Comparison Of Major Health Care Reform Proposals Side By Side

on Health Reform
This side-by-side compares the leading comprehensive reform proposals across a number of key characteristics and plan components. Included in this side-by-
side are proposals for moving toward universal coverage that have been put forward by the President and Members of Congress. In an effort to capture the most
important proposals, we have included those that have been formally introduced as legislation as well as those that have been offered as principles or in White
Paper form. This side-by-side will be regularly updated to reflect changes in the proposals and to incorporate major new proposals as they are announced.
The House Tri-Committee summary incorporates the major amendments to the legislation adopted by the three committees of jurisdiction during their mark-ups
of the bill. These amendments are identified using an abbreviation for the House panel that approved it — “E&C” for the Committee on Energy and Commerce;
“E&L” for the Committee on Education and Labor; and “W&M” for the Committee on Ways and Means.
Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Date plan announced
September 16, 2009
June 9, 2009
June 19, 2009
February 26, 2009
(passed by Committee October 13,
(passed by Committee July 15, 2009)
2009)
Overall approach
Require most U.S. citizens and legal Require individuals to have health
Require all individuals to have
President Obama outlined eight
to expanding access
residents to have health insurance.
insurance. Create state-based
health insurance. Create a Health
principles for health care reform
to coverage
Create state-based health insurance American Health Benefit Gateways
Insurance Exchange through which
in his FY 2010 Budget overview.
exchanges through which individuals through which individuals and small individuals and smaller employers
The President has indicated that
can purchase coverage, with premium businesses can purchase health
can purchase health coverage, with comprehensive health reform should:
and cost-sharing credits available
coverage, with subsidies available to premium and cost-sharing credits
• Reduce long-term growth of
to individuals/families with income
individuals/families with incomes up available to individuals/families
health care costs for businesses
between 100-400% of the federal
to 400% of the federal poverty level
with incomes up to 400% of the
and government.
poverty level (the poverty level is
(or $73,240 for a family of three in
federal poverty level (or $73,240 for • Protect families from bankruptcy or
$18,310 for a family of three in 2009) 2009). Require employers to provide a family of three in 2009). Require
debt because of health care costs.
and create separate exchanges through coverage to their employees or
employers to provide coverage to
which small businesses can purchase pay an annual fee, with exceptions
employees or pay into a Health
• Guarantee choice of doctors and
coverage. Assess a fee on certain
for small employers, and provide
Insurance Exchange Trust Fund,
health plans.
employers that do not offer coverage certain small employers a credit
with exceptions for certain small
• Invest in prevention and wellness.
for each employee who receives a tax to offset the costs of providing
employers, and provide certain
• Improve patient safety and quality
credit for health insurance through
coverage. Impose new regulations
small employers a credit to offset
care.
an exchange, with exceptions for
on the individual and small group
the costs of providing coverage.
• Assure affordable, quality health
small employers. Impose new
insurance markets. Expand
Impose new regulations on plans
coverage for all Americans.
regulations on health plans in the
Medicaid to all individuals with
participating in the Exchange and in • Maintain coverage when you
exchange and in the individual
incomes up to 150% of the federal
the small group insurance market.
change or lose your job.
and small group markets. Expand
poverty level.
Expand Medicaid to 133% of the
• End barriers to coverage for
Medicaid to all individuals with incomes
poverty level.
people with pre-existing medical
up to 133% of the federal poverty level.
conditions.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
1

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Individual mandate
• Require U.S. citizens and legal
• Require individuals to have
• Require all individuals to have
• The plan must put the country
residents to have qualifying health
qualifying health coverage.
“acceptable health coverage”.
on a clear path to cover all
coverage. Enforced through a tax
Enforced through a minimum tax
Those without coverage pay
Americans.
penalty of $750 per adult per year.
penalty of $750 per individual
a penalty of 2.5% of modified
The penalty will be phased-in
per year (maximum penalty per
adjusted gross income up to
according to the following schedule:
family of 4 times the individual
the cost of the average national
$0 in 2013; $200 in 2014; $400 in
penalty). Exemptions to the
premium for self-only or
2015; $600 in 2016; and $750 in
individual mandate will be granted
family coverage under a basic
2017. Exemptions will be granted
to residents of states that do not
plan in the Health Insurance
for financial hardship, religious
establish an American Health
Exchange. Exceptions granted for
objections, American Indians, and if
Benefit Gateway, members of
dependents, religious objections,
the lowest cost plan option exceeds
Indian tribes, those for whom
and financial hardship.
8% of an individual’s income or if
affordable coverage is not
the individual has income below
available, those without coverage
133% of the poverty level.
for fewer than 90 days, and those
with incomes below 150% FPL.
Employer requirements
• Assess employers with more than • Require employers to offer health • Require employers to offer
Not specified.
50 employees that do not offer
coverage to their employees and
coverage to their employees and
coverage a fee for each employee
contribute at least 60% of the
contribute at least 72.5% of the
who receives a tax credit for
premium cost or pay $750 for
premium cost for single coverage
health insurance through an
each uninsured full-time
and 65% of the premium cost for
exchange. The penalty is the
employee and $375 for each
family coverage of the lowest cost
lesser of a flat dollar amount
uninsured part-time employee
plan that meets the essential
equal to the average national tax
who is not offered coverage. For
benefits package requirements or
credit for each full-time employee
employers subject to the
pay 8% of payroll into the Health
receiving a tax credit or $400
assessment, the first 25 workers
Insurance Exchange Trust Fund.
times the total number of full-
are exempted.
[E&L Committee amendment:
time employees in the firm.
• Exempt employers with 25 or
Provide hardship exemptions
• Exempt employers with 50 or
fewer employees from the
for employers that would be
fewer employees from the penalty.
requirement to provide coverage.
negatively affected by job losses
• Require employers with 200 or
as a result of requirement.]
more employees to automatically
• Eliminate or reduce the pay
enroll employees into health
or play assessment for small
insurance plans offered by the
employers with annual payroll of
employer. Employees may opt out
less than $400,000:
of coverage if they have coverage
– Annual payroll less than
from another source.
$250,000: exempt
– Annual payroll between
$250,000 and $300,000: 2% of
payroll;
– Annual payroll between
$300,000 and $350,000: 4% of
payroll;
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
2

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Expansion of public
Require states to provide
• Grant individuals eligible for
low-income HIV-infected
programs (continued)
premium assistance to any
the Children’s Health Insurance
individuals and for family planning
Medicaid beneficiary with access
Program (CHIP) the option of
services to certain low-income
to employer-sponsored insurance
enrolling in CHIP or enrolling in
women. In addition, increase
if it is cost-effective for the state.
a qualified health plan through a
Medicaid payment rates for
To finance the coverage for the
Gateway.
primary care providers to 100% of
newly eligible (those who were
Medicare rates. [E&C Committee
not previously eligible for a full
amendment: Require states to
benchmark benefit package or
submit a state plan amendment
who were eligible for a capped
specifying the payment rates
program but were not enrolled),
to be paid under the state’s
states will receive an increase in
Medicaid program.] The coverage
the federal medical assistance
expansions (except the optional
percentage (FMAP). Initially, the
expansions) and the enhanced
percentage point increase in the
provider payments will be fully
FMAP will be 27.3 for states that
financed with federal funds. [E&C
already cover adults with incomes
Committee amendment: Replace
above 100% FPL and 37.3 for
full federal financing for Medicaid
other states. These percentage
coverage expansions with 100%
point increases will be adjusted
federal financing through 2014
over time so that by 2019, all
and 90% federal financing
states will receive an FMAP
beginning in year 2015.]
increase of 32.3 percentage points
• Require Children’s Health
for the newly eligible. High need
Insurance Program (CHIP)
states—those with total Medicaid
enrollees to obtain coverage
enrollment that is below the
through the Health Insurance
national average for enrollment
Exchange (in the first year the
as a percentage of the state
Exchange is available) provided
population and unemployment
the Health Choices Commissioner
rates of 12% or higher for August
determines that the Exchange
2009—will receive full federal
has the capacity to cover these
funding for the newly eligible for
children and that procedures
five years.
are in place to ensure the timely
• Require states to maintain
transition of CHIP enrollees
current income eligibility levels
into the Exchange without an
for children in Medicaid and the
interruption of coverage. [E&C
Children’s Health Insurance
Committee amendment: Require
Program (CHIP) until 2019. CHIP
that CHIP enrollees not be
benefit package and cost-sharing
enrolled in an Exchange plan
rules will continue as under
until the Secretary certifies that
current law. Beginning in 2014,
coverage is at least comparable
states will receive a 23 percentage
to coverage under an average
point increase in the CHIP match
CHIP plan in effect in 2011. The
rate up to a cap of 100% and a
Secretary must also determine
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Expansion of public
.15 percentage point increase in
that there are procedures to
programs (continued)
the Medicaid match rate. CHIP-
transfer CHIP enrollees into the
eligible children who are unable
exchange without interrupting
to enroll in the program due to
coverage or with a written plan of
enrollment caps will be eligible for
treatment.]
tax credits in the state exchanges.
Premium subsidies
• Provide refundable and
• Provide premium credits on a
• Provide affordability premium
• The plan must protect families’
to individuals
advanceable premium credits
sliding scale basis to individuals
credits to eligible individuals
from bankruptcy or debt because
to individuals and families with
and families with incomes up to
and families with incomes up to
of health care costs.
incomes between 133-400% FPL
400% FPL to purchase coverage
400% FPL to purchase insurance
• The American Recovery and
in 2013, and including individuals
through the Gateway. The
through the Health Insurance
Reinvestment Act makes coverage
and families with incomes
premium credits will be based
Exchange. The premium credits
more affordable for Americans
between 100-133% FPL in 2014, to
on the average cost of the three
will be based on the average cost
who lose their jobs and their
purchase insurance through the
lowest cost qualified health plans
of the three lowest cost basic
access to employer-based health
health insurance exchanges. The
in the area, but will be such that
health plans in the area and will
coverage by offering a subsidy of
premium credits will be tied to the
individuals with incomes less
be set on a sliding scale such
65 percent of the premium costs
second lowest-cost silver plan in
than 400% FPL pay no more than
that the premium contributions
for COBRA coverage.
the area and will be provided on
12.5% of income and individuals
are limited to the following
a sliding scale basis from 2% of
with incomes less than 150% FPL
percentages of income for
income for those at 100% FPL to
pay 1% of income, with additional
specified income tiers:
12% of income for those between
limits on cost sharing.
133-150% FPL: 1.5 - 3% of income
300-400% FPL.
• Limit availability of premium
150-200% FPL: 3 - 5% of income
• Exclude individuals with incomes
credits through the Gateway to
200-250% FPL: 5 - 7% of income
below 100% FPL from eligibility
U.S. citizens and lawfully residing
250-300% FPL: 7 - 9% of income
for the premium credits. These
immigrants who meet income
individuals will be eligible for
limits and are not eligible for
300-350% FPL: 9 - 10% of income
coverage through the Medicaid
employer-based coverage that
350-400% FPL: 10 - 11% of income
program.
meets minimum qualifying criteria [E&C Committee amendment:
• Provide cost-sharing subsidies to
and affordability standards,
Replaces the above subsidy
eligible individuals and families
Medicare, Medicaid, TRICARE,
schedule with the following:
with incomes between 100-200%
or the Federal Employee Health
133-150% FPL: 1.5 - 3% of income
FPL. For those with incomes
Benefits Program. Individuals
150-200% FPL: 3 – 5.5% of income
between 100-150% FPL, the cost-
with access to employer-based
200-250% FPL: 5.5 - 8% of income
sharing subsidies will result in
coverage are eligible for the
250-300% FPL: 8 - 10% of income
coverage for 90% of the benefit
premium credits if the cost of the
300-350% FPL: 10 - 11% of income
costs of the plan. For those with
employee premium exceeds 12.5%
350-400% FPL: 11 - 12% of income]
incomes between 150-200%, the
of the individuals’ income.
cost-sharing subsidies will result
[E&C Committee amendment:
in coverage for 80% of the benefit
Increase the affordability credits
costs of the plan.
annually by the estimated savings
achieved through adopting a
• Limit availability of premium
formulary in the public health
credits and cost-sharing subsidies
insurance option, pharmacy
through the exchanges to U.S.
benefit manager transparency
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
5

