[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.
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    \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.

                                  
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