a negative impact on future economic growth.
    ---------------------------------------------------------------------------
        \1\ See, letter from Douglas W. Elmendorf, Director, Congressional
    Budget Office, to the Honorable George Miller, Chairman, Committee on
    Education and Labor, dated July 17, 2009. The letter provides a
    preliminary analysis by the CBO and the Joint Committee on Taxation of
    H.R. 3200, as introduced on July 14, 2009, and does not reflect any
    modifications or amendments made after that date.
    ---------------------------------------------------------------------------
                Employer ``Pay or Play'' Mandate
        Over 160 million people, or about 62 percent of the
    population under age 65, obtain health care insurance from
    their employers. Despite rising costs, this number has remained
    relatively consistent over the past decade, and most employees
    are happy with the coverage they receive from their employers.
    One of the primary reasons for the success of the employer-
    sponsored system is the ERISA-based regulatory structure that
    generally allows multi-state employers to voluntarily offer
    uniform health benefits to their employees, irrespective of
    location, by freeing the employer-sponsored plan from
    regulation by the states. Under the current ERISA structure,
    many employers gain administrative efficiencies and voluntarily
    design health plans tailored to the needs of their employees
    and families. This has permitted the private sector to develop
    innovative benefit designs and payment policies to control
    health care costs and improve quality.
        As reported, H.R. 3200 imposes an unprecedented new tax on
    virtually all employers. Specifically, Title III, Subtitle B,
    ``Employer Responsibility,'' mandates that all employers offer
    ``acceptable'' coverage under a ``qualified health benefits
    plan'' to each of their employees, or pay an 8 percent payroll
    tax to the federal government.\2\ The ``acceptable'' coverage
    will be designed and determined by the new Health Benefits
    Advisory Committee and the Health Choices Commissioner. Section
    312 provides that for full-time employees, employers have to
    contribute at least 72.5 percent of the applicable premium of
    the lowest cost plan for individuals, and 65 percent of the
    applicable premium of the lowest cost plan for family coverage.
    The mandate is also extended to part-time employees, but the
    bill fails to specify who is a part-time employee and leaves it
    to the federal government to define this term and create new
    employer contribution rules for such employees. In a provision
    only trial lawyers could like, the bill subjects ERISA group
    health plans to state court lawsuits. Finally, under Section
    321, employers will be subjected to fines of up to $500,000 in
    the event they are found to be in noncompliance with the Act's
    onerous new mandates.
    ---------------------------------------------------------------------------
        \2\ The only exception to the mandate considered by the Committee
    was a sliding scale wage tax in Section 313, exempting only the very
    smallest employers with annual payrolls of less than $250,000, and
    limiting the payroll tax for companies with payroll of less than
    $400,000 annually. Under Section 313, employers with a payroll of less
    than $250,000 are not subject to any payroll tax. Companies with
    payrolls of $250,000 to less than $300,000 are subject to a 2 percent
    payroll tax; $300,000 to under $350,000 at 4 percent; and employers
    with payroll of $350,000 to less than $400,000 are taxed at 6 percent.
    Companies with payroll of more than $400,000 are taxed the full eight
    percent.
    ---------------------------------------------------------------------------
        The new taxes on employers pose multiple problems, and have
    been the subject of much commentary from the representatives of
    those employers who will be directly impacted by the Democrats'
    new tax plan. For example, in a letter dated July 9, 2009 to
    Chairman Miller and Ranking Member Kline, Steve Pfister, the
    Senior Vice President of the National Retail Federation stated:

              Employer mandates of any kind amount to a tax on
            jobs. We can think of few more dangerous steps to take
            in the middle of a recession. We need to add new jobs,
            not exacerbate the near double-digit unemployment
            numbers. We cannot afford to have new and existing jobs
            priced out of our collective reach because of mandated
            health coverage.