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Premium subsidies
exceptions). Individuals with
to individuals (continued)
access to employer-based
coverage are eligible for the
premium and cost-sharing
credits if the cost of the employee
premium exceeds 11% of
the individuals’ income [E&C
Committee amendment: To be
eligible for the premium and cost-
sharing credits, the cost of the
employee premium must exceed
12% of individuals’ income.].
Premium subsidies
• Provide small employers with
• Provide qualifying small
• Provide small employers with
Not specified.
to employers
fewer than 25 employees and
employers with a health options
fewer than 25 employees and
average annual wages of less
program credit. To qualify for the
average wages of less than
than $40,000 that purchase health
credit, employers must have fewer
$40,000 with a health coverage
insurance for employees with a
than 50 full-time employees, pay
tax credit. The full credit of 50% of
tax credit.
an average wage of less than
premium costs paid by employers
Phase I: For tax years 2011
$50,000, and must pay at least
is available to employers with 10
and 2012, provide a tax credit
60% of employee health expenses.
or fewer employees and average
of up to 35% of the employer’s
The credit is equal to $1,000
annual wages of $20,000 or less.
contribution toward the
for each employee with single
The credit phases-out as firm size
employee’s health insurance
coverage and $2,000 for each
and average wage increases and
premium if the employer
employee with family coverage,
is not permitted for employees
contributes at least 50% of the
adjusted for firm size (phasing
earning more than $80,000 per
total premium cost or 50% of
out as firm size increases) and
year.
a benchmark premium. The
number of months of coverage
• Create a temporary reinsurance
full credit will be available to
provided. Bonus payments are
program for employers providing
employers with 10 or fewer
given for each additional 10%
health insurance coverage to
employees and average annual
of employee health expenses
retirees ages 55 to 64. Program
wages of less than $20,000.
above 60% paid by the employer.
will reimburse employers for 80%
Tax-exempt small businesses
Employers may not receive
of retiree claims between $15,000
meeting these requirements
the credit for more than three
and $90,000. Payments from the
are eligible for tax credits of
consecutive years. Self-employed
reinsurance program will be used
up to 25% of the employer’s
individuals who do not receive
to lower the costs for enrollees in
contribution toward the
premium credits for purchasing
the employer plan. Appropriate
employee’s health insurance
coverage through the Gateway are
$10 billion over ten years for the
premium.
eligible for the credit.
reinsurance program.
Phase II: For tax years 2013
• Create a temporary reinsurance
and later, for eligible small
program for employers providing
businesses that purchase
health insurance coverage to
coverage through the state
retirees ages 55 to 64. Program
exchange, provide a tax credit
will reimburse employers for
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Creation of insurance
• Provide immediate assistance
• Create state-based American
• Create a National Health Insurance • The plan should provide portability
pooling mechanisms
until the new insurance market
Health Benefit Gateways,
Exchange, through which individuals
of coverage and should offer
rules go into effect for those
administered by a governmental
and employers (phasing-in eligibility
Americans a choice of health
with pre-existing conditions by
agency or non-profit organization,
for employers starting with smallest
plans.
creating a temporary high-risk
through which individuals and
employers) can purchase qualified
pool. Individuals who have been
small employers can purchase
insurance, including from private
denied health coverage due to a
qualified coverage. States may
health plans and the public health
pre-existing medical condition and
form regional Gateways or allow
insurance option.
who have been uninsured for at
more than one Gateway to operate • Restrict access to coverage
least six months will be eligible
in a state as long as each Gateway
through the Exchange to
to enroll in the high-risk pool and
serves a distinct geographic area.
individuals who are not enrolled
receive subsidized premiums. The • Restrict access to coverage
in qualified or grandfathered
high-risk pool will exist until 2013.
through the Gateways to
employer or individual coverage,
• Create state-based exchanges
individuals who are not
Medicare, Medicaid (with some
for the individual market and
incarcerated and who are not
exceptions), TRICARE, or VA
small business health options
eligible for employer-sponsored
coverage (with some exceptions).
program (SHOP) exchanges for
coverage that meets minimum
the small group market. Allow
qualifying criteria and affordability
small businesses with up to 100
standards, Medicare, Medicaid,
employees to purchase coverage
TRICARE, or the Federal Employee
through the SHOP exchanges
Health Benefits Program.
beginning in 2015 and permit
• Create a community health
states to allow businesses with
insurance option to be offered
more than 100 employees to
through state Gateways that
purchase coverage in the SHOP
complies with the requirements of
exchange beginning in 2017.
being a qualified health plan and
• Restrict access to coverage
meets the same requirements as
through the exchanges to U.S.
other plans relating to guarantee
citizens and legal immigrants.
issue and renewability, insurance
• Create the Consumer Operated
rating rules, quality improvement
and Oriented Plan (CO-OP)
and reporting, solvency
program to foster the creation of
standards, licensure, and benefit
non-profit, member-run health
plan information. Require the
insurance companies in all 50
community health insurance plan
states and District of Columbia.
to provide the essential benefits
To be eligible to receive funds,
package and offer coverage at
organizations must not be an
all cost-sharing tiers. Require
existing organization, substantially
that the costs of the community
all of its activities must consist of
health insurance plan be financed
the issuance of qualified health
through revenues from premiums,
benefit plans in each state in
require the plan to negotiate
which it is licensed, governance of
payment rates with providers, and
the organization must be subject
contract with qualified nonprofit
to a majority vote of its members,
entities to administer the plan.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
11

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Creation of insurance
must operate with a strong
Permit the plan to develop
[E&C Committee amendment:
pooling mechanisms
consumer focus, and any profits
innovative payment policies to
Permit members of the armed
(continued)
must be used to lower premiums,
promote quality, efficiency, and
forces and those with coverage
improve benefits, or improve the
savings to consumers. Require
through TRICARE or the VA to
quality of health care delivered to its
each State to establish a State
enroll in a health benefits plan
members. Require CO-OPs to meet
Advisory Council to provide
offered through the Exchange.]
the same requirements as private
recommendations on policies and • Create a new public health
insurance plans in the exchanges
procedures for the community
insurance option to be offered
related to solvency, licensure,
health insurance option.
through the Health Insurance
provider payments, network
• Require guarantee issue and
Exchange that must meet the same
adequacy, and any applicable state
renewability of health insurance
requirements as private plans
premium assessments.
policies in the individual and
regarding benefit levels, provider
• Require all state-licensed insurers
small group markets; prohibit
networks, consumer protections,
in the individual and small group
pre-existing condition exclusions;
and cost-sharing. Require the
markets to participate in the
prohibit insurers from rescinding
public plan to offer basic, enhanced,
exchanges.
coverage except in cases of
and premium plans, and permit it to
• Require guarantee issue and
fraud; and allow rating variation
offer premium plus plans. Finance
renewability and allow rating
based only on family structure,
the costs of the public plan through
variation based only on age
geography, the actuarial value of
revenues from premiums. For
(limited to 4 to 1 ratio), tobacco
the health plan benefit, tobacco
the first three years, set provider
use (limited to 1.5. to 1 ratio),
use (limited to 1.5 to 1 ratio), and
payment rates in the public plan
family composition, and geography
age (limited to 2 to 1 ratio).
at Medicare rates and allow bonus
in the non-group and the small
• Require plans participating in
payments of 5% for providers
group market (new rules for small
the Gateway to provide coverage
that participate in both Medicare
group market will be phased-
for at least the essential health
and the public plan and for
in over five years). Require risk
care benefits, meet network
pediatricians and other providers
adjustment in the individual
adequacy requirements, and
that don’t typically participate in
and small group markets and
make information regarding plan
Medicare. In subsequent years,
prohibit insurers from rescinding
benefits service area, premium
permit the Secretary to establish
coverage.
and cost sharing, and grievance
a process for setting rates. [E&C
• Require the exchanges to
and appeal procedures available
Committee amendment: Require
develop a standardized format
to consumers.
the public health insurance option
for presenting insurance
• Create three benefit tiers of plans
to negotiate rates with providers
options, create a web portal to
to be offered through the Gateways
so that the rates are not lower
help consumers find insurance,
based on the percentage of allowed
than Medicare rates and not
maintain a call center for
benefit costs covered by the plan:
higher than the average rates paid
customer service, and establish
– Tier 1: includes the essential
by other qualified health benefit
procedures for enrolling
health benefits, covers 76% of
plan offering entities.] Health care
individuals and businesses and
the benefit costs of the plan,
providers participating in Medicare
for determining eligibility for
and limits out-of-pocket costs
are considered participating
tax credits. Permit exchanges
to the Health Savings Account
providers in the public plan unless
to contract with state Medicaid
(HSA) current law limit ($5,950
they opt out.
agencies to determine eligibility
for individuals and $11,900 for
for tax credits in the exchanges.
families in 2010);
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
12

