Obama Care Pt-pt

Page 1 - Title page Page 2 - Disclaimers 'n stuff. Technically, this is a condensed version of the bill. I guess the actual legal version has a lot more legalese... or something. Pages 3-32 - Table of Contents Page 32, Sec. 1001 - Alters another bill (The Public Health Service Act), just to make room for the additions this bill is going to make. So when you read that other bill, it makes sense and doesn't look like a bunch of stuff was just tacked on at the end. Page 33, Sec. 2711 - Says that insurers can't have lifetime limits on the amount of care customers can get, and that starting in 2014, they can't have yearly limits either. So you get as much care as you need. Page 33, Sec. 2712 - No more "rescissions". In other words, Insurers can't just drop customers once they get sick. The only time they can drop a customer is if that customer commits fraud. Page 33, Sec. 2713 - Insurance plans need to include preventive care (colonoscopies, mammagrams, immunizations, etc.) without any extra costs (like co-pays). I should note that this section also includes something that led to a bit of controversy - It says that health insurance must include preventive care for women supported by the Health Resources and Services Administration. And the Health Resources and Services Administration, on the recommendation of the independent Institute of Medicine of the National Academy of Science, has determined that preventive care for women should include access to, amongst other things, contraception. Insurers must provide these services, and cannot require a copay for them. They are paid for by the insurance company. On February 10, 2012 (or February 15th, if you go by the header in the document), the Department of Health and Human Services issued a document, detailing its enforcement of this section. It clarifies that churches are exempt from being required to provide coverage for contraception, and that insurers are to create plans specifically for religiouslyowned businesses, like Catholic hospitals, so that employees still get contraceptive coverage through their employer without any of the costs being paid by the employer or the employee. Page 34, Sec. 2714 - Insurance plans need to cover dependents up to the age of 26 Page 35, Sec. 2715 - A year after the law was passed, the Secretary of Health and Human Services would need to get together with National Association of Insurance Commissioners to establish standards for the insurance industry. This is basically to make sure that everyone is using the same terms, the same language, and is providing the same information to customers, so customers have a better idea how to compare one policy to another. Page 37, Sec. 2715A - From now on, insurers must, in a clear, easy-to-understand format, make a bunch of information public: What their policies are, how many people are using their plans, how many claims they deny, financial information, etc. Page 37, Sec. 2716 - Refers to rules in another document, the Internal Revenue Code, but it looks like it's just making sure insurers don't give preferential treatment to rich people. I'm guessing this means a more expensive plan might cover more stuff, but wouldn't let the rich guy cut ahead of you in line at the doctor's office. Or something. Page 38, Sec. 2717 - 2 years after the law passed, the Secretary of Health and Human Services needs to establish rules for how insurers will report, on a yearly basis, the quality of care given under their plans, to be made available to the public online. This includes stuff relating to wellness and prevention programs (healthy eating, anti-smoking, etc.), as well as a big section making it clear that customers aren't supposed to be asked about gun ownership (in case someone thinks it might be a good idea to factor that into their reporting).

Page 40, Sec. 2718 - Insurance companies need to make public how much they spend on insurance claims, and what they make in profits. Starting in 2011, if their costs (and risks, and overhead, etc.) is less than 80-85% of the money they make, they need to send rebates out to their customers. Basically, they're not allowed to do price-gouging to make obscene profits. Page 42, Sec. 2719 - Insurers need to offer customers the ability to appeal a claim that was denied. This appeal process will be monitored under an external review process to make sure it's doing what it's supposed to. Page 43, Sec. 2719A - Makes sure that customers can decide their own doctors, and that if their insurance covers emergency care, customers can go to any emergency room without having to worry whether their insurance will cover that specific emergency room. Basically, this section insures that customers still have freedom of choice where they get their medical care. Page 46, Sec. 1002 - Adds the next part to a different bill, the Public Health Service Act Page 46, Sec. 2793 - The Secretary of Health and Human Services will offer grants to states so that the states can have a Consumer Service programs that will investigate problems customers have with insurance, help to spread information, answer questions, and help to facilitate appeals processes. Page 47, Sec. 1003 - Adds the next part to a different bill, the Public Health Service Act Page 47, Sec. 2794 - The Secretary of Health and Human Services will decide what constitutes an "unreasonable" increase in premiums, and conduct an annual review of increases in premiums to look for these. Insurers must explain their reasons for any such unreasonable increases before making them, and must make this information available to the public. If any insurer increases premiums too much or too fast, it may be dropped from "exchange" programs (more on this later). Page 49, Sec. 1004 - This is just detailing when some of the earlier stuff should happen. It's already all done. Page 49, Sec. 1101 - The Secretary of Health and Human Services will make a "high-risk pool" insurance program for people with pre-existing conditions, to make sure they can get insurance right now. The program ends in 2014 (because in 2014, insurers can't refuse anyone with a pre-existing condition). Page 52, Sec. 1102 - Gives a reimbursement to insurance plans that provide health insurance for early retirees Page 55, Sec. 1103 - Create a website ( http://www.healthcare.gov/ ) to help people find health insurance in their state, and give them information about options available to them. Page 56, Sec. 1104 - Making changes to a few other bills, The Health Insurance Portability and Accountability Act of 1996, and the Social Security Act, to add definitions and clarify the wording in some sections, and to specify that the paperwork people have to fill out should be clear, concise, and easy-to-understand, as well as to incorporate the use of medical cards used with electronic databases. Basically, this whole section is changing the wording in a few other bills so that all of the bills make things simple and easy for people to fill out paperwork (or simply use a medical card) at hospitals and stuff. Any health plans that don't follow these new rules for clarity will have to pay a fee. Page 63, Sec. 1105 - This is just detailing when some of the earlier stuff should happen. It's already all done. Page 64, Sec. 1201 - This one is changing another bill, the Public Health Service Act, by adding in the following section. Page 64, Sec. 2704 - Starting in 2014, No more turning people down due to "pre-existing conditions".

This is already in effect (as of 6 months after this bill passed) for anyone under the age of 19. Page 65, Sec. 2701 - Starting in 2014, the only things about you that insurers can take into consideration when determining your premium rates are whether you want to cover your family or just you, what your age is, whether or not you use tobacco, and other factors to be determined by each state (unless the Secretary of Health and Human Services believes a state's "rating area" to be inadequate, in which that rating area may be changed). Page 65, Sec. 2702 - Starting in 2014, Insurers must accept everyone who applies for coverage. Page 66, Sec. 2703 - Starting in 2014, Insurers must renew coverage for everyone who has it. Page 66, Sec. 2705 - Starting in 2014, Insurers can't restrict you from getting a plan based on past illnesses, genetic history, a disability, previous health care you've gotten, because you were the victim of domestic violence... basically, your personal health history is off-limits when it comes to insurers deciding what plans you can apply for. Page 70, Sec. 2706 - Starting in 2014, If a doctor or hospital is willing to work with an insurer, the insurer has to let them. Page 71, Sec. 2707 - Reiterating that the plans offered have to cover the stuff specified by the other sections of this bill. Page 71, Sec. 2708 - Starting in 2014, Waiting periods can't be longer than 90 days. Page 71, Sec. 2709 - This has to do with "Clinical Trials", stuff that's not ready for mass use yet, and that is still being tested. Basically, it's saying that starting in 2014, people should have access to that sort of trial if they want, and that their insurer shouldn't be able to screw with their insurance plans because they choose to participate in one. Page 74, Sec. 1251 - Says that when this law passed, no one had to change their plans. They could if they wanted, but they could totally keep their current plan if they like it. Page 75, Sec. 1252 - Says that the changes this law makes apply to all health plans companies offer, not just some. Page 75, Sec. 1253 - The Secretary of Labor needs to make a yearly report to Congress on self-insured employers. Page 76, Sec. 1254 - A year after this law passes, The Secretary of Health and Human Services needs to write a report on group health plans. Page 76, Sec. 1255 - You know the dozen or so "In 2014"s I've put in a bunch of the recent bulletpoints? Well, this is the part that specified they happen in 2014, with the exception of a few parts that start sooner. Page 77, Sec. 1301 - This section talks about what a plan needs to be in order to be "qualified" (basically, okay for an insurer to sell). It needs to be certified for the requirements of the insurance exchange it's going to be in (more on the exchanges later), it needs to have the features described in the next section, needs to be sold by a licensed insurer, needs to be sold at the same rate regardless of whether it's sold directly or in an exchange, etc. Page 78, Sec. 1302 - The last section talked about what a plan needs to be, but this one talks about what needs to be in it. And that's a lot of ground to cover, so bear with me. The Secretary of Health and Human Services is going to determine what the minimum levels need to be for everything, but this section outlines that by saying that health insurance plans must cover bare minimums of ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health services,

