The plans are Health Security America (HSA), and HR 676, cited as the United States National Health Insurance Act (or the Expanded and Improved Medicare for All Act). Health Security America health plan was designed primarily by Dr. Fred Bannister and very specifically described in his book Health Security America: Fixing the health care crisis. The United States National Health Insurance Act was led by Rep. John Conyers, D-MI. Both plans fall under the umbrella of “Medicare for All.”

Both of the “Medicare for All” plans are revolutionary and merit examination. The list below has some of the main points that need to be compared and contrasted, with the aim of ensuring that every American finally gets a fair health plan, unadulterated by the concerns of special interests such as drugs and device manufacturers, hospital and professional associations.

Issues:

(1) Which health plan gives the individual citizen a voice in a decision making process as free of unseen lobbyist influence as possible? Will information on major issues be as available to the individual citizen as it is to the special interests?

(2) Which health plan offers the more accessible, transparent, and above all simple administration?

(3) Which health plan will allow the citizen to make the final decisions on the cost (premiums) and coverage since he or she will pay this bill every month for HSA or yearly in taxes for HR 676?

(4) Which health plan will permit clear accountability (as opposed to vague, resistant bureaucracy)?

(5) Which health plan makes the citizen more cognizant of his or her personal and family health responsibility?

Abstract in chart form comparing two “Medicare for All” health care plans

Health Security America is compared to H.R.676 cited as the United States National Health Insurance Act (or the Expanded and Improved Medicare for All Act)

For convenience the sections in these comparisons will match the sections in H.R. 676. The book Health Security America: Fixing the health care crisis is available from the plan’s website: www.healthsecurityamerica.com. The author can be contacted at fredb@healthsecurityamerica.com . Rep. Conyers’ website: http://www.house.gov/conyers/

Sec. 101. Eligibility and Registration

HR 676:

(a) In general— all individuals residing in the United States (including any territory of the United States) are covered under the USNHI Program entitling them to a universal, best quality standard of care. Each such individual shall receive a card with a unique number in the mail. An individual's social security number shall not be used for purposes of registration under this section.
(b) Registration— Individuals and families shall receive a United States National Health Insurance Card in the mail, after filling out a United States National Health Insurance application form at a health care provider. Such application form shall be no more than 2 pages long.
(c) Presumption— Individuals who present themselves for covered services from a participating provider shall be presumed to be eligible for benefits under this Act, but shall complete an application for benefits in order to receive a United States National Health Insurance Card and have payment made for such benefits.

HSA:

(a) HSA is clear that all citizens are entitled to coverage. The individual citizen would apply for the insurance and could not be refused for any reason. If the citizen is disabled or unable to enroll, Medicaid—Social Services in each county or city would enroll him or her. If the citizen is indigent, the government will supply funding and Congress will determine at what level of income an individual has to be below before he or she would be eligible for this help. Below the age of 19 years all are automatically covered with no questions. Every person who has reached majority has a responsibility to apply and take an interest in his or her well being.

A person may reject the plan and carry no insurance. He or she will be billed by providers and be expected to pay based on HSA fees. The author of the plan makes the assumption that no concerned human wants to take the risk of no insurance if there is anyway he can afford it. Those that do take this risk might well be above the eligibility level for getting government help and if so they will be subject to dunning and be expected to pay with money or assets. These same people would be subject to a 6 month wait after joining the plan after the initial sign-up should they become ill and want the insurance.

Sec.102. Benefits and Portability

HR 676:

(a) In General— The health insurance benefits under this Act cover all medically necessary services, including—

(1) primary care and prevention;
(2) inpatient care;
(3) outpatient care;
(4) emergency care;
(5) prescription drugs;
(6) durable medical equipment;
(7) long term care;
(8) mental health services;
(9) the full scope of dental services (other than cosmetic dentistry);
(10) substance abuse treatment services;
(11) chiropractic services; and
(12) basic vision care and vision correction (other than laser vision correction for cosmetic purposes).

(b) Portability— Such benefits are available through any licensed health care clinician anywhere in the United States that is legally qualified to provide the benefits.
(c) No Cost-sharing— No deductibles, co-payments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits.

HSA:

(a) Benefits 1-6 are covered immediately after the plan begins functioning.