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Creation of insurance
• Create four benefit categories
– Tier 2: includes the essential
Permit the public plan to develop
pooling mechanisms
of plans plus a separate “young
health benefits, covers 84% of
innovative payment mechanisms,
(continued)
invincible plan” to be offered
the benefit costs of the plan,
including medical home and other
through the exchange, and in
and limits out-of-pocket costs
care management payments,
the individual and small group
to 50% of the HSA limit ($2,975
value-based purchasing, bundling
markets:
for individuals and $5,950 for
of services, differential payment
– Bronze plan represents
families); and
rates, performance based
minimum creditable coverage
– Tier 3: includes the essential
payments, or partial capitation
and would cover 65% of the
health benefits, covers 93% of
and modify cost sharing and
benefit costs of the plan, with
the benefit costs of the plan,
payment rates to encourage use
an out-of-pocket limit equal
and limits out-of pocket costs
of high-value services. [E&C
to the Health Savings Account
to 20% of the HSA limit ($1,190
Committee amendment: Clarify
(HSA) current law limit ($5,950
for individuals and $2,380 for
that the public health insurance
for individuals and $11,900 for
families).
option must meet the same
families in 2010);
• Require states to adjust payments
requirements as other plans
– Silver plan includes minimum
to health plans based on the
relating to guarantee issue and
benefits, covers 70% of the
actuarial risk of plan enrollees
renewability, insurance rating
benefit costs of the plan, with
using methods established by the
rules, network adequacy, and
the HSA out-of-pocket limits;
Secretary.
transparency of information.]
– Gold plan includes the minimum • Require the Gateway to certify
[E&C Committee amendment:
benefits, covers 80% of the
participating health plans, provide
Require the public health
benefit costs of the plan, with
consumers with information
insurance option to adopt a
the HSA out-of-pocket limits;
allowing them to choose among
prescription drug formulary.]
– Platinum plan includes the
plans (including through a
• Create four benefit categories of
minimum benefits, covers 90%
centralized website), contract with
plans to be offered through the
of the benefit costs of the plan,
navigators to conduct outreach
Exchange:
with the HSA out-of-pocket
and enrollment assistance, create
– Basic plan includes essential
limits;
a single point of entry for enrolling
benefits package and covers
– Young Invincible plan available to
in coverage through the Gateway
70% of the benefit costs of the
those 25 years old and younger
or through Medicaid, CHIP or
plan;
and provides catastrophic
other federal programs, and assist
– Enhanced plan includes
coverage only with the coverage
consumers with the purchase
essential benefits package,
level set at the HSA current law
of long-term care services and
reduced cost sharing compared
levels except that prevention
supports.
to the basic plan, and covers
benefits would be exempt from
• Prohibit plans participating in the
85% of benefit costs of the plan;
the deductible.
Gateways from discriminating
– Premium plan includes essential
• Reduce the out-of-pocket limits
against any provider because of
benefits package with reduced
for those with incomes up to 400%
a willingness or unwillingness to
cost sharing compared to the
FPL to the following levels:
provide abortions.
enhanced plan and covers 95%
– 100-200% FPL: one-third of the
of the benefit costs of the plan;
HSA limits ($1,983/individual
and $3,967/family);
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
1

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Creation of insurance
– 200-300% FPL: one-half of the
• Following initial federal support,
– Premium plus plan is a premium
pooling mechanisms
HSA limits ($2,975/individual
the Gateway will be funded by
plan that provides additional
(continued)
and $5,950/family);
a surcharge of no more than
benefits, such as oral health and
– 300-400% FPL: two-thirds of the
4% of premiums collected by
vision care.
HSA limits ($3,987/individual
participating health plans.
• Require guarantee issue and
and $7,973/family).
renewability; allow rating variation
• Permit states the option of
based only on age (limited to 2 to
creating a Basic Health Plan
1 ratio), premium rating area, and
for uninsured individuals with
family enrollment; and limit the
incomes between 133-200%
medical loss ratio to a specified
FPL. States opting to provide
percentage.
this coverage will contract with
• Require plans participating
multiple private plans to provide
in the Exchange to be state
coverage at the level of plans
licensed, report data as required,
in the exchanges. They are
implement affordability credits,
encouraged to include innovative
meet network adequacy
features in the contracts, such as
standards, provide culturally and
care coordination and incentives
linguistically appropriate services,
for using preventive services
contract with essential community
and should seek to contract with
providers, and participate in risk
managed care plans that meet
pooling. Require participating
specific performance measures.
plans to offer one basic plan for
States will receive 85% of the
each service area and permit
funds that would have been paid
them to offer additional plans.
as federal premium and cost-
[E&C Committee amendment:
sharing subsidies for eligible
Require plans to provide
individuals in the state with
information related to end-of-life
incomes between 133-200% FPL
planning to individuals and provide
to establish the Basic Health
the option to establish advance
Plan. Individuals with incomes
directives and physician’s order
between 133-200% FPL in states
for life sustaining treatment.]
creating Basic Health Plans will
• Require risk adjustment of
not be eligible for subsidies in the
participating Exchange plans.
exchanges.
• Provide information to consumers
• Require that at least one plan in
to enable them to choose among
the exchanges provide coverage
plans in the Exchange, including
for abortions beyond those for
establishing a telephone hotline
which federal funds are permitted
and maintaining a website and
and require that at least one plan
provide information on open
in the exchange does not provide
enrollment periods and how to
coverage for abortions beyond
enroll.
those for which federal funds are
permitted (in cases of rape or
incest or to save the life of the
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
1

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Benefit design
• Prohibit abortion coverage from
• Specify the criteria for minimum
[E&C Committee amendment:
(continued)
being required as part of the
qualifying coverage for purposes
Prohibit abortion coverage from
minimum benefits package;
of meeting the individual mandate
being required as part of the
require segregation of public
for coverage, and an affordability
essential benefits package;
subsidy funds from private
standard such that coverage is
require segregation of public
premium payments for plans that
deemed unaffordable if the
subsidy funds from private
choose to cover abortion services
premium exceeds 12.5% of an
premiums payments for plans that
beyond Hyde—which allows
individual’s adjusted gross income.
choose to cover abortion services
coverage for abortion services to
beyond Hyde—which allows
save the life of the woman and
coverage for abortion services to
in cases of rape or incest; and
save the life of the woman and
require there be no effect on state
in cases of rape or incest; and
or federal laws on abortions.
require there be no effect on state
or federal laws on abortions.]
• All qualified health benefits plans,
including those offered through
the Exchange and those offered
outside of the Exchange (except
certain grandfathered individual
and employer-sponsored plans)
must provide at least the essential
benefits package.
Changes to private
• Impose the same insurance
• Impose the same insurance
• Prohibit coverage purchased
• The plan must end barriers to
insurance
market regulations relating
market regulations relating
through the individual market from
coverage for people with pre-
to guarantee issue, premium
to guarantee issue, premium
qualifying as acceptable coverage
existing medical conditions.
rating, prohibitions on pre-
rating, prohibitions on pre-
for purposes of the individual
existing condition exclusions,
existing condition exclusions,
mandate unless it is grandfathered
risk adjustment, and rescissions
and prohibitions on insurance
coverage. Individuals can purchase
in the individual market, in the
plan rescissions in the individual
a qualifying health benefit plan
exchange, and in the small group
and group markets and in
through the Health Insurance
market, phasing in the new rules
the American Health Benefit
Exchange.
for small group market over five
Gateways. (See new rating and
• Impose the same insurance
years. (See new rating and market
market rules in Creation of
market regulations relating to
rules in Creation of insurance
insurance pooling mechanism).
guarantee issue, premium rating,
pooling mechanism.)
• Require health insurers to report
and prohibitions on pre-existing
• Require health plans to report the
their medical loss ratio.
condition exclusions in the insured
proportion of premium dollars
• Require health insurers to provide
group market and in the Exchange
spent on items other than medical
financial incentives to providers
(see creation of insurance pooling
care and require plans to compile
to better coordinate care through
mechanism).
information on coverage in a
case management and chronic
standard format.
disease management, promote
wellness and health improvement
activities, improve patient safety,
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
1

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Changes to private
• Require all new policies (except
reduce medical errors,
• Limit health plans’ medical
insurance (continued)
stand-alone dental, vision, and
and provide culturally and
loss ratio to a percentage
long-term care insurance plans)
linguistically appropriate care.
specified by the Secretary to be
to comply with one of the four
• Provide dependent coverage
enforced through a rebate back
benefit categories, including those
for children up to age 26 for all
to consumers. [E&L Committee
offered through the exchanges
individual and group policies.
amendment: Limit health plans’
and those offered outside of
• Require insurers and group plans
medical loss ratio to at least 85%.]
the exchanges. Require health
to notify enrollees if coverage does • Improve consumer protections by
plans in the individual and small
not meet minimum qualifying
establishing uniform marketing
group markets to at least offer
coverage standards for purposes
standards, requiring fair grievance
coverage in the silver and gold
of satisfying the individual
and appeals mechanisms,
categories. Existing individual and
mandate for coverage.
and prohibiting insurers from
employer-sponsored plans do
• Permit licensed health insurers
rescinding health insurance
not have to meet the new benefit
to sell health insurance policies
coverage except in cases of fraud.
standards. (See description of
outside of the Gateway. States
• Adopt standards for financial
benefit categories in Creation of
will regulate these outside-the-
and administrative transactions
insurance pooling mechanism.)
Gateway plans.
to promote administrative
• Require small employers to
simplification.
provide a plan with a deductible
• Create the Health Choices
that does not exceed $2,000
Administration to establish
for individuals and $4,000 for
the qualifying health benefits
families unless contributions
standards, establish the
are offered that offset deductible
Exchange, administer the
amounts above these limits. This
affordability credits, and
deductible limit will not affect the
enforce the requirements for
actuarial value of bronze plans
qualified health benefit plan
and does not apply to “young
offering entities, including those
invincible” plans. (See description
participating in the Exchange or
of benefit categories in Creation of
outside the Exchange.
insurance pooling mechanism.)
• Allow states the option of merging
the individual and small group
markets.
• Create a temporary reinsurance
program to help stabilize
premiums during the first
three years of operation of
the exchanges when the risk
of adverse selection due to
enforcement of the new rating
rules and market changes is
greatest. Finance the reinsurance
program through mandatory
contributions by health insurers.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
1

