Overview of House Action

1. What Direction Healthcare Reform? A Federal UpdateBy Wayne SakamotoSouthwest Florida Association of Health UnderwritersJanuary 6, 2010

2. Overview of House Action • House of Representatives passed HR 3962 220-215 on November 7 • House passage is just one step in a lengthy political process • The Senate still has yet to formalize a merged bill, go through what is expected to be a protracted an intense Senate floor debate and amendment process lasting, probably, into 2010 • Whatever passes the Senate must be combined with the House bill • Differences between the two bills must be resolved in such a way that the legislation will pass both chambers (Another Conference Committee) • The health reform effort is still a long way from over.

3. HR 3962 • Affordable Healthcare for America Act • Replaced HR 3200, which had passed the 3 Committees of jurisdiction for healthcare legislation in the House of Representatives in July. • CBO estimated the cost at $894 billion over 10 years, but conceded that “estimates are subject to substantial uncertainty.”

4. HR 3962 • Individuals would be required to obtain and maintain health insurance • Employers would be required to provide coverage or pay a fine • Market reforms such as modified community rating, guaranteed issue, no pre-existing condition exclusions • Establishes a government-run public plan

5. HR 3962 • An exchange would be established under a new independent federal agency (Health Choices Administration) headed by an appointed commissioner to offer private coverage and public plan coverage • Tax subsidies for those below 400% of FPL • Funded by taxes on high-income earners and funding for Medicare Advantage

6. HR 3962 • Individual Mandate • Individuals would be required to obtain and maintain “acceptable” health insurance • Acceptable coverage includes “qualified health benefit plans” (QHBP), an employer-based plan, a grandfathered individual plan, Medicare (Part A), Medicaid, or TRICARE/VA coverage • Nonresident aliens, individuals residing outside of the US, etc are exempt

7. HR 3962 • Individual Mandate • Individuals that do not maintain acceptable coverage would be subject to tax penalty equal to 2.5% of modified adjusted gross income or the national average premium for applicable single or family coverage as determined by the Secretary • Hardship waivers are included

8. HR 3962 • Employer Mandate • Employers must offer coverage through QHBP or grandfathered plans as permitted • Employers would be required to pay 72.5% of the cost of applicable coverage for individuals and 65% for family coverage • Part time employees must be covered on a pro-rated basis based on average hours worked

9. HR 3962 • Employers that do not offer applicable coverage could be subject to fine equivalent to 8% of payroll • Small employers with annual payroll up to $500,000 are exempt • Employers with payroll up to $585,000 would pay a fine equal to 2% • Employers with payroll between $585,000 and $670,000 would pay fine equal to 4% • 8% fine kicks in at payroll above $750,000

10. HR 3962 • Market Reforms • All health plans, fully insured or self funded, would be required to issue coverage regardless of health status • Elimination of pre-existing condition exclusions • Prohibition on annual or lifetime limits • Dependent coverage to age 26

11. HR 3962 • Applies HIPAA guaranteed renewability and guaranteed issue small group market rules to all health insurance markets. • Imposes modified community rating to all qualified plans regardless of size. Allows variances only for family enrollment, geographic area and age (2:1 age band) • Prohibits premium variation based on health status, gender, class of business, or claims experience

12. HR 3962 • CBO estimated the bill would cost $894 billion over 10 years, but that may be optimistic and does not measure true cost • The Centers for Medicare and Medicaid Services Chief Actuary estimated that the House bill would actually increase health care costs • By 2019, health costs would rise to 21.1% of GDP compared to 20.8% under current law

13. HR 3962 • CMS concluded that : “With the exception of proposed reductions in Medicare payments rates for providers, HR 3962 would not have a significant impact on future health care cost growth rates. In addition, the longer-term viability of the Medicare reimbursement rate reductions is doubtful.”

14. HR 3962 • Bill is basically dead on arrival in Senate • House will have little leverage in conference committee negotiations with such a small vote margin

15. Overview of Senate Action • Senate passed their reform bill 60-39 on December 24 • CBO estimates that bill would cost $850 billion over 10 years • Significantly different than House bill • Two bills need to be merged into one and pass each chamber before sent to the president for his signature

16. HR 3590 • The Patient Protection and Affordable Care Act • Would establish a government-run public plan option to be sold through new state exchanges with the opportunity for states to opt out. • Payment rates to providers would be determined by HHS and capped at the average rate of private plans.

17. HR 3590 • Start-up funds are provided for the creation of co-ops and states are allowed to offer their own public programs for those between 133% and 200% of the Federal Poverty Level (FPL) • Calls for the creation of state-based exchanges beginning in 2013 and limited to individuals and small groups until 2017, when large-group participation will be allowed. • Policies sold through the exchange would have be done by licensed agents or brokers

18. HR 3590 • Establishes an employer mandate for groups of 50 or more to provide qualified coverage with a $750 fine, indexed for premium growth, for non-covered employees • Requires individuals to obtain qualified coverage with a fine that begins at $95 in 2014, rises to $750 by 2016, and is indexed for inflation • Expands Medicaid eligibility to those earning up to 133% of the FPL

19. HR 3590 • Includes insurance market reforms such as guaranteed issue and renewability of all policies, no preexisting condition limitations or lifetime or annual limits, prohibitions on rating based on health status and gender, and only allowing rating factors of age (3:1), tobacco use (1.5:1), family status and geography • Includes a limited small-business tax credit to help the smallest of businesses with low-income employees with the cost of coverage

20. HR 3590 • CBO recently completed analysis of premium impact of the bill • Premiums per person in the nongroup market would be 10-13% higher in 2016 than projected under current law • Half of enrollees would receive subsidies that would reduce costs well below premiums that would be charged under current law