        In a July 15, 2009 general letter, Susan Eckerly, Senior
    Vice President of Public Policy for the National Federation of
    Independent Business (NFIB), stated that the NFIB, the nation's
    leading small business advocacy organization, opposed H.R. 3200
    because of the inclusion of an employer mandate. Ms. Eckerly
    stated, in part:

              Research shows an employer mandate could cost 1.6
            million jobs with more than 1 million of those jobs
            lost in the small business sector. The approach fails
            to increase affordability and, instead, devastates the
            economy--with the greatest impact being levied on the
            low-income community who will pay through depressed
            wages and lost jobs. . . . As if the mandate alone
            isn't destructive enough, the legislation uses perhaps
            the most egregious penalty of all--a payroll tax--as
            the penalty for those who cannot meet the obligations
            laid out in the bill. A payroll tax is particularly
            regressive because employers pay it regardless of
            whether or not their business is profitable. . . . The
            legislation even punishes employers who are currently
            providing insurance to their employees, but don't meet
            the premium contribution requirements in the bill
            (72.5% for individuals and 65% for family plans).

        In a letter dated July 15, 2009 to Chairman Miller and
    Ranking Member Kline, R. Bruce Josten, Executive Vice
    President, Government Affairs for the United States Chamber of
    Commerce, expressed opposition to the employer mandate. Mr.
    Josten stated:

              the bill contains a job-killing employer mandate and
            accompanying 8 percent payroll tax. Attempts to carve
            out some small businesses will not prevent the adverse
            economic consequences of this provision.

        The Majority claims that H.R. 3200 will save money and
    create new jobs. These assertions ignore the analysis of CBO
    which indicates that the pending legislation adds at least $239
    billion to the federal deficit over ten years, with that number
    likely to grow substantially in the following decade. Further,
    CBO has not found that H.R. 3200 controls or reduces underlying
    systemic health care costs, which is essential to making care
    and coverage more affordable. Finally, as reflected in the
    comments above, the new taxes on all employers will slow
    economic growth and stunt new job creation, particularly among
    those employers who struggle to reach or maintain
    profitability.
        Finally, some Committee and House Democrats have expressed
    serious reservations regarding the onerous requirements on
    employers. For example, in a letter dated July 9, 2009 from the
    fiscally conservative Blue Dog Coalition to Speaker Nancy
    Pelosi and Majority Leader Steny Hoyer, forty ``Blue Dog''
    Democrats stated that ``any additional requirements for
    employers must be carefully considered and done so within the
    context of what is currently offered. Small business owners and
    their employees lack coverage because of high and unstable
    costs--not because of an unwillingness to provide or purchase
    it. We cannot support a bill that further exacerbates the
    challenges faced by small businesses.'' \3\
    ---------------------------------------------------------------------------
        \3\ See, letter from ``Democratic Blue Dog Coalition'' to The
    Honorable Nancy Pelosi, Speaker, and The Honorable Steny Hoyer,
    Majority Leader, dated July 9, 2009. The letter, signed by forty
    Democrat Members of Congress, stated their belief that the tri-
    committee health care reform proposal ``lacks a number of elements
    essential to preserving what works and fixing what is broken'' in the
    health care system, and that legislation must include provisions to
    ensure deficit neutrality, delivery system reform, small business
    protections, rural health equity, and bipartisanship.
    ---------------------------------------------------------------------------
        Committee Republicans believe that the employer ``pay or
    play'' mandate is simply flawed policy that will destroy the
    voluntary, employer-sponsored ERISA health benefits structure,
    limit future flexibility to design affordable health plans,
    increase costs and cause significant job losses, and depress
    wage growth, especially for low-income Americans. This mandate
    would be especially hard on smaller or mid-sized firms that may
    not be eligible for an exemption, and who may struggle to reach
    and maintain profitability. Further, the proposed tax penalty
    percentage (eight percent for most employers) could increase in
    the future at the whim of Congress, especially if the federal
    government needs additional revenues to cover shortfalls in
    this massive new entitlement program, potentially increasing
    the burdens on employers.
        In addition, numerous structural components of the proposed
    mandate are problematic for employers and the current ERISA
    structure. In the fifth year of the exchange, employers whose
    workers choose coverage through an exchange will be forced to
    pay the eight percent tax to finance their workers' exchange
    policy, even if they provide coverage to their employees. This
    will certainly place increasing pressure on employer group
    health plans in the form of adverse risk selection, since
    employees could leave the group health plan for the exchange
    and shrink the size of the group plan's pool of participants.
    Many employers may simply choose to drop coverage and pay the
    tax, rather than administer and pay for an increasingly
    inefficient group health plan.