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Cost containment
• Eliminate fraud, waste, and abuse
(continued)
in public programs through more
intensive screening of providers,
the development of the “One PI
database” to capture and share
data across federal and state
programs, increased penalties
for submitting false claims, and
increase funding for anti-fraud
activities.
Improving quality/health • Simplify health insurance
• Develop a national quality
• Support comparative effectiveness • The plan must ensure the
system performance
administration by adopting a
improvement strategy that includes
research by establishing a Center
implementation of patient safety
single set of operating rules for
priorities to improve the delivery of
for Comparative Effectiveness
measures and provide incentives
eligibility verification, claims
health care services, patient health
Research within the Agency
for changes in the delivery
status, claims payment, and the
outcomes, and population health.
for Healthcare Research and
system to reduce unnecessary
electronic transfer of funds.
Publish an annual national health
Quality to conduct, support, and
variability in patient care. It must
• Establish a non-profit Patient-
care quality report card. Create an
synthesize research on outcomes,
support the widespread use of
Centered Outcomes Research
inter-agency Working Group on
effectiveness, and appropriateness
health information technology
Institute to identify research
Health Care Quality to coordinate
of health care services and
and the development of data
priorities and conduct research
and streamline federal quality
procedures. An independent
on the effectiveness of medical
that compares the clinical
activities related to the national
CER Commission will oversee
interventions to improve the
effectiveness of medical
quality strategy.
the activities of the Center. [E&C
quality of care delivered.
treatments. The Institute will be
• Develop, through a multi-
Committee amendment: Prohibit
• To lay the foundation for improving
overseen by an appointed multi-
stakeholder process, quality
use of comparative effectiveness
the health care delivery system
stakeholder Board of Governors
measures that allow assessments
research findings to deny or
and quality of care, the American
and will be assisted by expert
of health outcomes; continuity
ration care or to make coverage
Recovery and Reinvestment
advisory panels.
and coordination of care; safety,
decisions in Medicare.]
Act invests $19 billion in health
• Encourage states to develop
effectiveness and timeliness
• Strengthen primary care and
information technology, including
and test alternatives to the
of care; health disparities;
care coordination by increasing
$17 billion in incentives to
current civil litigation system as
and appropriate use of health
Medicaid payments for primary
providers to encourage their use
a way to improve patient safety,
care resources. Require public
care providers, providing Medicare
of electronic medical records,
reduce medical errors, increase
reporting on quality measures
bonus payments to primary care
and provides $1.1 billion for
the availability of a prompt
through a user-friendly website.
practitioners (with larger bonuses
comparative effectiveness
and fair resolution of disputes,
paid to primary care practitioners
research.
and improve access to liability
serving in health professional
insurance, while preserving an
shortage areas).
individual’s right to seek redress
in court. Recommend that
Congress consider establishing
a state demonstration project
to evaluate alternatives to the
current litigation system.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
2

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Improving quality/health • Establish a national Medicare pilot • Create a Center for Health
• Conduct Medicare pilot programs
system performance
program to develop and evaluate
Outcomes Research and
to test payment incentive models
(continued)
paying a bundled payment for
Evaluation within the Agency for
for accountable care organizations
acute, inpatient hospital services
Healthcare Research and Quality
and bundling of post-acute
and post-acute care services for an
to conduct and support research
care payments, and conduct
episode of care that begins three
on the effectiveness of health
pilot programs in Medicare and
days prior to a hospitalization and
care services and procedures to
Medicaid to assess the feasibility
spans 30 days following discharge.
provide providers and patients
of reimbursing qualified patient-
If the pilot program achieves stated
with information on the most
centered medical homes. [E&C
goals, develop a plan for making
effective therapies for preventing
Committee amendment: Adopt
the pilot a permanent part of the
and treating health conditions.
accountable care organization,
Medicare program.
The Center will be overseen by
bundled payment, and medical
• Establish a hospital value-based
an appointed multi-stakeholder
home models on a large scale if
purchasing program in Medicare to
advisory council.
pilot programs prove successful at
pay hospitals based on performance • Provide grants for improving
reducing costs.] [E&C Committee
on quality measures and extend the
health system efficiency, including
amendment: Conduct accountable
Medicare physician quality reporting
grants to establish community
care organization pilot programs
initiative beyond 2010.
health teams to support a medical
in Medicaid.]
• Improve care coordination for dual
home model; to implement
• [E&C Committee amendment:
eligibles by creating a new office
medication management
Establish the Center for
within the Centers for Medicare
services for treatment of chronic
Medicare and Medicaid Payment
and Medicaid services, the Federal
conditions; to design and
Innovation Center to test
Coordinated Health Care Office,
implement regional emergency
payment models that address
to align Medicare and Medicaid
care and trauma systems.
populations experiencing poor
benefits, administration, oversight • Require hospitals to report
clinical outcomes or avoidable
rules, and policies for dual
preventable readmission rates;
expenditures. Evaluate all models
eligibles.
hospitals with high re-admission
and expand those models that
• Develop a national quality
rates will be required to work with
improve quality without increasing
improvement strategy that includes
local patient safety organizations
spending or reduce spending
priorities to improve the delivery
to improve their rates.
without reducing quality, or both.]
of health care services, patient
• Create a Patient Safety Research
• [W&M Committee amendment:
health outcomes, and population
Center charged with identifying,
Require the Institute of Medicine
health. Create processes for the
evaluating, and disseminating
to conduct a study on geographic
development of quality measures
information on best practices for
variation in health care spending
involving input from multiple
improving health care quality.
and recommend strategies for
stakeholders and for selecting
• Develop interoperable standards
addressing this variation by
quality measures to be used in
for using HIT to enroll individuals
promoting high-value care.]
reporting to and payment under
in public programs and provide
• Improve coordination of care
federal health programs. Establish
grants to states and other
for dual eligibles by creating a
the Medicaid Quality Measurement
governmental entities to adopt
new office or program within
Program to establish priorities for
and implement enrollment
the Centers for Medicare and
the development and advancement
technology.
Medicaid Services.
of quality measures for adults in
Medicaid.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
2

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Prevention/wellness
• Require Medicaid coverage
• Award competitive grants to
• Improve prevention by covering
(continued)
for tobacco cessation services
state and local governments and
only proven preventive services in
for pregnant women, and for
community-based organizations
Medicare and Medicaid. Eliminate
states that provide coverage for
to implement and evaluate
any cost-sharing for preventive
and remove cost-sharing for
proven community preventive
services in Medicare and increase
preventive services recommended
health activities to reduce chronic
Medicare payments for certain
by the US Preventive Services
disease rates and address health
preventive services to 100% of
Task Force and recommended
disparities.
actual charges or fee schedule
immunizations, provide a one
• Prohibit insurance plans from
rates.
percentage point increase in the
charging cost-sharing (except
FMAP for these services and for
minimal cost-sharing) for
the tobacco cessation services.
preventive services. Permit
• Create a new Medicaid state
insurers to create incentives for
plan option to permit Medicaid
health promotion and disease
enrollees with at least two chronic
prevention practices.
conditions, one condition and risk • Permit employers to offer
of developing another, or at least
employees rewards—in the form
one serious and persistent mental
of premium discounts, waivers
health condition to designate a
of cost-sharing requirements, or
provider as a health home. Provide
benefits that would otherwise not
states taking up the option with
be provided—of up to 30% of the
90% FMAP for two years.
cost of coverage for participating
• Prohibit insurance plans (except
in a wellness program and
existing grandfathered plans and
meeting certain health-related
those that use a value-based
standards. Employers must
insurance design) from charging
offer an alternative standard
cost-sharing for preventive services.
for individuals for whom it
• Allow insurers to vary premium
is unreasonably difficult or
rates based on tobacco use. Any
inadvisable to meet the standard.
insurer that rates based on
The limit may be increased to 50%
tobacco use must provide
of the cost of coverage if deemed
coverage for comprehensive
appropriate. Encourage employers
tobacco cessation programs,
to provide wellness programs by
including counseling and
conducting targeted educational
pharmacotherapy.
campaigns to raise awareness of
• Provide grants to small
the value of these programs.
businesses to establish
• Provide grants to states to create
comprehensive, evidence-based
temporary Right Choices Programs
workplace wellness programs.
to provide uninsured adults with
• Permit employers to offer
incomes below 350% FPL access
employees rewards of up to 30%
to a one-time health risk appraisal,
of the cost of coverage for
referrals for preventive services, and
participating in a wellness
referrals to safety net providers for
program. Rewards may be in the
treatment of diagnosed illnesses.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
2

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Other investments
• Make improvements to the
• Establish a National Health
• Make improvements to the
• As an initial investment in
Medicare program:
Care Workforce Commission to
Medicare program:
strengthening the health care
– Provide a 50% discount on
make recommendations and
– Reform the sustainable growth
workforce, the American Recovery
brand-name prescriptions
disseminate information on health
rate for physicians, with
and Reinvestment Act provides
filled in the Medicare Part D
workforce priorities, goals, and
incentive payments for primary
$500 million to train the next
coverage gap for enrollees,
policies including education and
care services, and for services in
generation of doctors and nurses.
other than those who receive
training, workforce supply and
efficient areas;
low-income subsidies and those
demand, and retention practices.
– Eliminate the Medicare Part D
with incomes above $85,000/
• Increase the supply of health
coverage gap (phased in over
individual and $170,000/couples;
care professionals by increasing
15 years) and require drug
– Make Part D cost-sharing
loans for nursing students and
manufacturers to provide a
for full-benefit dual eligible
establishing loan repayment
50% discount on brand-name
beneficiaries receiving home
programs for public health
prescriptions filled in the
and community-based care
workers and pediatric specialists.
coverage gap;
services equal to the cost-
Expand funding for the National
– Increase the asset test for
sharing for those who receive
Health Service Corps.
Medicare Savings Program and
institutional care; and
• Support training of health
Part D Low-Income Subsidies to
– Provide a one-year increase
professionals in direct care,
$17,000/$34,000; and
in physician payments under
primary care, and dentistry;
– Eliminate any cost-sharing for
Medicare to prevent a reduction
provide health education and
preventive services in Medicare
in fees that would otherwise
training grants for professionals
and increase Medicare payments
take effect, with 10% bonus
in geriatric care and mental and
for certain preventive services
payments for primary care.
behavioral health; and provide
to 100% of actual charges or fee
Provide general surgeons
prevention, public health, and
schedule rates.
and primary care physicians
cultural competence training for
• Reform Graduate Medical
practicing in health professional
health care professionals.
Education to increase training
shortage areas with a 10%
• Improve access to care by
of primary care providers
Medicare bonus.
providing additional funding
by redistributing residency
• Establish a multi-stakeholder
to increase the number of
positions and promote training in
Workforce Advisory Committee
community health centers and
outpatient settings and support
to develop a national workforce
school-based health centers and
the development of primary care
strategy for recruiting, training,
nurse-managed health clinics.
training programs.
and retaining a health care
• Support training of health
workforce that meets current and
professionals, including advanced
projected health care needs.
education nurses, who will practice
• Increase the number of Graduate
in underserved areas; establish
Medical Education (GME) training
a public health workforce corps;
positions by redistributing
and promote training of a diverse
currently unused slots, with
workforce and provide cultural
priorities given to primary care
competence training for health
and general surgery and to
care professionals.
states with the lowest resident
physician-to-population ratios,
and increase flexibility in laws and
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
2

