comparison of house and senate health reform bills 11 24 09 - final

8/14/2019 Comparison of House and Senate Health Reform Bills 11 24 09 - FINAL

1/6

Issue Affordable Health Care for AmericaAct House Bill

Patient Protection and Affordable CareAct Senate Bill

Why This is Important

Prevention and Screening Services

Co-pays for preventionand screening services

Eliminates co-pays for all preventiveservices (including colorectal cancerscreening) that have a United StatesPreventive Services Task Force(USPSTF) A/B rating, and requirescoverage of these tests by privateinsurance.

Waives all Medicare co-pays (both co-insurance and deductibles) for preventiveservices.

Requires state Medicaid programs tocover (without co-pays) preventiveservices that are recommended by theUSPSTF and appropriate for Medicaidbeneficiaries.

Eliminates co-pays for all preventiveservices (including colorectal cancerscreening) that have a United StatesPreventive Services Task Force (USPSTF)A/B rating, and requires coverage of thesetests by private insurance.

Waives co-pays for most preventiveservices, requiring Medicare to cover 100percent of the costs. Services for which noco-pays or deductibles would be required

are the personalized prevention planservices and any covered preventive serviceif it is recommended with a grade of A or Bby the USPSTF.

Allows the Secretary of Health and HumanServices (HHS) to withdraw Medicarecoverage for a service not rated as A, B, C,or I by the USPSTF.

Eliminating co-pays for preventivecolorectal cancer screening will lower thecost of screening services for individualswhich will help to increase population-based screening rates.

Funding for publichealth activities

(including preventivescreenings)

Establishes a Prevention and WellnessTrust. Authorizes $15.4 billion in

funding over FY2011-FY2015 to fundprevention task forces, preventionwellness research, delivery ofcommunity-based prevention andwellness services, and core public healthinfrastructure and activities.

Establishes a prevention and public healthfund to be administered through the Office

of the Secretary at the Department of HHSto provide for an expanded and sustainednational investment in prevention andpublic health programs. This new fund willsupport public health activities includingprevention research and health screenings.

Also has a section regarding communitypreventive screenings, and specifically listscancer screenings as one of the communityinterventions needed to improve public

Funding for initiatives that incorporatecolorectal cancer screening are important to

increasing population-based screeningrates.

http://FightColorectalCancer.org/

November 24, 2009
http://fightcolorectalcancer.org/http://fightcolorectalcancer.org/http://fightcolorectalcancer.org/


2/6




health.

United StatesPreventive ServicesTask Force (USPSTF)

Converts the existing USPSTF into theTask Force on Clinical PreventiveServices. The task force is charged withconducting evidence based systemicreviews of data and literature todetermine which clinical preventiveservices (i.e., preventive servicesdelivered by traditional health careproviders in clinical settings) arescientifically proven to be effective.

Defines clear duties for both the USPSTFand the Task Force on CommunityPreventive Services (the Task Force onCommunity Preventive Services is anexisting task force that deals withpreventive programs and services outside ofthe doctor-patient relationship).

Provides for better coordination betweenthe two task forces.

The United States Preventive Services TaskForce (USPSTF) is the entity that setscreening guidelines for colorectal cancer.

Affordability of Care

Annual and lifetimelimits

No annual or lifetime limits for benefitsoffered under the essential benefitspackage.

Sets limits on maximum annual co-pays -$5,000 for an individual and $10,000 fora family.

Eliminates unreasonable annual limitsand lifetime limits on the dollar value ofbenefits for any participant or beneficiaryfor all group health plans and healthinsurance coverage required to provideessential health benefits (i.e., anyinsurance company or plan that participatesin the new health insurance exchange).

Many colorectal cancer patients face alifetime of cancer treatment. Caps oninsurance result in very difficult decisionsabout the care they will receive and howthey are going to pay for it.

Affordability of Insurance

High-risk pool Establishes a temporary three year highrisk plan to help those currentlyuninsured gain coverage. Includessubsidies for those under 400% of thefederal poverty level. Provides $5 billionto fund this program.

Establishes a temporary four year high riskhealth insurance pool to provide coverageto individuals until Jan. 1, 2014. Provides$5 billion to fund this program.

Many of the provisions in both the Houseand Senate bills will not take effectimmediately. Establishment of a high riskinsurance pool will help those individualswith pre-existing conditions afford healthinsurance until the provisions in the billeliminating pre-existing conditionexclusions take effect.


November 24, 2009


3/6




Pre-existing conditionsexclusions

No denial of coverage based on pre-existing health conditions in the plan.

A group health plan and a health insureroffering individual or group insurance maynot impose any pre-existing conditionexclusion with respect to such coverage.

Eliminating pre-existing conditionsexclusions is very important for cancerpatients. Pre-existing condition exclusionslock the millions of Americans with at leastone chronic illness (nearly one third of thepopulation) into existing plans andemployment.

C3 supports shortening the timeframe forthe elimination of pre-existing conditionexclusions and waiting periods for allindividuals in every health insurancemarket to ensure access to care.

Specifically, C3 supports shortening theimplementation timeframe to allow it tobegin in single insured and small groupplans in 2010 and to completeimplementation with large group and self-funded plans in 2011.

Expanding Access to Insurance

Increase number ofAmericans with accessto health insurance

Creates a public option, financed throughpremiums. It would use negotiated ratesno lower than Medicare rates.

Beginning in 2013, permanent privatehealth insurance market reforms wouldgreatly benefit cancer patients andsurvivors including the establishment ofa national health insurance exchangewhich would enable individuals whocannot get insurance through theiremployer to comparison shop.

Creates a community health insuranceoption and allows states to opt-out of theplan. Requires the HHS Secretary tonegotiate provider reimbursement rates not

higher than average rates paid by privateplans.

Increasing the number of Americans withhealth insurance will help reduce mortalityrates from colorectal cancer. Many studies

show that people who are uninsured aresubstantially less likely to be screened forcolorectal cancer. In addition, insurancestatus strongly influences survival amongthose diagnosed with colorectal cancer individuals with private insurance who arediagnosed with stage II colorectal cancerhave better survival outcomes thanindividuals who are uninsured and arediagnosed with stage I colorectal cancer.

What Services and Treatments Will Be Covered


November 24, 2009


4/6




Effect on statemandated colorectalcancer screeningbenefits

Nothing in the bill addresses thepreemption of state mandated colorectalcancer screening benefits.

Provides that insurers offering nationwideplans must clearly notify consumers thatthe policy may not contain some benefitsotherwise mandated and provide a detailedstatement of the benefits offered and thebenefit differences in that state.

Currently, at least 26 states and the Districtof Columbia require coverage of colorectalcancer screening tests. A few other statesrequire that they be offered or availablethrough Medicare Supplemental policies.

Required benefitspackage

The minimum services to be included inthe essential benefits package includepreventive services including thoseservices recommended with the grade ofA or B by the United States PreventiveServices Task Force (USPSTF).

The specifics of the plan would be basedon benefit standards recommended bythe Benefits Advisory Committee andadopted by the HHS Secretary.

Plans outside the exchange must offer atleast the essential benefits package.

The benefits covered in the essentialbenefits package will be defined by theHHS Secretary. The package will include,at a minimum, the following generalcategories: ambulatory patient services;emergency services; hospitalization;maternity and newborn care; mental healthand substance use disorder services;prescription drugs; rehabilitative servicesand devices; laboratory services; preventiveand wellness services and chronic diseasemanagement; pediatric services; and visioncare.

The HHS Secretary will determine thescope of the essential benefits package.The scope of the package should be equalin scope to the benefits provided under atypical employer plan. To inform this

determination, the Secretary of Labor shallconduct a survey of employer-sponsoredcoverage to determine the benefits typicallycovered by employers and report the resultsof the survey to the HHS Secretary.

This provision determines how coverage isdefined and what it will look like.

C3 strongly believes that colorectal cancerscreening and treatment should be a part ofthe minimum benefits package.