        Further, under the Democrat bill, there is no way of
    knowing whether the coverage currently enjoyed by tens of
    millions of employees and their families, including health
    savings accounts used in conjunction with high deductible
    health plans (HSA/HDHP), will meet the future ``acceptable''
    benefit and employer contribution requirements. For example, an
    HSA/HDHP individual plan with an actuarial value of 69 percent
    will not meet the requirements of this bill. Employers would
    have to change this benefit to comply with the new mandates, or
    the individual employee could face the individual tax for non-
    compliance.\4\ Also, employers who contribute less than the
    statutory amounts (72.5 percent and 65 percent for individual
    and family coverage, respectively) will have to change or be
    subjected to a new tax. This could cause some employers to drop
    coverage altogether.
    ---------------------------------------------------------------------------
        \4\ See, H.R. 3200, Sections 301, 401, July 14, 2009, regarding the
    new tax on individuals who fail to obtain acceptable insurance
    coverage.
    ---------------------------------------------------------------------------
        Clearly, the employer ``pay or play'' provisions are
    designed to make it more difficult for employers to offer
    ERISA-based group health plan coverage, and direct more
    employees and their families to the new federal health
    insurance exchange and its government plan, Medicare-based,
    option. Contrary to Democrat political rhetoric, there is a
    substantial likelihood that employees who like their current
    coverage will not be able to keep it.
        For these reasons, Committee Republicans object to the
    employer ``pay or play'' mandate in H.R. 3200.
                Impact on ERISA Preemption and Remedies
        Under current law, the ERISA regulatory structure preempts
    employers and group health plans from liability under state
    law. This has resulted in significant administrative savings
    and contributes to the ability of employers and group health
    plans to offer high quality, affordable health insurance
    coverage to more than 130 million Americans.
        The Tri-Committee bill raises serious questions and
    concerns regarding the continued viability of the current ERISA
    regulatory structure, and whether H.R. 3200 exposes employers
    and group health plans to new liabilities for claim decisions.
    Under current law, group health plans are required to comply
    with the requirements of ERISA, and any disputes are governed
    and resolved under its provisions. This ensures that employers,
    who may provide health insurance coverage for workers in all 50
    states, must comply with the federal law only, which permits
    the delivery of uniform benefits and saves administrative
    costs. They cannot be sued in state courts, under different
    laws.
        The bill appears to change this by creating two different
    penalty regimes inside the new insurance exchanges; for group
    health plans and their beneficiaries, there would be varied and
    unlimited penalties set forth under 50 different state laws. To
    the extent that group health plans are permitted to purchase
    through the insurance exchanges, they will be subjected to
    potentially expansive new state court liabilities.
        At the same time that they are subjecting private plans to
    a patchwork of state laws, Democrats chose to apply a uniform
    federal scheme similar to Medicare to the government-run health
    insurance plan. This would provide an unfair financial
    advantage to the government-run health plan since, unlike ERISA
    group health plans, the government-run plan would not have to
    face lawsuits and comply with up to 50 different sets of state
    laws.
        Two groups appear to benefit from this proposed structure:
    trial lawyers and the government bureaucrats running the
    government-run health plan. Further, ERISA group health plans
    would face significant new liabilities and costs which would
    likely cause them to drop coverage altogether, accelerating the
    movement from private, employer-sponsored health insurance to a
    government-run plan.
        For these reasons, Committee Republicans object to new
    liabilities imposed on ERISA employers and group health plans
    in H.R. 3200.
                The New Federal Bureaucracy and the Government-Run Health
                        Plan
        Committee Republicans are concerned that H.R. 3200 creates
    a massive new federal health insurance bureaucracy, the
    ``Health Choices Administration,'' that would create a ``one-
    size-fits-all'' standard for health coverage and vest
    unprecedented control with one individual, the new ``Health
    Choices Commissioner.'' This new Commissioner would be charged
    with governing the national exchange, enforcing insurance plan
    standards, distributing taxpayer subsidies, and fining non-
    compliant individuals, plans and employers. This structure
    would restrict the sale of insurance outside of the exchange,
    and ultimately would eviscerate private insurance markets over
    time.
        Under H.R. 3200, the Department of Health and Human
    Services (HHS) will be charged with creating a public health
    insurance option that would only be available in a national
    health insurance exchange. Although the plan would have to
    comply with requirements on private, exchange-available plans,
    the exchange would have no power under the bill to reject,
    sanction or terminate the government option run by HHS.
