It is difficult to describe the rage I feel about the shooting at Ft. Hood last week. I spent 10 years active duty Army, the first 5 of those years as an Arabic linguist, focusing on the counter-terrorism and counter-insurgency missions.  I was immersed in the culture, language, habits and practices and modes of communication of the Middle East and radical Islam for years.  I did not do this so I could value their cultural legacy, appreciate their contributions to society, or learn more diversity in my worldview.  I did this so I could exploit their communications, locate them, and kill them.

And here we have a terrorist working as a psychiatrist in the US Army. His entire education, residency, and board certification paid by the American taxpayer, not to mention his six figure annual salary.  He was under investigation for communicating with a wanted Imam who was known to be one of Al-Qaeda’s most prominent recruiters.  He was known to have posted anti-American and pro-radical comments on line and making those comments in conversation.  He was censured for turning his speech at a military psychiatry seminar into a dissertation on the virtues of Islam and a call for new proselytes.  All this was known and documented before Major Nidal Malik Hasan was even transferred to Ft. Hood, and well before he received his deployment orders to Afghanistan.

Yet this man was allowed to remain in the service.  He was allowed to play a critical role in the mental state of our warrior as they deployed and came home.  He was offered promotion as the standard program for psychiatrists who complete their studies, residency, and certification proceedings.  He was placed in roles of leadership, responsibility, and prestige among our warrior class, by virtue of his education.

How does one reconcile these things? Why was this allowed to happen?  Because he was Muslim. Because of political correctness and fear. It permeates even our own military ranks.  When making promotion and training selections, if there are two competitive and equally qualified candidates, if one of them is Muslim he will be selected. Because within the military, as elsewhere, there is a paranoia about avoiding the appearance of “intolerance,” “suspicion,” or “profiling”. White Christian officers have to be meticulously careful in their choice of words and associations, for fear of claims of equal opportunity policy violations or even the appearance of stepping out of line. Muslim officers apparently are not held to the same standard.

Make no mistake—this man was allowed to be in a position to do what he did because he was Muslim.  If a Christian zealot had been documented for similar behavior, he would have never made rank or even finished training.  Maj. Hasan shot and killed his fellow soldiers because he was Muslim. So many of our media outlets and even our own President are striving so hard to not acknowledge this, but it was this man’s interpretation of his religion that led him to shoot wounded soldiers at point-blank range, unarmed soldiers as they were running for cover or to help those already shot.  One witness’ account describes Hasan as putting the muzzle of his weapon square in the back of a soldier who was trying to shield a wounded comrade and emptying the remainder of the pistol’s magazine into his back. This from the man who sported an “Allah is Love” bumper sticker on his car.

Imams and Islamic clerics all over the world are praising Maj. Hasan as a hero, who they say executed a truly Islamic and honorable act of Jihad against the American military.  And we’re supposed to maintain a sense of political correctness and refusal to pass judgement.  I will pass judgement—it is requisite with my moral responsibilities and my own capacity for rational thought to call evil, evil.  And this act is evil. And pretending that it is anything other than it is—the first successful act of Islamic terror on American soil since 9/11—is evil, and shows dishonor and ingratitude to the members of our warrior class that were slain by this Islamic holy warrior (read: terrorist).

And continuing this blind devotion to suicidal political correctness is evil. The cast majority of the terrorist threats we face come from a very specific and identifiable demographic: Muslims aged 17 to 40. It is a simple thing to focus our counter-terrorism and security forces on this one demographic.  But we don’t. Because that would be racial profiling. I’m sorry—this demographic needs to be profiled.  And it’s high time that the inconvenience of being in this group becomes commensurate with the danger, threat, and destruction caused by this group.  Is it not morally and ethically unconscionable to place millions in danger because you fear to offend or inconvenience a small minority?

Many will think me hateful, intolerant, racist, or over-reactionary. I am a realist. Radical Islam is the existential threat to our civilization and the most imminent threat to our population.  There is nothing racist or intolerant in acknowledging this. It is based on statistics and the experience of history. We need to focus our investigations, our screening, and our other security methods on that group WE KNOW is the source of nearly all the individuals that mean us harm. The episode with Maj. Hasan and the act of domestic terror perpetrated at Ft. Hood last week should be a permanent wake-up call to rational and honest Americans everywhere.

I'm not sure what Nancy Pelosi is so excited about.  The Health Care Destruction Act passed tonight.  But she lost 39 of her own party to the opposition for the vote.  Her bill has very, very little in common with the bill in the Senate, and any attempt at consolidation is going to be a farce.  And even the Senate Bill, which is much less extreme (by reputation--nobody really knows because it doesn't exist in a form that Harry Reid is willing to let us read), is facing massive obstacles to passage to even get it to a point where they can start reconciling the two bills.  The opposition to the bill did not lose today.  Do not be disheartened.  The fact that Nancy lost 39 of her own caucus on this issue is a sign of hope for embarrassing failure to come.

No, the real loser of today was Barack Obama.  That may sound like a ludicrous statement, but that's only because you are missing some critical information.  As reported by the Associated Press, Obama entered a closed-door session with the Democratic representatives today to drum up some last-minute support, and according to Democratic Congressman Robert Andrews of New Jersey, Obama made the argument that the 13 soldiers murdered at Ft. Hood this week demonstrated what real sacrifice, is, as opposed to "casting a vote that might lose an election for you."

Excuse me?  I would expect MSNBC and Moveon.org and Code Pink to use an act of domestic terrorism against our military to make political points, but not the commander in chief of that military.  The fact that Obama can't make the mental distinction between campaigning and leading is a reality that he seems intent on reminding us of on a weekly basis.  But this is by far his worst betrayal of his own incompetence. Even if he were sincere in his value and appreciation of the sacrifice our military service members offer on the altar of freedom (which I doubt), to invoke it in the pursuit of his own self-serving agenda, in the presence of a group of people who if they had their way would have de-funded military operations in 2005 and 2006, is a stark reminder of how much he has not grown into the role this country elected him to.

And here's failure number two: his comments illustrated his contempt for the ideal of a representative Democracy.  He basically instructed his Democratic minions: forget your constituents.  They don't matter.  Their opinion is nothing compared to my agenda and my glory.  What other possible translation of "vote for this even if it costs you the next election" could there be?  Don't worry, Congress--the idiots that vote for you and whose priorities you are supposed to represent don't matter.  They can't possibly be expected to know what's best for them.  History demands that you sacrifice your job and the interests and values of your constituents upon the altar of Barack Obama.

Failure number three: Congressman Andrews reports that Obama said Democrats have a 70-year history of creating and defending programs like Social Security and Medicare.  He quoted Obama as saying today's vote "is going to define the difference between the Republican and Democratic parties for decades." I don't argue with this.  One of the few true statements Obama has made.  Democrats have a 70-year history of creating and defending government programs that have wasted taxpayer money, squandered precious resources, enlarged the scope and scale of the federal government so far past the limitations of Constitutional authority that it is hopeless to bring it back in line with our Law, and redistributed trillions of dollars of hard-earned wealth in order to create entitlements for people who are entitled to nothing--in order to buy those people's votes.  The Democrats create these programs regardless of the damage they do to the economy and to the middle class.  The defend these programs in spite of ludicrous cost over-runs and budget deficits, historical proof and empirical evidence that demonstrate beyond rational doubt that the programs are colossal failures.  It is precisely votes and programs like the one in the House today that define the difference between Republican and Democrat.  (Or at least between Conservative and Liberal.  Hopefully the Republicans have learned a lesson from their 2000 - 2006 forfeiture of conservative principles.) Obama's failure is that he doesn't understand that this fact proves his contempt for our society and for our Constitution.

I am probably one of 4 people in this country that has read the entire health care bill. It was a painful process, and let me tell you—the critics of the bill on Fox News don’t even have a clue of how bad it really is. Here are the parts of the Health Care Bill I find most troubling:

The federal government gets to decide how much profit a private health insurer can make and how much they pay their stockholders.

