Summary: H.R.5500 — 102nd Congress (1991-1992)All Information (Except Text)

There is one summary for H.R.5500. Bill summaries are authored by CRS.

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Introduced in House (06/25/1992)

Health Care for Every American Act of 1992 - Title I: Establishment of A State-Based National Health Insurance Program; Universal Eligibility; Enrollment - Establishes the State-Based National Health Insurance Program. Entitles every U.S. resident who is a citizen, national, or lawful resident alien to services. Provides for the eligibility of certain nonimmigrants and other individuals.

Requires each State program to provide for: (1) an enrollment mechanism, including a process for automatic enrollment at birth or immigration; and (2) issuance of a universal health insurance card to be used for identification and claims processing.

Provides for portability of benefits.

Ends, after a specified date, benefits and payments under: (1) titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act; (2) provisions of Federal law relating to Federal employees' health benefits; (3) provisions of Federal law relating to the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); and (4) certain veterans' medical benefits.

Title II: Comprehensive Benefits, Including Preventive Benefits and Benefits for Long Term Care - Entitles enrolled individuals to payment, subject to certain limitations and requirements, for comprehensive acute, preventive, mental health, drug and alcohol abuse treatment, long term care, and plan of care services (major service categories). Prohibits: (1) deductibles, coinsurance, or copayments for comprehensive acute and preventive services; (2) imposing a charge, except as provided under this Act, for covered services; and (3) insurance which duplicates payment for covered items or services. Permits State programs and employers to provide additional benefits.

Lists covered services in each major service category, specifying matters such as limits, cost-sharing requirements, and exclusions.

Mandates a report to the Congress on the effects of the cost-sharing under specified provisions of this Act and the optional State charge for non-enrollment with comprehensive health service organizations required under title V of this Act.

Title III: Provider Participation - Mandates a participation agreement between a State health insurance program and a provider addressing specified elements, including prohibitions on discrimination and charging for covered services other than as authorized under this Act.

Specifies requirements in order to be considered a qualified provider, including for health care practitioners, institutional and facility-based providers, community-based primary services providers, independent pathology laboratories, independent radiology services, providers of outpatient drugs and devices, and providers of covered transportation (including ambulance) services, in most cases requiring that they be licensed, meet State law requirements, and meet the requirements of this Act. Requires national and authorizes State minimum standards to assure service quality.

Defines a comprehensive health service organization (CHSO) as an organization that, in return for a capitated amount, furnishes, arranges for, or pays for a full range of health services to a population in a specified service area. Makes all eligible persons in that area eligible to enroll in the organization, subject to the organization's capacity. Sets forth CHSO requirements.

Title IV: Administration - Establishes the National Health Insurance Standards Board to develop policies, procedures, guidelines, and requirements to carry out this Act. Authorizes the Board to waive provisions of this Act to accommodate demonstration projects. Mandates uniform reporting requirements and standards and certain studies. Requires the Board to recommend to the Congress one or more proposals for the treatment of Federal health care facilities.

Mandates advisory committees on: (1) benefits; (2) payments and cost containment; (3) quality and utilization review; and (4) primary care and the medically underserved.

Requires the Board to provide for a National Health Advisory Council.

Mandates submission by each State (or, for neighboring States which so choose, by each region) of a plan for a State (or regional) health insurance program providing services under this Act. Sets forth plan requirements. Provides for sanctions for failure to meet the requirements, including placing the State program in receivership under the jurisdiction of the Board.

Prohibits a State, by intention or as an unstated consequence of budget allocations, from restricting timely access to medically necessary services or permitting potentially life threatening queues.

Mandates appointment in each State of: (1) a State Health Advisory Council; and (2) a quality control mechanism. Allows States to use fiscal agents.

Requires each State program to establish district health advisory councils covering distinct geographic areas to: (1) advise the State; (2) receive and investigate complaints by eligible persons and by providers; and (3) carry out district management and planning.

Requires each district health advisory council to provide assistance and technical support to community organizations and nonprofit agencies submitting funding applications under specified provisions of the Public Health Service Act.

Requires all Department of Health and Human Services activities to be complementary to this Act.

Title V: National Health Insurance Budget; Payments; Cost Containment Measures - Subtitle A: Budgeting and Payments to States - Requires the Board to annually establish a national health insurance budget specifying the total Federal and State expenditures for covered services, set as the sum of the capitation amounts under this title plus Federal administrative expenses.

Sets a national health insurance spending ceiling according to a specified formula involving: (1) the increase in the gross national product; (2) the Board's estimate of the increase in health care expenditures due solely to changes in the age or other risk characteristics of the U.S. population; and (3) percentage points set, for the first four years, by this Act and thereafter set by the Board.

Requires each State program to annually establish a State health insurance budget, with a separate account for graduate medical education expenses.

Provides for the computation of individual and state capitation amounts.

Entitles each State with an approved program to receive specified Federal payments involving the State capitation amount and the Federal contribution percentage. Requires the Board to establish a formula for the Federal percentage for each State, considering the State's per capita income and revenue capacity and other relevant economic indicators as appropriate.

