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7 items you didn’t know were in the Senate bill
Little-publicized provisions include breast-pumping rooms and bone scans

Final push for health reform
Nov. 30: The Senate begins the final push to pass its version of the health care bill, with abortion and public option. What will it take to get the votes? Chuck Todd reports from Washington.

By Mary Agnes Carey, Phil Galewitz and Laurie McGinley

updated 3:31 p.m. ET, Mon., Nov . 30, 2009
Pay attention: The "Patient Protection and Affordable Care Act" — better known as the Senate health care overhaul bill — is chock full of interesting but little publicized provisions affecting consumers. Sure, the bill is mainly a blueprint for overhauling the insurance system. But look closely and you'll see a variety of items that would affect people from the cradle to old age — from breast pump use to retiree health benefits. It's a congressional tradition, adding pet interests that otherwise might not pass to a big bill that at least will be put up for a vote.

Yes, there's plenty of time to change the bill. But political analysts say a final overhaul bill would more likely look like this measure than the version already approved by the House because Senate Democrats barely could agree on sending it to the floor for debate. In short, there's not much political room for major changes.

Nursing mothers get a break
Employers would be required to provide an unpaid "reasonable break time for nursing mothers" in the first year after giving birth. Women would be provided a private place, other than a bathroom, to use a breast pump. The provision exempts companies with fewer than 50 workers if the requirement would impose "an undue hardship," a determination left to the employer to make.

This provision was inserted by Sen. Jeff Merkley, D-Ore., who in June introduced the Breastfeeding Promotion Act. Merkley is promoting breast-feeding partly as a way to cut health costs. He cites studies showing breast-fed children have a lower rate of disease and illness in their lifetime.

But employers see yet another expense. "Every additional mandated rule further burdens employers who are struggling to keep jobs afloat," says Neil Trautwein, vice president of the National Retail Federation.

Twenty-four states already have protections for nursing mothers in the workplace, according to the National Conference of State Legislatures.

Learning to be an adult
Being a teenager is tough. The Senate wants to help with a provision allocating $400 million from 2010 to 2015 to help teens make the transition to adulthood.

The money goes to states primarily to set up sex education programs. But the money can also be used for "adult preparation" programs that promote "positive self esteem, relationship dynamics, friendships, dating, romantic involvement, marriage and family interaction."

In addition, the programs can teach financial literacy and other skills such as goal setting, decision-making and stress management. About $10 million of funding would go to "innovative youth pregnancy prevention strategies" in areas of the country with high teen birth rates.

The Personal Responsibility Education for Adulthood Training funding was approved as an amendment in the Senate Finance Committee. Republican Sen. Olympia Snowe of Maine joined all the Democrats in passing it.

Retiree health benefits
The Senate bill includes a provision designed to ease out-of-pocket costs for retirees who are under 65 but who still get health insurance from their former employer. The bill would create a temporary "reinsurance" program under which the government would pick up 80 percent of some high-cost insurance claims filed by retirees. Employers would use the savings only to make retirees' coverage more affordable by reducing their share of premiums or other costs. The Senate bill would set aside $5 billion for the program; the House-passed bill, which has a similar provision, has a $10 billion pot. The proposal has wide support among employer groups and labor unions.

The same can't be said of another provision in both bills. Companies would have to pay a tax on the government subsidies they receive for providing their Medicare-eligible retirees with prescription drug coverage. These subsidies, included in the 2003 law that created the Medicare drug benefit, were designed to encourage companies to keep offering drug coverage. Now, if the subsidies are taxed to help pay for a health overhaul, they become much less attractive to employers; some companies might drop drug coverage for retirees altogether, warned the American Benefits Council, an employer group, and the AFL-CIO in a joint letter to Congress. If that happened, the retirees would get their drug coverage from Medicare. Critics say that would ultimately cost the government more money than it would recoup by taxing the subsidies.

Promoting use of bone density scans
Rapid increases in Medicare payments for imaging services led lawmakers to reduce payments for some services, including those that test bone density.

The Senate bill is trying to boost payments, which have dropped by more than half since 2006, for a bone test known as dual energy X-ray absorptiometry (DXA) or bone densitometry. And those cuts have made it more difficult for patients to get access to the test, especially in physicians’ offices and clinics, according to the National Osteoporosis Foundation. The Senate bill would increase rates to 70 percent of what Medicare paid in 2006.

Raising the payment for bone density scans is a priority for two senators whom Reid hopes to win over in his bid to get 60 votes for his health care plan: Blanche Lincoln, a moderate Democrat from Arkansas, and Olympia Snowe, a moderate Republican from Maine.

Setting ER prices
Hospitals would have to limit how much they charge low-income uninsured emergency patients to the lowest amount they receive from insured patients for the same services.

The provision in the Senate bill comes more than six years after consumer groups in California and Texas began highlighting how hospitals were charging uninsured patients several times more for the same services as insured patients.

A 2007 study published in the journal Health Affairs showed that many "uninsured and other 'self-pay' patients for hospital services" were often charged "2 1/2 times what most health insurers actually paid and more than three times the hospital's Medicare-allowable costs." The study by Gerard Anderson of Johns Hopkins University also found the "gaps between rates charged to self-pay patients and those charged to other payers are much wider than they were in the mid-1980s."

