America's Affordable Health Choices Act of 2009


The proposed America's Affordable Health Choices Act of 2009 was an unsuccessful bill introduced in the U.S. House of Representatives on July 14, 2009. The bill was introduced during the first session of the 111th Congress as part of an effort of the Democratic Party leadership to enact health care reform. The bill was not approved by the House, but was superseded by a similar bill, the proposed Affordable Health Care for America Act, which was passed by the House in November 2009, by a margin of 220-215 votes but later abandoned.
A similar bill to HR 3200, called the "Affordable Health Choices Act", was introduced in the Senate on September 17, 2009. It too was unsuccessful as the Senate approved instead another proposal called the "Patient Protection and Affordable Care Act".
According to the Congressional Budget Office, HR 3200 included tax increases and spending cuts that reduce the net increase in the federal deficit to 1% of 2008 tax revenues. The CBO director subsequently noted that, in terms of total National Health Expenditure, non-governmental spending will increase as coverage expands.
The bill was originally sponsored by Representatives John Dingell, Charles Rangel, Henry Waxman, George Miller, Pete Stark, Frank Pallone, and Robert Andrews. The 1017 page PDF version of the bill is the first of three health care reform-related legislative proposals expected from the Democratic congressional leadership. Votes in the U.S. House of Representatives on this bill and on the Medicare for All Act, an alternative that would establish a national, universal single-payer health insurance, were previously expected in September 2009 and again in October 2009, before the actual November 2009 vote took place.

Elements of the bill

The summary of the bill includes the following elements, among others:
  1. Establishes a mandate to purchase private insurance for most individuals with an income above poverty level.
  2. Creates a mechanism to enforce the mandate in a sliding scale tax on those who do not purchase health insurance for most legal United States residents with an income above poverty level.
  3. Prohibits pre-existing condition exclusions.
  4. Requires adjusted community rating, guaranteed issue, and guaranteed renewal of individual and small group health insurance that: limits age rating variation of premiums to 2:1, prohibits gender and health status rating variation of premiums, allows variation of premiums by geographic area and family enrollment.
  5. Prohibits cancellation of coverage except for evidence of fraud.
  6. Limits annual out-of-pocket expenses to $5,000 for an individual and $10,000 for a family.
  7. Requires Health and Human Services to create a non-subsidized public health insurance plan with pricing based on private industry averages. Three optional levels of coverage are to be offered by the plan which must set premiums at a level sufficient to fully finance the costs of the health benefits the administrative costs related to operating the plan.
  8. Establishes a Health Insurance Exchange within a proposed Health Choices Administration, to provide a market place for insurers to sell qualifying plans on a public web site.
  9. Requires the creation of a risk equalization pool that will allow qualifying plans to minimize the impact of adverse selection of enrollees among the plans.
  10. Provides a tax credit for low-income individuals and families to help pay insurance premiums.
  11. Requires employers with payroll costs over $500,000 to provide health insurance that meets the minimum standard of coverage allowed in the HIE.
  12. Provides for a tax on employers that do not provide the required health insurance.
  13. Provides for a tax on couples with adjusted joint gross income exceeding $350,000
  14. Reduces Medicare payments to hospitals with excessive re-admissions.
  15. Further expands Medicaid eligibility and scope of covered preventive services, for lower-income individuals and families.
  16. Increases Medicaid payments to physicians for primary care.
  17. Provides for a phased-in elimination of the Medicare Part D coverage gap and requires drug manufactures to discount and/or rebate additional qualifying drugs originally excluded from the plan.
  18. Requires the Secretary of Health and Human Services to develop quality measures for the delivery of health care services in the United States.
  19. Establishes the Health Benefits Advisory Committee chaired by the Surgeon General of the United States.
  20. Prioritizes any eventual implementation of best practices in the delivery of health care.
  21. Establishes a National Prevention and Wellness Strategy along with appropriations for its trust fund.
  22. Outlines Administrative standards that reduces costs and improves service, including the ability for Administrators to determine an accurate total financial estimate at the point of service as well as enabling real time electronic transfer of funds to take place if possible.

    House Committees' mark-ups

America's Affordable Health Choices Act of 2009 has been amended in the nature of substitute during mark-up proceedings since its original introduction recorded in the Congressional Record on July 14, 2009. These amendments have only been voted on by each Committee involved in order to pass out of the Committee phase but have not been voted on by the full House membership, which is needed before the originally introduced legislation can be changed to reflect any amendments recommended by the Committees and passed by a full House vote.

House Committee on Energy and Commerce

House Committee on Education and Labor

Comparison with Senate versions

The Washington Post published comparison tables of the main House version with the two main Senate versions, which themselves may be summarized as:
3 VersionsHouseSenate HealthSenate FinishedNotes
Deficit increase/ reduction to 2019 -104+597-81Senate Health Committee has no jurisdiction to modify taxes
Cost1279645845-
Number of uninsured17M34M25M54M uninsured by 2019 without bill
Public optionYesYesNo
Individual mandateYesYesYes
Employer mandateYesYesYes
New taxesfam>350No*plan>21*outside Senate Health Committee jurisdiction
Insurance reformsYesYesYes
Expand MedicaidYesNo*Yes*outside Senate Health Committee jurisdiction
Insurance subsidiesYesYesYesprorated to $88k/family of 4, or tax creds

CBO analysis of the bill

The U.S. Congressional Budget Office is a non-partisan organization that analyzes the effect on the federal budget of proposed and existing legislation on behalf of the Congress. CBO analyzed the bill as of July 14, 2009 and reported the following:
In terms of what would happen for consumers, the CBO's methodology in a report in late July used a public plan with premiums about 10% lower than private plans.