    Further, the government plan would be subject to lawsuit only
    in federal courts; this differs substantially from private
    plans, including employer-sponsored group health plans
    currently regulated under the federal ERISA law, which would be
    subject to state court lawsuits (raising the costs for private
    plans).
        With respect to government-plan funding, ``start-up'' funds
    in the amount of $2 billion in taxpayer money would be provided
    from the Treasury. Although the plan's premium rates would be
    required to cover the cost of the benefits and administration,
    going forward there is no requirement that the government plan
    maintain a certain ``reserve'' level, similar to those required
    of state-based private insurance companies. This could give the
    government plan a potentially significant competitive advantage
    over private insurers.
        Importantly, the government plan would be based on the
    failed Medicare payment structure. Specifically, the plan would
    pay Medicare rates for at least the first three years, with
    Medicare-participating physicians getting a five percent bonus
    for the first three years. The problems with this structure are
    numerous. First, Medicare pays on a fee-for-service basis,
    which rewards those providers that increase the volume of
    medical services, as opposed to those providers that limit
    utilization and provide high quality care. The Medicare
    reimbursement structure is historically inflexible when it
    comes to designing and implementing more innovative policies
    and reimbursement structures. Private innovations, like paying
    for health care provider performance, and the adoption of
    prevention and wellness programs, are exceedingly difficult to
    duplicate in the Medicare structure given that it is a
    government-administered program which is highly resistant to
    change.
        Second, government health entitlement programs, like
    Medicare and Medicaid, routinely underpay health care
    providers, resulting in a cost-shift to private plans and
    private payers. This was confirmed in the testimony of a New
    Jersey hospital executive at a hearing before the Subcommittee
    on Health, Education, Labor and Pensions in March 2009.
    Reliance on existing Medicare payment rates, with minor
    adjustments, will, according to an estimate by The Lewin Group,
    an independent consulting company, significantly underpay
    health care providers, compensating them at rates 20-30 percent
    below what private plans pay for the same services. Even if
    adjustments are made to lower the underpayment rates, by
    design, the government-run plan will underpay providers to
    reduce premium costs, in order to increase enrollment and
    crowd-out private insurers. This inherent cost advantage built
    into the government plan created by H.R. 3200 will result in a
    government plan with artificially low premiums, which will
    likely have a negative impact on health care quality.
        These concerns were expressed in a letter from 13 health
    care providers and associations, including the Mayo Clinic, in
    a letter dated July 16, 2009 to Representative Ron Kind (D-WI).
    Specifically, these groups expressed concern that:

              . . . a public plan option with rates based on
            Medicare rates will have a severe negative impact on
            our facilities. Today, many providers suffer great
            financial losses associated with treating Medicare
            patients. For example, several of the systems that have
            signed onto this letter lost hundreds of millions of
            dollars under Medicare last year. These rates are
            making it increasingly difficult for us to continue to
            treat Medicare patients. The implementation of a public
            plan with similar rates will create a financial result
            that will be unsustainable for even the nation's most
            efficient, high quality providers, eventually driving
            them out of the market. In addition, should a public
            plan with inadequate rates be enacted, we will be
            forced to shift additional costs to private payers,
            which will ultimately lead to increased costs for
            employers who maintain insurance for their employees.
            We believe all Americans must have guaranteed portable
            health insurance, but it is critical that we not lose
            sight of the need to ensure adequate and equitable
            reimbursement.

        The results of a government-run health insurance plan are
    undeniable. Although Democrats argue the purpose of the
    government plan is to increase competition, it will have the
    exact opposite effect. Considering that the government plan
    will possess certain advantages (discussed above) it will not,
    by design, compete fairly with private insurance and group
    health plans. Studies of the effect of a government plan option
    indicate that there will be movement from private insurance
    coverage to a government-run plan which would concentrate
    control of health care with the government, which already
    controls almost half of the country's health care spending. For
    example, CBO analyses provided to the Committee on July 14 and
    July 17 indicate movement of individuals from private coverage
    to the government plan. In a June 2009 study, The Lewin Group
    found that a government plan open to all, and based on
    Medicare-level reimbursement rates, would result in almost 114
    million Americans losing their current private insurance
    coverage because of movement toward an artificially cheaper,
    benefit-rich government plan.\5\ Simply put, the availability
    of a government plan will create a cycle of increasing costs
    for those with private plans, forcing employers to drop
    coverage and pushing more workers into the government plan.