drugs, rehabilitative services, laboratory services, preventative services, and pediatric services that include oral and vision care. This section also goes into detail on just how the Secretary is to determine those minimum levels (be mindful of different types of people, be balanced, etc.). This section also limits how big deductibles can get starting in 2015 (no bigger than $2000 for individuals and $4000 for couples). On top of that, this establishes that plans should fall into Bronze/Silver/Gold/Platinum levels, with each corresponding to a different level of benefits. For Bronze, insurers pay for 60% of the costs of the benefits, Silver is 70%, Gold is 80% and Platinum is 90%. A plan that's not one of those could still be okay if it's a Catastrophic plan, which is only for people under 30 or with special tax exemptions, and it only has to cover three primary care visits. Additionally, any plan created for adults must also be available for children under 18. Whew! That was a long one! Okay, let's move on... Page 83, Sec. 1303 - A state may choose to fund plans that include abortion coverage, or they may not. It's up to each state to decide that. Basically, the folks who wrote the bill knew what a hot-button issue abortion was, and they wrote this section to pass the buck on to state lawmakers without siding one way or another. Page 87, Sec. 1304 - This section defines a bunch of terms. Okay, now we're about to get into health insurance exchanges, which allow plans to compete across different areas. The idea, if I'm getting this right, is that by having more insurance companies competing across a larger area, prices will be driven down due to competition. As I understand it, this is what they ultimately ended up doing instead of having a "public option" (optional state-run insurance to compete with the others). Since the public option got shot down before the bill was passed, this was seen as another way to encourage more competition in the market. It bears mention, that in the 6/28/12 Supreme Court ruling on this bill, it was declared that states are not required to establish health insurance exchanges, and that they cannot be penalized for refusing to do so by reducing the funding they get for Medicare and Medicaid. However, if any states choose to opt-out of the creation of these exchanges, the Secretary of Health and Human Resources may simply create the exchanges for those states directly (or even go as far as to create a multi-state exchange encompassing any number of states that refuse to create their own). This is just speculation, of course, but in any case, the court decision shouldn't greatly impact the creation of these exchanges. Page 88, Sec. 1311 - Another big one. This section sets aside money to the states so they can start up health insurance exchanges. The Secretary of Health and Human Services determines how much to keep giving the states based on how much progress they're making. States only have until 2015 to get their act together, though - after that they get no money. However, states must have something ready by 2014. States can choose to require insurers to have benefits that go above and beyond what this law requires, but they have to figure out how to pay for anything they come up with that requires more government money. by 2015, the exchanges need to be self-funding. States can even team up to make multi-state exchanges if they want. Page 99, Sec. 1312 - Individuals can get any plan they qualify for. If you qualify for it, you can get it, if you don't, you can't. This section seems to be talking about different ways people can get insurance (through employment, through a broker, etc.), and making sure they get it. Also, Congress has to make use of the same plans us ordinary taxpayers have. Page 102, Sec. 1313 - States need to keep track of the money these insurance exchanges are using, make sure they're working right financially, and watch out for fraud. Page 104, Sec. 1321 - The Secretary of Health and Human Services is to set the standards that these insurance exchanges are supposed to follow. If any state fails to follow them satisfactorily, fails to get it

set up in time, or chooses not to do it at all, the Secretary will set one up for them. Page 105, Sec. 1322 - This sets up the rules, as well as instructions for loans and grants, for the creation of non-profit, member-run insurers called Co-ops. Basically, what credit unions are to banks, this aims to be for traditional insurance companies. This section aims to make it easier for a bunch of people to band together to start their own non-profit insurance company to provide insurance all the people who banded together. The idea is to give people more options, and more competition in the market. Page 111, Sec. 1323 - This option is stricken and no longer exists. Looks like it was probably the public option back before it was kicked off of this bill. Page 111, Sec. 1323 (same number, different section) - Allocates money specifically for territories that aren't states, like Puerto Rico. Page 112, Sec. 1324 - This says that Co-ops have to work under the same laws as normal insurance companies. Page 112, Sec. 1331 - This allows the government to create a low-cost insurance option for people who make too much money to qualify for Medicaid, but who still make less than 200% of the poverty line (which is a number that depends on your age and how many are in your household, but this amount, at its lowest is a little over $20,000/year). Page 117, Sec. 1332 - If any state can come up with their own plan, one which gives citizens the same level of care at the same price as the PPACA, they can ask the Secretary of Health and Human Services for permission to do their plan instead of the PPACA. So if they can get the same results without, say, the mandate, they can be allowed to do so. Vermont, for example, has expressed a desire to just go straight to single-payer. Page 119, Sec. 1333 - In 2013, states can work with insurers to allow them to make plans available in multiple states with different laws and regulations Page 120, Sec. 1334 - A different way for an insurer to do a multi-state plan. Page 124, Sec. 1341 - Starting in 2014, states must either create or work with an already-existing nonprofit reinsurance agency. Reinsurance agencies basically buy insurance plans from insurers when they are deemed to be high-risk. This helps to keep premiums for other customers down, since otherwise insurers would have to raise prices to offset that risk. This section talks about some of the rules for these sorts of agencies. 50-100 medical conditions are to be identified as high-risk conditions that insurers can offer up to reinsurance agencies. Partly to offset the risk these agencies are taking by taking on these high-risk customers, reinsurers are tax-exempt. Page 127, Sec. 1342 - In 2014-2016, the government will create "Risk corridors", basically saying that in the first few years while insurers adjust to all these new rules, the government will help with some of the risk associated with insurance payouts. Page 128, Sec. 1343 - Each state will charge insurers who take on less risk, and make payments to insurers who take more risk, acting as an equalizer so that the companies that succeed aren't just the ones who cater mostly to demographics with a low amount of risk. Page 129, Sec. 1401 - Alters another document, the Internal Revenue Code, by adding the following section. Page 129, Sec. 36B - Starting in 2014, gives a refundable tax credit to everyone who makes too much to qualify for Medicaid, but makes less than 400% of the poverty line (which, again, is based on your age and how many people are in your household). Depending on how much you make, this could save

you up to $10,000 a year. A refundable tax credit is basically a discount on your taxes, and if it's more money than you pay in taxes, you actually get the extra money back as a refund. This is the bill's answer to the question "How will I afford insurance if I make too much to qualify for Medicaid, but not enough to afford insurance on my own?". Page 138, Sec. 1402 - If I'm reading this right, insurers must reduce costs (both co-pays and overall costs) for everyone who makes too much to qualify for Medicaid, but makes less than 400% of the poverty line (which, like I said last time, is based on your age and how many people are in your household). Depending on how much you make, your co-pay costs could be slashed by up to two-thirds the normal price, and your overall costs could be covered up to 94%. If you're an Indian (presumably Native American Indian) making under 300% of the poverty line, you have no co-pay. This section specifically says it only applies to citizens and legal aliens living in the US (so no illegal aliens allowed) Page 142, Sec. 1411 - It looks like this section instructs the Secretary of Health and Human Services to set up a way to check whether people are eligible to buy insurance. It looks like it's basically, in a roundabout way, trying to keep illegal aliens from being qualified for insurance, and setting up penalties for anyone who lies on insurance forms. Page 150, Sec. 1412 - This section instructs the Secretary of Health and Human Services to set up a way to check whether people are eligible for the tax credits and the insurance cost reductions (that "up to 400%" stuff). Basically, instructing him to set up a system to determine what people qualify for based on their income. And also, no illegal aliens. Page 152, Sec. 1413 - This section instructs the Secretary of Health and Human Services to set up standard forms and enrollment procedures for state-level programs like Medicaid and Child Health programs . Page 154, Sec. 1414 - The Secretary of Health and Human Services is allowed to share relevant tax information with those who need it in order to verify what people qualify for. Page 156, Sec. 1415 - All these tax credits and refunds won't count as income. So they won't be taxed or anything. Page 156, Sec. 1416 - The Secretary of Health and Human Services is instructed to conduct a study into the possibility of adjusting poverty levels based on where people live. Because making $30,000/year in rural Kansas is a hell of a lot different than making $30,000/year in San Francisco. Page 157, Sec. 1421 - Alters another document, the Internal Revenue Code, by adding the following section. Page 157, Sec. 45R - Businesses with 25 or fewer employees can get a tax credit worth up to 50% of the cost of the health care they provide their employees. The following parts deal with "The Requirement to Maintain Minimal Essential Coverage", AKA "The Mandate". This is one of the big parts that people have taken issue with, and the very same one that the Supreme Court recently ruled is constitutional (as long as it's seen as a tax and not a penalty, for all those lawyer-types out there). Page 162, Sec. 1501 - This is a big, fat, explanation for the reasons behind The Mandate. Basically, without the mandate, people might just decide not to pay for insurance, which places a huge risk not