Benefits advisory panel Establishes a Health Benefits AdvisoryCommittee chaired by the SurgeonGeneral with private members appointedby the President, the ComptrollerGeneral, and representatives of relevantfederal agencies.

Does not include a benefits advisory panelor committee. The HHS Secretary willdetermine the scope of the essentialbenefits package.

Cancer patient advocates and health careprofessionals providing cancer care shouldbe included in the benefits packageadvisory panel. The work of defining abenefits package should not be left solelyto government officials, health plan


November 24, 2009


5/6




officials, and health economists withoutpatient and provider input. Patients andhealth care providers bring importantexpertise and experience to inform benefitdesign and ensure that the benefit packagereflects the needs of patients. The advisorypanel should also have procedures forpublic participation and to allow for rapidrevision of the benefits package, if medicalevidence supports such changes.

Medicare Payment and Reimbursement

Clinical trials Provides that the first $2,000 per year received by an individual forparticipation in a clinical trial shall notbe counted as income for the purpose ofcalculating Social Security benefits.

Establishes an Office of Womens Healthat the Food and Drug Administration(FDA) to look at (among other things)womens participation in clinical trials.

Establishes an Office of Womens Health atthe FDA to look at (among other things)womens participation in clinical trials.

Establishes a new nonprofit corporation,the Patient-Centered Outcomes ResearchInstitute, charged with conductingcomparative effectiveness research.Provides that the institute shall appointexpert advisory panels to advise theInstitute during clinical trials. Allows forthe coverage of copayments or coinsurancefor patients in a clinical trial to the extentthat such coverage or other measures arenecessary to preserve the validity of aresearch project.

Cancer advocates have worked steadily formore than a decade to ensure that third-party payers cover the routine patients carecosts incurred in clinical trials. TheMedicare clinical trials coverage policy hasbeen in place since 2000, and more thanhalf of the states have enacted clinical trialscoverage laws. These coverage standardsensure that cancer patients can receive theircare in clinical studies, providing themaccess to all treatment options and ensuringthat the pace of clinical research is not

slowed by reimbursement issues.

Medicare Date ofService Rule (14 DayRule)

Nothing in bill addresses this issue.Provides for a two year demonstrationproject for separate and direct payments toindependent laboratory for complexdiagnostic laboratory tests performed aftera patient has left the hospital.

When patients are in the hospital, blood ortissue samples are often collected fortesting. Medicare regulations state that thelaboratory performing the test must bill thehospital, rather than Medicare, for testingon these samples. This regulation remainsin place except for tests ordered 14 days or


November 24, 2009


6/6




more after a patient has left the hospital.This regulation can impede timely patientcare. Medicare has said that it wontrecognize and pay directly for independentlaboratory services unless they come 14days after a patient has left the hospital.

C3 supports including the provisions fromH.R. 1699, thePatient Access to CriticalLab Tests Act of 2009 in the final healthreform bill since it will eliminate barriers totimely access to care by allowingindependent laboratories that offer

advanced diagnostic testing to billMedicare directly.

Long Term Savings from Increased Colorectal Cancer Screenings

Recognition ofcolorectal cancerscreening as a costsaver

Colorectal cancer screening is notspecifically mentioned as a cost-savingmeasure. However, there is a mention ofa waiver of deductible for colorectalcancer screening tests regardless ofcoding, subsequent diagnosis, andancillary tissue removal.

Colorectal cancer screening is notspecifically mentioned as a cost-savingmeasure.

Expresses the Sense of the Senate thatCongress should work with theCongressional Budget Office to look atlong term savings from prevention and

wellness programs.

While colorectal cancer screening is notspecifically mentioned as a cost-savingmeasure in either bill, other initiatives suchas the national prevention and wellnesstrust funds would increase population-based colorectal cancer screening rates andthis has the power to focus on colorectalcancer screening as a preventive and cost-saving measure.


November 24, 2009

comparison of house and senate health reform bills 11 24 09 - final

Documents