Senate Finance Committee
Senate HELP Committee
House Tri-Committee
America’s Healthy Future Act
Affordable Health Choices Act
America’s Affordable Health
President Obama
of 2009
(S. 1679)
Choices Act of 2009 (H.R. 3200)
Principles for Health Reform
Financing
CBO estimates the cost of the
The Congressional Budget Office
The Congressional Budget Office
President Obama dedicated $630
coverage components of the
estimates this proposal will cost
estimates the net cost of the proposal billion over ten years toward a
Chairman’s Mark, as amended during $645 billion over 10 years. Because (less payments from employers and
Health Reform Reserve Fund in his
mark-up, to be $829 billion over
the Senate HELP Committee does
uninsured individuals) to be $1.042
budget outline released in February
ten years. These costs are financed
not have jurisdiction over the
trillion over ten years. Approximately 2009 to partially offset the cost of
through a combination of savings
Medicare and Medicaid programs
half of the cost of the plan is financed health reform.
from Medicare and Medicaid and new or revenue raising authority,
through savings from Medicare and
taxes and fees. The net savings from
mechanisms for financing the
Medicaid, including incorporating
Medicare and Medicaid are estimated proposal will be developed in
productivity improvements into
to be $404 billion over ten years and
conjunction with the Senate Finance Medicare market basket updates,
the primary sources of these savings Committee.
reducing payments to Medicare
include incorporating productivity
Advantage plans, changing drug
improvements into Medicare market
rebate provisions, reducing potentially
basket updates, reducing payments to
preventable hospital readmissions,
Medicare Advantage plans, creating
and cutting Medicaid DSH payments.
the Medicare Commission charged
The remaining costs are financed
with finding savings in the program,
through a surcharge imposed on
changing the Medicaid drug rebate
families with incomes above $350,000
provisions, and cutting Medicaid
and individuals with incomes above
and Medicare DSH payments.
$280,000. The surcharge is equal to
(See descriptions of cost savings
1% for families with modified adjusted
provisions in Cost containment.) The
gross income between $350,000
largest source of new revenue will
and $500,000; 1.5% for families with
come from an excise tax on high cost
modified adjusted gross income
insurance, which CBO estimates will
between $500,000 and $1,000,000;
raise $201 billion over ten years.
and 5.4% for families with modified
Additional revenue provisions will
adjusted gross income greater
generate $196 billion over the same
than $1,000,000. These surcharge
time period. (See Tax changes related
percentages may be adjusted if
to health insurance.) CBO estimates
federal health reform achieves
the proposal will reduce the deficit by
greater than expected savings.
$81 billion over ten years.
Sources of information
http://www.finance.senate.gov/
http://help.senate.gov/
Ways and Means Committee:
http://www.whitehouse.gov/omb/
sitepages/baucus.htm
http://waysandmeans.house.gov/
budget/
MoreInfo.asp?section=52
http://www.HealthReform.gov
Energy and Commerce Committee:
http://energycommerce.house.
gov/index.php?option=com_content
&view=article&id=1687&catid=156&
Itemid=55
Education and Labor Committee:
http://edlabor.house.gov/
newsroom/2009/07/ed-labor-
approves-historic-hea.shtml
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
0

Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes
Rep. John Conyers
Rep. John Dingell
Patients’ Choice Act of 2009
U.S. National Health Care Act
National Health Insurance Act
(S. 1099 and H.R. 2520)
(H.R. 676)
(H.R. 15)
Date plan announced
May 20, 2009
January 26, 2009
January 6, 2009
(Has introduced similar legislation in each
Congressional session since 1957)
Overall approach
Create state-based health insurance exchanges
Create a public health insurance program for
Create a national health insurance program for
to expanding access
through which private plans offer coverage
all U.S. residents. Replace employer coverage
individuals meeting eligibility requirements.
to coverage
meeting certain benefit and other standards.
and eliminate the Medicare, Medicaid and CHIP
Require states to administer the program
Employers can continue to provide coverage
programs. Individuals are not required to pay
and provide for equivalent care for “needy”
to their employees, but the current tax
premiums or cost-sharing. Require conversion
individuals who do not meet eligibility
preference for employer-sponsored insurance
to a non-profit health care system. Provide
requirements. A National Health Insurance
will be replaced with a tax credit of $2,290 for
for global budgets for hospitals and negotiate
Board determines allotments for the classes of
individuals and $5,710 for families to provide
annual reimbursement rates with physicians
covered services. Financed by a value-added tax
incentives for insurance coverage. Maintain
and other non-institutional providers. Finance
imposed on certain transactions.
Medicaid coverage for low-income people with
program by redirecting current federal and state
disabilities, but integrate low-income families
health care spending, impose an employer/
currently eligible for Medicaid into private
employee payroll tax, and leverage additional
insurance.
taxes.
Individual mandate
• No requirement for individuals to have
• All individuals residing in the US are covered
• Individuals meeting certain requirements are
coverage. Permit states to establish procedures
under the United States National Health Care
entitled to benefits under the National Health
to automatically enroll individuals into low-
Act (USNHC).
Insurance Program.
cost, high-deductible coverage through the
exchange and to provide incentives to individuals
to maintain coverage from year to year.
Employer requirements
No provision.
No provision.
No provision.
Expansion of public
• Restructure the Medicaid program to provide
• Create a new public plan, the USNHC program, • Create a new public plan, covering medical,
programs
acute care only to low-income people with
that provides coverage for a comprehensive set
dental, podiatric, home-nursing, hospital, and
disabilities, children in foster care, low-income
of benefits, including long-term care services,
auxiliary services. A National Health Insurance
women with breast or cervical cancer, and
to all US residents.
Board, in consultation with a National Advisory
certain TB-infected individuals. Integrate
• Eliminate the Medicare, Medicaid, and CHIP
Medical Council determines the scope of
low-income families into private insurance
programs as beneficiaries of these programs
benefits consistent with the statute.
by providing them with a tax credit plus other
are eligible for the USNHC program.
• Continue Medicare, but enrollees may be
financial support. Eliminate the entitlement
• VA health programs will remain independent
transferred into the new program in the future.
for long-term care services under Medicaid
for 10 years after which they will either remain
Medicare beneficiaries are covered under the
and replace it with a block grant to states for
independent or be integrated into the USNHC
new program for services that are not covered
long-term care services for eligible elderly and
program. The Indian Health Service will remain
by Medicare.
disabled individuals.
independent for 5 years after which it will be
• Require states to provide equivalent services to
• Allow private facilities to compete with
integrated into the USNHC program.
those not eligible under the new plan. Current
Veteran’s Administration facilities to provide
federal Medicaid funds and other federal funds
care to veterans.
provided to states under the Social Security Act
• Allow eligible American Indians to access
are available for this purpose.
medical care outside of Indian Health Service
facilities.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
1