States have the option of covering abortions through Medicaid, which means federal funds will be paying for abortion.

The verification procedures for seeing if someone is an illegal immigrant are basically “Are you an undocumented alien?” “Why, no sir, I am not” “All-righty then…”

The public option, as well as new provisions for Medicaid and Medicare, are explicitly described as not subject to any administrative or judicial review. This means individuals cannot contest decisions made by the bureaucrats. There is no transparency to the process, and it is ripe for corruption. And let’s be honest, with our government, regardless of which party is in charge, corruption is a HUGE concern and is probably the “default setting”. Moreover, the Bill explicitly authorizes the govt to slash benefits if funds go low—i.e. care rationing.

Dozens of grant and contract programs in the bill explicitly favor community organizers. The definitions given of the entities providing health services aren’t even limited to health services—if a community organization like ACORN offers nutritional or family planning counseling, they are eligible for federal health care money. All the grant programs explicitly favor programs that funnel money to urban and “ethnically diverse” areas.

The bill creates tens of thousands of new government jobs. And not doctors/nurses—new government bureaucrats. To put in perspective: they are trying to “reduce costs” and “halt skyrocketing costs”, aren’t they? And they’re doing this by…adding to the system tens of thousands of government bureaucrats that don’t provide any medical service, don’t provide any economic growth or productivity. Nancy Pelosi said that this Bill was all about “jobs, jobs, jobs”. And she’s right—it creates tens of thousands of jobs. But there’s something she is too stupid to understand: a government job is not generally a good thing. In order to create a government job, the money has to be taken out of the private sector. The government does not produce anything—it only consumes. It is staggering how many government offices, officers, committees, panels, you name it, that this Bill seeks to create. And I know how government offices operate. For crying out loud, *I* am a government bureaucrat. And the bureaucracy is awful; the most unproductive, unaccountable, unresponsive arrangement imaginable. The heart and soul of this bill is expansion of the bureaucracy. Its blood is billions of dollars in payments to community organizers and social engineers.

The Health Insurance Exchange the Bill sets up is initially fairly small in scope—it’s supposed to be a “stop-gap” for people between insurance coverage, and the exchange can’t deny anyone with the money to pay the premiums. But here’s the rub—you have to have the money to pay the premiums. Unless, of course, you don’t have the money for the premiums, in which case somebody else has the money for your premiums through the auspices of the government.

Another problem with the Health Insurance Exchange—this is where the Public Option resides. Which means it is institutionally defaulted to grow and expand. At first it’s a fairly innocuous assist for people with dropped coverage, but it is designed to be the default provider for the nation. That’s why there are hundreds of pages of guidance for the rules and specifications of health plans offered through the exchange. The Public Option is not “free” health care. The premiums are still there and are still just as high as private insurance. But in the case of the public option, the premiums are paid by a) the very rare individual paying into it of their own choice, b) Monopoly money printed by the government, or c) and far more likely, other people that are already paying for their own health insurance before being mugged to pay for yours.

The measures in this Bill are paid for primarily from increased taxes. We’ve all heard about the “cutting fraud, waste, and abuse” from Medicare in order to pay for this mess. There is, indeed, a specific provision in the bill to throw $100 million every year down the rabbit hole of “fighting fraud, waste, and abuse”. But there are no specific provisions for using that money. It’s a total fraud. There are several provisions to cut down on dual filings, overpayments, and whatnot, but the bureaucratic expansion the Bill creates in order to implement them completely overpower the potential benefit. The lion’s share of this funding, to the tune of $375 billion every year, comes from taxes levied against private insurance companies. The bill establishes a “fair market” factor that adjusts every year as necessary, and the insurance companies multiple this factor by the number of people they insure to find out how much money they get to sacrifice to the Federal Health Care Gods. Hooray! Screw the insurance companies! Right? The only person stupid enough to believe that insurance companies will swallow this additional charge is Nancy Pelosi. This tax means more expensive premiums. Period.

More on the public option. The specifics of the federal mandates on insurance coverage are horrible—you won’t be able to buy minimum coverage. The max deductibles and requirements for zero cost sharing for multiple services ensure that people won’t be able to buy less insurance even if they want to; the bill criminalizes not paying for exactly the quantity of coverage they tell you to. Any employer that either fails to or chooses to not provide coverage as mandated by the govt pays 8% of its payroll to the govt instead. This is much, much cheaper than most companies currently pay for insurance. Hundreds of thousands of workers will be dumped out of their employer-provided coverage because the plans will simply disappear—makes economic sense to the employers. And they will automatically get enrolled in the public option, and the rest of us start paying for it. And they will have to do this, too—because any point where you don’t have the federally mandated quantity of coverage, you get fined 2.5% of your annual salary. Additionally, every penny over $500k of annual salary ($1 million for joint filers) is taxed at an ADDITIONAL 5.4%. There is little in the bill to reduce costs. There is much in the bill to increase costs, federal expenditures, and expand bureaucracy, but rather than reduce costs, they are artificially lowering costs for some by pillaging from others.

There’s a lot more, too. There are also several things that are probably really good ideas. But overall this Bill is an atrocity. I fear for the country that is governed by the clowns and criminals that produced such a document. If this is how bad it has gotten, I honestly don’t know if there’s a way back or way out from the horrific state we have placed ourselves in. Don’t ever trust the government to solve anything. They don’t work for you anymore, and they are not here to help.

The second half of the notes of what every section of the Health Care Bill does.

1501—modifies regulations regarding resident physicians at hospitals. If there are fewer residents than that hospital’s reference level, then the remaining slots are taken away and redistributed to other facilities. If a hospital is expanding and requires more residents, it can apply and get slots redistributed from other facilities. I guess this reduces payments to hospitals with fewer residents and enables other hospitals to expand their programs and get more federal money for them. Dictates special treatment for certain hospitals over others (rural areas, training critical or low-availability specialists, etc.)
1502—allows clinic and home-visit time to count toward resident training. Patient care activities in “A non-provider setting”. Calls for a science project that reimburses teaching hospitals for teaching costs; a teaching health center will contract with teaching hospitals to train residents, and the residents in training will not count against the hospital’s allotted residents.
1503—counts residents’ time spent in researching specific patient care issues or attending training or seminars geared to addressing a particular patient’s needs as time spent towards full-time equivalency.
1504—if a hospital closes, all the residency positions authorized for that hospital are redistributed to other hospitals in the same State.
1505—Lists the training objectives of residency programs and dictates the terms for a study on the ability of hospitals’ programs to meet those objectives; Report to Congress on how to improve training programs, develop curricula, and regulate the accreditation process of those programs.

1601—appropriates $100 million a year to fight waste, fraud, and abuse. I’m not kidding. There are no additional provisions or details—just an extra 100 million a year to fight waste, fraud, and abuse.

1611—Increases fines for making false claims or giving false information or omitting info in reports to medicare.--$50k per false statement or omission.
1612—Does the same for others submitting false info in support of a fraudulent claim
1613—fines for delaying inspection by the govt. $15k/day for delaying an audit or inspection of a care provider or their records
1614—empowers govt to inspect hospice care providers, punish/sanction for inadequate care, and terminate their accreditation.
1615—penalties for health services providers that file claims for individuals that are excluded from participation in a federal health care program. This is just a racket to siphon money off of service providers that don’t keep up with their records.
1616—Augmented penalties against Medicare Advantage or Medicare Part D service providers that provide false information.
1617—augmented penalties for service providers that violate marketing regulations
1618—enhanced penalties for getting in the way or otherwise obstructing examinations or audits of any program or provider that gets any money at all from any Federal health care program
1619—detailed procedures for dealing with claims filed by or inadvertently paid to people excluded from federal programs. These include those convicted of felony drug charges, health care system crimes, patient abuse, etc.
1620—Inspector general of Medicare can exclude from participation the owners and officers of entities/facilities convicted of anything that would exclude them as detailed in 1619.
1621—protocol for service providers to report themselves for violations they commit.