Health exchange details

Businesses with ten or fewer employees can use the exchange in the first year after the act begins. The cutoff changes to twenty or fewer employees the next year. On the third year, the 'Health Choices Commissioner' has the authority to phase in businesses with more employees. The legislation does not specify any further phases, leaving that up to the officer to decide.
The act creates new standards, intended by lawmakers as methods of consumer protection, for what would be considered a minimally acceptable insurance plan. Employers that currently offer insurance have a five-year grace period after the act begins before they would be subject to the standards. Individuals would be free to purchase their own private insurance, or work with the public option, in this period and afterward.

Health Benefits Advisory Committee

According to Division A, Title I, Subtitle C, Section 123 of HR 3200, a Health Benefits Advisory Committee shall be established to be chaired by the Surgeon General of the United States. It will consist of 9 more individuals who are not federal employees that are appointed by the President of the United States. It will also consist of 9 members who are appointed by the Comptroller General of the United States. Also, up to eight more members will be appointed in even numbers by the President of the United States who are federal employees and officers. Each member of the committee will serve three year terms. The Health Benefits Advisory Committee will recommend to the United States Secretary of Health and Human Services benefit standards and periodic updates to such standards.

Debate and controversies

Reimbursement for counseling about living wills

One often-cited provision of the un-passed bill would have authorized Medicare reimbursement for physicians who provide voluntary counseling about such subjects as living wills. The provision is based on a separate bill that was cosponsored by Republican Charles Boustany of Louisiana, a surgeon, and is similar to end-of-life counseling signed by President George W. Bush. This Advance Care Planning Consultation section was criticized by some Republicans and conservatives such as Betsy McCaughey, a lobbyist for the healthcare industry who also helped to defeat the Clinton health care plan of 1993. These critics allege that it includes mandatory language aimed at pressing elderly and disabled patients toward euthanasia. Their interpretation was the basis for the charge about this section by prominent Republican 2008 Vice Presidential candidate Sarah Palin.
However, the "level of productivity in society" or panels claim is not mentioned in the actual legislation, which is structured primarily to amend in the Social Security Act, Section 1861 of definitions that are used in sections regarding reimbursements for end-of-life counseling, including the use of Advance Directives.
Charles Boustany's Democratic cosponsor, Earl Blumenauer of Oregon, has called this attack on the bill "an all-time low".
Blumenauer said the measure would block funds for counseling that presents suicide or assisted suicide as an option, and called references to death panels or euthanasia "mind-numbing". He said that "the majority of Congressional Republicans supported the similar provisions for terminally ill elderly patients that were part of the 2003 prescription drug bill" and that, out of the dozens of Republican proposals for revising the bill, "not a single word" was said against end-of-life counseling. He said that Rush Limbaugh, Virginia Foxx, Newt Gingrich, Charles Grassley and other Republicans defended the death panel story only after Betsy McCaughey's editorials, and that some people at town hall meetings even wanted to "keep government out of their Medicare," a government run program. Blumenauer said that as recently as April 2008 then-governor Palin supported end-of-life counseling as part of Health Care Decisions Day. Palin's office called this comparison "hysterically funny" and "desperate". Republican Senator Johnny Isakson, who co-sponsored a 2007 end-of-life counseling provision, called the euthanasia claim "nuts". Analysts who examined the end-of-life provision Palin cited agreed that it merely authorized Medicare reimbursement for physicians who provide voluntary counseling for advance health care directives. According to TIME and ABC, Palin and McCaughey made false euthanasia claims.
The page 425 legislation began as a separate bill that was co-sponsored by Republicans Charles Boustany, Patrick Tiberi and Geoff Davis. Boustany, a heart surgeon, said the end-of-life legislation was a "good medical practice". 204 GOP House members and 42 GOP Senators voted for a 2003 Medicare prescription drug bill that included end-of-life counseling. The 2003 legislation only covered end-of-life counseling for terminally ill patients, which the Republican Charles Grassley supported. Grassley said that the 2009 end-of-life counseling would "pull the plug on grandma" and that "You shouldn't have counseling at the end of life, you should have done that 20 years before," which is what the 2009 legislation would allow. Republican Newt Gingrich defended the death panel claim, but previously praised the Gundersen Lutheran Health System for encouraging the widespread use of Advance Directives.
The federal requirement that hospitals help patients with things like living wills began when Republican George H. W. Bush was president. Section 1233 merely allows doctors to be paid for their time. However, between 30 percent and 45 percent of Americans believed in the death panel story. According to PolitiFact, private health insurance companies already ration health care by income, by denying health insurance to those with pre-existing conditions and by caps on health insurance payments. Rationing exists now, and will continue to exist with or without health care reform.
The "death panel" argument was endorsed by an erroneous editorial in the Investor's Business Daily, which analogized the bill to the National Health Service in the United Kingdom and editorialized: "People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless." The Investor's Business Daily editorialists had to beat a retreat and quickly retracted its claim after it was pointed out that Hawking was in fact British, and had lived his entire life in the United Kingdom with treatment from the NHS. Stephen Hawking responded, "I wouldn't be here today if it were not for the NHS. I have received a large amount of high-quality treatment without which I would not have survived."
On a separate issue, physician and conservative commentator Charles Krauthammer has criticized what he sees as a naive focus on living wills by the policymakers over other types of medical advice. He has written: