america's affordable health choices act of 2009 america's affordable health choices act of 2009 the proposed america's affordable health choices act of 2009 (h.r. 3200) was an unsuccessful bill introduced in the u.s. house of representatives on july 14, 2009. the bill was introduced during the first session of the 111th congress as part of an effort of the democratic party leadership to enact health care reform. the bill was not approved by the house, but was superseded by a similar bill, the proposed affordable health care for america act (hr 3962), which was passed by the house in november 2009, by a margin of 220-215 votes but later abandoned. this article is part of a series onhealthcare reform in theunited states history debate legislation preceding social security amendments of 1965 emtala (1986) hipaa (1996) medicare modernization act (2003) psqia (2005) superseded affordable health care for america (h.r. 3962) america's affordable health choices (h.r. 3200) baucus health bill (s. 1796) proposed american health care act (2017) medicare for all act (2021, h.r. 1976) healthy americans act (2007, 2009) health security act (h.r. 3600) latest enacted affordable care act (h.r. 3590) health care and education reconciliation act (h.r. 4872) reforms obama administration proposals public opinion reform advocacy groups rationing insurance coverage systems free market health insurance exchange nationalized insurance publicly-funded single-payer canadian vs. american two-tier universal third-party payment models all-payer rate setting capitation fee-for-service global payment united states portal health care portal a similar bill to hr 3200, called the "affordable health choices act" (hr 1679), was introduced in the senate on september 17, 2009. it too was unsuccessful as the senate approved instead another proposal called the "patient protection and affordable care act". according to the congressional budget office, hr 3200 included tax increases and spending cuts that reduce the net increase in the federal deficit to 1% of 2008 tax revenues. the cbo director subsequently noted that, in terms of total national health expenditure, non-governmental spending will increase as coverage expands. the bill was originally sponsored by representatives john dingell, charles rangel, henry waxman, george miller, pete stark, frank pallone, and robert andrews. the 1017 page pdf version of the bill is the first of three health care reform-related legislative proposals expected from the democratic congressional leadership. votes in the u.s. house of representatives on this bill and on the medicare for all act, an alternative that would establish a national, universal single-payer health insurance, were previously expected in september 2009 and again in october 2009, before the actual november 2009 vote took place. elements of the bill the summary of the bill includes the following elements, among others: establishes a mandate to purchase private insurance for most individuals with an income above poverty level. creates a mechanism to enforce the mandate in a sliding scale tax on those who do not purchase health insurance for most legal united states residents with an income above poverty level. prohibits pre-existing condition exclusions. requires adjusted community rating, guaranteed issue, and guaranteed renewal of individual and small group health insurance that: limits age rating variation of premiums to 2:1 (200 percent), prohibits gender and health status rating variation of premiums, allows variation of premiums by geographic area and family (vs. individual) enrollment. prohibits cancellation of coverage except for evidence of fraud. limits annual out-of-pocket expenses to $5,000 for an individual and $10,000 for a family. requires health and human services to create a non-subsidized public health insurance plan with pricing based on private industry averages. three optional levels of coverage are to be offered by the plan which must set premiums at a level sufficient to fully finance the costs of the health benefits the administrative costs related to operating the plan. establishes a health insurance exchange (hie) within a proposed health choices administration, to provide a market place for insurers to sell qualifying plans on a public web site. requires the creation of a risk equalization pool that will allow qualifying plans to minimize the impact of adverse selection of enrollees among the plans. provides a tax credit for low-income individuals and families to help pay insurance premiums. requires employers with payroll costs over $500,000 to provide health insurance that meets the minimum standard of coverage allowed in the hie. provides for a tax on employers that do not provide the required health insurance. provides for a tax on couples with adjusted joint gross income exceeding $350,000 (80% of this figure for single people) reduces medicare payments to hospitals with excessive re-admissions. further expands medicaid eligibility and scope of covered preventive services, for lower-income individuals and families. increases medicaid payments to physicians for primary care. provides for a phased-in elimination of the medicare part d coverage gap and requires drug manufactures to discount and/or rebate additional qualifying drugs originally excluded from the plan. requires the secretary of health and human services (hhs) to develop quality measures for the delivery of health care services in the united states. establishes the health benefits advisory committee chaired by the surgeon general of the united states. prioritizes any eventual implementation of best practices in the delivery of health care. establishes a national prevention and wellness strategy along with appropriations for its trust fund. outlines administrative standards that reduces costs and improves service, including the ability for administrators to determine an accurate total financial estimate at the point of service as well as enabling real time electronic transfer of funds to take place if possible (mirrors currently existing laws). house committees' mark-ups america's affordable health choices act of 2009 has been amended in the nature of substitute during mark-up proceedings since its original introduction recorded in the congressional record on july 14, 2009. these amendments have only been voted on by each committee involved in order to pass out of the committee phase but have not been voted on by the full house membership, which is needed before the originally introduced legislation can be changed to reflect any amendments recommended by the committees and passed by