Benefits 7-12 are all-encompassing and much of the extent of cost unknown and much is open ended. Every one of these benefits might be included if citizens after the hearing processes and voting takes place decide they can afford them and want them. Citizens in the HSA plan determine coverage and premiums with the added rule that they may not accrue long-term debt.

(b) There is no difference in portability and it is appropriate.

(c) HR-676 offers everything free but does not consider cost in relationship to coverage. Citizens may well decide this is appropriate but it will need to be changed from the current Medicare rules if this is going to happen and the present form of Medicare is predicted to go into default in 2020. Deductibles have pros and cons to them and citizens will have to decide.

Sec.103. Qualification of Participating Providers

HR 676:

(a) Requirement to Be Public or Non-profit-

(1) IN GENERAL- No institution may be a participating provider unless it is a public or not-for-profit institution.
(2) CONVERSION OF INVESTOR-OWNED PROVIDERS- Investor-owned providers of care opting to participate shall be required to convert to not-for-profit status.
(3) COMPENSATION FOR CONVERSION- The owners of such investor-owned providers shall be compensated for the actual appraised value of converted facilities used in the delivery of care.
(4) FUNDING- There are authorized to be appropriated from the Treasury such sums as are necessary to compensate investor-owned providers as provided for under paragraph (3).
(5) REQUIREMENTS- The conversion to a not-for-profit health care system shall take place over a 15-year period, through the sale of US Treasury Bonds. Payment for conversions under paragraph (3) shall not be made for loss of business profits, but may be made only for costs associated with the conversion of real property and equipment.

(b) Quality Standards-

(1) IN GENERAL- Health care delivery facilities must meet regional and State quality and licensing guidelines as a condition of participation under such program, including guidelines regarding safe staffing and quality of care.
(2) LICENSURE REQUIREMENTS- Participating clinicians must be licensed in their State of practice and meet the quality standards for their area of care. No clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.

(c) Participation of Health Maintenance Organizations-

(1) IN GENERAL- Non-profit health maintenance organizations that actually deliver care in their own facilities and employ clinicians on a salaried basis may participate in the program and receive global budgets or capitation payments as specified in section 202.
(2) EXCLUSION OF CERTAIN HEALTH MAINTENANCE ORGANIZATIONS- Other health maintenance organizations, including those which principally contract to pay for services delivered by non-employees, shall be classified as insurance plans. Such organizations shall not be participating providers, and are subject to the regulations promulgated by reason of section 104(a) (relating to prohibition against duplicating coverage).

(d) Freedom of Choice- Patients shall have free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities.

HSA:

(a) Requirement to be public or non-profit: The entire (a) section on profit-taking status of HR-676 is really not necessary in HSA, which accomplishes the necessary health reform in a simpler and less expensive manner. Hospitals will be governed and overseen by regional planning agencies. The operating people in the hospitals will stay in the same positions and of course it will be non-profit but the people who own the assets will be paid rent on their investment determined by appraisals. They will not be paid rent or dividends based on the profit and loss statement as currently done. This will save the US Treasury much money.

HSA’s mechanism of operating by providers will make them independent of institutions such as large clinics, HMO’s or other managed care plans by virtue of the payment schedules. The clinics and whoever currently owns them will be paid rent by providers determined by the marketplace. Again, this will not require outlays from the Treasury and assumption of ownership. This all will stay in our current marketplace with no influence on health care other preventing further outlays from our government.

(b) Quality standards: Quality standards as in HR-676 are fine with the addition of the peer review of local medical societies and other professional societies that do peer review. This will add another level to quality.

(c) Participation of health maintenance organizations: These organizations can continue to exist but they will function by the same rules and fees as any independent physician or other provider. There will be no capitation payments or other negotiations to reach them. It will be unlikely HMO’s will continue to exist once their providers are freed to run their own practice or business. There will not be enough money to pay for the administration and providers at the same time. If they continue to exist they will be functioning under much lower salary structures than now.

(d) Freedom of choice: As in HR-676, patients shall have free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities.

Sec.104. Prohibition Against Duplicating Coverage

HR 676:

(a) In General— It is unlawful for a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act.
(b) Construction— Nothing in this Act shall be construed as prohibiting the sale of health insurance coverage for any additional benefits not covered by this Act, such as for cosmetic surgery or other services and items that are not medically necessary.

