In Massachusetts, Blue Cross Blue Shield along with Harvard Pilgrim Health Care and Tufts Health Plan, have begun sending out letters requesting rate rollbacks from hospitals and doctors. Blue Cross sent letters to nearly one-third of its network – their contracts will expire in October.

Many hospitals are not happy about the proposed cutbacks. Only hospitals that carry clout and market power currently can afford the power to charge significantly more for services. Meanwhile, other health insurance providers receive considerably less for similar services. For the majority of hospitals, price decreases are not feasible – many are struggling as it stands, especially with cuts to the Medicaid program already underway.

Massachusetts has always been a leader in healthcare reform. Currently, most residents are required to have health insurance and insurance costs have been rising drastically. The negotiations between hospitals and insurance providers could mean disruption on the patient side. If hospitals refuse to conform to negotiations, then patients may have to find other in-network providers, while negotiations are underway.

The goal of Obama's health care reform was indeed affordable health insurance. However, this new system is proving to be a maze of red tape and uncertainty. Health insurance plans are constantly changing, meaning a grandfathered health insurance plan may almost be an impossible feat. Moreover, the question of costs –for both health insurance providers and hospitals – may be something of a mission impossible.

Blue Cross Blue Shield of Massachusetts says they are trying to avoid upsetting smaller hospitals by targeting providers that are well paid and profiting and asking them to cut costs. Struggling hospitals, on the other hand, may actually receive small increases. What the impact of negotiations, which are notoriously heated and drawn out, on health insurance and hospital costs be remains to be seen.

Written by Lani Shadduck
HULIQ.com

Nearly two months after President Obama signed the Health Care and Education Reconciliation Act of 2010, insurance companies are beginning to make changes to policies and Connecticut employers are scrambling to understand what mandates Mohit Ghose, vice president of public affairs, Aetnawill take immediate effect.

While the law's major provisions, which aim to expand coverage to 32 million Americans and hundreds of thousands of residents in Connecticut, don't go into effect until 2014, there are some significant policy changes that hit the books this year.

Last week, for example, the Internal Revenue Service unveiled eligibility guidelines for the small business health care tax credit, which goes into effect immediately and encourages small employers to offer health insurance coverage for the first time or maintain coverage they already have in place.

Stephen Jewett, a spokesman for the Farmington-based health insurer ConnectiCare, said many of the new mandates that will go into effect this year are already in place in Connecticut. The new law, for example, extends the dependent coverage age of young adults to up to age 26, but Connecticut already has that measure in place.

The state also has a strong appeals process for claim denials, a feature of the federal bill. And insurance products with lifetime or annual dollar limits on medical claims, which will soon be forbidden, are not prevalent in the Connecticut marketplace, Jewett said.

"Connecticut was already well ahead of the curve in implementing many of the health reform mandates that will be going into effect immediately," Jewett said.

One important new measure that will impact Connecticut businesses is the tax credit, which is available to small employers that pay at least half the cost of single coverage for their employees in 2010.

According to the IRS, for tax years 2010 to 2013, the maximum credit is 35 percent of premiums paid by eligible small business employers, and 25 percent of premiums paid by eligible employers that are tax-exempt organizations, including nonprofits.

The maximum credit goes to smaller employers — those with 10 or fewer full-time workers — paying annual average wages of $25,000 or less. The credit is completely phased out for employers that have 25 employees or more or that pay average wages of $50,000 per year or more.

Eligible small businesses can claim the credit as part of the general business credit starting with the 2010 income tax return they file in 2011.

The federal government estimates that as many as 4 million businesses could be eligible for the tax credit.

Whether the health care reform law will reduce costs for businesses is up for debate, and no one really has a clear answer yet. Insurers remain adamant that cost drivers weren't addressed in the health care law.

"While the bill does very good things to improve access, any rational observer recognizes it doesn't do enough on cost control," said Mohit Ghose, the vice president of public affairs at Hartford-based health insurer Aetna.

Ghose said the richer benefits and new mandates that are part of the health care reform package will increase costs.

Aetna and many other insurers, for example, sell employer-sponsored plans with lifetime maximum benefits.

They are offered because they come with more affordable premiums which can be attractive, especially to small business owners.

Under the new law, however, lifetime maximum caps will no longer be permitted.

"There will be price impacts, but we are not able to put a dollar figure on it yet," Mohit said.

