The The Patient Protection and Affordable Care Act as Passed is a transparent little document comprising a mere 2409 pages in pdf format, and Senate Democrats have made it conveniently available online.
One of the flagship provisions of this historic bill (“historic” meaning that this bill has already been discussed as much as the Magna Carta) will make it impossible for anyone to be denied health insurance on the basis of pre-existing conditions.
Health insurance for all of us, even if we’re actually sick! That’s the name of the game, but it isn’t exactly the name of the bill, and although coverage for individuals with pre-existing conditions has remained at the top of Democratic talking-points for 14 long months, I was surprised to see that the word “pre-existing” only appears 5 times in 2409 pages of legislative language, mostly in Sec. 1101 of Subtitle B, and…
Here it is! That awfully famous “section” in all it’s glory, along with a few typographical peculiarities which arise from pasting pdf into html.
Subtitle B-Immediate Actions to
2 Preserve and Expand Coverage
3 SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNIN4
SURED INDIVIDUALS WITH A PREEXISTING
6 (a) IN GENERAL.-Not later than 90 days after the
7 date of enactment of this Act, the Secretary shall establish
8 a temporary high risk health insurance pool program to
9 provide health insurance coverage for eligible individuals
10 during the period beginning on the date on which such pro11
gram is established and ending on January 1, 2014.
12 (b) ADMINISTRATION.-
13 (1) IN GENERAL.-The Secretary may carry out
14 the program under this section directly or through
15 contracts to eligible entities.
16 (2) ELIGIBLE ENTITIES.-To be eligible for a
17 contract under paragraph (1), an entity shall-
18 (A) be a State or nonprofit private entity;
19 (B) submit to the Secretary an application
20 at such time, in such manner, and containing
21 such information as the Secretary may require;
23 (C) agree to utilize contract funding to es24
tablish and administer a qualified high risk pool
25 for eligible individuals.
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1 (3) MAINTENANCE OF EFFORT.-To be eligible to
2 enter into a contract with the Secretary under this
3 subsection, a State shall agree not to reduce the an4
nual amount the State expended for the operation of
5 one or more State high risk pools during the year pre6
ceding the year in which such contract is entered into.
7 (c) QUALIFIED HIGH RISK POOL.-
8 (1) IN GENERAL.-Amounts made available
9 under this section shall be used to establish a quali10
fied high risk pool that meets the requirements of
11 paragraph (2).
12 (2) REQUIREMENTS.-A qualified high risk pool
13 meets the requirements of this paragraph if such
15 (A) provides to all eligible individuals
16 health insurance coverage that does not impose
17 any preexisting condition exclusion with respect
18 to such coverage;
19 (B) provides health insurance coverage-
20 (i) in which the issuer’s share of the
21 total allowed costs of benefits provided
22 under such coverage is not less than 65 per23
cent of such costs; and
24 (ii) that has an out of pocket limit not
25 greater than the applicable amount de47
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1 scribed in section 223(c)(2) of the Internal
2 Revenue Code of 1986 for the year involved,
3 except that the Secretary may modify such
4 limit if necessary to ensure the pool meets
5 the actuarial value limit under clause (i);
6 (C) ensures that with respect to the pre7
mium rate charged for health insurance coverage
8 offered to eligible individuals through the high
9 risk pool, such rate shall-
10 (i) except as provided in clause (ii),
11 vary only as provided for under section
12 2701 of the Public Health Service Act (as
13 amended by this Act and notwithstanding
14 the date on which such amendments take ef15
16 (ii) vary on the basis of age by a factor
17 of not greater than 4 to 1; and
18 (iii) be established at a standard rate
19 for a standard population; and
20 (D) meets any other requirements deter21
mined appropriate by the Secretary.
22 (d) ELIGIBLE INDIVIDUAL.-An individual shall be
23 deemed to be an eligible individual for purposes of this sec24
tion if such individual-
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1 (1) is a citizen or national of the United States
2 or is lawfully present in the United States (as deter3
mined in accordance with section 1411);
4 (2) has not been covered under creditable cov5
erage (as defined in section 2701(c)(1) of the Public
6 Health Service Act as in effect on the date of enact7
ment of this Act) during the 6-month period prior to
8 the date on which such individual is applying for
9 coverage through the high risk pool; and
10 (3) has a pre-existing condition, as determined
11 in a manner consistent with guidance issued by the
13 (e) PROTECTION AGAINST DUMPING RISK BY INSUR14
15 (1) IN GENERAL.-The Secretary shall establish
16 criteria for determining whether health insurance
17 issuers and employment-based health plans have dis18
couraged an individual from remaining enrolled in
19 prior coverage based on that individual’s health sta20
21 (2) SANCTIONS.-An issuer or employment-based
22 health plan shall be responsible for reimbursing the
23 program under this section for the medical expenses
24 incurred by the program for an individual who, based
25 on criteria established by the Secretary, the Secretary
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1 finds was encouraged by the issuer to disenroll from
2 health benefits coverage prior to enrolling in coverage
3 through the program. The criteria shall include at
4 least the following circumstances:
5 (A) In the case of prior coverage obtained
6 through an employer, the provision by the em7
ployer, group health plan, or the issuer of money
8 or other financial consideration for disenrolling
9 from the coverage.
10 (B) In the case of prior coverage obtained
11 directly from an issuer or under an employment12
based health plan-
13 (i) the provision by the issuer or plan
14 of money or other financial consideration
15 for disenrolling from the coverage; or
16 (ii) in the case of an individual whose
17 premium for the prior coverage exceeded the
18 premium required by the program (adjusted
19 based on the age factors applied to the prior
21 (I) the prior coverage is a policy
22 that is no longer being actively mar23
keted (as defined by the Secretary) by
24 the issuer; or
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1 (II) the prior coverage is a policy
2 for which duration of coverage form
3 issue or health status are factors that
4 can be considered in determining pre5
miums at renewal.