1631—authorizes secretary to apply special unfavorable treatment to programs or providers if there is high levels or suspicion of fraudulent activity. Can be additional screening, increased oversight, moratorium on enrollment.
1632—requirements to report associations (within last 10 years) with service provider or supplier that either has unpaid debt to federal program or has been excluded from participation in it.
1633—establishes a payment modifier within applicable fee schedules that apply to certain procedures, tests, or devices that the secretary determines are likely targets for fraud or abuse.
1634—demands reports from supplier/providers, whatever the secretary deems necessary
1635—any supplier or provider that wants to play with federal programs has to have in place a waste and abuse prevention program; the program is up to the provider but has to be approved by the secretary
1636—maximum period for submitting claims to federal health programs is reduced from 36 months to 12 months.
1637—only physicians that are accredited and enrolled in medicare program can order durable medical equipment or home health services under federal funding.
1638—physicians have to maintain and provide upon request documentation for any and all referrals or orders for durable medical equipment or home health services or anything else the secretary deems susceptible to fraud and abuse. Physician can be disenrolled/suspended.
1639—physican can’t order any of the above mentioned things unless he has a face-to-face with the patient within the previous 6 months.
1640—power to subpoena people for waste/fraud/abuse investigations extended beyond office of secretary of social security to include the secretary of health and human services.
1641—over-payments under federal health programs must be repaid to govt within 60 days of over payment.
1642—hardship waivers are available to beneficiaries of Medicare Part A and Part B. This section makes them available to beneficiaries of any federal health program
1643—renal dialysis facilities have to provide ownership and association and compensation arrangement information.
1644—billing agents, clearinghouses, or other 3rd party payees have to be registered under Medicare
1645—administrative changes for the previous increases in fines for false claims, extends the statute of limitations for prosecuting false claims from 6 years to 10 years.
1646—requires all medicare payments to be processed through direct deposit or electronic fund transfer using insured depository institutions. No more bags of cash to anonymous “doctors”.
1647—established the office of Inspector General for the Health Choices Administration Yea!!! More bureaucrats!!!!!

1651—mandates disclosure and sharing among various federal and state agencies of various elements of information required to detect and reduce waste, fraud, and abuse.
1652—aligning and eliminating redundancy within two existing health databases.
1653—guarantees that the Health Insurance Portability and Accountability Act of 1996 applies to all information and provisions of this bill.

1701—expansion of eligibility for Medicaid. Under age 65, household income under 150% of federal poverty level. Gradual expansion downward (age 18, age 5, birth). Matching federal funds for state Medicaid payments for newborns
1702—states must use National Health Insurance Exchange. Must enroll people referred to them by the exchange, no questions asked.
1703—States are not allowed to restrict CHIP or Medicaid eligibility standards beyond the point they were restricted as of 16 June 2009. Ever.
1704—cuts Medicaid DSH payments to states, incrementally, through 2019. DSH (disproportionate shared hospital) payments are payments directly to hospitals. This provision slashes that by $1.5 billion in 2017, $2.5 billion in 2018, and $6 billion in 2019. These cuts will be considered “overpayment” to the states and come out of the states’ claim authorizations. The cuts are not evenly spread—they are focused on states that have lower % of uninsured, lower proportion of Medicaid-dependent patients, and probably tend to vote republican.
1705—expands “outstationing”—filing of Medicaid claims and processing them at locations other than the place of care.

1711—mandates/expands Medicaid coverage of preventive services as directed for health insurers and for Medicare.
1712—ADDS tobacco cessation materials to the list of “drugs” covered by Medicaid
1713—Adds home nurse visitation (newborn, well-baby) to Medicaid coverage.
1714—Allows state Medicaid programs the option of covering Family Planning Services through state Medicaid—thus making abortions partially federally funded. Pg 1048-1049

1721—Medicaid pay-per-service payouts increased. 80% in 2010, 90% in 2011, 100% in 2012. Also, 1.25% bonus paid for primary care services. This replaces lower increases previously determined in other legislation.
1722—Medicaid home-care pilot program. 5 years, deals with special categories of patients, including fragile children and high-risk pregnant women. Pays for administrative costs of the program (instead of the state). $1.235 billion over 5 years.
1723—Medicaid payments for language services.
1724—States can opt to cover Free-Standing Birth Centers and have Medicaid pay help pay
1725—Expansion of coverage of vaccines for children—more health centers
1726—Mandates Medicaid coverage of podiatrists and optomotrists
1727—“ “ therapeutic foster care
1728—Mandates states submit new plans to ensure adequate payment for services. If secretary doesn’t like the plan, the state has to try again.
1729—If a juvenile delinquent is eligible for Medicaid before incarceration, he will get it again after incarceration (if still under age 18). The state is responsible for enrolling youths before release.
1730—develop measures to quantify state of maternity and adult care under state Medicaid programs. Maintain and Report these metrics to Congress annually. Appropriates $40 million for the 5 years 2010-2014. Creates pilot program that tests out, under Medicaid, the same kind of care models under Medicare for this bill

1731—States can opt to have Medicaid cover low-income HIV positive individuals. This coverage would be exempt from funding limitations currently placed on US territories. This coverage does not add to amounts expended for other coverage.
1732—transitional Medicaid assistance was set to expire in 2010—this extends it to 2012.
1733—CHIP programs have to cover children in increments of 12 continuous months
1734—infants/toddlers, children whose families have recently lost coverage or cannot afford employer-based coverage will not be subject to standard CHIP waiting periods
1735—coverage for adult day care
1736—exceptions and exemptions for the Marshall Islands, Micronesia, and Palau
1737—Medicaid coverage of non-emergency transportation to site of medically necessary services.
1738—states can make it easier for certain people to qualify for Medicaid prescription coverage—patient has high costs of prescriptions and has exhausted their own coverage—states can disregard certain percentages of their income in order to make them “eligible” for coverage
1739—provisions to confirm adequacy and staffing of Community Living Assistance Services. $7 million per year 2011-2013.

1741—polishing of Medicaid payments procedures for pharmaceuticals. Including demanding reimbursements from companies in the case of recalls. Dictates pricing and timeliness of payments.
1742—rebates to the govt for payments for drugs that are only re-formulations existing drugs. Reduces the govt payment to states for prescription reimbursement
1743—expands Medicaid prescription coverage to enrollees of managed care organizations
1744—medicaid payment now eligible for graduate medical education programs as specified in the bill.
1745--$6 billion of supplemental payments for nursing facilities, 2010-2012.
1746—mandates states report to the govt Medicaid expenditures and rates.
1747—calls for studies on federal payments to state Medicaid programs, in order to make recommendations about adjusting or eliminating payment floors or ceilings
1748—extends a budgeting gimmick about to expire through the end of FY 2010
1749—Extends temporary increase in federal medical assistance that was in last year’s American Recovery and Re-investment Act through 2011

1751—attempts to cut waste/fraud by prohibiting Medicaid reimbursement for treatment of conditions that can be filed under multiple Medicaid codes (and has already been filed for that code) or conditions that are related to or resultant from health care treatment.
1752—any entity trying to contract to provide Medicaid services must have in place and agree to provide self-evaluations and internal reviews of the integrity oftheir processes
1753—suppliers and providers of Medicaid equipment and services must have a federal compliance program in place
1754—Gives the govt more time to adjust payments to states downward in order to compensate for earlier overpayments.
1755—application to Medicaid managed care organizations of the 85% medical loss ratio found earlier in the Bill.
1756—if a provider or physician or facility is terminated from eligibility under medicare, state care plans, child care plans, etc., they are also terminated from Medicaid.
1757—State Medicaid programs must exclude from participation in providing services anybody that owns, manages, or controls any entity that has been terminated from program, has uncorrected overpayments, or is affiliated with another entity that is also in violation.
1758—additional data has to be reported and shared to help detect waste, fraud, and abuse
1759—similar to a provision for medicare—billing agents, clearinghouses, and alternate payees have to be registered under Medicaid and adhere to standards
1760—Medicaid can’t be used to reimburse legal fees due to litigation of states, providers, physicians, facilities, etc.
1761—The secretary has to establish uniform coding standards and all State Medicaid agencies have to use them

1771—provides massive increases in Medicaid funding to US territories, incrementally each year from 2011 to 2019. Massive amounts of money. Also mandates “parity” among all 50 states by 2020; dictates development of a list of actions that states must take between now and 2020 to ensure parity in Medicaid financing. Note that parity is not equality—states with higher per capita incomes will not be treated equally.