    ---------------------------------------------------------------------------
        \5\ See, The Impact of the House Health Reform Legislation on
    Coverage and Provider Incomes, Testimony of John Sheils, Vice
    President, The Lewin Group, before the Energy and Commerce Committee,
    U.S. House of Representatives, June 25, 2009. http://www.lewin.com/
    content/publications/June25TestimonyUpdateJul09.pdf.
    ---------------------------------------------------------------------------
        The new federal health care bureaucracy, with its myriad
    rules for private plans and government-run insurance option,
    will ultimately decrease the competitiveness of private
    insurance and group health plans, essentially resulting in a
    government takeover of the health care system. The government's
    track record on health care is not one to be duplicated; the
    Medicaid program does not pay for the full cost of medical
    care, is routinely underfunded, and places a substantial burden
    on states. The Democrat answer in H.R. 3200 is to increase
    Medicaid eligibility to 133 percent of the federal poverty
    level, which would exacerbate health care provider
    underpayments, create a new entitlement mentality, and
    substantially increase the federal government's Medicaid
    payments in perpetuity. Medicare underpays health care
    providers, is an outdated and inflexible benefit design, and
    has unfunded obligations totaling $37.8 trillion. The House
    Democrat answer is not to first fix Medicare but to create a
    new federal entitlement program for those under 65 based on
    Medicare, spend more than $1.3 trillion, and raise taxes on
    Americans. These policies do nothing to control existing health
    care costs, and only serve to worsen the nation's long-term
    fiscal outlook while removing decisions from the hands of
    doctors and patients and placing them in the hands of
    Washington bureaucrats.
        Clearly, if Americans like their current coverage and the
    quality of their health care, it will be in jeopardy under the
    Democrats' plan as set forth in H.R. 3200.
                Republican Alternative
        Committee Republicans agree that the health care system is
    in dire need of reform and stand ready to work with Committee
    Democrats to forge a truly bipartisan compromise. However,
    Committee Republicans believe the policies contained in H.R.
    3200, which seek to expand health care insurance coverage at
    great cost without first addressing and controlling underlying
    health care costs and provider shortages, are doomed to fail.
        Republicans agree with Democrats that the problem of the
    uninsured must be addressed. The Majority notes that 47 million
    individuals are uninsured; however, this population is not
    homogenous. According to a report released by the Congressional
    Research Service on September 14, 2009, approximately 20
    percent of the uninsured are non-citizens. Further,
    approximately 10 million more individuals may already be
    eligible for existing government insurance programs, but are
    not enrolled, and many millions more are young or voluntarily
    choose to go without coverage. Rather than creating a massive
    new federal entitlement program, Republicans believe underlying
    costs must be addressed in order to make coverage more
    affordable and accessible, with implementation of targeted
    approaches to address the specific characteristics of the
    uninsured population.
        The first step to lower health care costs is to address
    overspending in the current system.\6\ To lower costs,
    Committee Republicans would consider: changes to the tax code
    to permit individuals to share some of the same advantages as
    those with employer-sponsored coverage; promote incentives to
    save for future health care costs; promote meaningful medical
    liability reforms to reduce costly and unnecessary defensive
    medicine practices; provide existing government programs with
    additional authority and resources to stop fraud and abuse; and
    permit small business to band together to offer health
    insurance at lower costs.
    ---------------------------------------------------------------------------
        \6\ In testimony before the Senate Health, Education, Labor and
    Pensions Committee on July 16, 2009, 030 Director Douglas Elmendorf
    stated that all of the Democrat proposals reviewed to date, including
    H.R. 3200, do little, if anything, to control health care costs.
    ---------------------------------------------------------------------------
        Republicans and Democrats agree that small businesses face
    unique and difficult challenges in securing affordable health
    insurance coverage. Yet the Democrat response to this challenge
    is to construct an elaborate new federal bureaucracy and
    entitlement program, with the imposition of massive new taxes,
    administrative requirements and penalties on all but the very
    smallest employers, Republicans have tirelessly advocated for
    targeted, less costly measures to address the specific problems
    confronting small businesses--small business, or association,
    health plans constitutes one such measure that can be enacted
    immediately and would permit small businesses to band together
    to pool their purchasing power and enjoy the same benefits as
    larger employers.