Requires each State program to provide for a process and standards regarding the approval of capital purchases or leases for new or renovated facilities and for equipment valued over an amount specified by this Act or by the Board.

Allows a State program, where a CHSO is available, to impose a charge for individuals who are enrolled with the CHSO for the receipt of covered services under this Act. Requires that the charge be assessed relative to income and specifies miniumum and maximum charges.

Subtitle B: Payments by States to Providers - Requires direct payment by a State program to institutions and facilities for operating expenses under an approved negotiated annual prospective global budget. Allows institutions and facilities to raise private funds for new facilities, major renovations, and equipment, declaring that the expenditure of the private funds does not obligate the State program to provide for continued support for the expenditures.

Entitles every independent health care practitioner to payment for the provision of covered services either, at the practitioner's election, by a fee-for-service method or a capitation method. Allows a State program, through an agreement with an organization representative of independent practitioners or otherwise, to pay individual practitioners through an annual salary, hourly payments, or other method under which aggregate payments do not exceed the amounts that would otherwise be made. Requires the Board to establish models and encourage State programs to implement alternative methodologies incorporating global fees for related services or for a basic group of services furnished to an individual over a period of time.

Requires the State program to establish, after negotiations, a prospective payment schedule based on a relative value scale and conversion factors established by each State and providing for the application of expenditure targets. Allows State Programs to have practitioner-specific adjustments reflecting practitioner use patterns and to publicly disclose the use patterns.

Requires payment to: (1) CHSOs to be determined by the State based on a global budget or on the basic capitation amount determined by the State program on the basis of the average estimated expenditures for an enrollee with the same actuarial characteristics as the enrollee; (2) community based primary health services to be based on a global budget or be made on an individual patient basis; and (3) care managers to be made directly by each State program pursuant to payment schedules, based on negotiations, capitation, or other methods, under an annual prospective budgeting system.

Requires the Board to establish a list of approved prescription drugs and biologicals the board determines necessary for health, employability, or self-management and eligible for coverage. Allows the Board to exclude ineffective, unsafe, or over-priced products where better alternatives are available. Requires the Board to determine product prices. Authorizes the Board to conduct price negotiations, on behalf of State health programs, with drug manufacturers and distributors.

Requires each State program to provide for payment for a drug furnished by an independent pharmacy based on the drug's cost to the pharmacy plus a dispensing fee according to a schedule set by the State program.

Requires the Board to establish a list of approved durable medical equipment and therapeutic devices and equipment (including eyeglasses, hearing aids, and prosthetic appliances) the Board determines necessary for health, employability, or self-management and eligible for coverage. Requires the Board to determine product prices. Authorizes the Board to conduct price negotiations, on behalf of State health programs, with equipment and device manufacturers and distributors. Allows the Board to exclude ineffective, unsafe, or over-priced products where better alternatives are available.

Mandates determination by the State program of the amount of payment for other covered services in accordance with payment methodologies specified by the Board.

Requires the Board to establish, in addition to payment otherwise provided in this title, model payment methodologies and other incentives that promote the provision of services in medically underserved areas. Authorizes the Board to waive required payment methodologies as necessary to allow alternative payment schemes or conduct experiments and demonstration projects.

Subtitle C: Malpractice Reform - Authorizes the Board to award grants to State programs for the development and implementation of programs for medical malpractice reforms. Authorizes appropriations.

Mandates a study of medical malpractice, including regarding: (1) ineffective or unnecessary medical testing and practices; (2) the occurrence of malpractice and malpractice awards; (3) the adequacy of existing licensing and discipling procedures in preventing malpractice; and (4) the reasonableness of malpractice insurance premiums and rate-setting practices. Authorizes appropriations.

Subtitle D: Mandatory Assignment and Administrative Provisions - Declares that payments for benefits under this Act constitutes payment in full, requires the furnishing entity to accept the payment as such, and prohibits the entity from accepting any payment other than from the State program, except for authorizd cost-sharing. Provides for sanctions in the same manner as under specified provisions of title XVIII (Medicare) of the Social Security Act.

Requires a State program to establish: (1) a timely and administratively simple procedure for reimbursement to all providers under this Act; and (2) an appeals process regarding provider payments.

Title VI: Financing - Creates the National Health Insurance Trust Fund. Appropriates to the Fund all: (1) tax increases from this Act; and (2) amounts that would otherwise have been appropriated to carry out titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act, the Federal employees health benefit program, and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). Transfers to the Fund any amounts remaining in the Federal Hospital Insurance Trust Fund or the Federal Supplementary Medical Insurance Trust Fund.

Directs the Secretary of the Tresury to: (1) develop a formula for determining and collecting National Health Insurance premiums from individuals and employers to finance covered services; (2) determine the aggregate premiums for each taxable year; and (3) collect premiums from individuals using a formula with specified characteristics, including that it be income-based and progressive.

