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.
Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Date plan announced April – May 2009 June 9, 2009 June 19, 2009 February 26, 2009
Overall approach to The Senate Finance Committee Require all individuals to have Require all individuals to have President Obama outlined eight
expanding access to released a series of papers laying health insurance. Create state- health insurance. Create a Health principles for health care reform
coverage out options for health reform. While based American Health Benefit Insurance Exchange through which in his FY 2010 Budget overview.
not a formal proposal, these papers Gateways through which individuals individuals and employers can The President has indicated that
offer a framework for achieving and small businesses can purchase purchase health coverage, with comprehensive health reform
health reform goals and present the health coverage, with subsidies premium and cost-sharing credits should:
range of options the Committee will available to individuals/families available to individuals/families • Reduce long-term growth of
consider as it works to draft health with incomes up to 500% of the with incomes up to 400% of the health care costs for businesses
reform legislation. federal poverty level. Impose new federal poverty level. Require and government.
Require all individuals to have regulations on the individual and employers to provide coverage to
• Protect families from bankruptcy
health insurance. Create a Health small group insurance markets. employees or pay into a Health
or debt because of health care
Insurance Exchange through which Expand Medicaid to all individuals Insurance Exchange Trust Fund,
costs.
individuals and small businesses with incomes up to 150% of the with exceptions for certain small
• Guarantee choice of doctors and
can purchase health coverage, with poverty level. employers, and provide certain
health plans.
subsidies available to individuals/ small employers a credit to offset
the costs of providing coverage. • Invest in prevention and wellness.
families with incomes between 100
Impose new regulations on plans • Improve patient safety and quality
and 400% of the federal poverty
participating in the Exchange and in care.
level. Impose new regulations on
the non-group and small group the small group insurance market. • Assure affordable, quality health
insurance markets. Expand Expand Medicaid to 133% of the coverage for all Americans.
Medicaid and CHIP and offer a poverty level. • Maintain coverage when you
temporary Medicare buy-in for the change or lose your job.
pre-Medicare population. • End barriers to coverage for
people with pre-existing medical
conditions.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Individual mandate • Require all individuals to have • Require all individuals to have • Require all individuals to have • The plan must put the country
insurance that meets minimum qualifying health coverage. “acceptable health coverage”. on a clear path to cover all
coverage standards. Enforced Enforced through a tax penalty, Enforced through a 2% tax Americans.
through an excise tax equal to a the amount of which is to be on adjusted gross income
percentage of the premium for determined by the Secretary of up to the cost of the average
the lowest cost option available the Treasury. Exemptions to the national premium for the basic
through the Health Insurance individual mandate will be granted plan in the Health Insurance
Exchange in the area where the to residents of states that do not Exchange. Exceptions granted for
individual resides. Exemptions will establish an American Health dependents, religious objections,
be granted for financial hardship; Benefit Gateway, members of and financial hardship.
if the lowest cost plan option Indian tribes, those for whom
exceeds 10% of an individual’s affordable coverage is not
income; and if the individual has available, and those who can
income below 100% of the poverty demonstrate financial hardship.
level.
Employer requirements • Proposed Option A: Require Policy under development. • Require employers to offer Not specified.
employers with more than coverage to their employees and
$500,000 in total payroll per contribute at least 72.5% of the
year to offer coverage to their premium cost for single coverage
employees and contribute at and 65% of the premium cost for
least 50% of the premium or pay family coverage of the lowest cost
an assessment. The employer plan that meets the essential
assessment could be structured benefits package requirements or
in several ways: 1) a set fee per pay 8% of payroll into the Health
enrollee per month based on total Insurance Exchange Trust Fund.
annual payroll; 2) a tiered penalty • Exempt certain small businesses
calculated as a percentage of (to be determined) from
payroll; or 3) a larger penalty only the employer “pay or play”
on firms with annual payroll of requirement.
more than $1,500,000.
• Proposed Option B: No employer
“pay or play” requirement.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Expansion of public Medicaid • Expand Medicaid to all individuals • Expand Medicaid to all individuals • As a foundation for health
programs • Expand Medicaid to all individuals with incomes up to 150% FPL. with incomes up to 133% FPL. reform, the President signed
with incomes up to 115% FPL, Individuals eligible for Medicaid Newly eligible, non-traditional the Children’s Health Insurance
with a possible increase in will be covered through state (childless adults) Medicaid Program Reauthorization
eligibility for parents, pregnant Medicaid programs and will not beneficiaries may enroll in Act (CHIPRA), which provides
women, and children to a be eligible for credits to purchase coverage through the Exchange coverage to 11 million children.
higher level. Coverage could be coverage through American if they were enrolled in qualified
provided through the current Health Benefit Gateways. health coverage during the
program structure or by enrolling • Grant individuals eligible for six months before becoming
children, pregnant women, the Children’s Health Insurance Medicaid eligible. After five years,
parents, and childless adults in Program (CHIP) the option of states may request that some
the Health Insurance Exchange. enrolling in CHIP or enrolling in or all categories of Medicaid
Another alternative is to enroll a qualified health plan through a beneficiaries obtain coverage
all populations except childless Gateway. through the Exchange provided
adults in Medicaid. Under this • Create a public plan to be offered the state can demonstrate the
approach, childless adults would through state Gateways. The ability to provide wrap-around
not be eligible for Medicaid but details of the public plan are coverage and the plans in the
would be given tax credits to under development. Exchange are deemed capable of
purchase coverage through the supporting this population.
Exchange or to buy-in to Medicaid. • Provide optional Medicaid
Children’s Health Insurance coverage to low-income HIV-
Program infected individuals; provide
• After September 30, 2013, expand optional Medicaid coverage for
CHIP eligibility to 275% FPL. Once family planning services to certain
the Health Insurance Exchange is low-income women.
fully operational, CHIP enrollees • Require CHIP enrollees to obtain
would obtain coverage through coverage through the Health
the Exchange and states would Insurance Exchange.
be required to continue to provide
services not covered by plans in
the Exchange, including Early and
Periodic Screening, Diagnosis, and
Treatment (EPSDT) services.
Medicare
• Until the Health Insurance
Exchange is underway, allow
individuals aged 55-64 without
coverage to buy-in to Medicare at
full-cost.