        Additionally, Committee Republicans support policies that
    would provide employers with greater flexibility to promote
    prevention and wellness programs, and financially reward
    employees who seek to achieve or maintain a healthy weight,
    quit smoking, and better manage chronic diseases like diabetes.
    Changing payment structures to reward high quality care, rather
    than volume of medical services, and increasing care
    coordination, can also help control health care costs. Further,
    before creating another federal entitlement program and adding
    to the federal deficit, Committee Republicans believe it is
    necessary to address the long-term fiscal solvency of existing
    federal entitlement programs.
        Committee Republicans would also seek to expand access by
    strengthening employer-sponsored coverage to millions of people
    who are already eligible, encourage states to create or modify
    programs to guarantee all Americans have access to affordable
    coverage regardless of pre-existing medical conditions, promote
    policies to increase portability of coverage regardless of
    employment status, and help employers offer coverage by
    reducing administrative costs through a small business tax
    credit.
        In short, Committee Republicans support policies that
    promote individual behavior and responsibility for health care
    and coverage decisions, and maintain the doctor-patient
    relationship, while keeping the federal government out of the
    business of dictating health care coverage requirements or
    favoring a government-insurance model over private coverage.
    Committee Republicans remain willing to work with Democrats in
    developing a compromise bipartisan health care reform bill.
                Republican Amendments
        Committee Republicans offered twenty-six amendments during
    the Committee's consideration of H.R. 3200 on July 16 and 17.
    Republican amendments attempted to highlight significant
    concerns with H.R. 3200 and improve some of the more troubling
    provisions of the bill. In general, Committee Republicans
    offered solutions to the health care crisis, and expressed
    significant concerns regarding: the significant cost of H.R.
    3200; the adverse impact on the economy, workers, families and
    small businesses; the government takeover of the health care
    system; the fact that under H.R. 3200 those who like their
    coverage won't be able to keep it; preservation of the doctor-
    patient relationship; and opposition to likely rationing of
    medical care under the Democrat proposal.
        Specifically, Committee Republicans offered amendments
    intended to:
               Strike provisions creating the new ``Health
            Choices Administration;''
               Strike provisions creating the national
            health insurance exchange;
               Strike the employer ``pay or play'' mandate;
               Strike the government-run insurance plan;
               Ensure that the coverage provided by ERISA
            group health plans, now and in the future, would be
            preserved under the plan;
               Ensure deficit neutrality;
               Suspend the bill where the national
            unemployment rate exceeded 8% in two consecutive
            months;
               Preserve the protective remedies of ERISA
            for ERISA-governed plans;
               Prevent mandated coverage of abortion
            services;
               Prohibit federal funding for abortion
            services under the bill;
               Prohibit any tax increase on American
            families with annual incomes under $250,000;
               Provide employers and employees with greater
            flexibility to promote prevention and wellness
            programs, which are proven to increase personal
            responsibility and lower health care costs;\7\
    ---------------------------------------------------------------------------
        \7\ Specifically, Republicans offered an amendment to permit
    employers to vary employees' health insurance premiums by up to 50
    percent to encourage participation in health promotion and disease
    prevention programs. Current law already permits variations up to 20
    percent. Employer-based prevention and wellness programs have a proven-
    track record of improving employee health and lowering health care
    expenses and insurance coverage premiums. See, Paul Speranza, Jr.,
    Testimony before the Committee on Education and Labor, ``The Tri-
    Committee Draft for Health Care Reform'' (June 23, 2009) at 3-4. This
    amendment was voluntarily withdrawn in the hope that the Majority would
    work with Republicans to adopt this common-sense provision; Republicans
    continue to urge that this provision be included in any reform
    legislation.
    ---------------------------------------------------------------------------
               Permit consumer-directed health plans to
            remain viable options;\8\ and
    ---------------------------------------------------------------------------
        \8\ During this Committee's consideration of H.R. 3200, Republicans
    introduced an amendment to permanently grandfather consumer-directed
    health plans and arrangements, so that millions of individuals could
    continue to save for future health care needs and benefit from this
    coverage. The Majority rejected this amendment, which highlights the
    fact that if you like your current coverage, you will not be able to
    keep it under H.R. 3200.
    ---------------------------------------------------------------------------
               Permit small businesses to pool together to
            purchase health insurance through Association Health
            Plans.
        Each of these amendments was rejected, by and large on a
    party-line basis.