1781—clerical adjustments to previous legislation for clarification purposes.
1782—extends cost-sharing financing gimmick with Medicare from 2010 through 2012 (this has already been extended several times). Also removes several funding restrictions for dual-eligible (Medicaid and medicare) individuals, covering 100% of costs.
1783—States are required to require hospitals and clinics to report costs of services provided. The report is to the state as well as to customers, and must be available in an easy format, preferably online.
1784—Secretary must report to Congress on the shortfall between Medicaid payments and the actual costs of providing care in nursing facilities. Must make recommendations for adjustments. Same thing is required for Pediatrics. Appropriates $11.8 million additional for implementation of the provisions of this bill that impact Medicaid or CHIP.
1785—Secretary HHS must issue guidance on best ways to inform Medicaid eligibles of their eligibility.
1786—states that THIS BILL does not change any CURRENT prohibitions of applying Medicaid or CHIP financing to illegal aliens.
1787—Science project to come up with a model in which mental health institutions get paid to provide care for free. The care would be fore “stabilization” of emergency conditions only. (e.g. suicide watch). The project is run by states who apply to have their costs recouped by Dept. HHS. Project lasts 3 years. Appropriates $75 million for the project. States and Dept HHS have to report to Congress and come up with plan to implement any system-wide changes.
1788—Funding limitations and by-number appropriations in the Social Security Act for certain Medicaid services are deleted and replaced with, in effect, “use as much money as you need”.
1789—Places additional administrative requirements on Medicaid brokers.
1790—Says it’s not a state’s fault if their state provisions are not in line with the new and improved Medicaid if this bill gets passed—gives them special leeway until they can legislate state programs into compliance.

1801—Sharing of taxpayer return information to Social Security Administration to more easily identify people ineligible for Medicaid/medicare prescription drug coverage.
THIS ONE IS CRITICAL*******
1802—Changes US Tax Code to create a new Comparative Effectiveness Research” trust fund. Appropriates $300 million over 3 years to start it out, after which it is fed by fees on health insurance and self-insured plans, and additional funds proportional to the number of people enrolled in Medicaid/medicare. The fees are generated using a “fair share per capita amount” that is levied against private health insurance plans. Note—the fee is leveraged against the Provider of the insurance plan. The fair share per capita amount is basically a factor, established by the secretary of HHS, that is multiplied by the number of people covered by a certain plan and the total amount is charged to the plan provider (which of course is passed on in higher premiums). Coincidentally, this fee does not apply to the government option plan. The spread of this amount will be calculated so that revenues to the trust fund ever year after 2012 will be $375 million. 2.6% of the fund and its revenues will be available every year to pay for the studies, programs, research, administrative requirements, and hookers of the bureaucrats researching “comparative effectiveness” of federal health care programs.

1901--This measure deletes an entire subsection of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The subsection deleted is the one that contained all the limitations on funding and the provisions to limit cost that were contingent on a trigger. The trigger is therefore deleted and the cost and expenditure controls eliminated.
1902—The comparative cost adjustment program of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 is repealed. This was a 6-year study that was supposed to start next year and was geared to check the feasibility of making drug cost-related adjustments to Medicaid/medicare premiums.
1903—Extends the Gainsharing Project established by the Deficit Reduction Act of 2005. This project seeks to reduce costs and improve care by improving coordination between hospitals and physicians. Was supposed to expire this year. Extends through next year and throws another $1.6 million at it.
1904—Provides for grants to states to pay for home visits of families with young children. Provides money for training outreach individuals and sets criteria for households and neighborhoods to focus on (low-income, high incidence of abuse). The scary thing is I see nothing that says that a state has to make the program optional for the families—it only says that it is optional for the state to conduct the program and apply for the grants. Appropriates $50 million for 2010, $100 million for 2011, $150 million for 2012, $200 million for 2013, and $250 million for 2014. ($650 million total)
1905—special treatment mandated for people that are eligible for both Medicaid and medicare, in order to ensure maximum coverage. Also seeks to increase the efficiency of processing dual claims and inter-agency coordination (another study!)
1906—Dept. HHS conducts a study on the diseases and conditions that are most cost intensive for federal programs. Study will include recommendations on directions of research to reduce these costs.
1907—creates new bureaucracy within the Medicaid/Medicare office – the Center for Medicaid and Medicare Innovation – to test innovative service delivery and payment models. Prohibits administrative or judicial review of any of the models or techniques the office tries out on guinea pig regions. Appropriates $350 million in 2010, $440 million in 2011, and $550 million in 2012. Increases administrative budget of the Center for Medicaid/Medicare Services by $25 million per year.
1908—Bill does not impact the requirement for hospitals to provide emergency care.
1909—Disregards portions of patients’ income when considering for participation in clinical trials.


2002—Creates a new Federal fund—the Public Health Investment Fund (PHIF). The fund is created depositing $4.6 billion in 2011, $5.6 billion in 2012, $6.9 billion in 2013, $7.8 billion in 2014, and $9 billion in 2015 (total $33.9 billion). Lists specific purposes already legislated within the Public Health Service Act that the money can be used for. The purposes are dictated below.
2003—This funding must be counted as new expenditures for purposes of deficit calculation.
2101—Use 1 of the PHIF: increased funding for community health centers.
2201—Augments the National Health Service Corps with funds from PHIF. Rules for certification of corps workforce and their obligated service in return for loans to finish medical certifications. Increases loan repayment amount for Service Corps members to $50k
2202—Specifies money to be made available from the PHIF for the Service Corps.

2211—Establishes new loan repayment program for dentists and primary care providers in certain high-need areas of the country. Doctors agree to 2 years of full-time indentured servitude in exchange for student loan repayments.
2212—Financial need considerations for participation in program.
2213—Special grants to medical schools or health training centers to incentivize training in family practice, pediatrics, and other primary care providers. Preference is to be given for training/educational institutions with a record of training individuals from “disadvantaged backgrounds”.
2214—Awards and grants for training medical residents in “community-based” settings. Preference is to be given for training/educational institutions with a record of training individuals from “disadvantaged backgrounds”.
2215—Awards and grants for training various kinds of dentists. Preference is to be given for training/educational institutions with a record of training individuals from “disadvantaged backgrounds”.
2216—directives to allocate funds from the PHIF to pay for all this crap.
2217—Conduct a study on the effectiveness of loans and scholarships on incentivizing doctors to pursue particular specialties, on the retention of such care providers, and on encouraging those care providers to serve in “underprivileged areas”.

2221—Augments funding for nurse-managed health care centers and nurse training. Increases student loan amounts; directives to allocate funds from the PHIF to pay for all this crap

2231—Establishes the Public Health Workforce Corps. Empowers Secretary to place and appoint Corps members in positions of responsibility where the Secretary thinks they are needed. Establishes a scholarship program for anyone enrolled in a health-related scholarship program. The applicant must serve in the health workforce corps 1 year per academic year covered by the scholarship (max 4 years). The Scholarship pays all educational expenses plus a monthly stipend of $1300. Also sets up a loan repayment program for students in health-related career fields. Loan repayment is maxed at $35k per year for 2 years (2 years obligated service).
2232—public health workforce training and enhancement program—grants, awards, fellowships, etc. for individuals seeking training and institutes providing the training. Preference is to be given for training/educational institutions with a record of training individuals from “disadvantaged backgrounds” or who end up serving in “underprivileged areas”.
2233—bureaucratic crap adjusting wording to reflect proposed changes.
2234—Special grants for institutes providing graduate medical residents training in preventive medicine specialties.
2235—directives to allocate funds from the PHIF to pay for all this crap.