• Phase-out or reduce the two-
year waiting period for Medicare
eligibility for people with
disabilities.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Expansion of public Public Health Insurance Option • Create a new public health
programs (continued) • Proposed Option A: Create a insurance option to be offered
new public plan to be offered through the Health Insurance
through the Exchange that will Exchange that must meet the
be subject to the same rating same requirements as private
and risk adjustment rules as the plans regarding benefit levels,
private plans. The public plan provider networks, consumer
could be administered by the protections, and cost-sharing.
federal government, by multiple Require that costs of the public
third-party administrators, or by plan be financed through revenues
the states. from premiums. Set provider
• Proposed Option B: Do not create payment rates in the public plan
a public plan option. at Medicare rates and allow bonus
payments of 5% for providers
that participate in both Medicare
and the public plan and for
pediatricians and other providers
that don’t typically participate in
Medicare. Permit the public plan
to develop innovative payment
mechanisms, including medical
home and other care management
payments, value-based
purchasing, bundling of services,
performance based payments, or
partial capitation.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Premium subsidies to • Provide refundable tax credits • Provide premium credits • Provide affordability premium • The plan must protect families’
individuals to individuals and families with on a sliding scale basis to credits to individuals and families from bankruptcy or debt because
incomes between 100 and 400% individuals and families with with incomes up to 400% FPL of health care costs.
FPL to purchase insurance incomes up to 500% to purchase to purchase insurance through • The American Recovery and
through the Health Insurance coverage through the Gateway. the Health Insurance Exchange. Reinvestment Act makes coverage
Exchange. The level of the The premium credits will be The premium credits will be more affordable for Americans
premium tax credit could be set determined by the Secretary, but based on the average cost of the who lose their jobs and their
as a percentage of income or as a will be such that individuals with three lowest cost basic health access to employer-based health
percentage of the premium, with incomes less than 500% FPL pay plans in the area and will be set coverage by offering a subsidy of
additional limits on cost-sharing. no more than 10% of income and on a sliding scale such that the 65 percent of the premium costs
individuals with incomes less than premium contribution is no more for COBRA coverage.
150% FPL pay 1% of income, with than 1% of income for individuals
additional limits on cost sharing. with income at or below 133% FPL
• Individuals are not eligible for and no more than 10% of income
premium credits through the for individuals with income at
Gateway if they have access to 400% FPL.
employer-based coverage that • Provide affordability cost-sharing
meets minimum qualifying criteria credits to individuals and families
and affordability standards, or are with incomes up to 400% FPL. The
eligible for Medicare, Medicaid, cost-sharing credits are offered
TRICARE, or FEHBP. on a sliding scale basis such that
the cost-sharing limit for those
with income at or below 133%
FPL is $250 per individual and
$500 per family and for those with
income at 400% FPL is $5,000 per
individual and $10,000 per family.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Premium subsidies to • Provide certain small employers • Provide qualifying small • Provide small employers with Not specified.
employers that purchase insurance for their employers with a health options fewer than 25 employees and
employees with a tax credit. The program credit. To qualify for the average wages of less than
full credit of 50% of the average credit, employers must have fewer $40,000 with a health coverage
total premium cost paid by the than 50 full-time employees, pay tax credit. The full credit of 50% of
employer would be available an average wage of less than premium costs paid by employers
to employers with 10 or fewer $50,000, and must pay at least is available to employers with 10
employees and whose employees 60% of employee health expenses. or fewer employees and average
have average annual wages of less The credit is equal to $1,000 annual wages of $20,000 or less.
than $20,000. The tax credit would for each employee with single The credit phases-out as firm size
be phased out as firm size and coverage and $2,000 for each and average wage increases.
earnings increase. The tax credit employee with family coverage,
would not be payable in advance adjusted for firm size (phasing
or refundable. out as firm size increases) and
number of months of coverage
provided. Bonus payments are
given for each additional 10% of
employee health expenses above
60% paid by the employer.
• Create a temporary reinsurance
program for employers providing
health insurance coverage to
retirees ages 55 to 64. Program
will reimburse employers for
80% of retiree claims between
$15,000 and $90,000. Program
will end when the state Gateway is
established.
Tax changes related to • Considers several health Not specified. Not specified. Not specified.
health insurance insurance-related tax changes
affecting the tax preference for
employer-sponsored insurance,
health savings accounts,
flexible spending accounts, and
deductions for medical expenses.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Creation of insurance • Create one national or multiple • Create state-based American • Create a National Health • The plan should provide portability
pooling mechanisms regional Health Insurance Health Benefit Gateways through Insurance Exchange through of coverage and should offer
Exchanges through which which individuals and small which individuals and employers Americans a choice of health
individuals and small employers employers can purchase qualified (phasing-in eligibility for employers plans.
can purchase qualified insurance. coverage. States may form starting with smallest employers)
• Require all state-licensed insurers regional Gateways or allow more can purchase qualified insurance.
in the non-group and small group than one Gateway to operate in • Restrict access to coverage
markets to participate in the a state as long as each Gateway through the Exchange to
Health Insurance Exchange(s). serves a distinct geographic area. individuals who are not enrolled
• Require guarantee issue and • Require the Gateway to certify in qualified or grandfathered
renewability and allow rating participating health plans, provide coverage, Medicare, Medicaid
variation based only on age, consumers with information (with some exceptions), TRICARE,
tobacco use, family composition, allowing them to choose among or VA coverage.
and geography (not health status) plans, contract with navigators to • Create four benefit categories
in the Exchange(s). conduct outreach and enrollment (basic, enhanced, premium, and
• Require the Exchange(s) to assistance, and create a single premium plus) of plans to be
develop a standardized format point of entry for enrolling in offered through the Exchange.
for presenting insurance coverage through the Gateway or Require participating plans to
options, create a web portal to through Medicaid, CHIP or other offer one basic plan for each
help consumers find insurance, federal programs. service area and permit them to
maintain a call center for • Require states to adjust payments offer additional plans.
customer service, and establish to health plans based on the • Require guarantee issue and
procedures for enrolling actuarial risk of plan enrollees renewability; allow rating variation
individuals and businesses and using methods established by the based only on age (limited to 2 to
for determining eligibility for tax Secretary. 1 ratio), premium rating area, and
credits. • Require plans participating family enrollment; and limit the
in the Gateway to provide medical loss ratio to 85%.
incentives to providers to better • Require plans participating
coordinate care, reduce hospital in the Exchange to be state
readmissions and implement licensed, report data as required,
wellness and health promotion implement affordability credits,
activities; prohibit plans from meet network adequacy
contracting with hospitals with standards, provide wrap-around
greater than 50 beds unless those coverage for Medicaid eligible
hospitals adopt patient safety and individuals, provide culturally and
discharge planning programs. linguistically appropriate services,
and contract with essential
community providers.