        Although some amendments were adopted in an attempt to
    improve the legislation,\9\ many attempts to amend and improve
    a flawed bill were rejected. Committee Republicans are
    concerned that the bill remains fundamentally flawed;
    nevertheless, Committee Republicans continue to stand ready to
    work with Committee Democrats to draft and enact bipartisan
    health care reform legislation.
    ---------------------------------------------------------------------------
        \9\ A limited number of amendments were adopted. For example, the
    Committee accepted language to exclude TRICARE (the Department of
    Defense's civilian healthcare program for active and retired military
    personnel) from the provisions of the bill; to express the sense of
    Congress that Members who vote for the bill enroll in the new
    government-run plan; to ensure non-discrimination for spiritual care;
    and to maintain the private right to contract for medical services.
    ---------------------------------------------------------------------------

    Conclusion

        Committee Republicans support the voluntary, private health
    care system and meaningful reforms to that structure, while
    opposing measures that would serve to increase federal
    government control over the health care system. Committee
    Republicans are also committed to ensuring that the costs of
    health care reform efforts do not add to the federal deficit or
    result in higher taxes, which will have the effect of
    restricting American economic growth. The goal of controlling
    health care spending is not accomplished by adding more than
    $1.3 trillion in new spending to America's health care bill.
    While perhaps well-intentioned, H.R. 3200 is not an acceptable
    health care reform bill. For all of the foregoing reasons, we
    respectfully oppose enactment of H.R. 3200 as reported from the
    Committee on Education and Labor.

                                       John Kline.
                                       Cathy McMorris Rodgers.
                                       Thomas E. Petri.
                                       Tom Price.
                                       Howard P. ``Buck'' McKeon.
                                       Rob Bishop (UT).
                                       Peter Hoekstra.
                                       Brett Guthrie.
                                       Michael N. Castle.
                                       Bill Cassidy.
                                       Mark E. Souder.
                                       Tom McClintock.
                                       Vernon J. Ehlers.
                                       Duncan D. Hunter.
                                       Judy Biggert.
                                       David P. Roe.
                                       Todd Russell Platts.
                                       Glenn Thompson.
                                       Joe Wilson.

                 SUPPLEMENTAL VIEWS OF THE HONORABLE TOM PRICE

        Over the course of nearly a quarter century as a physician,
    I cared for thousands of patients. And caring for each and
    every one of them was a privilege. So when I left the practice
    of medicine to shape public policy and the health care delivery
    system of this nation, I did so clinging to a steadfast
    aspiration to achieve full access to affordable, quality health
    care for all Americans, while preserving the patient-doctor
    relationship without governmental interference.
        Relying on my experiences as a physician, I can attest to
    how current federal laws and incentives retard access to health
    care and often put a bureaucrat in between a patient, his
    family, and their doctor. The tax code institutes a third-party
    health care model making it difficult for those to gain
    coverage outside of an employer or government entity. And the
    federal health care programs that do exist dictate to patients
    which doctors they may see and how frequently, and which
    procedures or tests doctors may or may not order or provide.
        H.R. 3200, America's Affordable Health Choices Act of 2009,
    marks the latest attempt to fundamentally alter our health care
    financing and delivery structure. This measure, however, is a
    transformational piece of legislation intended to erode
    personal and private decision-making while further
    institutionalizing the very errors of current federal health
    care laws and programs. The end result will be a system built
    on penalties, mandates, rationing, and bureaucracy--all of
    which are fundamental threats to quality care. For example:
         Sec. 102 of H.R. 3200 grandfathers out health
    insurance coverage on the individual market. Issuers of
    existing coverage may not enroll new individuals, alter
    benefits and cost-sharing, and increase premiums. These plans
    will no longer be available.
         Sec. 123 of H.R. 3200 creates the Health Benefits
    Advisory Committee, a new panel to recommend covered benefit
    standards, including treatments, items and services, and cost-
    sharing. The Committee is comprised primarily of either
    political appointees or federal bureaucrats, and these are the
    folks who will be making these critical decisions.
         Sec. 141 of H.R. 3200 creates the Health Choices
    Administration, a new federal agency charged with establishing
    the Health Insurance Exchange. The Administration is the final
    arbitrator of what is a qualified health benefits plan (i.e.
    ``acceptable'') under the exchange and is charged with
    enforcement.