HSA:

(a) The mechanisms of HSA would make selling duplicate benefits virtually impossible but HSA has no quarrel with this statement.

(b) Construction: Full agreement with HR-676

Finances
Subtitle A—Budgeting and payment

Sec.201. Budgeting Process

HR 676:

(a) Establishment of Operating Budget and Capital Expenditures Budget-

(1) IN GENERAL— To carry out this Act there are established on an annual basis consistent with this title—

(A) an operating budget;
(B) a capital expenditures budget;
(C) reimbursement levels for providers consistent with subtitle B; and
(D) a health professional education budget, including amounts for the continued funding of resident physician training programs.

(2) REGIONAL ALLOCATION— After Congress appropriates amounts for the annual budget for the USNHI Program, the Director shall provide the regional offices with an annual funding allotment to cover the costs of each region's expenditures. Such allotment shall cover global budgets, reimbursements to clinicians, and capital expenditures. Regional offices may receive additional funds from the national program at the discretion of the Director.

(b) Operating Budget— The operating budget shall be used for—

(1) payment for services rendered by physicians and other clinicians;
(2) global budgets for institutional providers;
(3) capitation payments for capitated groups; and
(4) administration of the Program.

(c) Capital Expenditures Budget— The capital expenditures budget shall be used for funds needed for—

(1) the construction or renovation of health facilities; and
(2) for major equipment purchases.

(d) Prohibition Against Co-Mingling Operations and Capital Improvement Funds— It is prohibited to use funds under this Act that are earmarked—

(1) for operations for capital expenditures; or
(2) for capital expenditures for operations.

HSA:

(a)

(1) No disagreement on an operating budget
(2) Once the board has all the necessary citizen information to set premiums and coverage the budget will be set for the non-profit citizen-owned HSA insurance corporation. Providers will bill HSA based on the fee schedule given them and will operate their part of the health system independently. They will be paid within 14 days after computer submission. (This will be the only method of submitting bills)

(b). The operating budget shall be used for—

(1) This: payment for services rendered by physicians and other clinicians
(2) But not this: institutional providers will bill just as others do.(They have patient base as do non-institutional providers)
(3) Or this: there will be no capitated groups.
(4) This: administration of the program

(c)

(1) Hospitals will bill as do others (based on a fee schedule) and they will allocate funds for themselves but per the regional health planning rules set down for them
(2) Equipment purchases of size will be governed again by the regional health planning agency.

(d)

(1) Hospitals will administer the spending of money received from the insurance payments but still under the broad guidance of the regional planning agency.
(2) Same as above number (1)

In summary of the budget process: HSA is in agreement with some of this section’s paragraph subjects but is more specific and will reach goals by a totally different method.

The decisions of this section will be made by citizens not by congress and given to directors. HR-676 would be classified as decisions coming from the top down.

In summary, citizens will make all major decisions, since they will be paying the bill and receiving the coverage. This will be a pay as you go system with no long-term debt allowed. The Board of Information will provide the citizens with information and knowledge to make these decisions via the citizen governance mechanisms in HSA The citizen has a responsibility to listen, watch and participate in the governance. This will be the best way to limit special interest influence such as drug companies, professional groups and hospital associations. It is assumed not all 295 million people will participate in the HSA governance process but what number would? It is not unreasonable to think that 10,000 people would pay attention to such a serious matter.

Sec.202. Payment of Providers and Health Care Clinicians

HR 676:

(a) Establishing Global Budgets; Monthly Lump Sum—

(1) IN GENERAL— The USNHI Program, through its regional offices, shall pay each hospital, nursing home, community or migrant health center, home care agencies, or other institutional provider or pre-paid group practice a monthly lump sum to cover all operating expenses under a global budget.
(2) ESTABLISHMENT OF GLOBAL BUDGETS— The global budget of a provider shall be set through negotiations between providers and regional directors, but are subject to the approval of the Director. The budget shall be negotiated annually, based on past expenditures, projected changes in levels of services, wages and input, costs, and proposed new and innovative programs.