Gloria Barone, a spokesperson for Cigna, the Philadelphia-based health insurer with major Connecticut operations, said insurers are focused on reducing the underlying drivers of health care costs to offset the potential of rate increases.

That includes pushing prevention and wellness rather than sick care, helping passive customers become active customers, and paying doctors for quality outcomes rather than volume of services.

"These messages are not new, but are even more important now as the law did not address costs in a significant way," she said.

Bruce Barth, a partner at Robinson & Cole in Hartford, said other provisions that will go into effect Sept. 23 include prohibiting health plans from:

• Imposing any preexisting condition exclusions for children who are under age 19;
• Placing lifetime dollar limits on medical claims;
• Placing unreasonable annual dollar limits on claims;
• Rescinding health coverage once an individual is covered under the plan, unless the individual acted fraudulently or made an intentional misrepresentation of a material fact.

Also starting in September, group health plans must cover certain preventive services and immunizations without cost to the employee, Barth said.

More meaningful changes go into effect in 2014, when states will be required to set up Small Business Health Options Programs, or "Shop Exchanges," where employers will be able to pool together to buy insurance.

Mundaca explained the guidance during a teleconference, where he clarified that small businesses can receive the credit for traditional health insurance as well as for add-on dental, vision and other limited-scope health insurance coverage. There are an estimated 4 million small businesses that may be eligible for tax credits starting this year; the credit, though, will not be received until after businesses have been able to file their taxes in 2011.

The guidance was released days after NFIB joined the lawsuit against health care, and Small Business Administration administrator Karen Mills said that most small businesses "are excited about this tax credit."

"Small-business owners everywhere are rightfully concerned that the unconstitutional new mandates, countless rules and new taxes in the healthcare law will devastate their business and their ability to create jobs," Dan Danner, President and CEO of NFIB, shared.

Author Home Testing Blog!

Health care reform means affordability. The new law creates health insurance exchanges - competitive marketplaces where individuals and small businesses can buy affordable health care coverage. It also provides families and small businesses with the largest tax cut for health care in history.

Health care reform means accountability. Insurance companies will be held accountable to keep premiums down and to prevent denials of care and coverage, including for pre-existing conditions.

Health care reform means responsibility. This bill puts you and your doctor - not insurance companies - in charge of your health care.

The new law includes several key provisions that will help you and your family. Some of them go into effect this year, while others are phased in over time.

The law provides immediate help to the uninsured. It provides immediate access to insurance for Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool.

It closes the Medicare Part D Donut Hole.The new law ends the Medicare Part D donut hole for prescription drug coverage, starting with a $250 rebate for those in the donut hole in 2010. It provides a 50% discount on brandPname drugs in the donut hole, beginning in 2011. It also phases in additional discounts for brand?name and generic drugs to close the donut hole completely by 2020.

The law extends coverage for young people until age 26.The law requires health plans to aUow young people to remain on their parents' insurance up to their 26th birthday.

It provides free preventive care under Medicare. The law eliminates co-payments for preventive services and exempts preventive services from deductibles under the Medicare program.

The law provides $40 bUlion in tax credits to smaU businesses to help them offer employees coverage. Eligible employers wUl receive tax credits and vouchers to help pay premiums. SmaU businesses with fewer than 50 employees, or 96 percent of America's businesses, wUl be exempt from the shared responsibihty requirement.

It provides help to early retirees.The law creates a temporary re-insurance program - until the Exchanges are avaUable - to help offset the costs of expensive health claims for employers that provide health benefits for retirees aged 55 to 64.

The law provides funding for Community Health Centers, expanding access to health care in communities where it is needed most. It also invests in training programs to increase the number of primary care doctors, nurses, and pubhc health professionals avaUable to serve you.

The law makes key investments in Medicaid and chUdren's health. It expands eügibüity for Medicaid to include aU non-elderly Americans with income below 133 percent of the Federal Poverty Level - about $11,000 for individuals and about $24,000 for famines - and provides fair assistance to states to help cover the costs of these new Medicaid populations. It maintains current funding levels for the Children's Health Insurance Program (CHIP) through fiscal year 2015 and increases payments to primary care doctors in Medicaid.