21. HR 3590 • The CBO estimates smaller premium effects in the group market. • Premiums could range from a 1% percent increase to 2% reduction in the small group market (less than 50 employees) • In the large group market, premiums would remain essentially flat, ranging from zero to 3% lower in 2016 relative to current law • Analysis does not factor in effect of small business tax credit or surtax on high cost benefit plans

22. Where Do We Go From Here? • Congressional leadership has multiple options to proceed so it remains a very fluid situation • Typically, different versions of House and Senate bills are reconciled through a Conference Committee • House and Senate negotiators then agree on a single bill (called a conference report) that each chamber must pass • Fillibuster rules would still apply in the Senate, so 60 votes would be necessary to pass

23. Where Do We Go From Here? • Congressional leadership may forgo formal conference committee to iron out the differences between the bills • House and Senate leadership could agree on changes and then submit revised bill to each chamber for vote • Approach might make passage easier, but is inconsistent with the pledge of transparency and openness • Final bill will likely closely resemble Senate bill

24. Timeline • Administration and congressional leadership would like to have a bill signed by the president before his State of the Union address, but that may not happen • If congressional leaders go through a formal conference committee, negotiations would not start until mid-late January and bill would likely not be finalized until sometime in February • Merging the bills outside the conference committee likely would not expedite the process much, but would prevent some delaying tactics.

25. Key Issues In A Final Bill • Health Care Cost Containment • None of the bills adequately address underlying cost drivers • Focus of the legislation is coverage • Coverage Affordability • New rules in all of the bills will make private health insurance premiums go up • Rating requirements could particularly impact middle-size employers • Ineffective individual mandate • Strict mandated benefit requirements and a minimum level of required coverage that far exceeds typical market offerings today

26. Key Concerns • Public program expansion • Should be limited to medically needy • Will also impact the cost-shift and state budgets • Financing • House Bill—Disproportionably impacts our nation’s small business owners and also will cause more than 6 million privately insured seniors to lose their Medicare Advantage coverage • Senate—Is their financing sustainable? Will all plans eventually be “Cadillac” plans? Also cuts Medicare (but will this happen?)

27. Key Concerns • Government-run public plan option • No matter how limited, never can truly be level and will cause cost-shift • Employer mandate to provide coverage is unnecessary and would have a devastating economic impact • House Bill—72.5% employee coverage, 65% dependents, part-time workers, kicks in at $500K payroll, 8% payroll penalty • Senate HELP—60% premiums, part-time workers, 50+ employees • Senate Finance—No direct mandate. Requires employers of 50+ to pay a fine for low income employees who aren’t offered “affordable coverage”

28. NAHU Action • House • Formal letter and press statement opposing H.R. 3962 • Grassroots support to thank “no” voters • Meetings and HUPAC action to key House moderates to prepare for conference • Senate • Targeted action to grass tops and members with Moderate Senators • Senate meetings and HUPAC action to key moderates • Behind the scenes suggestions to negotiating staff • Working on potential floor amendments • Assisting with value of the agent materials for floor debate • Overall • Outreach to employers • Work with coalition partners • Media interviews • Press Statements • Op-Eds / Letters to the Editor • Social media

29. COBRA • COBRA Subsidy provisions enacted as part of American Recovery and Reinvestment Act of 2009 were set to expired at the end of the year • Subsidy program allows Fed. Govt to pay 65% of COBRA or state continuation premiums for up to nine months for employees involuntarily let go between Sept 1, 2008-Dec 31, 2009 • Senators Brown (D-OH) and Casey (D-PA) introduced S. 2730: COBRA Subsidy Extension and Enhancement Act that President signed on December 19 • Extend subsidy timeframe by 6 months (from 9 to 15) • Extend subsidy to individuals involuntarily terminated between Jan 1, 2010-June 30, 2010 • Extend to employees whose hours are reduced so they no longer qualify for employer-group plan • Increase subsidy amount from 65% to 75% of the employees premium

30. 2010 Elections • Mid Term Elections set for November 2010 • All House Seats • 1/3 of Senate Seats • Including Senators Reid, Dodd, Lincoln, Bayh • 37 Governor’s Races • May effect timing of health care reform in 2010 • Hesitant to take on such major legislation in an election year

31. Conclusion • Reconciling House and Senate bills will be difficult, but some kind of legislation will emerge • Will Democrats in the House support a watered-down Senate bill? • What will the Obama Administration accept and what kind of pressure will be brought to bear?

32. Conclusion • With so much political capital invested, some kind of “healthcare reform” bill will be passed. • Administration and Congressional leadership will accept some reforms and declare victory • Final bill will surely be less ambitious than was originally introduced • Reforms are needed, but reform must be done right.

33. Upcoming NAHU Events COBRA Subsidy Seminar – Jan 6th & 7th NAHU Legislative Town Hall Webinar – January 8th FAHU & NAIFA’s Florida Health Care Summit in Tallahassee – Jan 11th NAHU’s 2010 Capitol Conference – March 8th – 10th

34. Unauthorized Entities The State of Florida has taken a very strong position on the issue of unauthorized entities. An unauthorized entity is an insurance company that is not licensed by the Florida Department of Financial Services. Agents and brokers have responsibility for conducting reasonable research to ensure that they are not writing policies or placing business with unauthorized entities. Lack of careful screening can result in significant financial loss to Florida residents due to unpaid claims and/or theft of premiums. Agents may be held liable when representing these unauthorized entities. It is the agents and brokers’ responsibility to give fair and accurate information regarding the companies they represent. Any questions about the authorized status of a company can be checked by calling the Florida Department of Financial Services at 1-877-693-5236 or 850-413-3089.

35. Wayne Sakamotowayne@healthii.com, (239) 591-1199Michael J. KeeganNAHU Dir of State Affairs – Reg 5 mkeegan@nahu.org, (703) 276-3809