• Require risk adjustment of
participating Exchange plans.
• Provide information to consumers
to enable them to choose among
plans in the Exchange, including
establishing a telephone hotline
and maintaining a website.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Benefit design • Create four benefit categories • Create three benefit tiers based on • Create an essential benefits Not specified.
(lowest, low, medium, and high). the percentage of allowed benefit package that provides a
Require all plans to provide a costs covered by the plan, ranging comprehensive set of services
comprehensive set of services and from 76% of benefit costs for the as recommended by the Health
prohibit inclusion of lifetime limits lowest tier to 93% of benefit costs Benefits Advisory Council. The
on coverage or annual limits on for the highest tier. Require plans essential benefits package covers
benefits. to provide at least the essential 70% of the actuarial value of the
• All policies (except certain benefits specified by the Medical covered benefits; limits annual
grandfathered employer- Advisory Council and prohibit cost-sharing to $5,000/individual
sponsored plans) must comply inclusion of lifetime or annual and $10,000/family; and does not
with one of the four benefit limits on benefits. impose annual or lifetime limits
categories, including those offered • Establish a Medical Advisory on coverage.
through the Exchange and those Council to make recommendations • All qualified health benefits plans,
offered outside of the Exchange. on essential health care benefits, including those offered through
criteria for minimum qualifying the Exchange and those offered
coverage, and affordability outside of the Exchange (except
standards. certain grandfathered individual
and employer-sponsored plans)
must provide at least the essential
benefits package.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Changes to private • Require guarantee issue and • Require guarantee issue and • Prohibit coverage purchased • The plan must end barriers to
insurance renewability and allow rating renewability of health insurance through the individual market coverage for people with pre-
variation based only on age, policies in the individual and small from qualifying as acceptable existing medical conditions.
tobacco use, family composition, group markets; prohibit pre- coverage for purposes of the
and geography (not health status) existing condition exclusions; and individual mandate unless it
in the non-group, micro-group allow rating variation based only is grandfathered coverage.
(2-10 employees), and small group on family structure, geography, Individuals can purchase a
markets. Require risk adjustment the actuarial value of the health qualifying health benefit plan
in all markets. plan benefit, and age (with only 2 through the Health Insurance
• Require all state-licensed insurers to 1 variation). Exchange.
in the non-group and small group • Require health insurers to: • Require guarantee issue and
markets to participate in the report cost information; to meet renewability and allow rating
Health Insurance Exchange. medical loss ratios established variation based only on age
• Require all insurers to issue by the Secretary or provide (limited to a 2 to 1 ratio), premium
policies in each of the four new rebates to enrollees; to provide rating area, and family enrollment
benefit categories. incentives to providers to better in the small group market and
• Allow states the option of merging coordinate care, reduce hospital the Exchange. Prohibit imposition
the non-group and small group readmissions and reduce medical of any pre-existing condition
markets. errors. exclusions.
• Require insurers to provide • Limit health plans’ medical loss
coverage for preventive care ratio to 85% enforced through a
services without cost sharing. rebate back to consumers.
• Provide dependent coverage for • Require all insurers to offer
children up to age 26. coverage that meets the essential
benefits package requirements.
• Standardize health care claims
forms, operating rules for
using and processing health
care transactions, and quality
reporting requirements and
increase electronic exchange of
administrative and clinical data.
State role • Allow states the option of merging • Establish American Health • Require states to enter into a Not specified.
the non-group and small group Benefit Gateways meeting Memorandum of Understanding
insurance markets. federal standards and adopt with the Health Insurance
• Require state insurance individual and small group market Exchange to coordinate
commissioners to provide regulation changes. enrollment of individuals in
oversight of health plans with • Create temporary “RightChoices” Exchange-participating health
regard to consumer protections, programs to provide uninsured plans and under the state’s
rate reviews, solvency, reserve individuals with immediate access Medicaid program.
fund requirements, and premium to preventive care and treatment • May require states to determine
taxes and to define rating areas. for identified chronic conditions. eligibility for affordability credits
States will receive federal grants through the Health Insurance
to finance these programs. Exchange.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Cost containment • Encourage adoption and use of • Establish a Health Care Program • Simplify health insurance • The plan should reduce high
health information technology Integrity Coordinating Council administration by standardizing administrative costs, unnecessary
by expanding eligibility for and two new federal department health care claims forms, tests and services, waste, and
the Medicare HIT incentives positions to oversee policy, operating rules for using other inefficiencies that consume
in the American Recovery and program development, and and processing health care money with no added benefit.
Reinvestment Act to include oversight of health care fraud, transactions, and quality • The plan must invest in public
additional providers. waste, and abuse in public and reporting requirements and health measures proven to reduce
• Eliminate fraud, waste, and abuse private coverage. increasing electronic exchange of cost drivers in our system—
in public programs through more • Develop a national prevention and administrative and clinical data. such as obesity, sedentary
intensive screening of providers, health promotion strategy that • Modify provider payments under lifestyles, and smoking—as
the development of the “One PI sets specific goals for improving Medicare to: well as guarantee access to
database” to capture and share health. Create a prevention and – Reform the sustainable growth proven preventive treatments.
data across federal and state public health investment fund rate for physicians and include The American Recovery and
programs, increased penalties to expand and sustain funding incentive payments to physicians Reinvestment Act provides
for submitting false claims and for prevention and public health practicing in efficient areas; $1 billion for prevention and
violating EMTALA, and increase programs. – Reduce payments to hospitals wellness.
funding for anti-fraud activities. • Provide grants for improving with excess readmissions and
• Restructure payments to Medicare health system efficiency, including apply the readmissions policy to
Advantage plans to promote grants to establish community post acute care providers and
efficiency and quality. health teams to support a medical physicians; and
• Require drug or device home model; to implement – Reform payment for post acute
manufacturers to disclose medication management services; care services to include a
payments and incentives given to design and implement regional bundled payment for post acute
to providers and any investment emergency care and trauma care services.