(b) Three Payment Options for Physicians and Certain Other Health Professionals—

(1) IN GENERAL— The Program shall pay physicians, dentists, doctors of osteopathy, psychologists, chiropractors, doctors of optometry, nurse practitioners, nurse midwives, physicians' assistants, and other advanced practice clinicians as licensed and regulated by the States by the following payment methods:

(A) Fee for service payment under paragraph (2).
(B) Salaried positions in institutions receiving global budgets under paragraph (3).
(C) Salaried positions within group practices or non-profit health maintenance organizations receiving capitation payments under paragraph (4).

(2) FEE FOR SERVICE—

(A) IN GENERAL— The Program shall negotiate a simplified fee schedule that is fair with representatives of physicians and other clinicians, after close consultation with the National Board of Universal Quality and Access and regional and State directors. Initially, the current prevailing fees or reimbursement would be the basis for the fee negotiation for all professional services covered under this Act.
(B) CONSIDERATIONS— In establishing such schedule, the Director shall take into consideration regional differences in reimbursement, but strive for a uniform national standard.
(C) STATE PHYSICIAN PRACTICE REVIEW BOARDS— The State director for each State, in consultation with representatives of the physician community of that State, shall establish and appoint a physician practice review board to assure quality, cost effectiveness, and fair reimbursements for physician delivered services.
(D) FINAL GUIDELINES— The regional directors shall be responsible for promulgating final guidelines to all providers.
(E) BILLING- Under this Act physicians shall submit bills to the regional director on a simple form, or via computer. Interest shall be paid to providers whose bills are not paid within 30 days of submission.
(F) NO BALANCE BILLING— Licensed health care clinicians who accept any payment from the USNHI Program may not bill any patient for any covered service.
(G) UNIFORM COMPUTER ELECTRONIC BILLING SYSTEM- The Director shall make a good faith effort to create a uniform computerized electronic billing system, including in those areas of the United States where electronic billing is not yet established.

(3) SALARIES WITHIN INSTITUTIONS RECEIVING GLOBAL BUDGETS—

(A) IN GENERAL— In the case of an institution, such as a hospital, health center, group practice, community and migrant health center, or a home care agency that elects to be paid a monthly global budget for the delivery of health care as well as for education and prevention programs, physicians employed by such institutions shall be reimbursed through a salary included as part of such a budget.
(B) SALARY RANGES— Salary ranges for health care providers shall be determined in the same way as fee schedules under paragraph (2).

(4) SALARIES WITHIN CAPITATED GROUPS—

(A) IN GENERAL— Health maintenance organizations, group practices, and other institutions may elect to be paid capitation premiums to cover all outpatient, physician, and medical home care provided to individuals enrolled to receive benefits through the organization or entity.
(B) SCOPE- Such capitation may include the costs of services of licensed physicians and other licensed, independent practitioners provided to inpatients. Other costs of inpatient and institutional care shall be excluded from capitation payments, and shall be covered under institutions' global budgets.
(C) PROHIBITION OF SELECTIVE ENROLLMENT— Selective enrollment policies are prohibited, and patients shall be permitted to enroll or disenroll from such organizations or entities with appropriate notice.
(D) HEALTH MAINTENANCE ORGANIZATIONS— Under this Act—

(i) health maintenance organizations shall be required to reimburse physicians based on a salary; and
(ii) financial incentives between such organizations and physicians based on utilization are prohibited.

HSA:

(a) Establishing Global Budgets; Monthly Sum:

(1) Each facility will bill via a fee for service system determined by the same Medicare system we use now or would adapt to this. This is a simple uncomplicated way to accomplish this.

(2) There will be no global budget for an institution or other providers covered on this plan. It will up to citizens to determine if Nursing homes and facilities other than hospitals, health providers and drugs are covered. If they do cover it will be under fee for service method. (The caveat still holds that citizens will most likely declare educational some large clinics and hospitals and fund them in whatever way is appropriate—and probably much more than with just fee for service payments due to the nature of the educational activity.)

(b) (A) Fee for service will be the only method of payment.
(B) and (C) will not have salaries attached to them. If a group wishes to have salaried providers they will take these monies out of fee for service of other associated providers. (Remember one of the vital rules of HSA; there will be no non-compete contracts such that I think a group of physicians, as an example, wanting to give someone a salary out of their fee for service payment will be few. ( In general administration will not be able to create very many provider-salaried positions, since the people contributing to this with their own fees would not stay in such a situation and would move on) This same idea will reduce administration to only needful situations. There will be no capitated health maintenance organizations. Non-profit is somewhat of a misnomer in that administrative salaries are taken before profit is declared so being non-profit does not necessarily control high salaries and waste.