Sens. Tom Coburn and Richard Burr
Reps. Paul Ryan and Devin Nunes
Rep. John Conyers
Rep. John Dingell
Patients’ Choice Act of 2009
U.S. National Health Care Act
National Health Insurance Act
(S. 1099 and H.R. 2520)
(H.R. 676)
(H.R. 15)
State role
• Create, at state option, state health insurance
No provision.
• Assume responsibility for administration of the
exchanges that meet federal standards.
program. States must submit a state plan of
• Form voluntary compacts (at state option) with
operations that designates a state agency for
other state exchanges to diversify pooling,
administering the program benefits; creates,
ease administrative burdens, and increase the
among other things, an advisory committee;
availability of innovative insurance products.
establishes local health service areas to
further decentralize program administration;
and provides a plan for ensuring that benefits
will be provided efficiently and to all areas of
the state.
Cost containment
• Encourage adoption and use of health
• Establish annual budgets for health care
• Require the National Health Insurance
information technology by providing incentives
professional staffing, capital expenditures,
Board to establish allotments for each of five
to hospitals and individual providers. Create
reimbursement for providers, and health
classes of services to be provided under the
personal health records maintained by an
professional education.
program (medical services, dental services,
independent health record bank and available
• Pay institutional providers, including hospitals,
home-nursing services, hospital services,
to the individual through a card, much like an
nursing homes, community or migrant health
and auxiliary services). Allotments are made
ATM card.
centers, home care agencies, and other
to the states based on population, medical
• Allow providers to form accountable care
institutional and prepaid group practices,
professionals and facilities, and cost of
organizations and receive bonuses in Medicare
a monthly lump sum to cover operating
services.
if they improve quality and satisfaction while
expenses.
• Require a study of cost control mechanisms,
also lowering costs.
• Pay physicians and other non-institutional
including an analysis of the impact on medical
• Adopt competitive bidding for Medicare
providers based on a simplified fee scheduled
malpractice claims and liability insurance on
Advantage plans and set the benchmark bid to
or as a salaried employee in an institution
health care costs.
106% of Medicare fee-for-service payments.
receiving a global budget or in a group practice
• Require Medicare beneficiaries making
or HMO receiving capitation payments.
more than $170,000 per year (for couples)
• Establish a uniform electronic billing system
to pay more for Medicare Part B and Part D
and create an electronic patient record system.
premiums.
• Allow only public or not-for-profit institutions
to participate in USNHC. Private physicians,
clinics, and other participating providers may
not be investor owned.
• Require USNHC program to negotiate annually
prices for drugs, medical supplies, and
assistive equipment.
• Establish a prescription drug formulary that
encourages best practices in prescribing and
promotes use of generics and other lower cost
alternatives.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Rep. Tom Price (Republican Study Committee)
Sen. Bernie Sanders
Rep. Pete Stark
Empowering Patients First Act
American Health Security Act of 2009
AmeriCare Health Care Act of 2009
(H.R. 3400)
(S. 703)
(H.R. 193)
Date plan announced
July 30, 2009
March 25, 2009
January 6, 2009
Overall approach
Allow people who purchase coverage in the
Create a state-based public health insurance
Create a new public plan, modeled on Medicare,
to expanding access
individual market to deduct the cost of premiums program for all U.S. residents. Replace employer as default coverage for all Americans. Individuals
to coverage
from their income taxes. Provide refundable tax
coverage and eliminate the Medicare, Medicaid
in a qualified group plan or Medicare may opt
credits to individuals and families with incomes
and CHIP programs. Individuals are not required out of AmeriCare. Require employers and
below 300% FPL to purchase insurance in the
to pay premiums or cost-sharing. Provide for
individuals to contribute toward the cost of the
individual market. Establish Association Health
global budgets for hospitals and negotiate
plan, with federal premium subsidies available
Plans and Individual Membership Associations
annual reimbursement rates with physicians
for individuals below 300% FPL. Use Medicare’s
through which employers and individuals can
and other non-institutional providers. Finance
administrative structure to govern the plan.
purchase coverage. Implement state high-
program by redirecting current federal and state Financed by premium contributions from
risk pools or reinsurance programs to provide
health care spending, impose an employer/
employers and individuals, state maintenance of
coverage for people with pre-existing health
employee payroll tax, and leverage a new health
effort payments, and from general revenue.
conditions. Require states to provide coverage to care income tax.
90% of children with family incomes below 200%
FPL as a condition for expanding child eligibility
to 300% FPL, and require states to provide
vouchers to children eligible for Medicaid and
CHIP, to be used to purchase private insurance.
Individual mandate
• No requirement for individuals to have
• All individuals residing in the US are entitled
• All U.S. residents are entitled to coverage
coverage. Permit employers to automatically
to coverage under the American Health
under AmeriCare. Individuals may choose not
enroll individuals in the lowest cost group
Security Act.
to enroll in the AmeriCare plan if they have
health plan as long as they can opt out of
coverage under a group health plan.
coverage.
Employer requirements
• Permit employers to offer employees a
• Prohibit employers from offering health
• Require employers to contribute at least 80%
defined contribution for the purchase of health
benefits that duplicate those provided by State
of the AmeriCare premiums for employees
insurance in the individual market.
health security programs.
or at least 80% of the cost of the group plan
• Require employers to disclose to employees
if the employer provides qualifying employee
the total amount the employer spends on the
coverage. Employers with fewer than 100
employee’s health insurance premium.
employees will be given an additional three
years to come into compliance with this
provision. A surcharge may be imposed on
employers to prevent adverse selection.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Rep. Tom Price (Republican Study Committee)
Sen. Bernie Sanders
Rep. Pete Stark
Empowering Patients First Act
American Health Security Act of 2009
AmeriCare Health Care Act of 2009
(H.R. 3400)
(S. 703)
(H.R. 193)
Expansion of public
• Require states to achieve coverage for 90% of
• Create a new state-based American Health
• Create a new public plan, modeled on
programs
children with family incomes below 200% FPL
Security Program that provides coverage for
Medicare, as default coverage for all
who are eligible for public coverage before
a comprehensive set of benefits to all U.S.
Americans.
they can expand CHIP for children with family
residents.
• AmeriCare plan enrollees are subject to
incomes between 200% FPL and 300% FPL.
• Eliminate the Medicare, Medicaid, and CHIP
deductibles ($350 individual/$500 family) and
Require states to provide premium assistance
programs as beneficiaries of these programs
coinsurance of 20% until limits on out-of-
for Medicaid and CHIP enrollees with access to
are eligible for State Health Security Programs.
pocket (OOP) expenses are met. The OOP limits
employer-sponsored insurance. Require states • Veteran’s Affairs and Indian Health Service
are $2,500 per individual and $4,000 per family.
to offer vouchers to individuals who would
programs remain independent.
Deductibles and limits are indexed to inflation.
otherwise be eligible for Medicaid and CHIP
• Prohibit coverage under state Medicaid
for the purchase of alternative private health
and CHIP programs for benefits covered by
insurance.
AmeriCare plans.
Subsidies to individuals
• Provide a refundable tax credit of $2,000 for
• Individuals are not required to pay premiums
• Low-income individuals (family income <200%
individuals and $5,000 for a family of four with
to obtain coverage nor are they charged
FPL) are not required to pay premiums and are
incomes up to 200% FPL for the purchase of
copayments or coinsurance for covered
not subject to deductibles and co-insurance.
health insurance in the individual market.
benefits.
• Provide premium subsidies and reduced
Phase down the credit for individuals and
deductibles for individuals with family incomes
families with incomes between 200% FPL
between 200% and 300% FPL.
and 300% FPL. Citizens and legal permanent
• Limit OOP costs for deductibles and
residents of the United States are eligible for
coinsurance to 5% of income for those between
the tax credit.
200 and 300% FPL, and 7.5% of income for
• Permit individuals eligible for other health
those between 300 and 500% FPL.
benefit programs, including Medicare,
• No deductibles and coinsurance for pregnancy-
Medicaid, CHIP, TRICARE, Veterans’ Affairs, the
related services and covered benefits provided
Federal Employee Health Benefits Program,
to children (up to age 24).
and subsidized group coverage to receive a
tax credit instead of coverage through the
program.
Subsidies to employers
• Provide small employers (50 and fewer
No provision.
No provision.
employees) with a temporary tax credit to adopt
auto-enrollment procedures and to contribute
toward coverage for employees who choose
to purchase private coverage in the individual
market.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Rep. Tom Price (Republican Study Committee)
Sen. Bernie Sanders
Rep. Pete Stark
Empowering Patients First Act
American Health Security Act of 2009
AmeriCare Health Care Act of 2009
(H.R. 3400)
(S. 703)
(H.R. 193)
Benefit design
• Allow tax credit and employer defined
• Provide coverage for services including hospital • Provide the same benefits available through
contribution to be used for all HIPAA eligible
and professional services; community-based
Medicare, with the addition of benefits, such as
coverage, except certain limited or disease-
primary health care; preventive care; long-
well-child visits, early and periodic screening,
specific plans.
term acute and chronic care services, including
diagnostic, and treatment (EPSDT) services
• Prohibit use of federal funds to be used to
home and community-based services;
for children, prenatal and obstetric care, and
provide coverage for abortions, except to save
prescription drugs; dental services; mental
family planning services to reflect the needs of
the life of the woman or in cases of rape or
health and substance abuse; diagnostics
a younger population.
incest.
tests; outpatient therapy; durable medical
equipment; and other services as specified by
the American Health Security Standards Board.
Changes to private
• Permit insurers to sell insurance policies
• Prohibit insurers from duplicating State health • Allow AmeriCare supplemental policies to be
insurance
across state lines. Insurers must designate
security program but they may offer coverage
offered that meet minimum federal standards,
one state as its primary state and the laws
for benefits not covered by the health security
including standardized benefits, limitations on
and regulations in the primary state apply to
program.
sales commissions, and the following:
coverage offered in that state and in other
– Require insurers that offer AmeriCare
states. Allow individuals whose premiums for
supplemental policies to do so on a
individual health insurance exceed the national
guarantee issue and renewability basis
average premium by 10 percent or more to
and prohibit them from charging higher
purchase coverage in another state.
premiums based on health status.
• Require insurance companies to disclose the
– Require insurers offering AmeriCare
true health insurance plan costs to employers.
supplemental policies to meet minimum
medical loss ratios (85% for group policies;
75% for individual policies).
State role
• Encourage states to implement a high-risk
• Create a state health security program to
• Require states to make maintenance of effort
pool, reinsurance pool, or other risk adjusted
provide health care services to state residents.
payments in the amount of the state share
mechanism. States must have a high-risk
May join with one or more neighboring states to
of Medicaid and CHIP spending for benefits
pool, reinsurance pool, or other risk adjusted
form a regional health security program. State
replaced by the AmeriCare plan.
mechanism in place in order for state residents
programs must designate a single state agency • Allow states to impose more stringent
to be eligible to receive tax credits to purchase
to administer the program; establish state
requirements on entities offering AmeriCare
insurance.
health security budgets; establish provider
supplemental policies than specified by the
• Allow states to establish a Health Plan and
payment methodologies; license and regulate
Secretary.
Provider Portal website to provide information
health providers and facilities; establish a
on all health plans and health care providers in
quality review system; create an independent
the state.
ombudsman program to resolve consumer
complaints and disputes; publish an annual
report on the operation of the state program;
and create a fraud and abuse prevention and
control unit.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
0

Rep. Tom Price (Republican Study Committee)
Sen. Bernie Sanders
Rep. Pete Stark
Empowering Patients First Act
American Health Security Act of 2009
AmeriCare Health Care Act of 2009
(H.R. 3400)
(S. 703)
(H.R. 193)
Cost containment
• Adopt medical malpractice reforms that limit
• Establish annual budgets for operating
• Generally apply Medicare payment
lawsuit rewards and create state health care
expenditures, administrative costs, health
mechanisms, adjusted to reflect the AmeriCare
tribunals to review cases and render decisions.
professional education, and quality assessment
population.
Parties will still have access to state courts if
activities.
• Limit payments to private plans offered
not satisfied with decisions.
• Require states to pay institutional providers,
through AmeriCare (similar to Medicare
• Reduce Medicaid and Medicare Disproportionate
including hospitals and nursing facilities,
Advantage) to average per capita costs under
Hospital Share (DSH) funds if there is a decrease
through an annual prospective global budget
AmeriCare.
in the national uninsurance rate of 8% or more.
and develop payment methodologies for
• Require AmeriCare to develop a fee schedule
• Enhance efforts to detect and eliminate
independent health practitioners that include
for outpatient drugs and biologics, to negotiate
fraud and abuse in Medicare and Medicaid by
incentives to encourage practitioners to choose
directly with drug companies for the purchase
providing funding for the Office of the Inspector
primary care medicine.
price of those drugs and biologics, and to
General of the Department of Health and
• Limit national health security spending growth
encourage greater use of generics and lower
Human Services. Identify instances where
to the average annual percentage increase in
cost alternatives.
Medicare should be, but is not, acting as a
the gross domestic product.
• Require AmeriCare contractors to submit
secondary payer to an individual’s private
• Establish individual and state capitation
electronic claims.
coverage.
amounts and risk adjustment methodologies
• Apply Medicare provisions relating to fraud
• Reinstate the Medicare Trigger, which requires
to be used for developing state and national
and abuse and administrative simplification to
the President to submit a plan to contain
global budgets.
AmeriCare plans.
Medicare costs if 45% or more of the program’s • Limit state administrative costs to 3% of total
funding comes from general tax revenues for
expenditures.
two consecutive years.
• Create state fraud and abuse prevention and
control units to investigate and prosecute
violations of state law.
• Develop provider payment methodologies
that include global fees for related services
furnished to individuals over time.
• Establish prices for approved prescription
drugs, devices, and equipment.
Improving quality/health • Prohibit comparative effectiveness research
• Create an American Health Security Quality
• Apply Medicare provisions relating to outcomes
system performance
from being used to deny coverage of a health
Council to review and evaluate practice
research and quality to AmeriCare.
care service under a Federal health care
guidelines and performance measures; adopt
program and require the Federal Coordinating
methodologies for profiling practice patterns
Council for Comparative Effectiveness
and identifying outliers; and develop guidelines
Research to present research findings to
for medical procedures to be performed at
relevant specialty organizations before publicly
centers of excellence.
releasing them.
• Improve access to care through grants to
• Create a process to develop performance-
support the development of primary care
based quality measures that could be applied
centers to serve medically underserved
to physician services under Medicare.
populations in urban and rural areas and the
expansion of school health service sites.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
1