interest held by a physician. systems. • Restructure payments to Medicare
• Improve transparency of Advantage plans to link to
information about skilled nursing fee-for-services payments and
facilities. incorporate incentives for quality;
• Allow providers organized as require Medicare Advantage plans
accountable care organizations to have medical loss ratios of at
that voluntarily meet quality least 85%.
thresholds to share in the cost- • Increase the Medicaid drug
savings they achieve for the rebate percentage and extend
Medicare program. the prescription drug rebate to
• Improve prevention by covering Medicaid managed care plans.
only proven preventive services
in Medicare and Medicaid and
providing incentives to Medicare
and Medicaid beneficiaries to
complete behavior modification
programs.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 0

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Cost containment • Reduce waste, fraud, and abuse in
(continued) public programs by
– Refusing Medicaid payments for
health care-acquired conditions;
– Allowing provider screening,
enhanced oversight periods, and
enrollment moratoria in areas
identified as being at elevated
risk of fraud in all public
programs;
– Requiring Medicare and
Medicaid program providers
and suppliers to establish
compliance programs; and
– Requiring evaluations and
reports under Medicare and
Medicaid integrity programs.
• Improve transparency of
information about skilled nursing
facilities.
• Improve prevention by covering
only proven preventive services
in Medicare and Medicaid and
eliminate any cost-sharing for
preventive services.
• Develop a national strategy to
improve the nation’s health
through evidenced-based
clinical and community-based
prevention and wellness
activities. Create task forces
on Clinical Preventive Services
and Community Preventive
Services to develop, update, and
disseminate evidenced-based
recommendations on the use of
clinical and community prevention
services.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Improving quality/health • Strengthen primary care and • Develop a national strategy to • Support comparative effectiveness • The plan must ensure the
system performance chronic care management by improve the delivery of health research by establishing a Center implementation of patient safety
providing bonus payments to care services, patient health for Comparative Effectiveness measures and provide incentives
certain primary care providers outcomes, and population health Research within the Agency for changes in the delivery
and providing reimbursement that includes publishing an annual for Healthcare Research and system to reduce unnecessary
for certain care management national health care quality report Quality to conduct, support, variability in patient care. It must
activities for patients with hospital card. and synthesize research on support the widespread use of
stays related to a major chronic • Develop, through a multi- outcomes, effectiveness, and health information technology
condition. stakeholder process, quality appropriateness of health care and the development of data
• Establish a framework to set measures that allow assessments services and procedures. An on the effectiveness of medical
national priorities for comparative of health outcomes; continuity independent CER Commission interventions to improve the
clinical effectiveness research. and coordination of care; safety, will oversee the activities of the quality of care delivered.
• Create a Chronic Care effectiveness and timeliness Center. • To lay the foundation for improving
Management Innovation Center of care; health disparities; • Strengthen primary care and the health care delivery system
within CMS to disseminate and appropriate use of health care coordination by increasing and quality of care, the American
innovations that foster patient- care resources. Require public Medicaid payments for primary Recovery and Reinvestment
centered care coordination reporting on quality measures care providers, providing Medicare Act invests $19 billion in health
innovations for high-cost, through a user-friendly website. bonus payments to primary care information technology, including
chronically ill Medicare • Create a Patient Safety Research practitioners serving in health $17 billion in incentives to
beneficiaries. Center charged with identifying, professional shortage area, providers to encourage their use
• Bundle payments for acute, evaluating, and disseminating conducting a Medicare pilot of electronic medical records,
inpatient hospital services and information on best practices for program to test payment incentive and provides $1.1 billion for
post-acute care services occurring improving health care quality. models for accountable care comparative effectiveness
within 30 days of discharge from a • Develop interoperable standards organizations, and conducting research.
hospital. for using HIT to enroll individuals pilot programs in Medicare and
• Establish a hospital value-based in public programs and provide Medicaid to assess the feasibility
purchasing program to pay grants to states and other of reimbursing qualified patient-
hospitals based on performance governmental entities to adopt centered medical homes.
on quality measures. and implement enrollment • Improve coordination of care
• Develop a strategy for the technology. for dual eligibles by creating a
development, selection, and new office within the Centers for
implementation of quality Medicare and Medicaid Services
measures that involves input from and allow certain Medicare
multiple stakeholders. Improve Advantage plans to serve as fully
public reporting of quality and integrated dual eligible special
performance information that needs plans.
includes making information • Develop national priorities for
available on the web. performance improvement and
• Require enhanced collection quality measures for the delivery
and reporting of data on race, of health care services.
ethnicity, and primary language.
Also require collection of access
and treatment data for people with
disabilities.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Improving quality/health • Reduce racial and ethnic
system performance disparities by conducting a study
(continued) on the feasibility of developing
Medicare payment systems for
language services and provide
Medicare demonstration grants
to reimburse culturally and
linguistically appropriate services.
• Develop standards for the
collection of data on race,
ethnicity, and primary language.
Other investments • Promote prevention and wellness • Establish a national, voluntary • Require a report on the • As an initial investment in
by providing grants to states to insurance program for purchasing continued role for Medicare and strengthening the health care
implement innovative approaches community living assistance Medicaid Disproportionate Share workforce, the American Recovery
to promoting integration of health services and supports (CLASS Hospital payments including the and Reinvestment Act provides
care services to improve health program). The program will appropriate targeting of Medicare $500 million to train the next
and wellness outcomes and provide individuals with functional and Medicaid DSH payments to generation of doctors and nurses.
providing tax credits to small limitations a cash benefit to hospitals and the distribution of
businesses that implement proven purchase non-medical services and Medicaid DSH among the states.
wellness programs. supports necessary to maintain • Reform Graduate Medical
• Change the Medicaid FMAP community residence. The program Education to increase training
formula to include data on a is financed through voluntary of primary care providers by
state’s poverty level and increase payroll deductions: all working redistributing residency positions
Medicaid FMAP rates during adults will be automatically enrolled and promote training in outpatient
economic downturns to assist in the program, unless they settings.
states in financing increased choose to opt-out. • Support training of health
Medicaid enrollment. • Establish a National Health professionals, including
• Reform Graduate Medical Care Workforce Commission to advanced education nurses,
Education to increase training make recommendations and who will practice in underserved
of primary care providers and disseminate information on health areas; establish a public health
promote training in outpatient workforce priorities, goals, and workforce corps; and promote
settings, and ensure the policies including education and training of a diverse workforce
availability of residency programs training, workforce supply and and provide cultural competence
in rural and underserved areas. demand, and retention practices. training for health care
• Improve the availability of long- • Reform Graduate Medical professionals.
term care services by increasing Education to increase the supply, • Provide grants to each state
access to home and community education, and training of doctors, health department to address
based services through changes in nurses, and other health care core public health infrastructure
Medicaid program requirements workers, especially in pediatric, needs.
and through grants to states. geriatric, and primary care. • Provide full federal funding
• Improve access to care by for Medicaid expansions and
providing additional funding enhanced federal funding for
to increase the number of Medicaid improvements.
community health centers and
school-based health centers.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Senate Finance Committee Senate HELP Committee House Tri-Committee President Obama
Policy Options Affordable Health Choices Act Health Reform Proposal Principles for Health Reform
Financing Not specified. Considering a range Not specified. Not specified. President Obama dedicated $630
of options for achieving savings and billion over ten years toward a
for generating new revenues. Health Reform Reserve Fund in his
budget outline released in February
2009 to partially offset the cost of
health reform.