In response to the criticism, many hospitals have set up programs for the uninsured to apply for financial assistance and obtain discounted care. The Senate provision would require all hospitals to have such programs.

Singing the blues
Non-profit Blue Cross and Blue Shield health plans would have to spend at least 85 cents of every premium dollar on health services or forfeit their special federal tax deductions. The Congressional Budget Office estimates this provision in the Senate bill would cost the Blues' plans about $400 million over the next decade.

Historically, Blue Cross and Blue Shield plans received a tax-preferred status because they were created to provide a more significant “community benefit” than other insurance companies. But the Blues have come under increasing scrutiny from state and federal lawmakers and consumer watchdog groups for charging high rates, racking up profits (revenues over expenses) and paying top executives no differently than their for-profit insurance counterparts.

Several Blues' plans converted to for-profits in the past 15 years. Of the 39 Blue Cross and Blue Shield plans nationwide, 24 are now non-profit.

Transparency in drug pricing
Pharmaceutical benefit managers are a critical part of the nation’s health care system. Administering drug plans for more than 210 million insured Americans, they negotiate discounts on prescription drugs with retail pharmacies and wholesalers and also get rebates from drug makers.

At the urging of Sen. Maria Cantwell, D-Wash., the Senate Finance Committee inserted language into its health bill that would force the benefit managers, known as PBMs, to disclose details of those negotiations — including how much of the savings were passed on to consumers.

Adding that transparency to drug pricing, Cantwell maintains, would help lower drug prices. “We want the consumer to benefit as greatly as possibly from the discounts that PBMs are helping to negotiate,” Cantwell said earlier this year.

The PBMs don’t see it that way. Cantwell’s amendment, they argue, would “allow competing drug manufacturers and pharmacies to learn prices their competitors charge and raise prices accordingly. It would decrease, not increase, competition among them,” Mark Merritt, president and chief executive officer of the Pharmaceutical Care Management Association, wrote in a Nov. 24 letter to Senate Majority Leader Harry Reid, D-Nev. Merritt’s group represents PBMs.

© 2009 This information was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery. © Henry J. Kaiser Family Foundation. All rights reserved.



( 8 comments — Leave a comment )
Dec. 2nd, 2009 12:58 pm (UTC)
Well that all seems eminently sensible - I am horrified to think that any company currently might think the toilet is a good place to express breast milk!

I mean, would they be happy to eat sandwiches prepared in there?
Dec. 3rd, 2009 08:12 am (UTC)
I worked at a place once where, whenever anyone pointed out that we didn't have a break room, they pointed toward the very tiny bathroom. Not exactly an employee friendly atmosphere!

The problem with all those sensible ideas is that, as usual, the proposed bills from both houses of Congress have buried the good ideas under mountains of very bad ideas. What would be wrong with voting on these proposals individually, so the general public can see the specifics of what's being debated?
Dec. 3rd, 2009 01:03 pm (UTC)
What would be wrong with voting on these proposals individually, so the general public can see the specifics of what's being debated?

It would be a good idea... and many politicians seem to regard good ideas as automatically unacceptable.

Do you do clause by clause at the committee stage in public? I have a feeling that Tynwald do.
Dec. 4th, 2009 06:32 am (UTC)
A lot of it is written down and decided before it ever comes to committee, and not all the committee activities are public -- which by itself is a clear violation of the law. Ultimately, one of the biggest problems in our system is that a few powerful Congressmen control committees, and often even the legislators on the committees can be shut down by those chairmen. The elected officials who aren't on the committees don't get a say in proposed legislation at all until (or unless) it gets to a floor vote -- and by that time they can only vote up or down on the entire package, rather than individual parts of it. That's why so many useless pork barrel projects are tacked onto important legislation.
Dec. 2nd, 2009 02:27 pm (UTC)
Those are all things that I'd want to see as part of any decent health system
Dec. 3rd, 2009 08:09 am (UTC)
Agreed. Too bad they're wrapped up in all the horribly bad things in the current bill, along with more government control over our lives and economy, bloated bureaucracy, cuts to Medicare, mountains of unrelated add-ons, and absolutely nothing addressing tort reform, cross-state competition, or any real life attempts to control the rising costs of health care.

The best thing to do would be to vote on these issues individually, so we can bring in the good parts and keep out the bad parts -- but that's not going to happen, because then the public would get a real look at what the bad parts are.
Dec. 3rd, 2009 03:26 pm (UTC)
Atually forget tort reform for now

your current system wastes bilions in horribly complex billing systems for multiple insurance companies and more billions in unnecessary tests for those who can pay .

That's why your system is obscenely expensive compared to the rest of the world without your results being better
Dec. 4th, 2009 06:24 am (UTC)
Of course, one of the reasons for all those unnecessary tests is the fear that doctors will get hit by huge, career crippling lawsuit judgments -- because of a lack of tort reform. Besides that, one of the reasons insurance costs are so high is because insurance companies aren't allowed to compete across state lines -- and the irony is, this huge proposed health care overhaul doesn't address either of those problems.
( 8 comments — Leave a comment )

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