The Congressional Black Caucus looks forward to working with President Obama, Congress, and you to buUd a stronger, healthier America. (NNPA)

by U.S. REP. CAROLYN CHEEKS KILPATRICK

Special To THE OBSERVER

WASHINGTON — Health insurance companies are lobbying federal and state officials in an effort to ward off strict regulation of premiums and profits under the new health care law.

The effort is, in some ways, a continuation of the battle over health care that consumed Congress last year.

Insurance lobbyists are trying to shape regulations that will define “unreasonable” premium increases and require them to pay rebates to consumers if the companies do not spend enough on patient care.

For their part, consumer groups say they worry that their legislative victories could be undone or undercut by the rules being written by the federal government and the states.

The health care overhaul provides a classic example of how the impact of a law depends on regulations needed to interpret it. The rules deal with relatively technical questions but go to the heart of the law, pushed through Congress by President Obama and Democratic leaders with no Republican support.

More than 40 provisions of the law require or permit agencies to issue rules. Lobbyists are focusing on two whose stated purpose is to ensure that consumers “get value for their dollars.”

One bars insurers from carrying out an “unreasonable premium increase” unless they first submit justifications to federal and state officials. Congress did not say what is unreasonable, leaving that to rule writers.

Another provision, effective Jan. 1, requires that a minimum percentage of premium dollars be spent on true medical costs related to patient care — not retained by insurers as profit or used to cover administrative expenses. Insurers must refund money to consumers if they do not meet the standards, known as minimum loss ratios.

Michael W. Fedyna, vice president and chief actuary of Aetna, underlined the importance of this issue, saying no other aspect of the law would be so “influential in shaping the future of the health care marketplace in the United States.”

The definition of medical loss ratio will “determine the willingness of health plans to enter new markets and remain in existing markets,” he said.

Senator John D. Rockefeller IV, Democrat of West Virginia, said the definition would be just as important for consumers and small businesses.

“The health insurance industry has shifted its focus from opposing health care reform to influencing how the new law will be implemented,” he said.

The law requires insurers to spend a minimum percentage of premiums on health care services and “activities that improve health care quality” for patients.

Insurers are eager to classify as many expenses as possible in these categories, so they can meet the new test and avoid paying rebates to policyholders.

Thus, insurers are lobbying for a broad definition of quality improvement activities that would allow them to count spending on health information technology, nurse hot lines and efforts to prevent fraud. They also want to include the cost of reviewing care by doctors and hospitals, to determine if it was appropriate and followed clinical protocols.

Some consumer advocates, like Carmen L. Balber of Consumer Watchdog, favor a strict, narrow definition of quality improvement activities, limited to those that produce measurable benefits to individual patients.

Alissa Fox, a senior vice president of the Blue Cross and Blue Shield Association, said that if the definition is too narrow, “health plans will come under enormous pressure to cut back quality improvement activities, including highly effective programs to reduce hospital infection rates.”

But Charles N. Kahn III, president of the Federation of American Hospitals, a trade group, said he feared that the quality improvement category would become a “catchall for a wide variety of expenses not directly related to patient care.”

Under the new law, insurers in the large group market are generally supposed to spend 85 percent of customers’ premiums on “clinical services” and quality-enhancing activities. The minimum is 80 percent for coverage sold to individuals and small groups.

Insurers and insurance regulators say that some companies will be unable or unwilling to meet the new standards.

House Speaker (and powerful woman) Nancy Pelosi told a group of media executives and editors that the recently passed health insurance reform bill will lead to new jobs by enabling would-be entrepreneurs to take professional risks such as starting their own companies.

"The entrepreneurial spirit of America is unleashed," she said, because the bill allows people to leave unsatisfying jobs they keep only for the medical insurance. "I can take risks, I can be entrepreneurial, I can follow my passion," she told the small audience gathered at the Paley Center for Media in New York. "I can change jobs without fearing that I'm hurting my family."

During the two-hour conversation, moderated by Paley Center CEO Pat Mitchell, Pelosi repeatedly raised the issue of jobs and unemployment. She noted that some parts of the economy seem to be improving, noting the increase in GDP and stock-market gains. "We have to do more for job creation," she added.

She suggested that the health bill eventually will create new jobs in medical technology and other areas, as will pending legislation on alternative energy.

Heading into the midterm elections of 2010, Obama has something concrete to show for his leadership, and that cannot be discounted. What matters more than anything at this juncture is how quickly the concrete benefits of health care reform start to flow to the millions of Americans in desperate need of help. Many of the bill's most important provisions do not kick in for many years, but others—the elimination of pre-existing conditions, the ability to enroll dependent children up to the age of 26—will be in effect by September, and they speak to the needs of middle-class voters, who have to be kept in the political fold. Whether this will be enough is hard to say.

Social Security was passed in 1935, but the benefits it promised did not start to flow until 1940 for the small first group of retirees. It was not until the '50s that something approximating universal coverage became a reality, and even today non-workers are not covered in their own right. African-Americans were robbed of Social Security benefits, even if they had worked all their lives, because the exclusions that were built into the original legislation to placate Southern politicians who threatened to veto the whole package were not reversed for decades. As it happens, Social Security was fairly popular from its inception, largely because it was sold as a contributory insurance policy rather than a "handout" or act of charity toward the elderly poor and because it offered something for (almost) everyone. But it took time before it was fixed in the social policy firmament to the point where its opponents were silenced. Some of them are still with us, as the proposals for privatization demonstrated not long ago.

Once American families begin to depend on the safety net — whether for retirement, higher education or health care — the popularity of these provisions becomes very hard to diminish, even by those committed to unraveling them. This is, no doubt, why opponents of healthcare reform are so eager to snarl it up in the courts or rally the base for repeal. They too are students of history. They know that if American families start to rely on these new forms of health insurance, to factor them into their household ledgers, the reforms will become entrenched to the point of no return.

In the meantime, we can expect a high level of conflict, obfuscation, court challenges and tea parties designed to rally the conservative base and delay the implementation of health care reform. This too is a familiar story. Indeed, virtually every episode in the development of the American welfare state has been surrounded by contentious politics, and in many instances the opposition won the day. In the 1940s FDR and New Deal Democrats hoped to establish universal health care and a "cradle to grave" welfare state through the Wagner-Murray-Dingell bill. But they were torpedoed by Congressional opposition, as was the establishment of a "right to a job" when the Full Employment bill was gutted in committee. Harry Truman's Fair Deal — which sought to build on the New Deal by including health care, public housing and a permanent Fair Employment Practices Commission to prevent racial discrimination — was largely blocked by a Republican Congress.

But it wasn't just the political class that split over the New Deal. Ordinary middle-class citizens were deeply torn as well. Much as they wanted FDR to save them from the ravages of the Depression, those on the left saw him as tepid and too cozy with employers. They denounced Roosevelt for lowering wages, failing to nationalize the banks and edging away from his commitment to "the forgotten man."

On the "ordinary" right, farmers in the heartland who avoided the relief rolls decried their neighbors who accepted public benefits (other than Agricultural Adjustment Administration checks), while small shopkeepers and accountants bemoaned the loss of tax dollars from their paychecks to support the indolent even as they filled the grocery orders paid for by the Federal Emergency Relief Administration. Opinion polls from the 1930s make it clear that a majority of the country was sure that the unemployed could find work if they really wanted it. Most of all, the rejection of cash relief, of any policy that smacked of support for the able-bodied non-worker, was nearly universal. Public employment was more widely embraced and grew in popularity as the ravages of the Depression left fewer and fewer alternatives in the labor market.

As historians like Jason Scott Smith have noted, programs like the Works Progress Administration were often embraced by people who were otherwise hostile to government expenditures. Many moderate and conservative voters adopted the reverse NIMBY view that other New Deal projects might be wasteful boondoggles but the WPA project in their district was indispensable. We can see the modern echo of this attitude in conservative Republicans who voted against the stimulus bill as a spending orgy but were happy to hand out giant cardboard checks in their home districts for projects financed from stimulus funds.

Similar objections to social programs were raised during the Johnson years. Medicare was probably the most important innovation of the Great Society, but when Johnson worked overtime to pass the original legislation, public support for the idea waffled. In 1962, 70 percent of Democrats and 48 percent of Republicans surveyed in the National Election Studies thought that "government ought to help people get doctors and hospital care at low cost." By 1964, when a historic Medicare proposal passed in the Senate, Democratic support had declined to 60 percent and Republicans weighed in with 29 percent. The same survey asked respondents if they preferred providing health insurance for the elderly by allowing them to buy private plans or if they thought government should finance a program through Social Security. In 1962, 55 percent supported the idea of government-financed health plans; by 1965, that number had dropped to 46 percent. Eventually, however, as people began to rely on the program's benefits, support began to build. Today, Medicare garners strong and steady backing from the public. Indeed, it is a "third rail" that politicians approach at their peril. Obama's Republican opponents vowed to prevent even a single dollar in cuts to Medicare, and tea party protesters shouted, "Keep your government hands off my Medicare!"

For some time to come we can expect the firestorm of opposition to health care reform that is unfolding today to persist, even from people who stand to benefit from the provisions of the new law. The rose-colored glasses through which we sometimes view the legacy of the New Deal and the Great Society often obscure how contentious the debates were or how long they continued after the passage of key legislation. We should not be deterred by the noise coming out of the tea party. The weight of history is against them.

The Associated Press, in a separate story: Liberals were not without their infighting on health reform as well, but those "who vowed to take revenge against conservative Democrats who opposed President Barack Obama's health care law have little to show for their anger six months before the midterm election." Most of the 34 lawmakers who opposed the legislation are facing "only token opposition — if any — from the left." But Sen. Blanche Lincoln is facing stiff opposition in her re-election bid in Arkansas. Three unions and MoveOn.org have together pledged nearly $5 million to unseat her after her "mixed" voting record on health reform (Evans, 5/2).

The Hill: The health reform debate is driving fundraising related to the issue of abortion. "Abortion had been a second- or third-tier issue in recent cycles, said Marjorie Dannenfelser, who directs the Susan B. Anthony List (SBA), an anti-abortion group that supports primarily female candidates. 'This time it's completely in the light of day. It is top of mind. It is a driving force.'" The group plans to spend $10 million this election cycle. "In California, the group is competing directly with EMILY's List, a group that backs pro-abortion-rights female Democrats. EMILY's List is vigorously supporting incumbent Sen. Barbara Boxer (D-Calif.) in what's expected to be a tough reelection fight." That group spent $43 million in 2008 on the elections (Miller, 5/3).

The Associated Press/ABC News: Lawmakers are also using the lessons they learned in health reform and applying them to other big-ticket legislative initiatives, such as financial reform. Democrats have learned from the plodding course the health effort took in committee to move more swiftly this time around. "Last year, ... health care negotiations between Democrats and Republicans on the Senate Finance Committee chewed through crucial months before [President Barack] Obama finally pulled the plug. Opponents of the legislation used the time to attack the president's plan, claiming falsely it would have led to death panels for the elderly, for example, and draining away public support. Democrats faced angry voters at dozens of town hall meetings over the summer. In the end, nearly 13 months after Obama brought Democrats and Republicans to the White House to start work together, the bill passed without a single GOP vote." They are hoping that other legislation won't share a similarly winding path (Werner, 5/1).

Roll Call: Medical interests — the drug industry, doctors, hospital and medical product makers — spent more than $876 million lobbying on health reform. "Within the health care industry, drug companies racked up the biggest lobbying tab, spending $253 million. They were followed by hospitals, which spent $108 million, and doctors and surgeons, who spent $59 million. Thomas Mann, a political scholar at the Brookings Institution, said one difference between this health care push and the last time the issue came up, during the Clinton administration, was that many in the health care industry supported the overhaul legislation. 'A good percentage of that lobbying budget was spent on behalf of reform,' Mann said" (Roth and Knott, 5/3).

This is part of Kaiser Health News' Daily Report - a summary of health policy coverage from more than 300 news organizations. The full summary of the day's news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

President Barack Obama kept telling us that his reform would “bend the cost curve” to slow the dramatic increase in health care costs.

Tossing aside the jargon, it seems that Obama was suggesting that his reform would lower costs over time, which was, clearly, wrong.

It’s also likely to end up costing more than $311 billion, as many of the cuts to Medicare are likely to be unpopular and perhaps even illegal.

It was a laughable idea to think that we could both extend coverage to millions of uninsured Americans and save money. Quality of coverage would nosedive if we cut costs while extending coverage to more Americans.

As it turns out, we will be spending more for additional coverage. Any economist could have told you that. Also, the cuts to Medicare will cost many seniors good coverage; the report estimates that half of all seniors currently using Medicare Advantage will drop out due to the rising premiums.

The report also estimates that 14 million Americans will lose employer coverage by 2019 as many employers drop health coverage. Additionally, the new taxes of medical devices makers are likely, according to the report, to be passed along to consumers, raising the cost of all sorts of needed medical equipment such as orthopedics or wheelchairs.

While we did indeed get health care reform, the net number of Americans who actually gain meaningful coverage from this bill is probably low, and many seniors will suffer a sharp decline in the quality of their Medicare coverage due to sharp Medicare cuts.

And one thing is for sure, costs will keep rising, and employers and the federal government will keep paying more and more with every passing year to provide health coverage.

This health care reform profoundly failed to “bend the cost curve” of spiraling health care costs.

What would real reform look like that could contain costs? Let’s get a popular one out of the way. Many Republicans view tort reform as the panacea to our health care issues.

Tort reform would make it harder to sue doctors for malpractice when they make mistakes. Supposedly health care lawsuits are causing exploding health care costs. But the Congressional Budget Office has estimated that tort reform will only save between $6 billion to $7 billion a year. That’s a nice chunk of change, but no cure-all.

Others have suggested that we go after the drug companies; either by raising taxes on them or by reforming patent laws to allow more generics to reach the market. But drugs make up less than one-tenth of total health care costs in America, and most of the dollars we spend on pharmaceutical drugs are recycled into research and development and testing of new drugs.

Many other ideas have been floated, but they lack the scope to solve the problem. We can save a few dollars here and there, but these piecemeal suggestions miss the point.

The fundamental problem with our health care system is us –– and our unhealthy ways. Americans are getting fatter and lazier, and so our health care costs are rising.

Socialized medicine works better in societies where people are skinny and active, as is the case in much of Europe.

But we face a situation in America where our government has to cover more and more sickly people. The amount of people with heart problems, diabetes and other such expensive diseases is soaring.

A government that takes on the burden of people’s stupid life choices will face ever-increasing costs. If we are to truly implement working public health in the U.S., the government must begin punishing people who eat too much or who don’t exercise.

Few politicians are willing to tell their constituents to shape up, but spiraling deficits will force action. The government can’t afford for its citizens to be fat, lazy and sickly if it has to pay the bill.

If health care returns to being privately provided, and people have to pay for their lifestyle choices, be it smoking, overeating or not working out, costs will start to be contained.

We need to bend the waistline curve and the cost curve will follow.

Editorials Editor Ian Bezek is a senior economics major. His column appears Mondays in the Collegian. Letters and feedback can be sent to letters@collegian.com.

Perhaps the first new benefit, and one that's particularly relevant for families who are celebrating graduations this spring, will require insurance companies to cover dependent children until age 26. This coverage kicks in no later than Sept. 23.

Another change coming quickly will establish high-risk insurance pools for people who have been denied health-insurance coverage. It is likely to be expensive, but available, perhaps as soon as August.

Medicare faces many changes, most of them not fully determined yet. But one thing is clear: the "doughnut hole" in coverage, which occurs after people spend more than $2,830 for drugs, can produce a $250 rebate check later this year. Starting next year, Medicare will provide more coverage of prescription drugs.

Small businesses that have just a few employees can qualify for tax credits this year if they provide health insurance benefits.

Many of the reform's more controversial aspects will be phased in over the next four years, including an increased Medicare tax on incomes above $200,000.

Also, coming in 2014, is a requirement that everyone buy health insurance or else pay a fine to the IRS.

Virginia passed a law this year to block the mandatory purchase of insurance, and Attorney General Ken Cuccinelli has filed a lawsuit challenging the federal bill on constitutional grounds.

Here are several changes made by the reform that take effect this year, based on information from the Associated Press and various insurance companies. Inside this section is a timeline for when other changes are expected to take effect.

Young adults and children

The act requires all health insurance plans to cover dependent children until age 26. This is expected to be effective after Sept. 23 under negotiations between the government and insurance companies. Some insurers may provide it sooner.

Also: Insurers cannot deny coverage to children with pre-existing health problems. In addition, insurers cannot put lifetime dollar limits on coverage, and cannot cancel policies except for fraud.

Middle-age people

Sets up a high-risk insurance pool to provide coverage for uninsured people with medical problems. Expected to be in effect by August, and continue through 2014. There is little federal regulation of the rates insurance companies can charge for pools, although states may review rate changes.

Examples of prevailing rates can be found in West Virginia and North Carolina, which already have high-risk pools. Middle-age individuals there can be charged $700 to $1,000 or more per month.