Sources of information Go to following link: http://finance. http://help.senate.gov/ http://edworkforce.house.gov/ http://www.whitehouse.gov/omb/
senate.gov/sitepages/baucus.htm budget/
then select these items http://www.HealthReform.gov
5-11-09 Baucus, Grassley Policy
Options for Expanding Health
Care Coverage: Proposals to
Provide Affordable Coverage to All
Americans
4-28-09 Baucus, Grassley Policy
Options for Transforming the Health
Care Delivery System: Proposals to
Improve Patient Care and Reduce
Health Care Costs
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

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 to Create state-based health insurance exchanges Create a public health insurance program for Create a national health insurance program for
expanding access to through which private plans offer coverage all U.S. residents. Replace employer coverage individuals meeting eligibility requirements.
coverage meeting certain benefit and other standards. and eliminate the Medicare, Medicaid and CHIP Require states to administer the program
Allow employers to continue providing coverage programs. Individuals are not required to pay and provide for equivalent care for “needy”
to their employees, but replace 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
with a tax credit for individuals and families for global budgets for hospitals and negotiate Board determines allotments for the classes of
to provide incentives for insurance coverage. annual reimbursement rates with physicians covered services. Financed by a value-added tax
Integrate low-income families into private and other non-institutional providers. Finance imposed on certain transactions.
insurance by providing additional financial program by redirecting current federal and state
support and maintain Medicaid coverage for health care spending, impose an employer/
low-income people with disabilities. employee payroll tax, and leverage additional
taxes.
Individual mandate • No requirement for individuals to have • All individuals residing in the US are covered • Individuals meeting certain requirements are
coverage. under the United States National Health Care entitled to benefits under the National Health
Act (USNHC). Insurance Program.
Employer requirements Not specified. No provision. No provision.
Expansion of public • Restructure the Medicaid program to • Create a new public plan, the USNHC program, • Create a new public plan, covering medical,
programs provide care only to low-income people with that provides coverage for a comprehensive set dental, podiatric, home-nursing, hospital, and
disabilities. Integrate low-income families into of benefits, including long-term care services, auxiliary services. A National Health Insurance
private insurance by providing them with a tax to all US residents. Board, in consultation with a National Advisory
credit plus other financial support. • Eliminate the Medicare, Medicaid, and CHIP Medical Council determines the scope of
• Allow private facilities to compete with programs as beneficiaries of these programs benefits consistent with the statute.
Veteran’s Administration facilities to provide are eligible for the USNHC program. • Continue Medicare, but enrollees may be
care to veterans. • VA health programs will remain independent transferred into the new program in the future.
• Allow eligible American Indians to access for 10 years after which they will either remain Medicare beneficiaries are covered under the
medical care outside of Indian Health Service independent or be integrated into the USNHC new program for services that are not covered
facilities. program. The Indian Health Service will remain by Medicare.
independent for 5 years after which it will be • Require states to provide equivalent services to
integrated into the USNHC program. those not eligible under the new plan. Current
federal Medicaid funds and other federal funds
provided to states under the Social Security Act
are available for this purpose.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

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)
Premium subsidies to • Provide a tax credit of $2,300 for individuals • Individuals are not required to pay premiums • Individuals are not required to pay premiums to
individuals and $5,700 for families to be used to purchase to obtain coverage nor are they charged obtain coverage.
insurance. copayments or coinsurance for covered
• Provide additional financial support to low- benefits.
income families to enable them to afford
private insurance.
Premium subsidies to Not specified. No provision. No provision.
employers
Tax changes related to • Reform the tax code to eliminate the exclusion No provision. No provision.
health insurance of the value of health insurance plans offered
by employers from workers’ taxable income.
• Allow individuals and families purchasing
high-deductible health plans that are less than
the value of the tax credit to deposit the excess
amount into a health savings account.
• Change health savings account (HSA)
requirements by allowing health insurance
premiums to be paid tax-free from an HSA,
increasing the allowable contribution amounts
for people with chronic conditions, and
permitting high-deductible health plans to
cover preventive services, maintenance costs of
chronic diseases, and concierge-style primary
care services.
Creation of insurance • Partner with states to create State Health No provision other than pooling achieved through No provision other than pooling achieved through
pooling mechanisms Insurance Exchanges through which individuals USNHC. new public program.
can purchase qualified private insurance.
• Require plans participating in the Exchanges
to provide coverage on a guarantee issue basis
and to provide coverage similar to that provided
to Members of Congress.
• Require risk-adjustment among insurance
plans participating in the Exchange. A non-
profit, independent board will develop the risk-
adjustment methodology.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

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)
Benefit design • Provide coverage that meets the same • Provide coverage for all medically necessary • Provide the following classes of personal
statutory requirements used for the health services, including primary care and health services:
benefits for Members of Congress. prevention; inpatient care; outpatient care; – Medical services including primary and
emergency care; prescription drugs; durable specialty care;
medical equipment; long-term care; palliative – Dental services;
care; mental health services; dental services; – Podiatric services;
chiropractic services; basic vision correction;
– Home-nursing services;
hearing services; and podiatric care.
– Hospital services, for a maximum of 60 days
in a benefit year;
– Auxiliary services including diagnostic
laboratory services, X-ray and related
therapy, physiotherapy, optometry services,
prescription drugs, and eyeglasses.
Changes to private Not specified. • Prohibit insurers from duplicating USNHC No provision.
insurance benefits but they may offer coverage for
benefits not covered by the USNHC program.
