*

Early, periodic, screening, diagnosis and treatment services (EPSDT) are included for children in the public program. Privately insured families can buy this coverage for their children from the public plan at cost (or at a subsidized rate for families under 200% of poverty).

a

Deductibles are $250 for an individual and $500 for family. Coinsurance is 20% for all services except prenatal care, well-child care, mammograms and pap smears, which have no coinsurance, and limited mental health services which have 50% coinsurance. The maximum a person or family must spend out of pocket is $3,000 in a year.

One year after the effective date of this plan, the Office of Technology Assessment shall report to the Secretary on an assessment of the cost-effectiveness of prescription drugs for the purpose of inclusion in the benefit package as a preventive service.

Assistance for Small Business

1.

2.

3.

Insurance reforms and a minimum benefit package will make obtaining private insurance for small groups more predictable and affordable. (See below.)

To stimulate voluntary coverage, employers with fewer than 25 workers and average payroll below $18,000 will be eligible for tax credits/subsidies for 40% of the cost of health insurance for workers and their dependents. After the tax credit/subsidy for employers of ten employees or less ends, businesses of ten employees or less, previously eligible for the credit, who are at extreme financial risk would be allowed to purchase coverage from the public plan at a percentage of payroll. This specific percentage of payroll would be consistently set at a relatively low rate to ensure affordability.

No employer with fewer than 100 workers would be required to purchase coverage or contribute to the cost of coverage if coverage targets were met voluntarily. (See phase-in schedule

for details.)

Insurance Market Reform

1.

2.

For all employment-based health insurance:

* No pre-existing conditions exclusions.

* No denial of coverage for any individual in the group.

For those who wish to sell a health insurance product to employers in the small group market new rules would apply:

*

Guaranteed acceptance of all groups wishing to purchase insurance.

Insurers would set rates on the same terms to all groups in specified areas.

Rates may not be increased

enrolled in a plan.

selectively for any g:cup

Enrollment would be for a specified minimum period.

States would be restricted from regulating the content of health insurance benefits, but benefits would be standardized, to the extent possible, across carriers. At least one basic benefit package would have to be offered by each insurer in the small group market.

Managed care plans would be required to be offered to small groups if such plans are available to larger employers in the area.

A self-financed voluntary reinsurance mechanism through which insurers could reinsure high-risk persons or groups would be established.

Quality Assurance

1.

2.

The

federal government should develop and implement a comprehensive national system of quality assurance which

includes:

*

*

*

*

The development of national practice guidelines and standards of care, already begun by the newly created Agency for Health Care Policy and Research. Physicians and physician organizations should be widely utilized in establishing and reviewing practice guidelines and standards of care.

The development and implementation of a uniform data system that covers all health care encounters, regardless of payment source or setting. These data would provide a common foundation for all payers' quality assessment activities and for examining the effectiveness of medical care and identifying health policy and research concerns.

The development and testing of new, more effective methods of quality assurance and assessment.

The development and oversight of local review organizations that have skills in data integration and analysis, quality assessment and quality assurance.

The appropriate committees of jurisdiction in Congress should hold hearings on the malpractice issue. The Prospective Payment Assessment Commission and the Physician Payment Review Commission will be directed to review costs under the new program. The cost containment commission described below will convene experts, providers, lawyers and consumers to study and conduct demonstration projects related to medical malpractice reform in order to make recommendations to Congress on actions to be taken on the federal level.

12

Cost Containment Initiatives

1.

2.

3.

Insuring all Americans through a job-based/public program and reforming the private insurance market will distribute the costs of insurance more fairly by:

Reducing the cost-shift that now Occurs from the uninsured to the insured population.

Reducing the cost-shift that now Occurs from employers who do not provide insurance to employers who cover their workers and dependents.

Assuring small business access to a minimum benefit package at predictable rates, regardless of employees' health

status.

Adoption of a quality assurance strategy (described above) and
reform of the medical malpractice system will assure greater
value for the dollar in the delivery of medical services.

Measures to promote efficiency in provider payment would include:
Cost-sharing in the minimum benefit package

*

that makes consumers sensitive to price.