Group health insurance plans, including employer-provided plans, are protected from immediate change. Some of these plans could be affected later by employer mandates and an excise tax.

Senior citizens

Rebates for the Medicare "doughnut hole" will provide a $250 check, to be sent to people enrolled in Part D Medicare whose drug costs enter the coverage gap between $2,830 and $6,440 in total spending. This goes into effect this year. Beginning in 2011: A 50 percent discount will be available on brand-name drugs, along with coverage of generic drugs. The "doughnut hole" is to be completely covered by 2020.

Employers

Small businesses with fewer than 25 employees can get tax credits for 2010 when they provide coverage for workers.

Employers with more than 200 workers must enroll all new full-time employees in coverage, if it is provided. Employees could opt out of the coverage. Exact date of effectiveness is unclear in bill.

2010

By December, health care reform:

-Reduces projected Medicare payments to hospitals, home-health agencies, nursing homes, hospices, and other providers.
-Places a 10 percent tax on indoor tanning.
-Requires insurers to cover preventive care.
-Assists states in launching programs to educate consumers and help them file complaints and appeals regarding insurance companies.

Starting in 2011-

The reform creates a voluntary long-term care insurance program that provides some money to help disabled people stay in their homes, or cover some nursing home costs.
-Provides a 10 percent Medicare bonus to primary care physicians and surgeons in underserved areas such as inner cities and rural communities.
-Freezes payments to Medicare Advantage plans, the private insurers who cover about one-fourth of seniors. Further reductions would be phased in over three to seven years.
-Community health centers receive more funding to provide basic care for low-income people.
-Requires employers to report the value of health insurance protection on workers' W-2 forms.
-Imposes $2.3 billion in annual fees on drug makers, to increase in coming years.

Starting in 2012-

Sets up a program to create non-profit insurance co-ops that would compete with insurance companies.
-Initiates Medicare reforms by encouraging doctors and hospitals to band together in quality-driven "accountable care organizations" along the lines of the Mayo Clinic.
-Sets up a pilot program to test more efficient ways of paying doctors, hospitals, nursing home and other providers. Successful experiments would be widely adopted.
-Reduces Medicare payments to hospitals with high rates of preventable readmissions.

Starting in 2013

-Standardizes insurance-company paperwork, a first step to reduce administrative costs.
-Increases Medicare payroll tax on individuals making more than $200,000 per year and on couples making more than $250,000 per year. Tax rate goes from 1.45 percent to 2.35 percent above those thresholds.
-Adds a new tax of 3.8 percent on income from investments.
-Imposes a 2.3 percent sales tax on medical devices. Exempt from the tax are eyeglasses, contact lenses and hearing aids.
-Limits medical-expense contributions to tax-sheltered flexible spending accounts (FSAs) to $2,500 per year.
-Raises threshold for claiming medical expenses on itemized tax returns from 7.5 percent to 10 percent of income.

Starting in 2014-

People are required to have health insurance or pay a fine to the IRS. Exceptions are allowed for hardship. Penalties start at $95 per person, rising to $695 in 2016.
-Coverage is greatly expanded as states create health-insurance exchanges, which have been compared to supermarkets where individuals and small businesses can shop for coverage. People who already have employer coverage won't see any changes.
-Provides income-based tax credits for people using the exchanges, on a sliding scale that reduces the cost of insurance in households below $88,000 income.
-Employers are encouraged to continue offering health insurance. The reform bill penalizes employers with more than 50 workers if any of their workers get coverage through the exchanges and receive a tax credit. The penalty is $2,000 times the total number of employees. However, employers can deduct the first 30 workers.
-Prohibits insurers from denying coverage to people with medical problems, and from refusing to renew their coverage.
-Insurers cannot limit coverage based on pre-existing conditions, and cannot charge higher rates to people in poor health.
-Premiums can vary for only four reasons: Age, place of residence, family size and tobacco use.
-Medicaid is expanded to cover households up to 133 percent of the federal poverty line, which would be $28,300 for a family of four. Low-income childless adults also would be covered for the first time.

Starting in 2015

-Creates a payment program for doctors that would promote increased quality for Medicare beneficiaries.
-Sets up advisory board to lower costs, extend Medicare solvency, promote quality and efficiency and expand care.

Starting in 2018-

Imposes a tax on employer-sponsored health insurance worth more than $10,200 for an individual and $27,500 for a family plan.