just on themselves, but the hospitals who will eventually have to treat them when they get sick or injured. The economy loses a ton of money due to uninsured people needing emergency care, which in turn makes insurance premiums more expensive as that cost is passed on. What's more, medical expenses account for 62% of bankruptcies, which introduces even more stress into the economy. And with this bill getting rid of "pre-existing conditions", if there was no mandate, people would just wait to buy insurance until they need it, which pretty much defeats the whole point of insurance. In addition, requiring people to get insurance will make millions of people healthier and live longer. Besides, the more healthy people who have insurance, the less of a risk insurers are taking, which lowers everyone's prices. Page 164, Sec. 5000A - This is the actual mandate. If you can afford healthcare (if it costs less than 8% of your income), but don't get it, you will be hit in your tax return with an annual tax of $95, or up to 1% of income, whichever is greater. This will rise to $695, or 2.5% of income, by 2016. This section makes an exception for those with religious exemptions (the Amish), members of Indian tribes, and prison inmates. It also specifies that no one's going to be charged with any crime or anything, it's just a new tax if you don't comply. Page 171, Sec. 6055 - Insurers need to tell the government who they're insuring, either directly or through employers, in which case they need to tell the government which employer they're working through too. Page 173, Sec. 1511 - This one is changing another bill, the Fair Labor Standards Act of 1938, by adding in the following section. Page 173, Sec. 18A - If an employer has over 200 employees, and offers a health plan to those employees, new employees will be automatically signed up for that health plan, though employees can opt-out if they don't want it. Page 173, Sec. 1512 - This one is changing another bill, the Fair Labor Standards Act of 1938, by adding in the following section. Page 173, Sec. 18B - Employers need to notify new employees about their options with health insurance exchanges and tax credits. Page 174, Sec. 1513 - Alters another document, the Internal Revenue Code, by adding the following section. Page 174, Sec. 4980H - Starting in 2014, if an employer has over 50 full-time employees and doesn't offer them insurance, the employer has to pay a fee of $2000/year per employee. If they employ parttime employees, their hours are to be added together to see how many full-time employees they'd represent (in other words, it's not a simple head count). The Secretary of Labor is to conduct a report to see what effect this has on employees' wages. Page 178, Sec. 1514 - Alters another document, the Internal Revenue Code, by adding the following section. Page 178, Sec. 6056 - Employers need to report to the Secretary of Health and Human Resources about the insurance being used by the employees working for them. Page 180, Sec. 1515 - Alters another document, the Internal Revenue Code, by adding that you can't get a plan using an insurance exchange through a "cafeteria plan" (a plan where you specifically pick what is and isn't covered). I think this is saying that if you're well enough off that you're going to nitpick the details of your insurance policy, you can buy all of the elements of that policy directly. Page 181, Sec. 10108 - This section has to do with Free Choice Vouchers. Judging from news reports,

it looks like it has since been repealed. It would have required employers to provide these vouchers to employees. Page 181, Sec. 139D - More on Free Choice Vouchers. Again, looks like it was killed off after the bill passed. Page 183, Sec. 1551 - Says that this part of the bill uses the same definitions as another bill, the Public Health Service Act. Page 183, Sec. 1552 - 30 days after this act passed, the Secretary of Health and Human Services had to publish online all of the authorities he has been given under the act. Page 183, Sec. 1553 - The Federal Government, States, and insurers cannot discriminate against doctors and hospitals that refuse to do assisted suicide. Page 184, Sec. 1554 - The Secretary of Health and Human Services will not promote regulation that limits peoples' ability to get health care, or limits doctors' ability to communicate with patients. Page 184, Sec. 1555 - Any Federal Health Insurance Programs created by this act are optional (anything like Medicare and Medicaid, for example). No one has to join them. Page 184, Sec. 1556 - Alters another bill, the Black Lung Benefits Act. From what I can tell, this has to do with health problems suffered by coal miners. It looks like it's extending the dates to cover more recent issues. Page 185, Sec. 1557 - Health insurance programs benefiting from Federal credits and subsidies cannot discriminate against anyone based on age, gender, race, etc. Page 185, Sec. 1558 - Alters another bill, the Fair Labor Standards Act of 1938, by adding the following section. Page 185, Sec. 18C - Employers can't discriminate against employees that have received tax credits. Page 186, Sec. 1559 - The Inspector General of the Department of Health and Human Services is in charge of administration and implementation of this law, as it pertains to his department. Page 186, Sec. 1560 - Names a few random laws and says "this bill doesn't change any of these laws". Page 186, Sec. 1561 - Alters another bill, the Public Health Service Act, by adding the following section. Page 186, Sec. 3021 - 180 days after this bill was passed, a couple of Health Information Technology committees will work to start spreading information and helping people enroll in Health and Human Service programs Page 188, Sec. 1562 - The Comptroller General of the United States is directed to conduct a study on the denial of coverage. This section details how he's to go about doing it. Page 189, Sec. 1563 - It looks like it's basically saying that when you buy a business, you can't use this bill as an excuse to ignore any of the usual laws when doing so. Page 189, Sec. 1563 (Same number, different section) - Alters another bill, the Public Health Service Act, by making many small changes. It looks like most of them are either slight alterations and rewordings, additional definitions of terms, and language that fits in better with this bill. Page 196, Sec. 715 - Alters another bill, the Employee Retirement Income Security Act, by adding that the rules in that document apply to group insurance plans as well as individual insurance plans.

Page 196, Sec. 9815 - Alters another document, the Internal Revenue Code of 1986, by adding that the rules in that document apply to group insurance plans as well as individual insurance plans. Page 197, Sec. 1563 (Yet another one with the same number, but a different section) - This basically just says that the Congressional Budget Office says that this bill will reduce the budget deficit, extend Medicare solvency, increase the Social Security Trust Fund, and have savings in a few other areas. It also says that these savings will go towards those programs and not folded back into the PPACA. Page 198, Sec. 2001 - Alters another bill, the Social Security Act, so that starting in 2014, everyone up to 133% of the poverty line is covered by Medicaid. From what I can tell, looking at the Social Security Act, it looks like it's currently a mishmesh of various qualifications, one being that a person is under 100% of the poverty line. So this will make for a pretty huge number of people who Medicaid grows to encompass. This section also increases federal funding to support the increase. However, it should be mentioned that a recent court ruling, amongst other things, made it clear that individual states could opt not to do this. However, in Justice Roberts' opinion "Congress may offer the States grants and require the States to comply with accompanying conditions, but the States must have a genuine choice whether to accept the offer.", so in other words, States can't be forced to do this, but they can be given incentives to do this. Page 210, Sec. 2004 - Alters another bill, the Social Security Act, so that starting in 2014, Medicaid covers former foster children under the age of 26. Page 210, Sec. 2005 - Increases the amount of Medicare money given to US Territories like Puerto Rico. Page 211, Sec. 2006 - Alters another bill, the Social Security Act. It looks like what it's doing is that starting in 2011, the amount of money the Federal Government chips in for medical care when there is a major disaster increases. Page 212, Sec. 2007 - Between 2014 and 2018, this cuts about $700,000,000 from a part of Medicaid called the Medicaid Improvement Fund, a yearly fund established to improve the management of Medicaid. Clearly, this was done to help fund this bill, which itself tries to improve Medicaid (along with everything else). Page 213, Sec. 2101 - Alters another bill, the Social Security Act, so that Between October 2005 and September 2009, the amount of money allocated to the Children's Health Insurance Program (CHIP) increases, and this section says that states that want to get this increased funding need to make sure that the health insurance provided under CHIP meets the same standards as those in this bill. Page 216, Sec. 2102 - Alters two other bills, the Social Security Act, and the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA). It looks like it's just coordinating everything so it all makes sense together. Page 217, Sec. 2201 - Alters another bill, the Social Security Act, by adding the following section. Page 217, Sec. 1943 - This calls for the creation of a website for people who use Medicaid and CHIP to sign up for and renew insurance plans using their state's insurance exchanges. Page 219, Sec. 2202 - Alters another bill, the Social Security Act. From what I can tell, it looks like this allows a hospital to choose whether they want to be able to make a determination whether or not a patient is covered under Medicaid. I'm just guessing here, but I think that this is to streamline things and make it easier for hospitals to sign patients up for Medicaid if a patient looks like they might qualify for Medicaid.

Page 220, Sec. 2301 - Alters another bill, the Social Security Act, to allow Medicaid to cover "Freestanding Birth Centers", which look like they are essentially an establishment which is not a hospital, but which provides services to mothers giving birth. So... picture a maternity ward without the rest of the hospital, and that seems like the sort of thing they're describing. Page 221, Sec. 2302 - Alters another bill, the Social Security Act, to say that if a child has been diagnosed with a terminal illness, and the parents have chosen to pay for hospice care, that paying for hospice care doesn't mean that they are giving up any other forms of care that Medicaid and CHIP might provide for their child as well. Page 222, Sec. 2303 - Alters another bill, the Social Security Act, to provide those with a low income (an amount which is to be decided by each State) access to family planning medical services. From what I can tell, this means stuff like STD testing, contraceptives, etc. Okay, it looks like a lot of the stuff coming up pertains to long-term care - for people who are bedridden and need medical supervision, people who are in a nursing home or have an in-home caregiver, etc. Page 225, Sec. 2304 - Alters another bill, the Social Security Act, to clarify the wording of one part. Page 225, Sec. 2401 - Alters another bill, the Social Security Act, so that beginning in October 2011, states may provide those with an income level under 150% of the poverty line (which, like I said in Part 1, is based on your age and how many people are in your household) care in a nursing home, in-home care, etc. It looks like this section is optional for States to follow, but those that choose to do it (and follow numerous standards set in place by this section) will benefit from an increase in Federal funding. Page 230, Sec. 2402 - Directs the Secretary of Health and Human Services to create regulations for various types of state-provided long-term care (again, stuff like nursing homes and in-home care), allowing states to cater to those who could benefit from different kinds of long-term care while still working within pre-set standards. Page 233, Sec. 2403 - Alters another bill, the Deficit Reduction Act of 2005. Reading around on this, it looks like this has to do with states funding long-term care, and transitioning into and out of hospitals (as opposed to nursing homes and in-home care). The Deficit Reduction Act had a part to smooth this transition, and this section extends that part, as well as expanding the people it can cover (based on how long a person has been receiving long-term care). Page 234, Sec. 2404 - Alters another bill, the Social Security Act. It's hard to parse through this one, since it bounces around to different sections of the Social Security Act, but the gist of it seems to deal with a part of the Social Security Act that happens when your spouse becomes institutionalized in some form of long-term care, and the state helps with your expenses during that time (because long-term medical care can be costly). This section seems to make it so that from 2014-2019, this help also includes medical coverage. Page 234, Sec. 2405 - Sets aside $50,000,000 (over a five-year period) to help pay for another bill, the Older Americans Act of 1965. Page 234, Sec. 2406 - This is basically the bill talking about how important a topic long-term care is, and saying in a general way that Congress should talk about it more and that more support should be made for community-level care (like nursing homes and in-home care) as opposed to only hospital care. Page 235, Sec. 2501 - Alters another bill, the Social Security Act, to increase the size of the drug