         Sec. 301 and Sec. 401 of H.R. 3200 impose a
    ``personal responsibility'' on every American to obtain
    ``acceptable'' health insurance coverage or face a tax of 2.5
    percent on gross income.
         Sec. 313 and Sec. 412 of H.R. 3200 impose a tax of
    eight percent of average wages paid on employers. Providing
    health care to employees is no longer a voluntary benefit and
    only the smallest businesses are exempt.
         Sec. 221 of H.R. 3200 creates a public health
    insurance option, available through the Health Insurance
    Exchange, to ``compete'' against privately run health insurance
    coverage. Independent analysis by both the Congressional Budget
    Office and the Lewin Group has concluded that millions of
    Americans would lose their existing coverage as a result of
    this government-run plan.
        Certainly, the status quo is unacceptable. Yet, a true
    health care reform package empowers patients first; it builds
    on what is working and fixes what is flawed without disrupting
    or destroying quality care; it does not ingrain what is broken
    and scraps what works.
        Before consideration of H.R. 3200, a bipartisan,
    fundamental rethinking of this nation's health care delivery
    system could have been possible if reform focused on a patient-
    centered approach and championed personal ownership and
    coverage over government control. Further, any effort needed to
    embrace the same health care principles most Americans embrace:
    accessibility, affordability, choices, innovation, quality and
    responsiveness.
        As the leader of a group of conservative Republicans in the
    House of Representatives faithfully committed to these
    principles and the implementation of reform, I introduced H.R.
    3400, the Empowering Patients First Act. It represents the
    possibility of a new patient-centered era in American health
    care without putting the government in charge.
        For starters, the measure ensures all Americans have access
    to affordable coverage through a series of tax credits,
    deductions, and tax equity. It makes it feasible for
    individuals to pick any health care plan, not just what is
    offered by the government or at work, meaning that no matter
    who is paying the bill, patients own and control their own
    health plan. This puts Americans in a position whereby
    insurance companies are responsive to them rather than a third-
    party.
        There is portability to maintain coverage if someone
    changes jobs or moves across state lines. To establish a viable
    marketplace, barriers are knocked down so coverage can be
    purchased across state lines.
        And since one cannot be serious about reform without
    addressing the medical liability crisis, the Empowering
    Patients First Act provides for the creation of specialized
    health care courts relying on the expertise of medical
    specialty societies to relieve upward pressure on medical
    costs.
        This same commitment to principles and reform by dedicated
    Republicans inspired my personal efforts during the mark up of
    the America's Affordable Health Choices Act of 2009 before the
    Committee on Education and Labor. Yet every attempt to offer
    common sense amendments was defeated by Committee Democrats on
    near party line votes. For example:
               An amendment to ensure current coverage
            provided by employer-sponsored group plans would be
            considered a qualified health benefits plan. Rejecting
            the amendment flies in the face of ``If you like what
            you have, you can keep it,'' and restricts access to
            existing, affordable plans. (Amendment #11, defeated
            18-29).
               An amendment to permit states a waiver out
            of Division A of the Act, which contains the new health
            care bureaucracies, the individual and employer
            mandates, and the public health insurance option.
            Various states have already taken innovative steps to
            adopt comprehensive health care reform. (Amendment #29,
            defeated 19-28)
               An amendment to enable employers to
            contribute to a worker's account and permit that worker
            to purchase insurance coverage of his choice.
            (Amendment #40, defeated 19-29)
               An amendment to eliminate the ``tiered''
            payment structure for ``preferred'' and ``non-
            preferred'' physicians who participate in the public
            health insurance option. Without it, the existing
            provision forces health care providers to accept
            payments mandated by the federal government which are
            well below the actual cost and would likely result in
            the deterioration of quality care. (Amendment #41,
            defeated 19-29)
        In the end, the America's Affordable Health Choices Act of
    2009 rejects the health care principles most Americans embrace
    and embodies the go-it-alone attitude that House Democrats
    embarked on from the beginning. House Republicans were never
    consulted or brought into the process. In fact, more than 70
    percent of amendments offered by Republicans for final
    consideration in the mark up of the Committee on Education and
    Labor were defeated on near party line votes.
        It is why the end product is so terribly flawed and, if
    adopted, Congress will end up revisiting soon thereafter to
    correct many of its faults. It is with the sentiments outlined
    here that I oppose this legislation, and ask all House
    Republicans to do the same.

                                                             Tom Price.