2241—Ups federal scholarship amounts from $20k to $35k for students from disadvantaged backgrounds.
2242-- bureaucratic crap adjusting wording to reflect proposed changes.
2243—Bureaucratic rewording of existing legislation on diversity and cultural competency programs.

2251—cultural and linguistic competency training program for health professionals. Offers grants and awards to institutions that improve or establish training programs for linguistic competency to treat non-english speakers.
2252—provides for grants and awards to institutions that develop health professional training programs that promote delivery of health care across multiple disciplines and multiple settings (hospital, clinic, home, community, etc.)

2261—Secretary HHS establishes an Advisory Committee for Health Workforce Evaluation and Assessment. The committee will submit recommendations regarding the supply, diversity, and geographic distribution of the health workforce, the retention and expansion/contraction, etc. The committee consists of 15 people, one of which must be a representative or organized labor.

2271—mandates periodic “health workforce assessment” by Dept. HHS.

2281—Specifies appropriations from the PHIF to pay for lots of new programs—Diversity training (about $105 million per year), interdisciplinary training programs (about $100 million per year), and extending authorizations that have expired or are expiring soon through 2015.

2301—Creates the Prevention and Wellness Trust, using a total of about $15.5 billion from the PHIF. Secretary HHS must report a national strategy to promote wellness. Massive amounts of new spending on Prevention and wellness research ($1.25 billion over 5 years), delivery of community preventive and wellness services ($5.26 billion), and core public health infrastructure ($1.75 billion). Secretary will establish Task Force on Clinical Preventive Services to track effectiveness, evaluate studies and research and metrics, and otherwise waste space and money. Task force is 30 people. The task force will create the Clinical Prevention Stakeholder Board made up of even more people. Secretary will establish the Task Force on Community Preventive Services made up of 30 other appointees. The task force will create the Community Prevention Stakeholder Board made up of even more people. Sound redundant? I thought so, too. Authorizes the Dept. HHS to award grants to institutes that conduct research or projects in response to the recommendations of these task forces. No room for graft or corruption there, it there? Allows for awards and grants for institutions that conduct research or test projects on promoting healthy lifestyles (no tobacco, fighting obesity, etc.). Allows for awards and grants to entities that organize communities (community organizers?) into “Health Empowerment Zones” characterized by partnerships between the community, local government, and local health care facilities. Allows for grants and awards to address “core health infrastructure”, including health workforce training and competence, laboratory facilities, health information systems, financing, etc. Grants and awards focused on addressing “health disparities”—population-sp

My notes from reading the Affordable Health Care for America Act, as proposed by Nancy Pelosi.

Note: HHS = Health and Human Services. There are gaps in the numbered sections, that's because several sections were cut before the bill was published to the public. The numbering and ordering below is precisely how they appear in the version of the ironically titled "affordable health care for America Act" as published by the US House of Representatives. This is a 25-page condensation of a 1,990 page bill.

Section 101—sets up a “high risk” insurance pool -- provide health benefits starting jan 1 2010. costs no more than 125% of market rate????? Secretary of HHS determines if somebody was “dumped” from health plan by insurer or employer and recoup costs of covering that individual. Essential benefits: max deductible 1500, no annual limits allowed; maximum cost sharing 5000/ind., 10000 family. No pre-existing condition exclusion. State govts CANNOT cut funding from July 31 2009 levels
Pg 24 line 19 title 101 sec 6—no specifics for eliminating fraud, waste, and abuse
Creates $5 billion immediate slush fund. In the case of Insufficient funds, Secretary authorized to slash benefits = rationed care. Authorized to extend temporary high risk pool in order to avoid lapse of coverage during transition to “health exchange”

Section 102—attempt at lowering rates. Sec. HHS establishes a national Medical loss ratio for insurance companies, at least 85%- Any company who pays out less than the loss ratio of revenue from premiums to pay for medical costs of customers, the insurers must give money back to customers. This does not include the company’s operating costs, payroll, etc. Basically, it’s the federal govt telling an insurer how much profit they are allowed to have and how much money they are allowed to pay their employees—effective 1 jan 2010

Section 103--Amending previous legislation to make it harder for insurers to revoke coverage—they must demonstrate obvious fraud; they must provide written advanced notification of . Allow individuals to invoke federal watchdog (3rd party review) to force insurer to make the case for fraud, and insurer must provide coverage until review is complete—there is no provision for timeliness of this review, meaning that an individual can simply appeal and wait around with health insurance while the govt takes 3 to 33 years to review his case.

Section 104--Insurer must justify rate increases from year to year—must ask federal permission to increase premiums.
Section 105--Dependants up to age 27 are covered by parents’ coverage—mandatory
Section 106--Reduces pre-existing coverage “look-back” periods from 12 months to 3 months, making it harder for insurance companies to identify pre-existing conditions.
Section 107--Domestic Violence cannot be considered a pre-existing condition (pregnancy neither)
Section 108--Forcing insurers to provide surgical benefits for congenital or developmental deformities of minor children except cosmetic surgery
Section 109--Bans lifelong coverage caps
Section 110--Bans reduction of coverage or benefits of retirees—employers may apply for waiver
Section 111--Reimburse insurers that are providing coverage for retirees—anything over 15000 but less than 90000, can be reimbursed 80%. Insurer must use money to reduce premium costs, not as stated revenue or stock dividends. Creates $10 billion trust fund immediately

Section 112—incentives for employers to introduce health wellness programs—health awareness education, physical screenings, healthy living (tobacco, obesity, etc). Dept HHS and Dept Labor will validate a wellness program and certify it for a grant—equal to $150 x # of employees, but not more than $50,000 --1 jan 2010

Section 113—extends non-expired COBRA extension coverage until Health Exchange is stood up. Prohibits states from enforcing expiration dates, forcing state govts to keep paying.

Section 114—Grants for states to insure uninsured. States that already have a qualified program don’t get grants. States must pay 20% of the grant in order to get the grant --funding not specified

Section 115—Enforce standardized administrative actions electronically. Plan must be in place by 5 years later, and the plan must meet list of criteria, but no dollar estimate—cost determined by plan. Standardize claims processing procedures. Cost TBD. Free reign for HHS to penalize anyone that’s slow to adopt the standards

Section 201—Health plans have to meet new criteria (detailed later)
Section 202—Allows customers to keep the coverage they already have (i.e. allows private insurers to keep offering plans that people have already bought in to, they cannot enroll any new persons into those plans (if they don’t meet the later critieria) 5 yr grace period. After Y1, individual health insurance coverage MUST be participating in the Health Exchange.

Section 211—Qualified health benefits plan must have no pre-existing condition exclusion.
Section 212—continuations of coverage guaranteed. In order to axe anybody, there must be demonstrable fraud or notification of non-payment of premiums followed by grace period to allow person to pay up.
Section 213—Limits variance of premiums; For age, most expensive due to age cannot be more than twice as much as the cheapest due to youth and vigor. Rates can vary by area according to state insurance regulators. Uniform ratio of family price to indiv. price. Optional coverage prices will be determined by central commissioner. Requires a study and report within 18 mos
Section 214—Requires further research. Buffs up provisions of other bills, coverage/benefits cannot be limited or denied due to mental health or substance abuse.
Section 215—standards of provider network. Must have web portal
Section 216—Qualified health plan must insure dependant at option of customer, up to age 27
Section 217—Changes in coverage or costs must be notified 90 days in advance
Section 221—Exchange participants must adhere to standard detailed later, non-exchanged participants have more leeway.
Section 222—Qualified plan must cover: Hospitalization, out-patient, ER, professional services, equipment and supplies, prescriptions, rehabilitative services, mental health, substance abuse, behavioral health, preventive vaccines, maternity, well-baby, prosthetics and orthotics. There will be NO COST SHARING for maternity or well baby/child or vaccines.
Cost share total max 5000 for ind and 10000 for family per year. This increases proportional to the increase in premiums per year. Coverage is 70% of actuarial value.
Govt can’t mandate that a plan cover abortions, but does not prohibit federal funding of them (pg 110,) Dental care will be determined in a study to be conducted within 1 yr