rebates poor people get through Medicaid, and also to specify that no rebates are to be for an amount higher than the average price of the drug. Page 238, Sec. 2502 - Alters another bill, the Social Security Act, to allow Medicaid to cover more types of drugs, including Barbiturates, Benzodiazepines, and drugs that help people to quit smoking. Page 239, Sec. 2503 - Alters another bill, the Social Security Act. It looks like this sets a way to determine what the limits are for how much Medicaid is supposed to reimburse people for pharmacy drugs. Page 242, Sec. 2551 - Alters another bill, the Social Security Act. This one is cutting a lot of money from payments made to states called Disproportionate Share Hospital (DSH) Payments. These are payments that states then turn over to hospitals to help compensate them for treating emergency patients who don't have insurance. Clearly the idea is that since more patients will have insurance after the PPACA goes into full swing, hospitals won't need as much of these funds. From 2014-2020, $18.1 Billion will be cut from the amount given to states for this, and the Secretary of Health and Human Services is to decide how much each state gets cut based on what percentage of their population is insured, as well as a few other factors. Page 243, Sec. 2601 - Alters another bill, the Social Security Act. I'm not entirely sure about this, because it's hard to find information on it, but it looks like it gives states the option to get 5-10-year waivers so they don't have to follow Federal regulations for Medicaid when it comes to "Demonstration Projects" (Look farther down to see some of these), which looks like they are ways to test out new alternate approaches to Medicaid. However, the Secretary of Health and Human Resources can pull the plug on these waivers if it looks like a Demonstration Project isn't working the way it is intended. Page 244, Sec. 2602 - Directs the Secretary of Health and Human Resources to create the Federal Coordinated Health Care Office, which is in charge of managing the areas of overlap between Medicare and Medicaid, to make it more effective and efficient for people who qualify for both to get the services they're covered for, and make sure there's not any waste. Page 246, Sec. 2701 - Alters another bill, the Social Security Act, to add the next section. Page 246, Sec. 1139B - On a yearly basis from 2011-2014, and then every three years after 2014, the Secretary of Health and Human Services is to write a report on recommended standards for adult care for Medicaid patients, much like a similar report that's already written for children. This section also calls for the establishment of the Medicaid Quality Measurement Program to develop and test better methods of adult care (again, like a similar program already in existence for children). $60 Million will be set aside every year from 2010-2014 to fund this program. Page 248, Sec. 2702 - From what I can tell, this part directs the Secretary of Health and Human Services to look at individual state practices that withhold payment from hospitals for health conditions caused by the hospitals' own neglect and negligence, and adopt them as general Medicaid practices. Page 248, Sec. 2703 - Alters another bill, the Social Security Act, so that starting in 2011, states may choose to offer medical plans for those with chronic conditions that they're calling a "Health Home", which appears to be a phrase that doesn't mean what it seems to. A "Health Home" doesn't seem to be an actual "home" per se, but more like a team of specialists assigned to look after you and coordinate your care. Page 252, Sec. 2704 - From 2012-2016, the Secretary of Health and Human Resources will start up one of those "Demonstration Projects" I mentioned earlier to test the effectiveness of doing bundled programs in Medicaid.

Page 254, Sec. 2705 - From 2010-2012,The Secretary of Health and Human Resources will start up another one of those "Demonstration Projects" to give participating States an option to try out a different Medicaid payment structure for hospitals, so instead of paying hospitals based on the quantity of service they give, it's based on the quality. Page 255, Sec. 2706 - From 2012-2016, The Secretary of Health and Human Resources will start up another one of those "Demonstration Projects". This one gives states the opportunity to allow hospitals to become "Pediatric Accountable Care Organization", which looks like it's a way to reward Pediatric hospitals who find ways of saving money without reducing the amount of care patients receive. Page 256, Sec. 2707 - The Secretary of Health and Human Resources will start up another "Demonstration Project". This one gives states the opportunity to allow private psychiatric hospitals to be covered under Medicaid. This section allocates $75 Million for this, and specifies that it will be a three-year project that will happen sometime between 2011 and 2015. Page 258, Sec. 2801 - Alters another bill, the Social Security Act, to try to improve MACPAC, which looks like it handles Medicaid and CHIP payments. This section clarifies wording, emphasizes efficiency and preventive care, and adds in a bunch of directions to communicate more clearly and frequently with Congress and the states, as well as coordinating with MedPAC, which handles Medicare payments. It also allocates $9 Million for this in 2010, as well as reallocating $2 Million from Social Security for this (out of $12 Billion that year - so comparatively speaking not much). Page 263, Sec. 2901 - Goes into more detail on some rules regarding Native American Indians and the Indian Health Service. Page 263, Sec. 2902 - Alters another bill, the Social Security Act, so that a reimbursement to Native American Indian hospitals under Medicare Part B, previously due to expire in 2010, will continue on. Page 264, Sec. 2951 - Alters another bill, the Social Security Act, to add the next section. Page 264, Sec. 511 - 6 months after the bill passes, all states must conduct a "statewide needs assessment" to identify communities with high levels of crime, poverty, etc., how good state programs are at providing at-home medical visits for children, and the effectiveness of substance abuse treatment programs. States are report this information to the Secretary of Health and Human Resources, as well as informing the Secretary of what they intend to do to improve the situation in their state. This section authorizes the Secretary to make grants to states for these improvements (with an emphasis on communities in particularly bad shape), and directs the Secretary to track the improvements made after 3-5 years. This section also directs the Secretary to coordinate these efforts with the Maternal and Child Health Bureau and the Administration for Children and Families. From 2010-2014, $1.5 Billion is set aside for this section. Page 274, Sec. 2952 - Directs the Director of the National Institute of Mental Health to conduct a study on postpartum depression, and alters another bill, the Social Security Act, to add the next section. Page 275, Sec. 512 - Directs the Secretary of Health and Human Services to use grant money for projects to diagnose and treat postpartum depression. The Secretary is to track the progress of these projects and report to Congress on the results. $3 Million is set aside for this in 2010, and "sums as may be necessary" in 2011 and 2012. Page 277, Sec. 2953 - Alters another bill, the Social Security Act, to add the next section. Page 277, Sec. 513 - From 2010-2014, the Secretary of Health and Human Resources will give each state funding (based on the size of that state's population between ages 10-19) for sex education programs (pushing both abstinence and contraception). $375 Million is to be set aside for this from 2010-2014,

with some of that specifically set aside for youths who are homeless, have AIDS, live in areas with high youth birth rates, etc. Along with this, there are calls for studies to see how effective these programs are in reducing youth pregnancy rates. Page 282, Sec. 2954 - Alters another bill, the Social Security Act, to reinstate funding for abstinenceonly sex education programs from 2010-2014. Page 283, Sec. 2955 - Alters another bill, the Social Security Act, so that starting in 2010, children without a parent (or who don't want their parents to be in charge of their medical decisions) are given more information about the importance of designating a Power of Attorney when it looks like they may need one to make medical decisions for them. Page 285, Sec. 3001 - Alters another bill, the Social Security Act, so that starting in 2013, the Secretary of Health and Human Services will establish a "hospital value-based purchasing program" so that instead of reimbursing hospitals based on the number of patients they have treated, they are reimbursed based on their success with a measure of specific conditions (heart failure, pneumonia, acute myocardial infarction), surgeries, and stuff like negligence. These measures are to take into account stuff like age, sex, race, severity of illness, etc., as well as the hospitals' prior success with these conditions, how much they've improved, and how they compare to other hospitals. Page 296, Sec. 3002 - Alters another bill, the Social Security Act, to extend a program called the Physician Quality Reporting System, which offers an increase in pay as an incentive to doctors to report to the Secretary of Health and Human Services about the quality measures taken in their hospital. This amount decreases in 2012, and ends in 2015. Starting in 2015, doctors who fail to make these reports will have their pay reduced, and in 2016 it will be reduced even further. Page 298, Sec. 3003 - Alters another bill, the Social Security Act, to direct the Secretary of Health and Human Services, starting in 2012, to use claims data (and possibly other data) to give doctors information about resources and methods available to them to improve care for their patients. Page 301, Sec. 3004 - Alters another bill, the Social Security Act, to make it so that starting in 2014, long-term care hospitals that fail to report to the Secretary of Health and Human Services about the quality measures taken in their hospital will receive reduced funding. Page 304, Sec. 3005 - Alters another bill, the Social Security Act, to direct "PPS-Exempt Cancer Hospitals", beginning in 2014, to report to the Secretary of Health and Human Services about the quality measures taken in their hospital. Page 305, Sec. 3006 - Directs the Secretary of Health and Human Services to develop a "value-based purchasing plan" in Medicare for "skilled nursing facilities", "home health agencies" and "ambulatory surgical centers", to make the pay they get under Medicare to be based on the quality of care they give based on criteria to be determined by the Secretary. These plans were to be presented to Congress throughout 2011. Page 307, Sec. 3007 - Alters another bill, the Social Security Act, to direct the Secretary of Health and Human Services to come up with a "value-based payment modifier" to begin in 2013, which will pay doctors based on the quality and cost-effectiveness of their care (based on measures to be set by the Secretary). Page 310, Sec. 3008 - Alters another bill, the Social Security Act, so that starting in 2015, hospitals get less money when they treat patients for problems caused by their own negligence. This section also directs the Secretary of Health and Human Services to conduct a study in 2012 to see how this change will affect quality of care and costs. Page 312, Sec. 3011 - Alters another bill, the Public Health Service Act, to add the next section.