State role • Create state Health Insurance Exchanges that No provision. • Assume responsibility for administration of the
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.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

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)
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
• Emphasize prevention by developing a institutional and prepaid group practices, professionals and facilities, and cost of
national strategic prevention plan, creating a monthly lump sum to cover operating services.
a web-based prevention tool capable of expenses. • Require a study of cost control mechanisms,
producing personalized prevention plans, and • Pay physicians and other non-institutional including an analysis of the impact on medical
implementing national science-based media providers based on a simplified fee scheduled malpractice claims and liability insurance on
campaigns on health promotion and disease or as a salaried employee in an institution health care costs.
prevention. receiving a global budget or in a group practice
• Reward seniors who adopt healthier behaviors or HMO receiving capitation payments.
with lower Medicare premiums. • Establish a uniform electronic billing system
• Allow providers to form accountable care and create an electronic patient record system.
organizations and receive bonuses in Medicare • Allow only public or not-for-profit institutions
if they improve quality and satisfaction while to participate in USNHC. Private physicians,
also lowering costs. clinics, and other participating providers may
• Adopt competitive bidding for private plans in not be investor owned.
Medicare. • Require USNHC program to negotiate annually
• Require higher income Medicare beneficiaries prices for drugs, medical supplies, and
to pay more for Medicare Part B and Part D assistive equipment.
premiums. • Establish a prescription drug formulary that
• Adopt medical malpractice reforms that create encourages best practices in prescribing and
independent expert panels or state “health promotes use of generics and other lower cost
courts” or both to review cases and render alternatives.
decisions. Parties will still have access to state
courts if not satisfied with decisions.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

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)
Improving quality/health • Create a new Health Care Services • Require participating providers to meet state • Require state and local administration to:
system performance Commission to establish uniform measures quality and licensing guidelines. – Promote coordination among providers,
for reporting price and quality information. The • Create a National Board of Universal Quality between providers and public health centers
HSC, managed by five commissioners from the and Access to address issues, such as access and educational and research institutions.
private sector appointed by the President, will to care, quality improvement, administrative – Emphasize prevention of disease, disability,
issue a report containing guidelines regulating efficiency, budget adequacy, reimbursement and premature death.
the publication and dissemination of health levels, capital needs, long term care, and – Insure the provision of efficient, high quality
care information and will be authorized to staffing levels. services.
enforce these standards. • Establish a universal standard of care relating
to appropriate staffing levels; appropriate
medical technology; scope of work in the
workplace; best practices; salary levels for
medical professional and support staff.
Other investments • Make changes to Medicaid long-term care • Establish regional budgets to cover the full • Provide grants for training and education of
services to provide states with a defined array of long-term care services covered by the professional and technical personnel needed to
allotment for Medicaid long-term care services USNHC program. provide or administer benefits. Makes available
in exchange for having the Medicare program • Establish a USNHC Employment Transition $5 million in 2010 and 2011; and up to one half
assume responsibility for the premiums, Fund to assist people who lose their jobs as of one percent of benefit payments annually
cost-sharing, and deductibles for low-income a result of the transition to the new national thereafter.
Medicare beneficiaries and ensure choice system.
between institutionalized and home-based • Create a mechanism to facilitate the conversion
long-term care services. of for-profit providers of care to not-for-profit
status and provide compensation for the
financial losses associated with the conversion.
Financing Not specified, but claims proposal is revenue and The USNHC program will be funded through Program will be financed through a National
budget neutral. the USNHC Trust Fund. Funding for the Trust Health Care Trust Fund. The trust fund will
Fund will come from redirecting existing federal be funded with a value-added tax of 5 percent
payments for health care; increasing the imposed on certain transactions.
income tax for the top 5% of earners, instituting
a modest and progressive payroll tax, and
imposing a tax on stock and bond transactions.
Sources of information http://coburn.senate.gov/public/index. http://conyers.house.gov/index. http://www.house.gov/dingell/issue_healthcare.
cfm?FuseAction=HealthCareReform. cfm?FuseAction=Issues.Home&Issue_ shtml
Home&ContentRecord_id=5e3b30a4-802a-23ad- id=063b74a4-19b9-b4b1-126b-f67f60e05f8c
4b44-14f0219114c6
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Sen. Bernie Sanders Rep. Pete Stark Sens. Ron Wyden and Bob Bennett
American Health Security Act of 2009 AmeriCare Health Care Act of 2009 Healthy Americans Act
(S. 703) (H.R. 193) (S. 391)
Date plan announced March 25, 2009 January 6, 2009 February 5, 2009
Overall approach to Create a state-based public health insurance Create a new public plan, modeled on Medicare, Require most Americans to purchase private
expanding access to program for all U.S. residents. Replace employer as default coverage for all Americans. Individuals coverage (called Healthy Americans Private
coverage coverage and eliminate the Medicare, Medicaid in a qualified group plan or Medicare may opt Insurance or HAPI) meeting certain standards,
and CHIP programs. Individuals are not required out of AmeriCare. Require employers and with federal subsidies available for individuals/
to pay premiums or cost-sharing. Provide for individuals to contribute toward the cost of the families up to 400% of the federal poverty level.
global budgets for hospitals and negotiate plan, with federal premium subsidies available State-based Health Help Agencies administer
annual reimbursement rates with physicians for individuals below 300% FPL. Use Medicare’s the offering of HAPI plans, which have to meet
and other non-institutional providers. Finance administrative structure to govern the plan. federal benefit and other standards. Employers
program by redirecting current federal and state Financed by premium contributions from can continue to sponsor health plans but many
health care spending, impose an employer/ employers and individuals, state maintenance of are unlikely to do so because the favorable tax
employee payroll tax, and leverage a new health effort payments, and from general revenue. treatment for individuals of employer-paid and
care income tax. insurance is eliminated.
Individual mandate • All individuals residing in the US are entitled • All U.S. residents are entitled to coverage • Require all citizens over age 19 to have
to coverage under the American Health under AmeriCare. Individuals may choose not insurance along with dependent children.
Security Act. to enroll in the AmeriCare plan if they have Those without coverage are subject to a
coverage under a group health plan. financial penalty based on the number of
uncovered months and the weighted average
of HAPI premiums.