6 (3) CONSTRUCTION.-Nothing in this subsection
7 shall be construed as constituting exclusive remedies
8 for violations of criteria established under paragraph
9 (1) or as preventing States from applying or enforc10
ing such paragraph or other provisions under law
11 with respect to health insurance issuers.
12 (f) OVERSIGHT.-The Secretary shall establish-
13 (1) an appeals process to enable individuals to
14 appeal a determination under this section; and
15 (2) procedures to protect against waste, fraud,
16 and abuse.
17 (g) FUNDING; TERMINATION OF AUTHORITY.-
18 (1) IN GENERAL.-There is appropriated to the
19 Secretary, out of any moneys in the Treasury not oth20
erwise appropriated, $5,000,000,000 to pay claims
21 against (and the administrative costs of) the high risk
22 pool under this section that are in excess of the
23 amount of premiums collected from eligible individ24
uals enrolled in the high risk pool. Such funds shall
25 be available without fiscal year limitation.
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1 (2) INSUFFICIENT FUNDS.-If the Secretary esti2
mates for any fiscal year that the aggregate amounts
3 available for the payment of the expenses of the high
4 risk pool will be less than the actual amount of such
5 expenses, the Secretary shall make such adjustments
6 as are necessary to eliminate such deficit.
7 (3) TERMINATION OF AUTHORITY.-
8 (A) IN GENERAL.-Except as provided in
9 subparagraph (B), coverage of eligible individ10
uals under a high risk pool in a State shall ter11
minate on January 1, 2014.
12 (B) TRANSITION TO EXCHANGE.-The Sec13
retary shall develop procedures to provide for the
14 transition of eligible individuals enrolled in
15 health insurance coverage offered through a high
16 risk pool established under this section into
17 qualified health plans offered through an Ex18
change. Such procedures shall ensure that there
19 is no lapse in coverage with respect to the indi20
vidual and may extend coverage after the termi21
nation of the risk pool involved, if the Secretary
22 determines necessary to avoid such a lapse.
23 (4) LIMITATIONS.-The Secretary has the au24
thority to stop taking applications for participation
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1 in the program under this section to comply with the
2 funding limitation provided for in paragraph (1).
3 (5) RELATION TO STATE LAWS.-The standards
4 established under this section shall supersede any
5 State law or regulation (other than State licensing
6 laws or State laws relating to plan solvency) with re7
spect to qualified high risk pools which are established
8 in accordance with this section.
And then we’re off to Sec 1102, REINSURANCE FOR EARLY RETIREES!
But there’s a twist!
Although “pre-existing” only appears 5 times in the bill, “preexisting” appears another 7 times, and I have to confess that I like the sections with “pre-existing” better than the sections” with “preexisting,” for reasons that will probably be obvious after perusing one of the “preexisting” sections.
”SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EX8
CLUSIONS OR OTHER DISCRIMINATION
9 BASED ON HEALTH STATUS.
10 ”(a) IN GENERAL.-A group health plan and a health
11 insurance issuer offering group or individual health insur12
ance coverage may not impose any preexisting condition
13 exclusion with respect to such plan or coverage.”; and
14 (B) by transferring such section (as amended by
15 subparagraph (A)) so as to appear after the section
16 2703 added by paragraph (4);
17 (3)(A) in section 2702 (42 U.S.C. 300gg-1)-
18 (i) by striking the section heading and all
19 that follows through subsection (a);
20 (ii) in subsection (b)-
21 (I) by striking ”health insurance issuer
22 offering health insurance coverage in con23
nection with a group health plan” each
24 place that such appears and inserting
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1 ”health insurance issuer offering group or
2 individual health insurance coverage”; and
3 (II) in paragraph (2)(A)-
4 (aa) by inserting ”or individual”
5 after ”employer”; and
6 (bb) by inserting ”or individual
7 health coverage, as the case may be”
8 before the semicolon; and
9 (iii) in subsection (e)-
10 (I) by striking ”(a)(1)(F)” and insert11
12 (II) by striking ”2701” and inserting
13 ”2704”; and
14 (III) by striking ”2721(a)” and insert15
ing ”2735(a)”; and
16 (B) by transferring such section (as amend17
ed by subparagraph (A)) to appear after section
18 2705(a) as added by paragraph (4); and
19 (4) by inserting after the subpart heading (as
20 added by paragraph (1)) the following…
And so on, through many, many more strikes, transfers, and insertions.
And now, while all the good students strike, insert, and transfer language around 2409 pages of pdf, and eventually arrive at a full understanding of the PPACA, the rest of us will apply our limited intelligence to one simple element of this historic bill, and ask ourselves about the $5,000,000,000 (not quite yet) appropriated to cover patients with pre-existing (or preexisting) conditions, and other “high-risk” individuals, year by year beginning 90 days after the PPACA is enacted, until 2014, when all the other provisions of the PPACA are applicable.
That sounds like a lot of money, but remember that it’s supposed to cover (or fill up the gaps in coverage of) a lot of people who are sick already, or likely to get sick in a way that may cost a lot of money!
And to help us visualize the amounts of money involved, I have prepared a colorful illustration!
One red square is much bigger than the other!
But the little red square is supposed to cover a very big problem in the big red square!
How can $5 billion cover all currently uninsured “high-risk” individuals (including individuals with pre-existing conditions, which apparently includes anybody who is actually sick) as well as any “high-risk” individuals who lose their insurance between now and 2014?
Nobody seems to know.