(2) Fee for service:

(A) All fees will be negotiated under the same method Medicare uses at this time. All appeal processes will remain the same until citizens would choose to change.

(B) All current Medicare considerations will be used as now. (This office of Medicare will be incorporated into HSA)

(C) HSA agrees with practice review boards, but would add the county medical society peer review groups as well as the state society peer review groups. This will give an added layer of quality protection.

(D) Final guidelines will come out of the Board of Information but will start with current Medicare rules and regulations until changed by the HSA governance process.

(E) Billing is to be on 14-day cycle. It is electronic and there is no need to extend it.

(F) Agreed—no balance billing of patients allowed.

(G) Medicare electronic billing methods will be adapted—and if they are non-uniform, HSA will recommend WPS methods in Wisconsin and Illinois.

(3) Salaries within institutions receiving global budget:

(A) Providers within this system will be paid on fee for service as in any other atmosphere of health delivery. This allows the focus on exactly what is being done with the provider’s time. This will keep costs in line and reduce waste. Accountability must be maintained and salaries do not allow this to work as effectively.

(B) Salary ranges:
There will be a fee for service and this will be determined as Medicare now does with, of course, the oversight of citizens through the governing mechanism.

(4) Salaries within capitated groups:

(A) In HSA there will be no capitated groups. There will be fee for service done. If there are five services done there will be money coming for five services at the specific fee schedule set. This is the only way administration costs can be gotten under control.

(B) Scope: See (A) above

(C) Prohibition of selective enrollment is not allowed in HSA.

(D) Health maintenance organizations will be permissible, but will be based on fee for service. It is doubtful that this form of practice will survive with the 8 rules of HSA becoming the law. The removal of non-compete clauses will probably be the end of this failed group system of practice.

Sec. 203. Payment for Long-Term Care

HR 676:

a) Allotment for Regions— The Program shall provide for each region a single budgetary allotment to cover a full array of long-term care services under this Act.
(b) Regional Budgets— Each region shall provide a global budget to local long-term care providers for the full range of needed services, including in-home, nursing home, and community based care.
(c) Basis for Budgets— Budgets for long-term care services under this section shall be based on past expenditures, financial and clinical performance, utilization, and projected changes in service, wages, and other related factors.
(d) Favoring Non-Institutional Care— All efforts shall be made under this Act to provide long-term care in a home- or community-based setting, as opposed to institutional care.

HSA:

HSA does not include long-term care at this stage. It is felt that medical, surgical, hospital and drug coverage are the first things that need to be dealt with. The mechanisms used in the governance of HSA will allow for long-term care on what ever basis citizens would wish to include it.

Sec.204. Mental Health Services

HR 676:

(a) In General— The program shall provide coverage for all medically necessary mental health care on the same basis as the coverage for other conditions. Licensed mental health clinicians shall be paid in the same manner as specified for other health professionals, as provided for in section 202(b).
(b) Favoring Community-Based Care— The USNHI Program shall cover supportive residences, occupational therapy, and ongoing mental health and counseling services outside the hospital for patients with serious mental illness. In all cases the highest quality and most effective care shall be delivered, and, for some individuals, this may mean institutional care.

HSA:

(a) HSA shall provide coverage for all medically necessary mental health care on the same basis as the coverage for other conditions. Licensed mental health clinicians shall be paid in the same manner as specified for other health professionals in HSA

Sec.205 Payment for Prescription Medications, Medical Supplies, and Medically Necessary Assistive Equipment

HR 676:

a) Negotiated Prices— The prices to be paid each year under this Act for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Program.
(b) Prescription Drug Formulary—

(1) IN GENERAL— The Program shall establish a prescription drug formulary system, which shall encourage best-practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available.
(2) PROMOTION OF USE OF GENERICS— The formulary shall promote the use of generic medications but allow the use of brand-name and off-formulary medications when indicated for a specific patient or condition.
(3) FORMULARY UPDATES AND PETITION RIGHTS— The formulary shall be updated frequently and clinicians and patients may petition their region or the Director to add new pharmaceuticals or to remove ineffective or dangerous medications from the formulary.