Section 223—Health Benefits Advisory Committee. Consists of 21-27 people, 10-18 of which appointed by president. Determines benefit standards. Dictates cost sharing costs for enhanced and premium plans.
Section 224—procedures for adopting benefit standards. Bureaucratic crap
Section 231—Committee dictates uniform marketing standards for qualified health plans
Section 232—committee directs procedures for grievances due to denied claims. Findings of the panel are binding upon the insurance provider. Again, no provision for timeliness
Section 233—Standards for publication of plan information to the public. Contracting entities have a whole list of info they have to provide the committee or else face fines and other penalties. It is up to the insurer to make sure that their documentation is idiot-proof.
Section 234—the commissioner gets to decide the extent to which the standards apply to non-exchange participants.
Section 235—qualified plan must pay with same timeliness as Medicaid advantage.
Section 236—the committee determines standards for coordinating subrogation and reimbursements.
Section 237—Requires providers to simplify administrative processes as dictated by the Social Security Act ???
Section 238—Act does not interfere with state laws prohibiting discrimination against providers.
Section 239—Sec. HHS conducts study of pharmaceutical marketing practices and their use of physician prescribe information. Directs way to stop it and enforce “un-biased” marketing practices.
Section 240—Insurer must issue end-of-life counseling info, but Act will not interfere with state law in this regard.

Section 241—Establishes as independent agency in the executive branch the Health Choices Administration.
Section 242—implements and enforces plan standards; maintains health exchange, manages individual affordability credits; holds providers accountable through audits that the provider is then forced to pay for. Maintain stats and collect data; the commission punishes bad companies—fines, cutting off reimbursments for exchange participants, prevent the company from enrolling more people
Section 243—Agency has to communicate and collaborate with a whole list of orgs
Section 244—Ombudsman office to deal with RFIs, grievances, etc.

Section 251—Relationship to other acts. Bureaucratic crap.
Section 252—Non-discrimination of health care
Section 253—Whistleblower protection. Standard fare.
Section 254—Act does not infringe on collective bargaining agreements
Section 255—If one part of the bill is determined to be unconstitutional, that won’t impact the rest of the bill.
Section 256—Bill doesn’t impact state of Hawaii’s programs
Section 257—State attorneys general can sue on behalf of anyone in their state for monetary damages any provider that is found in violation of the act.
Section 258—Does not impact state or federal laws regarding abortion;
Section 259—Cannot discriminate against a medical service provider because they refuse to perform or refer patient for abortion
Section 260—FTC can prepare all kinds of reports on insurers regardless of for-profit status.
Section 261—act does not dictate in any way responsibilities of providers toward customers in any malpractice claim
Section 262—insurance providers no longer exempt from anti-trust laws
Section 263—Sec. HHS conducts a study on how to increase the use of electronic health records. Report NLT 31 DEC 2013.

Section 301—Health Insurance Exchange. Part of Health choices administration
302—Eligibles for Exchange—Everybody eligible so long as they are not maintaining coverage elsewhere. This is a gap coverage, enabling uninsured to get insured until they qualify for other coverage like medicare, Medicaid, tricare, etc.
303—In exchange, any provider can only offer one plan and one enhanced plan per area, if offer enhanced, can also offer premium, if premium, can offer premium-plus. Basic is 70% cost sharing, commission dictates the levels of other plans. Allowable 10% between tiers. States can add to minimum requirements and they will be in force.
304—bids and contracts for exchange participating insurers. The commissioner can waive federal contract standards that get in the way. Providers are responsible to be licensed in the state they offer in, provide data mandated by commission, be cheap, accept govt credits, and accept anybody—up to “capacity”, must include entities that provide services for low income and “medically under-served” people, and cater to culture and linguistic differences. Cannot discriminate service providers based on abortion
305—outreach and marketing for the exchange; enrollment from Sep to Nov; Automatic enrollment for people not eligible for Medicaid; enrollees pay insurer directly, are randomly reassigned if their plan gets axed; heavy reliance on state Medicaid system—the exchange determines state Medicaid eligibility and punts people off to the states; establish a plan to assist small businesses in dealing with the exchange; commission can provide coverage directly or through “nonprofit” providers selected by commission (huge corruption opportunity)
306—risk pooling adjustments—bureaucratic crap
307—Establishes Exchange trust fund—fed by taxes on people without acceptable coverage, taxes on employers not offering acceptable coverage, and taxes on providers who don’t pass muster
308—states are authorized to operate their own exchanges in lieu of the federal one, provided it meets minimum federal standards; states are also allowed to axe their own exchanges
309—Eff 1 Jan 2015 2 or more states can team up for interstate insurance compacts, subject to federal application approval; the commission can pay awards for states that do it, up to $1 million per state—NOTE*** authorizes money in the future without knowing how much money that will be.
310—Authorizes grants and loans for states to run non-profit insurance CO-Ops. The CO-OP cannot be state run or sponsored, must operate by popular vote of members, and be licensed. Appropriates $5 billion for this.
311—nothing in the bill impacts DoD or VA processes.

321—Public Option.---public option only available through the exchange. Can contract out to operate the administrative requirements. Create lots of bureaucrats (read: Ombudsmen). Acts as normal plan in the exchange, same rules apply, can offer enhanced and premium plans.
322—appropriates $2 billion in start up cash; the commission researches and sets premiums to cover all costs. The plan cannot be bailed out with federal funds.
323—health care providers that take Medicaid must take public option, can ask permission to opt out. Reimbursement rates are equal to medicare. NO ADMINISTRATIVE OR JUDICIAL REVIEW OF PUBLIC OPTION PAYMENTS IS ALLOWED
324—The commission must seek creative and more efficient ways to provide services, collect funds, provide payment options, etc. Standards do not have to be uniform in the public option across geographical regions.
325—There are preferred and non-preferred physicians. Preferred accept public option payment as “payment in full”. Non-preferred are the uppity ones. They agree to not impose charges greater than +15%. These physicians will get reimbursed less by the Public Option.
326—previously documented fraud and abuse provisions apply to the public option.
327—HIPAA insurance requirements apply
328—privacy act and other privacy legislation apply
329—Public Option is completely optional
330—members of Congress can enroll if they want
331—cooperate with VA to reimburse each other

341—Individual affordability credits—you get to apply to have your premiums reduced or your cost sharing proportion reduced; only citizens and legals are allowed, but verificationprocedures include a signature and a declaration they are legal. No database of illegals/legals is allowed. Starts off appropriating $30 million. Punts operating costs to social security administration. Amends social security act accordingly. It actually requires the administration to report conflicting records on citizenship status to the state, which is then required to ask the DHS for citizenship verification. Does not require any action be taken. Affordability credit cannot be used to help with abortion
342—Credits are available to individuals in the exchange program, not insured by employer, who makes less than 400% of poverty level. Also, if your employer offers insurance, but it would cost you more than 12% of your salary, you are eligible.
343—Premium credit. Chart on pg. 252,. Out of pocket cost caps max out at 5000/year.
344—Cost sharing credit—reduces cost sharing proportion, max out of pocket 5000/year
345—calculating and verifying income for applicants, penalties for liars.
346—special rules for US territories; lots of money allotted
347—No federal payments for illegal immigrants

401—individual responsibility; see section 501
411—employer must: offer indiv. and family Qualified Health Benefits Plan (QHPB), make contributions toward that coverage, if an employee declines coverage and gets insurance through the exchange, the employer must still make contributions to the health exchange.
412—employers required to pay 72.5% of premiums for indiv. and 65% of premiums for family. Part time employees also get coverage, and employer payment is proportional to the hours worked by the part time employee. Employers automatically enroll workers, but employee can opt out.
413—Employers can choose not to offer insurance, and instead pay 8% of payroll to health choices commission. This money is not counted as a proportion of the employee’s premiums. Employers with small payrolls can pay less according to chart on pg 276.
414—the commission can accuse and investigate employers if they feel they are encouraging employees to decline employer coverage in order to go to the exchange
415—calls for recurring annual study and report on the impact and status of employer contributions, making recommendations for possible adjustments
416—Call for study to investigate if employers should be elibible for exemption due to hardship.

421—massive amendment to the Employee retirement income security act of 1974—employer fails to pass muster, fined $100/day until rectified. Max $500,000. also excise taxes as listed in Internal Revenue Code of 1986—20% penalty
422—employers that fail to comply get taxed
423—amendment to Public Health Service Act to reflect section 421
424—Sec labor, treasury, HHS, and health choices commissioner pow-wow on making rules

501—Amendment to Internal Revenue Code of 1986—If at any time during a year you don’t have “satisfactory” health insurance, you are taxed 2.5% of gross income, maxed out at average national health care premium. Acceptable coverage is a QHBP, tricare, Medicare/aid, or a grandfathered pre-existing program

511—Amendment to Internal Revenue Code of 1986—taxes and punishments on employers that fail to pass muster.
512-- Amendment to Internal Revenue Code of 1986—8% tax on companies electing to not provide QHBP.—bureaucratic crap
521—assistance for small employers with low-paid employees. Lots of bureaucratic crap.

531—specification of govt. programs to cover insulin and prescription meds
532—more amendments—limitations on “cafeteria” plans—doesn’t count as QHBP unless salary reduction contributions are less than 2500
533—non-qualifying Health Savings Accounts are penalized a 20% excise tax (currently is 10%)
534—denies tax deduction for federal subsidies for prescriptions

541—sharing taxpayer information among depts. Of treasury and health choices commission
542-544—bureaucratic crap making required adjustments in wording to other bills.
545—Exclusion from gross income for medical care provided to American Indians.


551—additional tax of 5.4% of any adjusted gross income over $1 million for joint filers, $500k for individual filers.
552—2.5% tax on all sales of medical devices unless purchased at retail. i.e. tax on hospitals and doctors and patients that get their devices issued by them
553—expands reporting requirements to the IRS
554—Delays the Worldwide Application of Interest option for additional 9 years—2019. This is a tax option for people with overseas interests and accounts.

561—prevents treaties from reducing taxes
562—accountancy crap—nickels and dimes from state and local and taxpayers to make tax accounting more favorable to fed. Govt.
563—adjusting tax code to assume larger tax liabilities of large publically traded entities.

571—enabled self-employed individuals broad leeway in claiming health benefits for dependants for tax purposes.

Division B
Medicare/Medicaid “improvements”

1101—adjusts funding for nursing facilities under Medicaid, (guarantee it pushes payments downward)
1102—pushes back expiration date of pre-existing funding for inpatient rehabilitation facilitation coverage.
1103—massive adjustments to payment rate adjustment timelines. Very arcane and virtually impossible to understand.

1111—Adjustment in payment rates for sundry services; authorizes Sec. HHS to adjust rates in order to make these services “budget neutral”. Mandates 2% reduction in overall payments for ancillary services.
1112—mandates a report to Congress NLT 1 Jan 2016 on impact of reforms in reducing #of uninsured; results of report will push down funding to Medicaid starting FY2017; size of cuts TBD at that time.
1113—pushes off regulation of hospice care past 2010
1114—extending definitions of post-hospital care and physician care for coding and charging purposes

1121—calls for new feedback reports to be generated on how physicians use Medicaid/are.
1122—review and adjust periodically medical services that may be “misvalued” in the system. Authorizes to make adjustment to fee scheds as the dept. sees fit. Appropriated $20 billion for the project.
1123—incentive payments for efficiency (5% bonus). Regions that charge below reimbursement rates will get it, and region determined by zip code
1124—modification of physician rating program
1125—Redefines California fee schedule localities. Bureaucratic crap.

1131—more adjustments to fee schedules

1141—wheelchairs and other complex medical products—adjustments to wording and definitions, procedures for leasing and buying.
1142—extends payment for brachytherapy through 2012
1143—report to congress on fee-for-service medicare coverage NLT july 1 2011.—obviously trying to justify cutting the program or its funding
1144—requires surgical centers to submit service cost reports to keep on file in govt
1145—research costs of cancer hospitals and how the costs compare with others—authorizes adjustments to reimbursments.
1146—increases presumed utilization rate of imaging equipment from 50% to 75%--meaning less money for equipment, fewer devices. Currently, there’s 25% less payment for multiple uses on the same patient, the bill makes it 50% less payment
1147—further regulating medical devices, glasses, oxygen tanks, etc.
1148—bone mass measurement study—report on effectiveness and utility with an eye to kill it
1149—liberalizing payments for post-mastectomy thingies, biosimilar biological products; conduct study on setting up a mechanism for providing medical items via contracting bids

1151—cuts payments to hospitals for excess readmissions—if patients keep getting readmitted, pays out less each time, authorizes funds to study reasons for readmission and find ways to fix
1152—adjusting procedures for post-acute care by bundling services and consolidating processes. The pilot program gets $45 million 2010-2012
1153-1154 –adjustments to home health care payments. Bureaucratic crap
1155—making productivity improvements already in place in other legislation apply to home health services, calls for a study on variation in home health services, and standardizes procedures for making initial assessments
1156—provisions on tracking and reporting physician ownership or part ownership of medical facilities, I guess to deal with conflict of interest issues—physicians can’t make medicaire funded referrals to hospitals in which they have an ownsership interest. Funded $5 million per year every year starting 2010 and forever
1157—calls for study and report to Congress on geographic adjustment factors for medicare payments
1158—Revise medicare payment systems to respond to the geographic study, but can’t cost more than $8 billion a year in adjustment costs; the medicare improvement fund will be increased every year by the amount the Secretary deems necessary to implement adjustments.
1159—calls for study on geographic variation in health service utilization and promoting high-value health care; geographic influence on prices, health status, lifestyle, access to medical services, income and educational levels, etc. Make adjustments to pay schedules. $10 million appropriated for the study and analysis.
1160—implementing recommendations from 1159. Implementation plan must be budget neutral over 10 years. Dictates congressional procedures for implementation

1161—significant recalculation of Medicare Advantage benefits and payouts—downward push, with counties with high usage rates getting some extra attention. Gives govt free reign to axe Medicare Advantage plans that them deem noncompliant
1162—takes an administrative process in Medicare that was supposed to expire in 2010 and makes it permanent. My guess is it’s something that was pushing down reimbursments.
1163—2 week processing period for annual enrollments, shortens of annual enrollment season
1164—extends contracting process that was supposed to expire in 2010—thru 2012
1165—restricts employer group plan options for medicare advantage—can only be in group plan if 90% of eligibles are enrolled
1166—report due to congress within one year on how to improve risk and payment projections
1167—Kills the Medicare Advantage Plan Stabilization Fund and dumps the money into the Medical Insurance Trust fund.
1168—Calls for a study of changing the way medicare regions are tracked and managed.

1171—Limits cost sharing for individual health services; out of pocket expenses for individual services cannot be more than if they were part of larger plan
1172—modifies enrollment season if your medicare advantage plan gets axed
1173—requires MA providers to publish a laundry list of stats, including medical loss ratio. The plan must have a loss ration of at least 0.85, if lower, provider must refund money to customers. If they fail for 3 straight years, they cannot enroll anyone else. If for 5 years, the plan is axed
1174—Secretary can audit any MA plan provider they want, and provider pays the cost
1175—States can enforce federal standards, impose penalties, tattle on provider to govt.
1176—limits special circumstances under which outside-open-season enrollments can occur
1177—extends existing authorization for special need programs to restrict enrollment. Was slated to expire 2011, this pushes it out till 2016. Extends existing moratorium against certain geographic areas from 2010 to 2012.
1178—buffs up medicare senior housing plans—better plans for people living in retirement homes. Provides more incentive to put grandma in a home.

1181—buffs up Medicare part D by $500 in 2010 (per enrollee), increases medication coverage and reimbursement rates; starting 2011 thru 2019, each year must increase coverage total and decrease out-of-pocket threshold. Lists progressive % of increase in initial coverage limits for these years; Additional provision to force drug makers to provide rebates to individuals—for Part D or MA plans, anytime a manufacturer’s drug is paid for, that company must pay back to Medicare a portion of money proportional to the # of doses paid for. The rebate equals #doses x amount by which medicare rebate amount for that drug is greater than the average medicare rebate amount; fines companies big time if they delay or withhold information on pricing and dosage
1182—Forces pharmaceuticals to agree to discount certain drugs for Part D and MA and other federal drug plans. While individuals are in a gap in coverage, due to initial enrollment or other reason, 50% discount is forced.
1183—deletes a portion of the social security act limiting the timeframe a pharmacy in a hospital or clinic has to make claims
1184—eliminates a form of dual payment of claims by counting a claim as “paid” when it is covered by other programs. Brilliant and Revolutionary.
1185—substantive changes in drug plans, coverage, or cost sharing cannot take place mid-year—has to wait till next enrollment year
1186—Secretary will negotiate for lower costs for drugs and report results to congress
1187—Prescription plan providers are mandated to put in place controls to track dispensing and cut wasteful dispensing of drugs to enrollees living in long-term care housing
1188—PSPs have to offer to reduce or waive the co-pay for generic drugs in order to get people to take the generics instead of the name brand drugs
1189—secretary can accept state certification as interim licensing for PSP applicants

1191—Sets up bureaucratic committee (Telehealth Advisory Committee) to sit around and pretend to deal with rural issues with medicare. Adds Kidney Dialysis to a list of services afforded special reimbursement for rural areas; sets standards for accrediting “Telemedicine” physicians
1192—extends special funding for rural hospitals from 2010 to 2012
1193—extends “section 508” classification—higher payment rates for certain hospitals based on region.
1194—extends geographic floor criterion from 2010 to 2012, meaning that if the cost index (and therefore reimbursement rate) for a region is found to be below 1.00, it is assumed to be 1.00.
1195—extends payment for certain pathology services that were supposed to expire this year through 2011.
1196—Extends special bonus rate for ambulance service in rural areas from 2010 to 2012

1201—raises the monetary level below which people qualify for special perks Medicaid. You now have to be less poor to be considered poorest for Medicaid.
1202—eliminates cost sharing for a narrow group of people—free health care for people who probably should be in a permanent care facility
1203—waters down verification procedures for people trying to get low-income special treatment.
1204—Enhanced oversight for retro-active reimbursements for people who get the low-income subsidy. Must justify by line-item any reimbursement to the enrollee.
1205—dumbest thing so far. It calls for the use of an “intelligent process” to assign new enrollees to PSPs. But does not detail it—just tasks the secretary to actually take logistics and cost into account when enrolling people.
1206—more liberal enrollment policies for low-income subsidy people
1207—low income subsidy is not counted as income when making low-income subsidy decision

1221—SEC HHS conducts a study on medicare paying for interpreters for English-impaired enrollees, or some other way of funding them; the study evaluates which providers are providing what kind of language services. Appropriates $2 million for the study; authorizes the secretary to sanction/fine providers that do not provide “adequate” language services
1222—After the study is complete, provide at least 24 3-year grants ($500k) to medicare service providers to improve language services in communities that are “underserved”. Grant priority is given to providers with partnerships with Community Organizations. This program is a proof-of concept study that will be used to determine Medicare payments to providers of linguistic services; the three year program is appropriated $16million per year for 3 years ($48 million)
1223—Call for a report from Institute of Medicine on the health impact of language access services
1224—defines some critical language-related terms

1231—a waiver on cap of coverage for physical therapy is extended from 2009 to 2011
1232—extends eligibility for dialysis and immuno-supressive drugs for kidney transplant patients
1233—Medicare pays for end-of-life counseling (now called “advance care planning consultation”)
1234—Special enrollment period for enrollees, and Tricare beneficiaries can waive enrollment penalties
1235—normally you use two years ago for computing your income-related premium, but this creates a special circumstance allowing you to use last year if your income for that year is less due to the selling of your home at a loss.
1236—Conduct a fancy little science project trying to help enrollees make treatment decisions. Developing a “decision aid” for the enrollee to look at. Can be web portal, video, you name it. Money is authorized to pay for this, but the amount is not specified—“all costs”.

1301—Pilot program to find way to reduce the growth of expenditures. “Redesigned care practices”, rewards for best practices among physicians. Participants in the program don’t have to be medical practices—it has to be “organized at least in part for the purpose of providing physician’s services”. Participants report to a “best practices” website maintained by the secretary. Program pays out awards for participating care organizations that do things cheaply. Also measures “quality of care” in considering best practices. These measurements are not defined and are left up to the Secretary’s discretion. Program must start NLT 1Jan 2012. No administrative or judicial review of the program is allowed, including on the criteria of and to whom “awards” are paid. The Secretary can establish different performance standards for different kinds of participating organizations. The Secretary is authorized to limit participants’ exposure to “high cost patients”. Nudge nudge. Appropriated $25 million per year 2010-2014 and $20 million for 2015. ($120 million).

1302—5 year Pilot program for medical homes. Incentivize, test, and track different kinds of care facilities—Independent (operated and directed by physicians) vs. Community based (not-for profit local or state-run); medicare will pay these facilities per patient per month, as determined by the bureaucracy. The secretary can fund the start-up of community based facilities. $6 millino per year for 5 years just for operating and administering the program. $200 million per year 2010-2014 for the independent project, $125 million per year 2012-2016 for community based ($1.625 billion) plus initial implementation costs of $2.5 million per year 2010-2012.

1303—incentive payment of 5% above normal medicare reimbursement for certified primary care providers (10% bonus if you are in a registered shortage region)
1304—increases reimbursement rate for certified midwives
1305—waiver of cost-sharing for preventative services (cancer screenings, diabetic self-care training, screening for glaucoma, physical exams, vaccines, diabetic screening, etc, etc.) If medicare currently pays anything for these, it now pays 100%. For others, coverage will be determined later. Deductible is waived for these services.
1306—universal waiver of deductible for colorectal cancer screenings.
1307—excludes social worker services from medicare coverage under the skilled nursing facility payment system
1308—medicare coverage of marriage and family therapist services, mental health care provider.
1309—extends existing modification of fee schedule for mental health providers from 2009 to 2011.
1310—expands federal coverage of vaccines. Removes list of approved ones and replaces list with “federally approved and recommended vaccines”. Manufacturers of vaccines must enter into rebate agreement to pay to govt. any payment the receive that is above the average cost of vaccines
1311—expands medicare covered preventive services at qualified health centers
1312—Another science project. This is to see if they can make things cheaper by relying on in-home care providers. Sets target expenditure levels, and pays out rewards if the home-based provider in the study beats that level by 5%. $5 million per year 2010-2015.
1313—classifies a “certified diabetes educator” as a care provider under medicare and therefore eligible for payment/reimbursement. Sounds like some Congressman has a brother in law who is a certified diabetes educator.
1401—creates a new executive bureaucracy under the Agency for Healthcare Research and Quality, called “Center for Comparative Effectiveness Research”. This will poke, prod, and shake health care data in order to make it look like the reform plan is working. Er…I mean in order to identify most effective practices, procedures, practitioners, etc. Tasked to issue grants for research projects that fall within its mandate. Creates a commission to lead the direction of health care research in the country. Commission is 3 bureaucrats, 10 practicing physicians, and 6 more leeches drawing a government salary for pretending to work. For funding, see section 1802

1411—mandates that nursing facilities publish information to become more transparent—ownership details, governance/administration,