Rep. Tom Price (Republican Study Committee)
Sen. Bernie Sanders
Rep. Pete Stark
Empowering Patients First Act
American Health Security Act of 2009
AmeriCare Health Care Act of 2009
(H.R. 3400)
(S. 703)
(H.R. 193)
Improving quality/health • Create a health plan and provider portal
system performance
website to provide standardized information
(continued)
on health insurance plans and provider price
and quality data. Provide states with funding to
implement the standardized health plan and
provider portal website.
Prevention/wellness
• Allow insurers that offer health coverage
• Create an Office of Primary Care and
No provision.
through Individual Membership Associations
Prevention Research to identify research
and the individual market to establish premium
related to primary care and prevention
discounts/rebates for individuals for adherence
for children and adults and to establish a
to health promotion and disease prevention
system for collecting, storing, analyzing, and
programs.
disseminating information related to primary
• Allow employers to vary premiums and cost-
care and prevention research.
sharing up to 50 percent of the value of benefits
under the plan, based on participation in a
wellness program.
Long-term care
Not specified.
• Provide coverage for acute and chronic long-
No provision.
term care services through the State American
Health Security Programs.
• Limit spending on home and community-based
care to no more than 65% (or an established
alternative ratio) of the average amount that
would have been spent if all of the home-
based long-term care beneficiaries had been
residents of nursing facilities in the same area.
Other investments
• Establish a student loan fund with public or
• Redesign health professional education
No provision.
non-profit schools of medicine or osteopathic
programs to promote primary care so that
medicine to provide loans for medical students,
within five years at least 50% of residents in
including for those who enter training
medical resident education programs are
programs in fields other than primary care.
primary care residents and the number of
• Provide up to $50,000 of loan forgiveness for
mid-level primary care practitioners and
primary care providers who serve for at least
dentists meets certain targets.
5 years or 3 years in a medically underserved
• Provide funding to the Public Health Service
area.
to support the National Health Service Corps,
• Reform the sustainable growth rate for
health professions education, and nursing
physicians in the Medicare program.
education.
• Provide grants to states to support core public
health functions, including data collection and
analysis, investigation and control of adverse
health events, health promotion and disease
prevention activities, research on cost-effective
public health practices, and integration and
coordination of prevention programs and services.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
2

Sens. Ron Wyden and Bob Bennett
Former Majority Leaders:
Healthy Americans Act
Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391)
Crossing Our Lines: Working Together to Reform the U.S. Health System
Date plan announced
February 5, 2009
June 17, 2009
Overall approach
Require most Americans to purchase private coverage (called Healthy
Require all Americans and legal residents to have health insurance. Create
to expanding access
Americans Private Insurance or HAPI) meeting certain standards, with
state-based health insurance exchanges through which individuals and
to coverage
federal subsidies available for individuals/families up to 400% of the
employers can purchase health coverage, with premium credits available
federal poverty level. State-based Health Help Agencies administer the
to individuals/families with incomes up to 400% of the federal poverty level.
offering of HAPI plans, which have to meet federal benefit and other
Require employers to provide coverage to employees or pay a fee based on
standards. Employers can continue to sponsor health plans but many are
annual payroll, with exceptions for certain small employers, and provide
unlikely to do so because the favorable tax treatment for individuals of
certain small employers a credit to offset the costs of providing coverage.
employer-paid and insurance is eliminated.
Impose new regulations on plans participating in the exchanges and in the
individual and small group insurance markets. Expand Medicaid to 100% of
the poverty level.
Individual mandate
• Require all citizens over age 19 to have insurance along with dependent
• Require all Americans and legal residents to have health insurance that
children. Those without coverage are subject to a financial penalty based
meets minimum creditable coverage standards. Enforcement options
on the number of uncovered months and the weighted average
include: default enrollment in basic coverage through an employer or
of HAPI premiums.
the exchange when starting a job, tax penalties including loss of federal
deductions or exemptions, and a “fair share” fee added to income tax
liability to reflect the cost of uncompensated care. Exceptions granted for
religious objections and financial hardship.
Employer requirements
• Require employers to contribute an amount equal to a percentage of
• Require employers to offer coverage to their employees or pay a fee
the average premium of their workforce times the number of workers.
based on the percentage of payroll. The fees would range from 1% of
Percentage of the average premium varies for large and small employers
payroll for firms with annual payrolls between $1 million and $2 million
from 2% to 25%.
and 3% of payroll for firms with annual payrolls above $3 million.
• For the first two years, permit employers previously providing health
• Exempt small businesses with payrolls less than $1 million.
insurance to increase their workers’ wages by the amount of the health
insurance premium in lieu of the employer shared responsibility payment
described above.
• Employers who continue to sponsor health plans must provide
information on HAPI plans to employees.
• Require employers to deduct individual and family premiums from
workers’ payroll.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Sens. Ron Wyden and Bob Bennett
Former Majority Leaders:
Healthy Americans Act
Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391)
Crossing Our Lines: Working Together to Reform the U.S. Health System
Expansion of public
• Eliminate Medicaid and CHIP as comprehensive coverage programs and
• Expand Medicaid to all individuals with incomes up to 100% FPL.
programs
instead provide supplemental, wrap-around coverage for low-income
Initially, all individuals eligible for Medicaid and CHIP will obtain or
beneficiaries. Provides for a modified Medicaid long-term care services
retain coverage through state Medicaid programs. After five years, the
program.
HHS Secretary will be authorized to permit Medicaid and CHIP eligible
individuals to enroll in the exchange provided such coverage does not
result in increased cost sharing or loss of benefits.
• Allow states to create a state plan option to provide another choice of
coverage in the exchange. The state plan may be modeled after state
self-insured plan, co-op plans with consumer boards, or other designs.
The state plan must be actuarially sound; cannot be managed by the
same entity that regulates the state’s insurance markets; cannot
leverage participation in public programs as a means of developing
provider networks; cannot be provided special advantages with respect
to risk adjustment, premium rating, reserve rules, marketing, and
automatic enrollment; and must be self-sustaining. If, after five years,
HHS determines that affordability and coverage goals have not been met,
a proposal for a federal or a state plan to be offered in the exchanges will
be considered by Congress under an expedited procedure.
Subsidies to individuals
• Provide premium subsidies for individuals and families with incomes
• Provide tax credits on a sliding scale basis to individuals and families
between 100 and 400% FPL; those with incomes below 100% FPL would
with incomes up to 400% FPL to purchase insurance through the Health
not pay premiums.
Insurance Exchanges and families with incomes below 100% FPL will
• Provide a health care standard tax deduction for individuals and families
be enrolled in Medicaid and pay no premiums. Within the exchange,
with incomes above 100% FPL; would phase-out at higher income levels.
those with incomes between 100 and 150% FPL will pay 2% of income;
those with incomes between 150 and 250% FPL will pay 5% of income;
those with incomes between 250 and 350% FPL will pay 10% of income;
those between 350 and 400% FPL will pay 12.5%. The tax credits will be
refundable and advanceable.
• Limit premiums for individuals and families with incomes above 400%
FPL to no more than 15 percent of their income.
Subsidies to employers
No provision.
• Provide small employers with fewer than 25 employees who are mostly
low-wage with tax credits to help offer coverage to their workers.
Tax changes related
• Reform the tax code to eliminate the exclusion of the value of health
• Cap the income tax exclusion for employer-sponsored insurance at
to health insurance
insurance plans offered by employers from workers’ taxable income
the value of the FEHBP standard option and index that amount by
(with exceptions, such as for employer-paid retiree health coverage and
medical inflation over time. Exempt retirees and individuals covered by
coverage through
collectively bargained agreements until those agreements expire.
a collectively bargained plan).
• Provide a new health care standard deduction that phases out for higher
income taxpayers.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009
5