Employer requirements • Prohibit employers from offering health • Require employers to contribute at least 80% • Require employers to contribute an amount
benefits that duplicate those provided by State of the AmeriCare premiums for employees equal to a percentage of the average premium
health security programs. or at least 80% of the cost of the group plan of their workforce times the number of
if the employer provides qualifying employee workers. Percentage of the average premium
coverage. Employers with fewer than 100 varies for large and small employers from 2%
employees will be given an additional three to 25%.
years to come into compliance with this • For the first two years, permit employers
provision. A surcharge may be imposed on previously providing health insurance to
employers to prevent adverse selection. 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 0

Sen. Bernie Sanders Rep. Pete Stark Sens. Ron Wyden and Bob Bennett
American Health Security Act of 2009 AmeriCare Health Care Act of 2009 Healthy Americans Act
(S. 703) (H.R. 193) (S. 391)
Expansion of public • Create a new state-based American Health • Create a new public plan, modeled on • Eliminate Medicaid and CHIP as comprehensive
programs Security Program that provides coverage for Medicare, as default coverage for all coverage programs and instead provide
a comprehensive set of benefits to all U.S. Americans. supplemental, wrap-around coverage for low-
residents. • AmeriCare plan enrollees are subject to income beneficiaries. Provides for a modified
• Eliminate the Medicare, Medicaid, and CHIP deductibles ($350 individual/$500 family) and Medicaid long-term care services program.
programs as beneficiaries of these programs coinsurance of 20% until limits on out-of-
are eligible for State Health Security Programs. pocket (OOP) expenses are met. The OOP limits
• Veteran’s Affairs and Indian Health Service are $2,500 per individual and $4,000 per family.
programs remain independent. Deductibles and limits are indexed to inflation.
• Prohibit coverage under state Medicaid
and CHIP programs for benefits covered by
AmeriCare plans.
Subsidies to individuals • Individuals are not required to pay premiums • Low-income individuals (family income <200% • Provide premium subsidies for individuals and
to obtain coverage nor are they charged FPL) are not required to pay premiums and are families with incomes between 100 and 400%
copayments or coinsurance for covered not subject to deductibles and co-insurance. FPL; those with incomes below 100% FPL
benefits. • Provide premium subsidies and reduced would not pay premiums.
deductibles for individuals with family incomes • Provide a health care standard tax deduction
between 200% and 300% FPL. for individuals and families with incomes above
• Limit OOP costs for deductibles and 100% FPL; would phase-out at higher income
coinsurance to 5% of income for those between levels.
200 and 300% FPL, and 7.5% of income for
those between 300 and 500% FPL.
• No deductibles and coinsurance for pregnancy-
related services and covered benefits provided
to children (up to age 24).
Subsidies to employers No provision. No provision. No provision.
Tax changes related to • Impose a new health care income tax on • Individual premium payments for AmeriCare • Reform the tax code to eliminate the exclusion
health insurance individuals of 2.2% of taxable income. coverage are considered a tax and subject to of the value of health insurance plans offered
withholding. by employers from workers’ taxable income
(with exceptions, such as for employer-paid
retiree health coverage and coverage through
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 

Sen. Bernie Sanders Rep. Pete Stark Sens. Ron Wyden and Bob Bennett
American Health Security Act of 2009 AmeriCare Health Care Act of 2009 Healthy Americans Act
(S. 703) (H.R. 193) (S. 391)
Creation of insurance No provision other than pooling achieved through No provision other than pooling achieved through • Create new state-based purchasing pools
pooling mechanisms state health security programs. AmeriCare. (Health Help Agencies) that would offer a
choice of HAPI plans.
• Everyone, except people enrolled in Medicare,
retiree benefit plans, or military-related
coverage, are required to enroll in plans
through the Health Help Agencies. (Note:
employers can still sponsor health insurance
but would have to inform employees of HAPI
plans available through Health Help Agency.)
• Participating plans provide coverage similar
to that available through FEHBP.
• Require insurers to offer HAPI coverage on
a guaranteed issue basis and use adjusted
community rating principles in setting
premiums.
Benefit design • Provide coverage for services including hospital • Provide the same benefits available through • Provide benefits through HAPI plans that are
and professional services; community-based Medicare, with the addition of benefits, such as actuarially equivalent or greater in value than
primary health care; preventive care; long- well-child visits, early and periodic screening, the benefits offered under the Blue Cross/
term acute and chronic care services, including diagnostic, and treatment (EPSDT) services Blue Shield Standard Plan provided under the
home and community-based services; for children, prenatal and obstetric care, and Federal Employees Health Benefit Program
prescription drugs; dental services; mental family planning services to reflect the needs of (FEHBP).
health and substance abuse; diagnostics a younger population. • Additionally provide benefits for wellness
tests; outpatient therapy; durable medical programs and incentives to promote the use
equipment; and other services as specified by of these programs, coverage for catastrophic
the American Health Security Standards Board. medical events for an individual or family if
lifetime limits are exhausted, and full 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.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Sen. Bernie Sanders Rep. Pete Stark Sens. Ron Wyden and Bob Bennett
American Health Security Act of 2009 AmeriCare Health Care Act of 2009 Healthy Americans Act
(S. 703) (H.R. 193) (S. 391)
Changes to private • Prohibit insurers from duplicating State health • Allow AmeriCare supplemental policies to be • Require insurers to offer coverage on a
insurance security program but they may offer coverage offered that meet minimum federal standards, guaranteed issue basis and use adjusted
for benefits not covered by the health security including standardized benefits, limitations on community rating principles in setting
program. sales commissions, and the following: premiums; prohibit discrimination based on
– Require insurers that offer AmeriCare health status.
supplemental policies to do so on a • Require insurers to meet established medical
guarantee issue and renewability basis loss ratios.
and prohibit them from charging higher • Require insurers to create an electronic
premiums based on health status. medical record for each covered individual.
– Require insurers offering AmeriCare
supplemental policies to meet minimum
medical loss ratios (85% for group policies;
75% for individual policies).