Directs the Secretary of the Treasury to collect the premiums from employers by: (1) increasing the highest marginal corporate income tax rate; (2) increasing the employer and self-employment hospital insurance tax; and (3) imposing a surtax on regular and minimum taxes. Declares that such taxes shall be increased as specified by the Secretary. Mandates a method for employers to pay premiums otherwise payable by employees.

Amends Internal Revenue Code provisions relating to exclusions from gross income to define "accident or health insurance" to mean an approved State program under this Act. Removes provisions relating to amounts paid to highly compensated individuals under a discriminatory self-insured medical expense reimbursement plan.

Disallows deductions for employer expenses for health care services, whether or not covered under this Act. Declares that this does not disallow a deduction for National Health Care premiums.

Allows health insurance costs (currently, 25 percent of health insurance costs) of self-employed individuals to be deducted. Removes provisions ending the deductibility on a specified date.

Defines "medical care," for provisions relating to individual deductions for medical and dental expenses, to mean National Health Insurance premiums, cost-sharing, and other premiums for coverage under a State program.

Ends, after a specified date, the health insurance credit for coverage which includes at least one child.

Makes each State responsible for establishing a financing program for the implementation of the State program. Entitles each State with a State program approved by the Board to funding from the Board in the amounts provided under specified provisions of this Act.

Title VII: Promotion of Primary Health Care; Development of Health Service Capacity; Programs to Assist the Medically Underserved - Subtitle A: Promotion and Expansion of Primary Care Practitioners - Makes the Board responsible for certain activities toward a national goal of having, ten years after enactment of this Act, 50 percent of the physicians in medical residency programs being trained as primary care physicians, including coordinating graduate medical education policies and overseeing State program residency expenditures. Requires the Board to establish a method of applying the national goal to program goals for each medical residency program. Provides for enforcement, against State programs that fail to meet the goal, through reducing: (1) medical residency payments; and (2) the indirect portion of extramural biomedical and behavioral research grants from the National Institutes of Health (NIH).

Requires the Board to provide for an Advisory Committee on Graduate Medical Education.

Amends the Public Health Service Act to establish in NIH the Office of Primary Care and Prevention Research. Establishes in that Office: (1) the Coordinating Committee on Research on Primary Care and Prevention Research; and (2) the Advisory Committee on Research on Primary Care and Prevention Research.

Requires the NIH Director to: (1) establish a data system for the collection, storage, analysis, retrieval, and dissemination of information regarding primary care and prevention research conducted or supported by the national research institutes; and (2) establish and operate a program to provide information on research and prevention activities of the institutes relating to such research.

Authorizes appropriations for the Office.

Mandates priority, in providing financial assistance under certain provisions relating to health research and teaching facilities and training of professional health personnel, to applicants, a substantial percentage of whose graduates are (or are expected to be) providing primary care to a substantial number of medically underserved individuals. Places an additional requirement on residency programs that they provide significant experience in providing: (1) primary care to such individuals; or (2) such services in ambulatory health facilities.

Subtitle B: Grants for Expansion of Availability of Primary Care Services through Health Centers - Part 1: Primary Care Service Expansion Grants - Amends the Public Health Service Act to mandate grants to expand the availability of comprehensive primary health services in medically underserved areas. Authorizes appropriations.

Part 2: Reduction in Medical Malpractice Liability for Community Health Centers - Includes entities receiving Federal funds under provisions relating to migrant health centers, community health centers, health services for the homeless, or (as added by this Act) grants for expansion of the availability of primary care services (and officers, employees, or contractors of such entities who are licensed health care practitioners) in the coverage of provisions regulating civil actions for injury resulting from medical or related functions against commissioned officers or employees of the Public Health Service. Subrogates to the United States any insurance claim such an entity or person has.

Prohibits grants under such provisions unless the applicant has: (1) implemented policies and procedures to assure against malpractice; and (2) reviewed the professional credentials, claims history, and other information regarding its licensed health care practitioners; and (3) no history of claims against it under such provisions relating to officers and employees of the Public Health Service, or has cooperated with the Attorney General in defending against such claims and has taken corrective action.

Empowers the Attorney General, if certain conditions are met, to determine that an individual practitioner shall not be deemed a Public Health Service employee for purposes of these provisions.

Prohibits hospitals from denying admitting privileges to an otherwise qualified health care provider who is an officer, employee, or contractor of such an entity.

Mandates withholding from the amounts appropriated for such entities an annual estimate of the amount of all claims under provisions relating to such civil actions.

Subtitle C: Expansions in the National Health Service Corps - Authorizes appropriations for: (1) the National Health Service Corps Loan Repayment Program for physician and midlevel practitioner placements at entities receiving grants for expansion of the availability of primary care services; and (2) a number of contracts (for such repayments and scholarships under the National Health Service Corps Scholarship Program) sufficient to ensure the placement of a specified number of additional primary care physicians and a specified percentage increase in midlevel practitioners in health professional shortage areas.

Defines "midlevel practitioner" to include certified nurse midwives, certified nurse practitioners, physician assistants, and similar nonphysician health care practitioners.