a full house vote. house committee on energy and commerce see external link to mark-up summary house committee on ways and means see external link to mark-up summary house committee on education and labor kucinich amendment the kucinich amendment to health care bill hr 3200 grants states rights to single payer health care at the state level. this is how canada adopted single payer, with saskatchewan passing it first. in july 2009, the house education and labor committee approved the kucinich amendment by a vote of 27–19, with 14 democrats and 13 republicans voting for it. see external link to mark-up summary comparison with senate versions the washington post published comparison tables of the main house version with the two main senate versions, which themselves may be summarized as: 3 versions house senate health senate finished notes deficit increase(+)/ reduction(-) to 2019 ($b) -104 +597 -81 senate health committee has no jurisdiction to modify taxes cost($b) 1279 645 845 number of uninsured 17m 34m 25m 54m uninsured by 2019 without bill public option yes yes no individual mandate yes yes yes (see insurance subsidies) employer mandate yes yes yes new taxes($k) fam>350 no* plan>21 *outside senate health committee jurisdiction insurance reforms yes yes yes expand medicaid yes no* yes *outside senate health committee jurisdiction insurance subsidies yes yes yes prorated to $88k/family of 4, or tax creds(s.fin) cbo analysis of the bill the u.s. congressional budget office is a non-partisan organization that analyzes the effect on the federal budget of proposed and existing legislation on behalf of the congress. cbo analyzed the bill as of july 14, 2009 and reported the following: according to cbo's and jct's assessment, enacting h.r. 3200 would result in a net increase in the federal budget deficit of $239 billion over the 2010–2019 period. that estimate reflects a projected 10-year cost of the bill's insurance coverage provisions of $1,042 billion, partly offset by net spending changes that cbo estimates would save $219 billion over the same period, and by revenue provisions that jct estimates would increase federal revenues by about $583 billion over those 10 years. in terms of what would happen for consumers, the cbo's methodology in a report in late july used a public plan with premiums about 10% lower than private plans. health exchange details businesses with ten or fewer employees can use the exchange in the first year after the act begins. the cutoff changes to twenty or fewer employees the next year. on the third year, the 'health choices commissioner' has the authority to phase in businesses with more employees. the legislation does not specify any further phases, leaving that up to the officer to decide. the act creates new standards, intended by lawmakers as methods of consumer protection, for what would be considered a minimally acceptable insurance plan. employers that currently offer insurance have a five-year grace period after the act begins before they would be subject to the standards. individuals would be free to purchase their own private insurance, or work with the public option, in this period and afterward. health benefits advisory committee according to division a, title i, subtitle c, section 123 of hr 3200, a health benefits advisory committee shall be established to be chaired by the surgeon general of the united states. it will consist of 9 more individuals who are not federal employees that are appointed by the president of the united states. it will also consist of 9 members who are appointed by the comptroller general of the united states. also, up to eight more members will be appointed in even numbers by the president of the united states who are federal employees and officers. each member of the committee will serve three year terms. the health benefits advisory committee will recommend to the united states secretary of health and human services benefit standards and periodic updates to such standards. debate and controversies main article: health care reform debate in the united states reimbursement for counseling about living wills one often-cited provision of the un-passed bill would have authorized medicare reimbursement for physicians who provide voluntary counseling about such subjects as living wills. the provision is based on a separate bill that was cosponsored by republican charles boustany of louisiana, a surgeon, and is similar to end-of-life counseling signed by president george w. bush. this advance care planning consultation section was criticized by some republicans and conservatives such as betsy mccaughey, a lobbyist for the healthcare industry who also helped to defeat the clinton health care plan of 1993. these critics allege that it includes mandatory language aimed at pressing elderly and disabled patients toward euthanasia. their interpretation was the basis for the charge about this section by prominent republican 2008 vice presidential candidate sarah palin. my parents or my baby with down syndrome will have to stand in front of obama's "death panel" so his bureaucrats can decide, based on a subjective judgment of their level of productivity in society, whether they are worthy of health care.— sarah palin however, the "level of productivity in society" or panels claim is not mentioned in the actual legislation, which is structured primarily to amend a specific clause in the social security act, section 1861 of definitions that are used in sections regarding reimbursements for end-of-life counseling, including the use of advance directives. charles boustany's democratic cosponsor, earl blumenauer of oregon, has called this attack on the bill "an all-time low". blumenauer said the measure would block funds for counseling that presents suicide or assisted suicide as an option, and called references to death panels or euthanasia "mind-numbing". he said that "the majority of congressional republicans supported the similar provisions for terminally ill elderly patients that were part of the 2003 prescription drug bill" and that, out of the dozens of republican proposals for revising the bill, "not a single word" was said against end-of-life counseling. he said that rush limbaugh, virginia foxx, newt gingrich, charles grassley and other republicans defended the death panel story only after betsy mccaughey's editorials, and that some people at town hall meetings even wanted to "keep government out of their medicare," a government run program. blumenauer said that as recently as april 2008 then-governor palin supported end-of-life counseling as part of health care decisions day. palin's