Sens. Ron Wyden and Bob Bennett
Former Majority Leaders:
Healthy Americans Act
Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391)
Crossing Our Lines: Working Together to Reform the U.S. Health System
Creation of insurance
• Create new state-based purchasing pools (Health Help Agencies) that
• Create state or regional Health Insurance Exchanges through which
pooling mechanisms
would offer a choice of HAPI plans.
all individuals and small employers with 50 or fewer employees can
• Everyone, except people enrolled in Medicare, retiree benefit plans,
purchase qualified insurance. Implement a federal fallback if states or
or military-related coverage, are required to enroll in plans through
regions do not create exchanges in a timely manner.
the Health Help Agencies. (Note: employers can still sponsor health
• Require plans to offer benefits that are at least actuarially equivalent to
insurance but would have to inform employees of HAPI plans available
four established federal standards. The four standard plan levels are:
through Health Help Agency.)
high (similar to the FEHBP Blue Cross Blue Shield Standard Option),
• Participating plans provide coverage similar
medium (similar to a typical small group market plan), standard (similar
to that available through FEHBP.
to a typical individual market plan), and basic (equivalent to the federal
• Require insurers to offer HAPI coverage on a guaranteed issue basis and
minimum creditable coverage standard). Plans have flexibility to vary
use adjusted community rating principles in setting premiums.
cost sharing in each of the standard plan levels.
• Require guarantee issue and renewability; allow rating variation based
only on age (limited to 5 to 1 ratio), geographic region, and family
enrollment. States can opt to impose tighter consumer protections.
• Require risk adjustment of participating Exchange plans.
• Require exchanges to make available educational resources and
consumer support tools and to adopt strategies to improve plan choice.
Benefit design
• Provide benefits through HAPI plans that are actuarially equivalent or
• Create minimum creditable coverage standards for insurance plans
greater in value than the benefits offered under the Blue Cross/Blue
offered in all markets. Creditable coverage will include: catastrophic
Shield Standard Plan provided under the Federal Employees Health
protections, coverage for a comprehensive ranges of health care
Benefit Program (FEHBP).
services, and coverage of preventive care and prescription drugs before
• Additionally provide benefits for wellness programs and incentives to
the deductible. Creditable coverage must be at least as generous as a
promote the use of these programs, coverage for catastrophic medical
federal high-deductible plan. Permit states to increase the minimum
events for an individual or family if lifetime limits are exhausted, and full
standards provided that it does not increase federal costs.
parity for mental health benefits.
• Create the Healthy America Advisory Committee to issue annual reports
recommending modifications to the benefits, items, and services covered
by HAPI plans.
Changes to private
• Require insurers to offer coverage on a guaranteed issue basis and use
• Require guarantee issue and renewability and allow rating variation
insurance
adjusted community rating principles in setting premiums; prohibit
based only on age (limited to a 5 to 1 ratio with state option to reduce
discrimination based on health status.
the ratio), geographic region, and family enrollment in the individual and
• Require insurers to meet established medical loss ratios.
small group markets and the Exchange. Prohibit imposition of any pre-
• Require insurers to create an electronic medical record for each covered
existing condition exclusions. Allow existing plans in the individual and
individual.
small group markets to be grandfathered for five years before coming
into compliance with new insurance market reforms.
• Standardize health care claims processing to promote administrative
simplification of payment systems and collect and publish data on
medical loss ratios of plans participating in the individual and small
group markets.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Sens. Ron Wyden and Bob Bennett
Former Majority Leaders:
Healthy Americans Act
Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391)
Crossing Our Lines: Working Together to Reform the U.S. Health System
State role
• Create Health Help Agencies and ensure that participating insurers meet • Require states to establish, operate, and regulate state or regional
requirements related to solvency and financial standards, consumer
exchanges and to report annually on the number of plans offered through
protections, and establishment of wellness programs.
the exchange, the range of premiums, and the number of individuals
• Implement mechanisms, such as automatic enrollment, to ensure
covered through the exchange.
maximum enrollment
of individuals into private insurance.
Cost containment
• Adopt payment policies that reward providers for achieving quality and
• Invest in meaningful and effective use of HIT and ensure that HIT bonus
cost efficiency in prevention, early detection of disease, and chronic care
payments to providers are coordinated with new payments to achieve
management.
better care.
• Require insurers to create and implement electronic medical records for • Reform provider payments in federal health programs to pay for high-
each covered individual.
value care.
• Require insurers to adopt uniform billing and claims forms.
– Move from pay-for-reporting to pay-for-performance based on
• Encourage more rigorous study of new drugs and devices by granting
measures reflecting overall quality and coordination of care;
additional exclusivity and patent protections to those subjected
– Implement medical home payments that hold providers accountable
to comparative effectiveness reviews. Disallow tax deductions for
for patient results over time;
pharmaceutical manufacturers for direct to consumer advertising for
– Expand the use of bundled payments for episodes of care and link to an
most new drugs.
expanded “Centers of Excellence” program in Medicare;
• Require insurers and providers to publicly report data on medical
– Limit public program payments for unnecessary or inappropriate care,
outcomes, health care quality and costs.
such as for hospital-acquired conditions or hospital readmissions; and
• Provide bonuses to states that enact medical malpractice reforms.
– Establish accountable care organizations (ACOs) in Medicare and
permit ACOs that meet quality care benchmarks and reduce overall
costs to share in the savings achieved.
• Adjust Medicare market basket updates to reflect savings from delivery
system reforms, such as bundled payments, and reduce Medicare
payments to home health and skilled nursing facilities.
• Restructure payments to Medicare Advantage plans to align more closely
with fee-for-services payments and adopt incentives for quality reporting
and performance improvement.
• Reform prescription drug payments in Medicaid by increasing the drug
rebate rate while eliminating the “best price” provision.
• Adjust Medicare and Medicaid Disproportionate Share Hospital funding to
reflect reductions in uncompensated care. Payments should be reduced
by one-third over 10 years.
• Create a regulatory pathway for the approval of biosimilar and biogeneric
products.
• Restructure Medicare and Medigap cost sharing and reallocate Medicare and
Medicaid improvement funds.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Sens. Ron Wyden and Bob Bennett
Former Majority Leaders:
Healthy Americans Act
Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391)
Crossing Our Lines: Working Together to Reform the U.S. Health System
Improving quality/health • Encourage chronic care programs
• Support comparative effectiveness research that compares the risks,
system performance
• Require hospitals to demonstrate improvements in quality control,
benefits, and costs of different health care practices, evaluates and
including rapid response teams, heart attack treatments, procedures
revises policies that influence provider practices, and identifies
that reduce medication errors, infection prevention, procedures that
strategies for targeting practices to specific groups of patients.
reduce the incidence of ventilator-related illnesses.
• Improve quality monitoring and improvement by expanding funding for
• Provide enhanced Medicare payments to primary care providers and
the prioritization, development, endorsement and implementation of
require Medicare to develop a chronic disease management program.
qualify measures, requiring electronic quality reporting, and improving
• Establish a website for sharing evidence-based best practices and
the evaluation of new payment reform programs.
develop a program for incorporating these best practices into medical
• Improve care coordination for people with chronic conditions through
school curricula.
the creation of community health teams composed of care coordinators,
• Provide for improvements in end-of-life care.
nurse practitioners, social workers, nutritionists, and others to provide
patient-centered care that integrates existing prevention and care
management resources.
• Improve coordination of care for dual eligibles by creating a new program
that includes a mechanism for states and the federal government to
provide financial support to deliver integrated Medicare and Medicaid
services to this population.
• Address racial and cultural disparities by enhancing comparative
effectiveness research, realigning reimbursement to promote improved
patient outcomes, ensuring adequate provider capacity in underserved
areas, increasing the number of minorities entering the medical and
health professions, and developing and adopting standards for the
collection of data on race and ethnicity.
• Create an Independence Health Care Council (IHCC) to assess overall
system performance. The IHCC will analyze and report on cost and
quality data in federal programs and issue recommendations for
improving quality, reducing cost growth, and better coordinating the
delivery, reimbursement, and financing of federal health programs.
Prevention/wellness
• Promote prevention by providing premium discounts (including for
• Support a sustained, nationwide focus on public health wellness through
Medicare Part B premiums) for participation in approved wellness and
creation of a Public Health and Wellness Fund to invest in evidenced-
chronic disease management programs.
based prevention and wellness activities. These activities and provisions
• Require HAPI plans to ensure that primary care providers and individuals
include: no or limited cost sharing for proven preventive services, a new
create a care plan focused on wellness and prevention as part of the
wellness visit for Medicare beneficiaries to receive a personalized health
initial primary care visit.
risk assessment and prevention plan, a federal tax credit for certified
employer-based wellness programs that meet accountability and
reporting requirements, and a $3 billion annual investment in wellness
and prevention programs.
Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: october 15, 2009

Sens. Ron Wyden and Bob Bennett
Former Majority Leaders:
Healthy Americans Act
Sens. Howard Baker, Tom Daschle, and Bob Dole
(S. 391)
Crossing Our Lines: Working Together to Reform the U.S. Health System
Long-term care
• Permit states to create State Choices for Long-term Care Programs
No provision.
through their Medicaid programs to provide institutional and home and
community-based long-term care for eligible individuals.
• Create new long-term care insurance plans that meet standards
developed by NAIC or by federal regulations. Require additional
consumer protections for long-term care policies regarding guarantee
renewal, prohibitions on limitations and exclusions, pre-existing
conditions, and other issues.
Other investments
• Provide grants to school districts and communities to increase access to • Reform Graduate Medical Education to increase training of primary care
school-based clinics.
providers, promote training in settings and geographic areas where
• Permit states to create State Choices for Long-term Care Programs
providers will practice, and encourage integrated systems of care to
through their Medicaid programs to provide institutional and home and
increase reliance on a qualified non-physician workforce. Provide funding
community-based long-term care for eligible individuals.
for the training of more nurses and allied health professionals. Revise
• Create new long-term care insurance plans that meet standards
scope of practice laws to encourage use of advanced practice nurses,
developed by NAIC or by federal regulations.
pharmacists, and other allied health professionals.
• Consider additional financial incentives to ensure adequate provider
capacity in medically underserved urban and rural areas.
• Provide full federal funding for the Medicaid expansion so that states are
not required to pay any of the costs for the newly eligible populations.
Financing
In 2008, CBO scored an amended version of the bill which is very similar to The anticipated cost of health reform is $1.2 trillion over 10 years. The
this year’s version. In that CBO estimate, Federal costs would be offset by
delivery system, reimbursement, employer “pay” contribution, and tax
revenues and savings in first year of full implementation, Thereafter, the
exclusion reforms in the proposal (and related interactions) are expected
bill would be more than self-financing because of indexing growth in the
to achieve over $1 trillion in savings and new revenues. To ensure budget
value of the health insurance deduction and the subsidized benefits.
neutrality, Congress could enact additional Medicare or Medicaid savings,
Financing will come from combination of individual premiums, employer
create an enforceable budget “trigger” mechanism to slow spending
assessments, state and federal savings in Medicaid, elimination of most
growth above a target level, or empower the Independent Health Care
Medicare and Medicaid disproportionate share hospital (DSH) payments,
Council to develop additional recommendations for achieving federal
and changes in tax treatment of insurance.
spending growth targets.
Sources of information
http://wyden.senate.gov/issues/Legislation/Healthy_Americans_Act.cfm
http://www.bpcleadersproject.org/
http://wyden.senate.gov/issues/Health_Care.cfm
http://www.cbo.gov/ftpdocs/91xx/doc9184/05-01-HealthCare-Letter.pdf
THE HENRY J. KAISER FAMILY FOUNDATION
www.kff.org
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The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis
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