HSA:
(a) Negotiated prices: same as HR 676

(b) Prescription drug formulary: same as HR 676, but the provisions for updates and petition rights in 205 (b. 3) will be open to same citizen governance as all other topics in the HSA health plan.

Sec.206. Consultation in Establishing Reimbursement Levels

HR 676:

Reimbursement levels under this subtitle shall be set after close consultation with regional and State Directors and after the annual meeting of National Board of Universal Quality and Access.

HSA:

The method of determining reimbursement will be the same as now done with Medicare and will use its appeal processes and rule making mechanisms. (These current Medicare offices will be incorporated into the HSA governing process)

Subtitle B — Funding

Sec.211. Overview: Funding The USNHI Program

HR 676:

(a) In General- The USNHI Program is to be funded as provided in subsections (b) and (c).
(b) Annual Appropriation for Funding of USNHI Program- There are authorized to be appropriated to carry out this Act such sums as may be necessary.
(c) Intent- Sums appropriated pursuant to subsection (b) shall be paid for—

(1) by vastly reducing paperwork;
(2) by requiring a rational bulk procurement of medications;
(3) from existing sources of Federal government revenues for health care;
(4) by increasing personal income taxes on the top 5 percent income earners;
(5) by instituting a modest payroll tax; and
(6) by instituting a small tax on stock and bond transactions.

HSA:

(a) HSA is funded by premiums paid by citizens that have determined the coverage and premium. There is no money coming from taxes other than that which the government pays the premium for the poor.
(b) Premiums will calculated annually
(c) Intent:

(1) Premiums will be in the range of 50% less due to reduced paperwork, patients more attuned to their own personal health responsibility, control of waste, influence and by implementation of the 8 eight rules in HSA

(2) Premiums will be reduced partially due to bulk medicine negotiations and

(3) Revenues currently forwarded for poor and their health bills will also be used in HSA rather the Medicaid or other actual plans.

(4, 5, 6) The taxes referred to in (4), (5) and (6) will not be a part of HSA

Sec.212. Appropriations for Existing Programs for the uninsured

HR 676:

Notwithstanding any other provision of law, there are hereby transferred and appropriated to carry out this Act, amounts equivalent to the amounts the Secretary estimates would have been appropriated and expended for Federal public health care programs for the uninsured and indigent, including funds appropriated under the Medicare program under title XVIII of the Social Security Act, under the Medicaid program under title XIX of such Act, and under the Children's Health Insurance Program under title XXI of such Act.

HSA:

The funds in this section referred to in the last paragraph will be used for paying premiums for the indigent as identified by the government in their Congressional deliberations.

Title 111 — Administration

Sec.301. Public Administration; Appointment of Director

HR 676:

(a) In General— Except as otherwise specifically provided, this Act shall be administered by the Secretary through a Director appointed by the Secretary.
(b) Long-Term Care— The Director shall appoint a director for long-term care who shall be responsible for administration of this Act and ensuring the availability and accessibility of high quality long-term care services.
(c) Mental Health— The Director shall appoint a director for mental health who shall be responsible for administration of this Act and ensuring the availability and accessibility of high quality mental health services.

HSA:

(a) HSA (a non-profit insurance company) will be administered through its citizen government mechanisms described in detail in Health Security America: Fixing the health care crisis. In essence, there will be no direct link to the Executive Branch or Congress after HSA is up and running.

(b) and (c) Long-term care and mental health services will be controlled through HSA’s citizen government mechanisms as per (a) of this section should citizens decide they want to include this in their own non-profit insurance company.

Sec.302. Office of Quality Control

HR 676:

The Director shall appoint a director for an Office of Quality Control. Such director shall, after consultation with state and regional directors, provide annual recommendations to Congress, the President, the Secretary, and other Program officials on how to ensure the highest quality health care service delivery. The director of the Office of Quality Control shall conduct an annual review on the adequacy of medically necessary services, and shall make recommendations of any proposed changes to the Congress, the President, the Secretary, and other USNHI program officials.

HSA:

The same offices addressing quality control in the Medicare program will transfer to HSA In addition HSA will also have the county medical society peer review mechanisms which have proven very effective in the past. Any questions of quality control will be addressed by this office and any global issues requiring citizen input will be given to the board of information of HSA biannually for research and transferring to the HSA Regional Representatives for the usual hearing process and action/decision process addressed in the book Health Security America: Fixing the health care crisis.*

Sec. 303. Regional and State Administration; Employment of Displaced Clerical Workers

HR 676:

(a) Use of Regional Offices— The Program shall establish and maintain regional offices. Such regional offices shall replace all regional Medicare offices.
(b) Appointment of Regional and State Directors- In each such regional office there shall be—

(1) one regional director appointed by the Director; and
(2) for each State in the region, a deputy director (in this Act referred to as a `State Director') appointed by the governor of that State.

(c) Regional Office Duties—

(1) IN GENERAL— Regional offices of the Program shall be responsible for—

(A) coordinating funding to health care providers and physicians; and
(B) coordinating billing and reimbursements with physicians and health care providers through a State-based reimbursement system.

(d) State Director's Duties- Each State Director shall be responsible for the following duties:

(1) Providing an annual state health care needs assessment report to the National Board of Universal Quality and Access, and the regional board, after a thorough examination of health needs, in consultation with public health officials, clinicians, patients and patient advocates.
(2) Health planning, including oversight of the placement of new hospitals, clinics, and other health care delivery facilities.
(3) Health planning, including oversight of the purchase and placement of new health equipment to ensure timely access to care and to avoid duplication.
(4) Submitting global budgets to the regional director.
(5) Recommending changes in provider reimbursement or payment for delivery of health services in the State.
(6) Establishing a quality assurance mechanism in the State in order to minimize both under utilization and over utilization and to assure that all providers meet high quality standards.
(7) Reviewing program disbursements on a quarterly basis and recommending needed adjustments in fee schedules needed to achieve budgetary targets and assure adequate access to needed care.

(e) First Priority in Retraining and Job Placement— The Program shall provide that clerical and administrative workers in insurance companies, doctors offices, hospitals, nursing facilities and other facilities whose jobs are eliminated due to reduced administration, should have first priority in retraining and job placement in the new system.

HSA:

(a) Medicare infrastructure will be available to HSA. This includes technical, actuarial, regulatory and rule making offices with associated auditing facilities and any other currently functioning offices that could aid HSA in its mission.

(b) All regional directors are elected by citizens in publicly financed campaigns. Regional Directors will elect the board of information and the remaining officers of HSA. The specific mechanisms are spelled out in Health Security America: Fixing the health care crisis* and will be part of the by-laws of HSA enabled by Congressional legislation.

(c, d) Regional office and state director’s duties: The duties are similar but the difference is the non-profit corporation daily operation starts with the same rules and regulation as the present Medicare system. The Board of Information will offer any changes they think are necessary as time passes, and these will ultimately be approved by the citizens in the governance mechanism of HSA.

(e) First priority in retraining and job placement: The program shall provide that clerical and administrative workers in insurance companies, doctors’ offices, hospitals, nursing facilities and other facilities where jobs are eliminated due to reduced administration, should have first priority in retraining and job placement in the non-profit insurance company, HSA

Sec. 304. Confidential Electronic Patient Record System

HR 676:

(a) In General— The Secretary shall create a standardized, confidential electronic patient record system in accordance with laws and regulations to maintain accurate patient records and to simplify the billing process, thereby reducing medical errors and bureaucracy.
(b) Patient Option— Notwithstanding that all billing shall be performed electronically, patients shall have the option of keeping any portion of their medical records separate from their electronic medical record.

HSA:

(a) In general: The non-profit corporation, HSA, shall create a standardized, confidential electronic patient record system in accordance with laws and regulations to maintain accurate patient records and to simplify the billing process, thereby reducing medical errors and bureaucracy.
(b) Patient option: Notwithstanding that all billing shall be performed electronically, patients shall have the option of keeping any portion of their medical records separate from their electronic medical record.

Sec.305 National Board of Universal Quality and Access

HR 676:

(a) Establishment—

(1) IN GENERAL—There is established a National Board of Universal Quality and Access (in this section referred to as the `Board') consisting of 15 members appointed by the President, by and with the advice and consent of the Senate.
(2) QUALIFICATIONS— The appointed members of the Board shall include at least one of each of the following:

(A) Health care professionals.
(B) Representatives of institutional providers of health care.
(C) Representatives of health care advocacy groups.
(D) Representatives of labor unions.
(E) Citizen patient advocates.

(3) TERMS— Each member shall be appointed for a term of 6 years, except that the President shall stagger the terms of members initially appointed so that the term of no more than 3 members expires in any year.
(4) PROHIBITION ON CONFLICTS OF INTEREST— No member of the Board shall have a financial conflict of interest with the duties before the Board.

(b) Duties—

(1) IN GENERAL— The Board shall meet at least twice per year and shall advise the Secretary and the Director on a regular basis to ensure quality, access, and affordability.
(2) SPECIFIC ISSUES—The Board shall specifically address the following issues:

(A) Access to care.
(B) Quality improvement.
(C) Efficiency of administration.
(D) Adequacy of budget and funding.
(E) Appropriateness of reimbursement levels of physicians and other providers.
(F) Capital expenditure needs.
(G) Long-term care.
(H) Mental health and substance abuse services.
(I) Staffing levels and working conditions in health care delivery facilities.

(3) ESTABLISHMENT OF UNIVERSAL, BEST QUALITY STANDARD OF CARE- The Board shall specifically establish a universal, best quality of standard of care with respect to—

(A) appropriate staffing levels;
(B) appropriate medical technology;
(C) design and scope of work in the health workplace; and
(D) best practices.

(4) TWICE-A-YEAR REPORT—The Board shall report its recommendations twice each year to the Secretary, the Director, Congress, and the President.

(c) Compensation, Etc— The following provisions of section 1805 of the Social Security Act shall apply to the Board in the same manner as they apply to the Medicare Payment Assessment Commission (except that any reference to the Commission or the Comptroller General shall be treated as references to the Board and the Secretary, respectively):

(1) Subsection (c)(4) (relating to compensation of Board members).
(2) Subsection (c)(5) (relating to chairman and vice chairman)
(3) Subsection (c)(6) (relating to meetings).
(4) Subsection (d) (relating to director and staff; experts and consultants).
(5) Subsection (e) (relating to powers).

HSA:

HSA starts with the existing Medicare rules, regulations and fees. The governing of the individual provider offices will be done by the owners, and, in the case of hospitals, the same with oversight by regional planning agencies.

State medical societies with their complement of county societies have peer review committees that work to assure quality. They will begin to function again.

There is no problem with citizens deciding they want to pay for a new bureaucracy designated “The National Board of Universal Quality and Access” It could function just as HR 676 suggests, but this will be voted on by citizens. The mechanism is described in the governance sections of Health Security America: Fixing the health care crisis* Prior to the HMO, large-clinic method of practice, there was no crisis in quality that demanded a national bureaucracy.

Title IV—Additional Provisions

Sec. 401. Treatment of VA and IHS Health Programs

HR 676:

This Act provides for health programs of the Department of Veterans' Affairs and of the Indian Health Service to initially remain independent for the 5-year period that begins on the date of the establishment of the USNHI program, but after such period those programs shall be integrated into the USNHI program.

HSA:

HSA starts with the Medicare rules, fees and regulations and is a non-profit health insurance company governed by citizens. Veterans are receiving care as the consequences of Congressional actions that put them there—wars and other conflicts. Actuarial findings will be impossible to determine for this insurance company and determining premiums and coverage will be impossible. Unless a fair way can be determined the VA system will have to remain independent.

The Indian Health Service will be abandoned and included in the non-profit insurance company immediately on being enabled by Congress and a process for transfer can be done.

Sec. 402. Public Health and Prevention

HR 676:

It is the intent of this Act that the Program at all times stress the importance of good public health through the prevention of diseases.

HSA:

No difference.

Sec.403. Reduction in Health Disparities

HR 676:

It is the intent of this Act to reduce health disparities by race, ethnicity, income and geographic region, and to provide high quality, cost-effective, culturally appropriate care to all individuals regardless of race, ethnicity, sexual orientation, or language.

HSA:

This is the total intent of HSA

Title V—Effective Date

Sec.501. Effective Date

HR 676:

Except as otherwise specifically provided, this Act shall take effect on January 1, 2007, and shall apply to items and services furnished on or after such date.

HSA:

To take effect on a date specified by Congress.

*Health Security America: Fixing the health care crisis
Is available at www.healthsecurityamerica.com

Health Security America is the remedy.

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©2008 by the Coalition for a Health-Secure America
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