Page 312, Sec. 399HH - Directs the Secretary of Health and Human Resources to create a report in 2011 on a strategy to improve the delivery of health care services that will be presented to Congress. This strategy will be updated at least once a year, with annual updates submitted to Congress. Page 314, Sec. 3012 - Directs the President to put together an "Interagency Working Group on Health Care Quality", comprised of senior representatives from numerous agencies and departments (everything from the Department of Health and Human Services to the US Coast Guard), with the purpose of coordinating efforts between departments as they pertain to the strategy outlined in the last section. This group is to present a yearly report to Congress on their progress and recommendations. Page 315, Sec. 3013 - Alters another bill, the Public Health Service Act, to reorganize a part of that bill to make room for the following section, which is to be added. Page 316, Sec. 931 - Directs the Secretary of Health and Human Resources to consult with the Director of the Agency for Healthcare Research and Quality and the Administrator of the Centers for Medicare & Medicaid Services at least three times a year to look for any gaps in their quality measures. The Secretary will award grants to expand these quality measures as needed. This section also alters another bill, the Social Security Act, to have the Administrator of the Center for Medicare & Medicaid Services develop quality measures for those programs. From 2010-2014, $375 Million will be set aside for this section. Page 319, Sec. 3014 - Alters another bill, the Social Security Act. The part of the Social Security Act it refers to creates a privately-owned non-profit group comprised of both health insurance representatives, as well as representatives of consumer advocacy groups, whose job it is to recommend ways to improve the quality and efficiency of health-care. What this section looks like it does is direct this group to recommend specific measures, and direct the Secretary of Health and Human Resources to keep track of how well these measures do. Page 323, Sec. 3015 - Alters another bill, the Public Health Service Act, to add the next section. Page 323, Sec. 399II - The language is a bit confusing, but it looks like this section directs the Secretary of Health and Human Resources to create more efficient ways to collect data on the cost and effectiveness of health care, and directs the Secretary to give grants and contracts to organizations and individuals that will assist in this task. Page 324, Sec. 399JJ - Directs the Secretary of Health and Human Resources to create a website to report to the public on how successful the measures taken to ensure quality of care have been. This report will be provider-specific, so it looks like this will actually be a way to compare how effective different health care providers are. Page 325, Sec. 3021 - Alters another bill, the Social Security Act, to add the next section. Page 325, Sec. 115A - Starting on January 1, 2011, this section creates something called the Center for Medicare and Medicaid Innovation (CMI), meant to test new ways to make Medicare services and payments easier and more efficient, while keeping or improving the quality of care for patients. They have a website, which you can see here. There are 20 methods to be tested that are outlined in the ACA, but the Secretary may direct the CMI to test others that look like they have a good chance of improving Medicare and Medicaid. $10,005,000,000 will be set aside for this program from 2010-2019. Starting in 2012, the Secretary of Health and Human Resources is to submit a yearly report to Congress on the CMI. A few other minor language changes are made to the Social Security Act as well, mostly to accommodate the addition of the CMI. Page 332, Sec. 3022 - Alters another bill, the Social Security Act, to add the next section. Page 332, Sec. 1899 - By January 1, 2012, the Secretary of health and Human Services is to establish

the Medicare Shared Savings Program. This program allows for the creation of Accountable Care Organizations (ACOs), organizations comprised of a group of health care providers (hospitals, doctors, etc.). These organizations may then receive payments for lowering costs while maintaining standards of care for Medicare patients. The Secretary of Health and Human Services is to determine what these standards are, and how they are to be measured and reported. Basically, if a hospital or other qualified group of caregivers can find ways to reduce Medicare costs without sacrificing quality of care, they'll be rewarded for doing so (and undoubtedly successful methods can then be extended to other areas of Medicare). Page 337, Sec. 3023 - By January 1, 2013, the Secretary of Health and Human Services to establish a "pilot program" to test to see if hospitals and doctors bundling payments (like how your cable and internet bill might be bundled) can help to lower costs without lowering the quality of care for patients. By January 1, 2015, the Secretary is to report to Congress on the progress of this program. By January 1, 2016, the Secretary is to report to Congress on the results of this program. Page 343, Sec. 3024 - Alters another bill, the Social Security Act, to add the next section. Page 343, Sec. 1866E - Starting January 1, 2012, the Secretary of Health and Human Services to create a "demonstration program" to test payment incentives for doctors, nurses, etc. that provide on-call 24/7 in-home care. Basically, it looks like the thinking is that maybe if people with chronic conditions can get check-ups at home, they'll be less likely to need to go back to the hospital repeatedly for the same problem, less likely to make a trip to the emergency room, and more likely to get better-quality care. The Secretary of Health and Human Services is to develop standards for the care given to patients, and doctors who can reduce the costs of care for their patients while still meeting these standards will get incentive payments. $30,000,000 is set aside for this program from 2010-2015, and the Secretary is to report to Congress on its progress. The next few sections focus on reducing readmissions, where a patient keeps coming back for the same problem. Apparently, this is a big drain on Medicare. "One in five patients discharged from a hospital approximately 2.6 million seniors - is readmitted within 30 days, at a cost of over $26 billion every year" ( Source: The Center for Medicare and Medicaid Innovation ). Page 347, Sec. 3025 - Alters another bill, the Social Security Act, so that starting in 2012, the payments made under Medicare to hospitals will be slightly reduced in cases of excessive readmission. This is apparently to encourage hospitals to fix the problem a patient comes in with in the first place. This section also adds the following section to another bill, the Public Health Service Act. Page 352, Sec. 399KK - Within two years of the enactment of this section (So... March, 2012, I think), the Secretary of Health and Human Services will make a program for hospitals with a high amount of readmissions to improve their readmission rates. So, while the previous section penalizes them for having too many readmissions, this one helps them to get their readmissions to acceptable levels. Hospitals that do this will report to the Secretary on the changes they make and how effective they are. Page 352, Sec. 3026 - From January 1, 2011, to January 1, 2016, the Secretary of Health and Human Resources will create a program to try and improve the care for patients being transitioned from one location (like a hospital) to another (such as the at-home care or Community-Based Organizations, for the purpose of reducing readmissions. Page 354, Sec. 3027 - Alters another bill, the Deficit Reduction Act of 2005, to extend a demonstration project in that bill to last roughly another year, and setting aside an additional $1,600,000 for this. This demonstration project had to do with gainsharing. From what I can tell, it looks like the idea is to give doctors and hospital staff incentive to reduce costs (without reducing the quality of care) by giving them a portion of that savings.

Page 355, Sec. 3101 - This section was repealed. I'm not sure what it was before, but it's nothing more than a placeholder now. Page 355, Sec. 3102 - Alters another bill, the Social Security Act, to renew one part that sets a bottom limit for the Work Geographic Index (used for determining Medicare costs), as well as adding what looks like some additional criteria for determining those costs. Page 357, Sec. 3103 - Alters another bill, the Social Security Act, to renew one part that allows people to be exempted from some of the costs due to physical therapy expenses. Page 357, Sec. 3104 - Alters another bill, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. It's really hard to read through this, but as best I can tell, this just extends Medicare payments for laboratory services for an additional year (2010). Page 357, Sec. 3105 - Alters another bill, the Social Security Act. This one's also a bit difficult to read, but from what I can tell, it's just renewing funding for ambulance services for Medicare patients through 2011. Page 357, Sec. 3106 - Alters another bill, the Medicare, Medicaid, and SCHIP Extension Act of 2007. Another one that's difficult to read, but from what I can tell, it's just renewing funding for long-term care hospitals for Medicare patients for another two years. Page 357, Sec. 3107 - Alters another bill, the Medicare Improvements for Patients and Providers Act of 2008, extending funding for mental health treatments for Medicare patients an additional year (until 2010). Page 358, Sec. 3108 - Alters another bill, the Social Security Act, so that starting on January 1, 2011, Physician Assistants are added to the list of professionals (line nurses and doctors) allowed to order "post-hospital extended care services", services that a patient can be given after a 3+ day stay at a hospital. In other words, it's just giving physician assistants more freedom to sign you up for services you need after a long hospital stay. Page 358, Sec. 3109 - Alters another bill, the Social Security Act. It looks like this is just clarifying when pharmacies have to send accreditation information regarding their quality standards to the Secretary of Health and Human Services, as well as indicating exemptions for certain types of pharmacies. Page 359, Sec. 3110 - Alters another bill, the Social Security Act. It looks like the gist of it is that some beneficiaries of Tricare (civilian health benefits for veterans) will have an additional year to enroll in Medicare Part B, if they choose to do so. Page 360, Sec. 3111 - Alters another bill, the Social Security Act, to reduce the amount paid to hospitals for X-Ray bone density scans in 2010 and 2011, as well as directing the Secretary of Health and Human Resources to work with the Institute of Medicine of the National Academies to conduct a report on the effect that this has. Page 361, Sec. 3112 - Alters another bill, the Social Security Act, to cut all the funds going to the Medicare Improvement Fund in 2014. Specifically, this is cutting $22,290,000,000. Most likely this cut is because the PPACA does many of the same things the Medicare Improvement Fund is intended to, so this payment would be redundant. Page 361, Sec. 3113 - Directs the Secretary of Health and Human Services to conduct a two-year demonstration project, starting July 1, 2011, where complex lab tests are paid using separate payments. No later than two years after the demonstration project is completed (so by July 1, 2015), the Secretary

is to report to Congress on how this affected expenses and quality of care. $5,000,000 is set aside for this section from the Centers for Medicare & Medicaid Services Program Management Account, and the actual payments themselves are to get funds from the Federal Supplemental Medical Insurance Trust Fund. Page 362, Sec. 3114 - Alters another bill, the Social Security Act, so that starting on January 1, 2011, nurse-midwife services received through a fee schedule can receive up to as much as if those same services were administered by a doctor. The apparent purpose is to make nurse-midwife services more accessible. Page 363, Sec. 3121 - Alters another bill, the Social Security Act, to renew Medicare coverage for outpatient services in rural hospitals for another year (through January 1, 2011). Page 363, Sec. 3122 - Alters another bill, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, to extend from July 1, 2010 to July 1, 2011, payments to rural hospitals for clinical diagnostic laboratory tests covered under Medicare Part B. Page 363, Sec. 3123 - Alters another bill, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, to extend for an additional 5 years (ending sometime in 2014) a demonstration project to establish rural community hospitals. In addition, the number of these hospitals is doubled from 15 to 30, and the Secretary of Health and Human Services is to expand the states in which these hospitals can be located. This section also makes a series of minor language changes to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to make the language fit better. Page 364, Sec. 3124 - Alters another bill, the Social Security Act, to extend the Medicare Dependent Hospital (MDH) program for rural hospitals for another year (through October 1, 2012). Page 365, Sec. 3125 - Alters another bill, the Social Security Act, For the fiscal years 2011 and 2012, the amount paid to low-volume hospitals is increased by up to 25%, based on how many patients they've discharged. In addition, for those years, what qualifies as a "low-volume hospital" is expanded to include hospitals that are over 15 miles away from another qualifying hospital (instead of 25 miles away). Page 365, Sec. 3126 - Alters another bill, the Medicare Improvements for Patients and Providers Act of 2008, to expand a demonstration project revolving around community-level integrated health services on a county-by-county level. This section also removes the restriction on the number of counties that can be included in this demonstration project, and replaces some terminology. Page 366, Sec. 3127 - Directs the Medicare Payment Advisory Commission to conduct a study on how adequate payments to rural hospitals are. This report is to be given to Congress by January 1, 2011. Page 366, Sec. 3128 - Alters another bill, the Social Security Act, to increase payments for emergency hospital services and ambulances from 100% of what is deemed a "reasonable cost" to 101%. Page 366, Sec. 3129 - Alters another bill, the Social Security Act, so that starting on January 1, 2010, grant money in that bill given to rural hospitals stays available until it is used (rather than expiring). It also adds that this grant money can now be used to make sure these hospitals are up to the standards set in the PPACA. Page 367, Sec. 3131 - Alters another bill, the Social Security Act, so that starting in 2014, the Secretary of Health and Human Services will start to phase in changes to the amounts paid to caregivers for home health services, based on a number of factors, including the type and cost of services, whether the caregiver is rural or urban, whether the caregiver is for-profit or non-profit, etc. The phase-in is to be across 4 years, to make sure the shift in payments isn't too much of a shock to the market. In addition,

this section directs the Medicare Payment Advisory Commission to conduct a study on the effect this has on access to and quality of care. This report is to be given to Congress by January 1, 2015. On top of that, this section makes a number of smaller edits to indicate that the Secretary is to limit the amounts paid to these caregivers in a number of different ways. This section also alters another bill, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, to increase the payments made to rural home health services by 3% from April 1, 2010 to January 1, 2016. The Secretary is to conduct a study on home health agency costs for Medicare beneficiaries. The Secretary is to present this report to Congress no later than March 1, 2014. Also, after seeing the results of this study, the Secretary may conduct a demonstration project to test the changes recommended to improve services. If the Secretary decides to go ahead with this demonstration project, it is to last for four years, and start no later than January 1, 2015. The secretary is to set aside $500,000,000 from the the Federal Hospital Insurance Trust Fund to fund both the study and the demonstration project. And if the Secretary does choose to go ahead with this demonstration, he is to evaluate and report on it to Congress. Page 371, Sec. 3132 - Alters another bill, the Social Security Act, to direct the Secretary of Health and Human Services to gather data on payments for hospice care starting no later than January 1, 2011. At some point after October 1, 2013, the Secretary is to revise payments for hospice care. This section also says that a hospice care provider can only continue services if every 180 days they have a face-to-face meeting with the patient to determine whether that patient still needs hospice care. Page 373, Sec. 3133 - Alters another bill, the Social Security Act, so that starting in 2014, the method for determining disproportionate share hospital payments (payments to hospitals who treat indigent patients). will change, to be determined by a number of factors outlined here. It's a bit complicated, but the short version is that it looks like it'll be cutting these payments by about 75%, give or take. This is probably because it is expected that these hospitals will have far fewer uninsured patients to treat. Page 375, Sec. 3134 - Alters another bill, the Social Security Act, directing the Secretary of Health and Human Services to identify which services are "misvalued" (that are more expensive than they need to be or can be made more efficient through bundling). The Secretary is to make adjustments to the amount we pay hospitals for these services. This section also repeals a part of another bill, the Balanced Budget Act of 1997, that seems to direct the Secretary to just accept the generally accepted costs for these services. It also repeals a part of the Social Security Act that I'm having difficulty finding, but looks like it was something similar. Page 377, Sec. 3135 - Alters another bill, the Social Security Act. I had to do some looking around online to get a feel for just what this does, but from what I see here, it looks like starting in 2011, it's increasing from 50% to 75% a rate used in determining expenses related to costly diagnostic imaging equipment. and reduces the payments for the use of this equipment by 25%. This section also directs the Chief Actuary of the Centers for Medicare & Medicaid Services to report on whether this change in payments will reduce costs by $3,000,000,000. That report is to be made available no later than January 1, 2013. That strikes me as an oddly specific number, so I suspect that they expect that this will save that much. Page 378, Sec. 3136 - Alters another bill, the Social Security Act, to change the Medicare payment for powered wheelchairs. Beginning on January 1, 2011, for the first three months of paying for a powered wheelchair, it goes up from 10% of the cost to 15% of the cost, and for subsequent months it goes down from 7.5% of the cost to 6% of the cost. Page 379, Sec. 3137 - This one had me stuck longer than any other section so far. I had to look around for what others said about it to get a better idea. Some thanks go to this Google Books archived book. Anyway, this section alters another bill, the Tax Relief and Health Care Act of 2006, directing the Secretary of Health and Human Resources to report to Congress no later than December 31, 2011 on

