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7 Things You Didn't Know About Senate Health Bill

Pay attention: The "Patient Protection and Affordable Care Act" — better known as the Senate health care overhaul bill – is chock full of interesting but little publicized provisions affecting consumers. Sure, the bill is mainly a blueprint for overhauling the insurance system. But look closely and you'll see a variety of items that would affect people from the cradle to old age – from breast pump use to retiree health benefits. It's a congressional tradition, adding pet interests that otherwise might not pass to a big bill that at least will be put up for a vote.

Yes, there's plenty of time to change the bill. But political analysts say a final overhaul bill would more likely look like this measure than the version already approved by the House because Senate Democrats barely could agree on sending it to the floor for debate. In short, there's not much political room for major changes.

Here are some examples of what lies in this 2,074-page bill:

Nursing Mothers Get A Break

Employers would be required to provide an unpaid "reasonable break time for nursing mothers" in the first year after giving birth. Women would be provided a private place, other than a bathroom, to use a breast pump. The provision exempts companies with fewer than 50 workers if the requirement would impose "an undue hardship," a determination left to the employer to make.

This provision was inserted by Sen. Jeff Merkley, D-Ore., who in June introduced the Breastfeeding Promotion Act. Merkley is promoting breast feeding partly as a way to cut health costs. He cites studies showing breast-fed children have a lower rate of disease and illness in their lifetime.

But employers see yet another expense. "Every additional mandated rule further burdens employers who are struggling to keep jobs afloat," says Neil Trautwein, vice president of the National Retail Federation.

Twenty-four states already have protections for nursing mothers in the workplace, according to the National Conference of State Legislatures.

Learning To Be An Adult

Being a teenager is tough. The Senate wants to help with a provision allocating $400 million from 2010 to 2015 to help teens make the transition to adulthood.

The money goes to states primarily to set up sex education programs. But the money can also be used for "adult preparation" programs that promote "positive self esteem, relationship dynamics, friendships, dating, romantic involvement, marriage and family interaction."

In addition, the programs can teach financial literacy and other skills such as goal setting, decision-making and stress management. About $10 million of funding would go to "innovative youth pregnancy prevention strategies" in areas of the country with high teen birth rates.

The Personal Responsibility Education for Adulthood Training funding was approved as an amendment in the Senate Finance Committee. Republican Sen. Olympia Snowe of Maine joined all the Democrats in passing it.

Retiree Health Benefits

The Senate bill includes a provision designed to ease out-of-pocket costs for retirees who are under 65 but who still get health insurance from their former employer. The bill would create a temporary "reinsurance" program under which the government would pick up 80 percent of some high-cost insurance claims filed by retirees. Employers would use the savings only to make retirees' coverage more affordable by reducing their share of premiums or other costs. The Senate bill would set aside $5 billion for the program; the House-passed bill, which has a similar provision, has a $10 billion pot. The proposal has wide support among employer groups and labor unions.

The same can't be said of another provision in both bills. Companies would have to pay a tax on the government subsidies they receive for providing their Medicare-eligible retirees with prescription drug coverage. These subsidies, included in the 2003 law that created the Medicare drug benefit, were designed to encourage companies to keep offering drug coverage. Now, if the subsidies are taxed to help pay for a health overhaul, they become much less attractive to employers; some companies might drop drug coverage for retirees altogether, warned the American Benefits Council, an employer group, and the AFL-CIO in a joint letter to Congress. If that happened, the retirees would get their drug coverage from Medicare. Critics say that would ultimately cost the government more money than it would recoup by taxing the subsidies.

Promoting Use Of Bone Density Scans

Rapid increases in Medicare payments for imaging services led lawmakers to reduce payments for some services, including those that test bone density.

The Senate bill is trying to boost payments, which have dropped by more than half since 2006, for a bone test known as dual energy X-ray absorptiometry (DXA) or bone densitometry. And those cuts have made it more difficult for patients to get access to the test, especially in physicians' offices and clinics, according to the National Osteoporosis Foundation. The Senate bill would increase rates to 70 percent of what Medicare paid in 2006.

Raising the payment for bone density scans is a priority for two senators whom Reid hopes to win over in his bid to get 60 votes for his health care plan: Blanche Lincoln, a moderate Democrat from Arkansas, and Olympia Snowe, a moderate Republican from Maine.

Setting ER Prices

Nonprofit hospitals would have to limit how much they charge low-income uninsured emergency patients to the lowest amount they receive from insured patients for the same services.

The provision in the Senate bill comes more than six years after consumer groups in California and Texas began highlighting how hospitals were charging uninsured patients several times more for the same services as insured patients.

A 2007 study published in the journal Health Affairs showed that many "uninsured and other 'self-pay' patients for hospital services" were often charged "2 1/2 times what most health insurers actually paid and more than three times the hospital's Medicare-allowable costs." The study by Gerard Anderson of Johns Hopkins University also found the "gaps between rates charged to self-pay patients and those charged to other payers are much wider than they were in the mid-1980s."

In response to the criticism, many hospitals have set up programs for the uninsured to apply for financial assistance and obtain discounted care. The Senate provision would require all hospitals to have such programs.

Singing The Blues

Non-profit Blue Cross and Blue Shield health plans would have to spend at least 85 cents of every premium dollar on health services or forfeit their special federal tax deductions. The Congressional Budget Office estimates this provision in the Senate bill would cost the Blues' plans about $400 million over the next decade.

Historically, Blue Cross and Blue Shield plans received a tax-preferred status because they were created to provide a more significant "community benefit" than other insurance companies. But the Blues have come under increasing scrutiny from state and federal lawmakers and consumer watchdog groups for charging high rates, racking up profits (revenues over expenses) and paying top executives no differently than their for-profit insurance counterparts.

Several Blues' plans converted to for-profits in the past 15 years. Of the 39 Blue Cross and Blue Shield plans nationwide, 24 are now non-profit.

Transparency In Drug Pricing

Pharmaceutical benefit managers are a critical part of the nation's health care system. Administering drug plans for more than 210 million insured Americans, they negotiate discounts on prescription drugs with retail pharmacies and wholesalers and also get rebates from drug makers.

At the urging of Sen. Maria Cantwell, D-Wash., the Senate Finance Committee inserted language into its health bill that would force the benefit managers, known as PBMs, to disclose details of those negotiations – including how much of the savings were passed on to consumers.

Adding that transparency to drug pricing, Cantwell maintains, would help lower drug prices. "We want the consumer to benefit as greatly as possibly from the discounts that PBMs are helping to negotiate," Cantwell said earlier this year.

The PBMs don't see it that way. Cantwell's amendment, they argue, would "allow competing drug manufacturers and pharmacies to learn prices their competitors charge and raise prices accordingly. It would decrease, not increase, competition among them," Mark Merritt, president and chief executive officer of the Pharmaceutical Care Management Association, wrote in a Nov. 24 letter to Senate Majority Leader Harry Reid, D-Nev. Merritt's group represents PBMs.

This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.

Copyright 2023 Kaiser Health News. To see more, visit Kaiser Health News.

Mary Agnes Carey
Phil Galewitz
Laurie McGinley