Insurance reform that leads insurers to compete around efficient service delivery, rather than competing for "good" risks.

Extending "managed care" to small employers and including "managed care" as a means to provide the minimum benefit package in private insurance and the public plan.

Extending Medicare payment rules to the public program, which, in turn, serves as a model for private insurance. Recommending that the appropriate committees of jurisdiction in Congress hold hearings on the costs associated with medical malpractice liability, that the Prospective Payment Assessment Commission and the Physician Payment Review Commission review costs under the program proposed by the Commission and that a National Cost Containment Commission, made up of experts, public and private payers, providers and consumers, be created to assess cost experience and initiatives to contain costs in the public and private sectors and to make periodic recommendations to the Congress on federal initiatives.

Delivery Issues

.1.

-

Expanding health care insurance coverage should reinforce --not replace support for primary care delivery systems targeted at the poor and underserved. Organized primary care providers (e.g., local health departments and community health centers) should be recognized and reimbursed by private and public payors on the same basis as all other providers.

*

*

*

Promote an adequate supply and appropriate mix of personnel and facilities for underserved areas and populations through mechanisms including:

Provider payment methods in public programs that promote the availability of primary care practitioners and facilities and assure access to other needed services;

Special initiatives (such as the National Health Service Corps and other financial incentives) to attract a range of providers (physicians and other practitioners) to underserved areas, and to assist such providers through mechanisms such as professional backup systems and support networks for rural providers (e.g., telecommunications with other professionals and facilities, mobile medical services).

-

Support local efforts to develop outreach and facilitating services, for example, health education, transportation, home visiting, and translation services preferably linked to health care delivery programs to facilitate access to services and to encourage patients to seek and continue participation in health care.

-1

Support local efforts to reduce organizational and bureaucratic barriers to access through efforts such as the coordination and/or co-location of medical, welfare and social services (e.g., medical referrals, nutrition counseling and eligibility determinations for welfare and housing programs).

Undertake and support research and evaluation efforts to determine the effectiveness of primary care models and services aimed at addressing the needs of underserved communities.

Support programs of health promotion, disease prevention, risk reduction and health education toward the reduction of excess morbidity and mortality and toward the increase of healthy lifestyles. Federal support for such programs should total at least $1 billion annually beyond current

federal efforts.

Support an effective continuum of care, including short-term hospital-based and/or longer-term community based alcoholism and other drug treatment services.

Allow all uninsured pregnant women, and children ages 0-6, to enroll in public plan, if they are from non-working families or in families of workers whose employers do not

provide coverage. Costs would be subsidized, according to ability to pay, at least for those with family incomes below 200% of poverty.

Begin to improve reimbursement to providers for persons now served by Medicaid.

Phase II (Year 2)

Firms with 0-25 workers and average payrolls below $18,000 become eligible to receive a 40% tax credit/subsidy for cost of coverage if they provide it. The subsidy would be available for five years.

The public plan is made available to uninsured children up to age 18 (those from non-working families or families where workers' employers do not offer coverage). Subsidies would be available based on ability to pay, at least for those with family incomes below 200% of poverty.

Phase III (Year 3)

*

Firms with 100 or more workers are required to provide private insurance coverage or contribute a portion of payroll toward the cost of covering employees and dependents in the public plan.

Phase IV (Year 4)

*

*

If 80% of uninsured employees of firms with 25-100 workers (as of Year 1) are not insured through their employers, along with their dependents, all employers of this size are required to provide private insurance coverage or contribute toward the cost of their coverage in the public plan.

If coverage target is met, the Secretary of Health and Human Services is required to recommend to Congress ways to cover those still left out.

Phase V (Year 5)

*

If 80% of uninsured employees of firms with 0-25 workers (as of Year 1) are not insured through their employers, all employers of this size are required to provide coverage or contribute toward the cost of their coverage in the public plan.

If coverage target is met, the Secretary of Health and Human Services is required to recommend to Congress ways to increase coverage options for employees (and their nonworking dependents) who are not covered by their employers.

All non-working adults are covered through the public plan.