reforming the hospital wage index, which determines how Medicare will compensate various medical professionals. Anyway, the Secretary's report is to take numerous factors into consideration,and apparently is meant to contain costs. Page 381, Sec. 3138 - Alters another bill, the Social Security Act, to direct the Secretary of Health and Human Services to conduct a study on the costs associated with cancer hospitals compared to other hospitals. The secretary will determine an adjustment (presumably to payments) to account for the difference in costs. Page 381, Sec. 3139 - Alters another bill, the Social Security Act, referring to payments for biosimilar biologics. Biologics are medical treatments made from living organisms (like vaccines), and "biosimilar" refers to products that are effectively the same as existing products. This section says that Medicare will pay 106% of the cost of existing products for these biosimilar ones. It looks like the idea is to give upstart drug companies a chance to break into the market so they can compete with major drug companies that already exist. Page 382, Sec. 3140 - Directs the Secretary of Health and Human Services to establish a Medicare Hospice Concurrent Care demonstration program, which will last for 3 years. As I understand it, hospice care is care for patients who are dying that doesn't attempt to treat the ailment that the patient is dying from, it only tries to ease their pain. Generally, Medicare recipients have to choose one or the other. The demonstration program this section creates will allow for some patients to choose both. This demonstration program is intended to be cost-neutral, and the Secretary is to report to Congress on how this affected quality of care and cost-effectiveness. Page 383, Sec. 3141 - Directs the Secretary of Health and Human Services in how to go about calculating the Hospital Wage Index Floor apparently, to ensure that no hospital has a wage index beneath what is legally required, while still making the changes in wage indexes budget neutral. Page 383, Sec. 3142 - Directs the Secretary of Health and Human Services to conduct a study on costs and payments in urban Medicare-dependent hospitals. Within 9 months of the enactment of the PPACA, the secretary will submit this report to Congress. Page 384, Sec. 3143 - Says that nothing in the PPACA will reduce home health benefits guaranteed in the Social Security Act. The next series of sections is all about Medicare Advantage. For those unaware, Medicare Advantage (also known as Medicare+Choice and Medicare Part C) is an optional Medicare program for those who want to get their insurance through a private provider. However, since it was created, Medicare Advantage costs have ballooned to be over 12% more than costs for comparable services under traditional Medicare ( source ). The following sections, in a few different ways, seek to bring Medicare Advantage costs back in line with normal Medicare costs. The nonpartisan Congressional Budget Office estimates that from 2012 to 2021, this will save $507 billion ( source ). Page 384, Sec. 3201 - Firstly, this section has been repealed and replaced after the PPACA was passed by another bill, the Health Care and Education Reconciliation Act of 2010 (HCERA). However, the new text has been entered here. It amends another bill, the Social Security Act. It's got a lot of talk about numbers, but the gist of it seems to be that it's going to be lowering the amount paid for Medicare Advantage until the costs are more in line with the costs of normal Medicare. This section seeks to bring those costs back down to something comparable to normal Medicare costs. Page 389, Sec. 3202 - Alters another bill, the Social Security Act, to specify that starting on January 1, 2011, some specific services under Medicare Advantage cannot cost more than those under Medicare

Part A and B. This is essentially just additional details on the cost-saving stuff in section 3201. Also a lot of numbers talk regarding Medicare Advantage rebates. Page 391, Sec. 3203 - Another section repealed and replaced by HCERA. The current section alters another bill, the Social Security Act, to make it so that adjustment of costs for Medicare Advantage services continues on a yearly basis (previously it only continued until 2010). Page 392, Sec. 3204 - Alters another bill, the Social Security Act, so that starting in 2011, for the first 45 days of the year, people enrolled in Medicare Advantage can choose to change their plan to a standard Medicare plan. Page 392, Sec. 3205 - Alters another bill, the Social Security Act, to extend the Medicare Advantage Special Needs Program through 2014, as well as listing a lot of requirements that these plans would need to meet. Page 395, Sec. 3206 - Alters another bill, the Social Security Act, to renew until January 1, 2013 the ability for Medicare recipients to obtain Reasonable Cost Contracts. Page 395, Sec. 3207 - Making some sort of comment noting that the Secretary of Health and Human Services is to extend service area waivers for Medicare Advantage plans for providers who contracted with the Secretary for those waivers prior to October 1, 2009. Page 395, Sec. 3208 - Alters another bill, the Social Security Act, to make permanent senior housing facilities created under a specific demonstration project as of December 31, 2009. Page 396, Sec. 3209 - Alters another bill, the Social Security Act, to clarify that the Secretary of Health and Human Services has the right to reject bids for plans by a Medicare Advantage organization, and bids for plans by a Prescription Drug Plan sponsor, if those plans propose significant increases to costs or reductions to service. Page 396, Sec. 3210 - Alters another bill, the Social Security Act, to direct the Secretary of Health and Human Services to request the National Association of Insurance Commissioners to revise standards for supplemental Medicare benefit plans. The next group of sections deals with Medicare Part D, the Medicare Drug Prescription Program Page 397, Sec. 3301 - Alters another bill, the Social Security Act. Firstly, it says that starting January 1, 2011, any drug companies wanting to continue to work with Medicare Part D must participate in the Medicare Coverage Gap Discount Program outlined in this section. Secondly, it outlines the actual Medicare Coverage Gap Discount Program, which also starts January 1, 2011. This section addresses the infamous "Donut Hole" in coverage, which plagued Medicare recipients who purchased enough drugs to surpass the prescription drug coverage limit, but not enough to qualify for catastrophic coverage. It does so by making the drug companies that work with Medicare give discounts to those who fall within that gap. Page 405, Sec. 3302 - Alters another bill, the Social Security Act, so that the low-income benefit for Medicare part is calculated without taking into consideration discounts and rebates received under Medicare Advantage. This way, those getting discounts like that won't be penalized for it when purchasing drugs. Page 405, Sec. 3303 - Alters another bill, the Social Security Act. From what I can tell, starting January 1, 2011, it makes it so the Secretary of Health and Human Services can allow a prescription drug plan to charge low-income beneficiaries the low-income subsidy if the plan's premium is more expensive than the low-income subsidy plus a "de minimis" amount. That amount is apparently $2 ( source ). Page 406, Sec. 3304 - Alters another bill, the Social Security Act. This section deals with widows and

widowers on low-income assistance. Normally, Centers for Medicare and Medicaid Services check beneficiaries' financial status on a regular basis to make sure they still qualify for low-income programs , and if someone is making too much money in a given timeframe, they may no longer qualify as "low income". However, generally when someone's wife or husband dies, they inherit their significant others' stuff. This section says that that check on beneficiaries' status can not happen within a year of the death of a spouse, so someone isn't dropped from Medicare or Medicaid just because they lost a loved one. This section goes into effect January 1, 2011. Page 406, Sec. 3305 - Alters another bill, the Social Security Act, so that no later than January 1, 2011, when the Secretary of Health and Human Resources reassigns someone to a different Medicare drug plan (apparently due to a change in their economic status), they are to be informed of the differences between their old plan and the new one, as well as being informed of their right to request a coverage determination, exception, or reconsideration. Page 407, Sec. 3306 - Alters another bill, the Medicare Improvements for Patients and Providers Act of 2008, by designating an additional $15,000,000 be set aside to fund the State Health Insurance Program from 2010 through 2012, an additional $15,000,000 be set aside to fund Aging and Disability Resource Centers from 2010 through 2012, an additional $5,000,000 be set aside to fund a contract with the National Center for Benefits and Outreach Enrollment from 2010 through 2012. The Secretary of Health and Human Services can request support from the entities funded by this section for wellness and disease prevention outreach programs. Page 408, Sec. 3307 - Alters another bill, the Social Security Act. As I understand it, starting in 2011, Medicate Advantage insurance companies must include coverage for specific categories of drugs designated by the Secretary of Health and Human Services. Until the secretary designates which drugs are to be covered, these categories are to include anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals, and immunosuppressants for the treatment of transplant rejection. Page 409, Sec. 3308 - Alters another bill, the Social Security Act. From what I can tell, starting on January 1, 2011, if you make over $80,000 ($160,000 for couples filing taxes jointly), your Medicare Part D monthly costs will increase in a fashion similar to Medicare Part B. This amount will be taken out of your social security. Page 412, Sec. 3309 - Alters another bill, the Social Security Act so that on a date no earlier than January 1, 2012, if you're eligible for both Medicare and Medicaid, and receiving home or communitybased services instead of going to a hospital, you can't also qualify for cost-sharing under Medicare Part D. From what I can tell, this is because they can most likely get cost-sharing by other means. Page 412, Sec. 3310 - Alters another bill, the Social Security Act, so that starting on January 1, 2012, drug plans for patients in long-term care facilities must be more efficiently managed and drugs given to patients must be dispensed in a more efficient manner, using uniform dispensing techniques, to reduce waste. Page 413, Sec. 3311 - Directs the Secretary of Health and Human Services to create and maintain a complaint system, to be made available on Medicare.gov, and the Secretary shall report yearly to Congress on this system. It looks like this is the page for complaints. Page 413, Sec. 3312 - Alters another bill, the Social Security Act, to make a standard and uniform appeals process for those who feel their claim should not have been denied. This is to happen by January 1, 2012. Page 414, Sec. 3313 - Directs the Inspector General of the Department of Health and Human Services