State role • Create a state health security program to • Require states to make maintenance of effort • Create Health Help Agencies and ensure that
provide health care services to state residents. payments in the amount of the state share participating insurers meet requirements
May join with one or more neighboring states to of Medicaid and CHIP spending for benefits related to solvency and financial standards,
form a regional health security program. State replaced by the AmeriCare plan. consumer protections, and establishment of
programs must designate a single state agency • Allow states to impose more stringent wellness programs.
to administer the program; establish state requirements on entities offering AmeriCare • Implement mechanisms, such as automatic
health security budgets; establish provider supplemental policies than specified by the enrollment, to ensure maximum enrollment
payment methodologies; license and regulate Secretary. of individuals into private insurance.
health providers and facilities; establish a
quality review system; create an independent
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 

Sen. Bernie Sanders Rep. Pete Stark Sens. Ron Wyden and Bob Bennett
American Health Security Act of 2009 AmeriCare Health Care Act of 2009 Healthy Americans Act
(S. 703) (H.R. 193) (S. 391)
Cost containment • Establish annual budgets for operating • Generally apply Medicare payment • Promote prevention by providing premium
expenditures, administrative costs, health mechanisms, adjusted to reflect the AmeriCare discounts (including for Medicare Part B
professional education, and quality assessment population. premiums) for participation in approved
activities. • Limit payments to private plans offered through wellness and chronic disease management
• Require states to pay institutional providers, AmeriCare (similar to Medicare Advantage) to programs.
including hospitals and nursing facilities, average per capita costs under AmeriCare. • Adopt payment policies that reward providers
through an annual prospective global budget • Require AmeriCare to develop a fee schedule for achieving quality and cost efficiency in
and develop payment methodologies for for outpatient drugs and biologics, to negotiate prevention, early detection of disease, and
independent health practitioners that include directly with drug companies for the purchase chronic care management.
incentives to encourage practitioners to choose price of those drugs and biologics, and to • Require insurers to create and implement
primary care medicine. encourage greater use of generics and lower electronic medical records for each covered
• Limit national health security spending growth cost alternatives. individual.
to the average annual percentage increase in • Require AmeriCare contractors to submit • Require insurers to adopt uniform billing and
the gross domestic product. electronic claims. claims forms.
• Establish individual and state capitation • Apply Medicare provisions relating to fraud • Encourage more rigorous study of new drugs
amounts and risk adjustment methodologies and abuse and administrative simplification to and devices by granting additional exclusivity
to be used for developing state and national AmeriCare plans. and patent protections to those subjected to
global budgets. comparative effectiveness reviews. Disallow tax
• Limit state administrative costs to 3% of total deductions for pharmaceutical manufacturers
expenditures. for direct to consumer advertising for most
• Create state fraud and abuse prevention and new drugs.
control units to investigate and prosecute • Require insurers and providers to publicly
violations of state law. report data on medical outcomes, health care
• Develop provider payment methodologies quality and costs.
that include global fees for related services • Provide bonuses to states that enact medical
furnished to individuals over time. malpractice reforms.
• Establish prices for approved prescription
drugs, devices, and equipment.
Side-by-Side CompariSon of major HealtH Care reform propoSalS 

Sen. Bernie Sanders Rep. Pete Stark Sens. Ron Wyden and Bob Bennett
American Health Security Act of 2009 AmeriCare Health Care Act of 2009 Healthy Americans Act
(S. 703) (H.R. 193) (S. 391)
Improving quality/health • Create an American Health Security Quality • Apply Medicare provisions relating to outcomes • Encourage chronic care programs
system performance Council to review and evaluate practice research and quality to AmeriCare. • Require hospitals to demonstrate
guidelines and performance measures; adopt improvements in quality control, including
methodologies for profiling practice patterns rapid response teams, heart attack treatments,
and identifying outliers; and develop guidelines procedures that reduce medication errors,
for medical procedures to be performed at infection prevention, procedures that reduce
centers of excellence. the incidence of ventilator-related illnesses.
• Improve access to care through grants to • Provide enhanced Medicare payments to
support the development of primary care primary care providers and require Medicare
centers to serve medically underserved to develop a chronic disease management
populations in urban and rural areas and the program.
expansion of school health service sites. • Establish a website for sharing evidence-based
• Create an Office of Primary Care and best practices and develop a program for
Prevention Research to identify research incorporating these best practices into medical
related to primary care and prevention school curricula.
for children and adults and to establish a • Provide for improvements in end-of-life care.
system for collecting, storing, analyzing, and
disseminating information related to primary
care and prevention research.
Other investments • Redesign health professional education No provision. • Provide grants to school districts and
programs to promote primary care so that communities to increase access to school-
within five years at least 50% of residents in based clinics.
medical resident education programs are • Permit states to create State Choices for Long-
primary care residents and the number of term Care Programs through their Medicaid
mid-level primary care practitioners and programs to provide institutional and home and
dentists meets certain targets. community-based long-term care for eligible
• Provide funding to the Public Health Service individuals.
to support the National Health Service Corps, • Create new long-term care insurance plans
health professions education, and nursing that meet standards developed by NAIC or by
education. federal regulations.
• 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 

Sen. Bernie Sanders Rep. Pete Stark Sens. Ron Wyden and Bob Bennett
American Health Security Act of 2009 AmeriCare Health Care Act of 2009 Healthy Americans Act
(S. 703) (H.R. 193) (S. 391)
Financing The American Health Security Act will be funded Plan will be financed through an AmeriCare In 2008, CBO scored an amended version of the
through the American Health Security Act Trust Trust Fund. The trust fund will be financed with bill which is very similar to this year’s version.
Fund. Funding for the Trust Fund will come employer and individual premium payments, In that CBO estimate, Federal costs would be
from redirecting existing federal payments state maintenance of effort payments, and offset by revenues and savings in first year of
for health care; imposing a payroll tax of 8.7% general revenue for premium subsidies. full implementation, Thereafter, the bill would
on employers and employees; and imposing a be more than self-financing because of indexing
health care income tax of 2.2%. growth in the value of the health insurance
deduction and the subsidized benefits.
Financing will come from combination of
individual premiums, employer assessments,
state and federal savings in Medicaid, elimination
of most Medicare and Medicaid disproportionate
share hospital (DSH) payments, and changes in
tax treatment of insurance.
Sources of information http://www.sanders.senate.gov/news/record. http://www.stark.house.gov/index. http://wyden.senate.gov/issues/Legislation/
cfm?id=313855 php?option=com_content&task=view&id=1081& Healthy_Americans_Act.cfm
Itemid=103 http://wyden.senate.gov/issues/Health_Care.cfm
http://www.stark.house.gov/index. http://www.cbo.gov/ftpdocs/91xx/doc9184/05-01-
php?option=com_content&task=view&id=1238& HealthCare-Letter.pdf
Itemid=84
Last Modified: June 22, 2009
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