to conduct a study about the type of drugs used by those in Medicare Advantage plans, which the Secretary of Health and Human Resources is to present to Congress no later than July 1 every year starting in 2011. The Inspector General is also to conduct a study on the 200 most frequently-used Medicare Part D drugs and their pricing under both normal Medicare and Medicare Advantage. That report is to be given to Congress no later than October 1, 2011. Page 415, Sec. 3314 - Alters another bill, the Social Security Act. This one is hard to parse, but from what I can tell, it makes it so that starting on January 1, 2011, drugs paid by AIDS drug programs and Indian Health Services count towards calculations for determining qualification for Medicare Part D catastrophic care. I imagine that this is because someone with AIDS definitely needs catastrophic care. Not sure what Indian Health Services has to do with anything, though. Page 416, Sec. 3315 - This section was repealed by another bill, HCERA. However, it replaces it with similar text, which is mirrored here. It alters another bill, the Social Security Act, to give a $250 rebate to Medicare recipients who fall into that "donut hole" that I mentioned above in Section 3301. It's only in effect for 2010. Page 417, Sec. 3401 - This section alters another bill, the Social Security Act. It reduces the increases in payments that many various types of medical facilities and services were going to be getting through Medicare, undoubtedly to keep down Medicare's ballooning costs. For some of these services, it reduces those increases gradually, starting at a quarter of a percent less than what those payment increases were going to be, gradually going up to three-quarters of a percent less than what the payment increases were going to be. For some, it reduces increases in payments based on a productivity assessment (which, from what I can tell, is based primarily on what operating costs are). For some, it reduces the increases in payments by a flat amount. And for some, it reduces the increases in payment using some combination of those three methods. It bears note that this is undoubtedly what some alarmists believe is a reduction in Medicare services, but none of these reduce Medicare payments below what they are now, they only slow down the speed at which Medicare costs are rising, and it seems like it's largely trying to keep payments close to the actual costs needed by these facilities and services. Page 426, Sec. 3402 - Alters another bill, the Social Security Act, to say that from January 1, 2011 through December 31, 2019, "income thresholds" (if you earn more than that amount a year, you're considered high-income) for Medicare Part B will be frozen at their 2010 levels, rather than being tied to inflation like they previously had been. Looking around, apparently those thresholds are currently at $85,000 if you're single and $170,000 if you're filing taxes jointly. Freezing the thresholds means they'll stay at those dollar amounts instead of rising with inflation. Page 426, Sec. 3403 - Alters another bill, the Social Security Act, to create the Independent Medicare Advisory Board. This is one of the sections that brought up talk of "death panels!", but the truth is it's pretty benign. The board is to be comprised of 15 experts (who cannot hold any other employment while they are part of the board, so there's no conflict of interest) who are appointed by the President with the advice and consent of the Senate, as well as the Secretary of Health and Human Services, the Administrator of the Center for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration, who will be nonvoting members. The presidential appointees serve 6-year nonconsecutive terms. The board's purpose is to reduce Medicare spending per person by submitting proposals to be enacted by the Secretary unless Congress says otherwise. These proposals must cut costs, must not ration health care, and must not increase costs to Medicare recipients, must not cut Medicare benefits, and must not modify eligibility criteria. In addition, until 2019, these proposals must not reduce payments for hospitals and services (probably because the ACA already does some of that). It can cut payments for administrative expenses. The board is also to try and make its proposals increase Medicare solvency, improve quality of care, improve access to services, and reduce spending

in areas with excess growth in costs, while also taking into consideration the needs of care providers. Before these proposals go to the Secretary, they are to be reviewed by the Medicare Payment Advisory Commission. Then the Secretary reviews them, and then they are brought to Congress. Starting in 2014, these proposals are to be brought to both houses of Congress and the President by January 15 each year. The President will review this proposal for two days before bringing his own proposal to Congress. A few different committees in Congress are to review this proposal and report back to Congress on it by April 1. Congress is not allowed to make another bill to repeal or alter congressional consideration, although the Senate may waive Congressional consideration by use of a three-fifths vote that's subject to appeal. This section goes into all sorts of Congressional rules for how the proposal is to be considered before deciding whether to pass it. Anyway, Congress votes on whether to pass it, and the President may choose to veto it if it is passed (like any other bill). If the proposal passes, it is to be implemented by August 15. Additionally, in 2017, Congress can vote on whether to discontinue the board. If the board didn't create a proposal in a given year, it is still to report to Congress on matters relating to Medicare, and every year regardless it is to create a public report as well. They are also to do a yearly advisory report on recommendations for ways to improve health care outside of Medicare. Page 448, Sec. 3501 - Alters another bill, the Public Health Service Act, to add the next section. Page 448, Sec. 933 - Okay, I've had a damn difficult time trying to find the actual text of the Public Health Service Act. Everything I come up with doesn't seem to fit the text that this bill is inserting into it. This section directs the Director of the Agency for Healthcare Research and Quality to research, create, and to put into practice quality improvement practices and create training for those practices, and to and to this end it directs the Director to establish The Center for Quality Improvement and Patient Safety of AHRQ. This section sets aside $20,000,000 for 2010 though 2014 to be put towards carrying out this section. Page 452, Sec. 934 - Directs the Director of the Agency for Healthcare Research and Quality to give out grants to health providers that need financial help meeting the quality improvement measures mentioned in section 933. Recipients of these grants need to match every $5 of funds they receive with $1 of their own. Page 454, Sec. 3502 - Directs the Secretary of Health and human Services to establish a program to provide grants for community-based "health teams" to support primary care providers. It looks like this is creating a community-based support system of professionals so primary care doctors have specialists to refer patients to. These "health teams" need to have a plan to be self-sustaining within three years. Page 457, Sec. 3503 - Alters another bill, the Public Health Service Act, to add the next section. Page 457, Sec. 935 - Directs the Secretary of Health and Human Resources to establish a program no later than May 1, 2010, to provide grants to implement medication management services for the treatment of chronic diseases. Page 459, Sec. 3504 - Alters another bill, the Public Health Service Act, to change the wording of a few parts and add the following section. Page 459, Sec. 1204 - Directs the Secretary of Health and Human Resources to award at least 4 multiyear contracts to states that support pilot projects to test innovative new ways to do regional emergency care. States have to match every $3 of funds they receive with $1 of their own. Within 90 days of completing a pilot project, states are to report to the Secretary about it. This section also adds the following section. Page 462, Sec. 498D - Directs the Secretary of Health and Human Resources to support research of various government agencies in emergency medical care systems and emergency medicine.

Page 463, Sec. 3505 - Alters another bill, the Public Health Service Act, to direct the Secretary of Health and Human Services to establish 3 programs to award grants to Indian health facilities. The Secretary may also award grants to certain low-income trauma centers. It goes into detail as to what sort of trauma centers can get the grants and what sort of grants they can get. It also further alters the Public Health Service Act by adding the following section. Page 466, Sec. 1245 - Sets aside $100,000,000 to pay for the previous section in 2009, and "such sums as may be necessary" from 2010 through 2015. It also further alters the Public Health Service Act by adding the following section. Page 467, Sec. 1246 - Clarifies what "uncompensated care costs" means. It also further alters the Public Health Service Act by adding the following section. Page 467, Sec. 1281 - Allows states to award grants to create or strengthen trauma centers. Page 469, Sec. 1282 - Sets aside $600,000,000 to pay for the previous section in 2010 though 2015. Page 469, Sec. 3506 - Alters another bill, the Public Health Service Act, to add the following section. Page 469, Sec. 936 - Directs the Secretary of Health and Human Services to create a program to provide grants for the development of "Patient Decision Aids", materials to help patients and doctors to better know what their options are when there is a choice regarding different forms of treatment. These materials are to be made freely available. Page 472, Sec. 3507 - Directs the Secretary of Health and Human Services to conduct a study to determine whether health care decision-making would be improved by standardizing the way drug information is presented on prescription drugs. This study is to be done by 2011, and if it is determined that it would be improved, within 3 years the Secretary is to create regulation to enact that standardization. Page 472, Sec. 3508 - Directs the Secretary of Health and Human Services to award grants for demonstration projects to medical schools that incorporate quality improvement and patient safety into their curriculum. Schools can submit proposals and, the Secretary decides if it's worth trying, and the school tracks data on the new curriculum's results. For every $5 of grant money a school gets for this, the school must contribute $1 themselves. By 2012, the Secretary is to start submitting a yearly report to Congress on what demonstration projects are underway and how well they're doing. Okay, it looks like a lot of the upcoming stuff is establishing an Office on Women's Health in various health departments. They all seem to have a similar purpose - to advise the head of that particular department in matters that pertain to women's health, and in a few cases take over responsibility for functions relating to women's health. Page 473, Sec. 3509 - Alters another bill, the Public Health Service Act, to add the following section. Page 474, Sec. 229 - Establishes an Office on Women's Health under the Secretary of Health and Human Services, to be headed by a Deputy Assistant Secretary for Women’s Health. This office is intended to advise the Secretary on issues relating to women's health, as well as to establish the National Women’s Health Information Center, which is to assist with providing information regarding issues that effect women's health. By 2011, the Secretary is to submit reports to Congress every other year detailing the activities carried out under this section. The Office on Women's Health is to take over the functions previously belonging to the Office on Women’s Health of the Public Health Service. This section also alters another bill, the Public Health Service Act, to add the following section. Page 475, Sec. 310A - Establishes an Office on Women's Health under the Office of the Director of the Centers for Disease Control and Prevention, headed by a director appointed by the Director. This office

is intended to advise the Director on issues relating to women's health. This section also alters another bill, the Public Health Service Act, to add the following section. Page 477, Sec. 925 - Establishes an Office on Women's Health and Gender-Based Research under the Office of the Director of the Agency for Healthcare Research and Quality (note - the section of the Public Health Service Act this refers to is either mislabeled or has since changed. It says it changes Title IX, but it looks like it actually changes Subtitle VII). This office is intended to advise the Director on issues relating to women's health. This section also alters another bill, the Social Security Act, to add the following section. Page 477, Sec. 713 - Directs the Secretary of Health and Human Services to establish an Office on Women's Health under the Office of the Administrator of the Health Resources and Services Administration. This office is intended to advise the Administrator on issues relating to women's health, and to take over any Health Resources and Services Administration programs relating to women’s health. This section also alters another bill, the Federal Food, Drug, and Cosmetic Act, to add the following section. Page 478, Sec. 1101 - Establishes an Office on Women's Health under the Commissioner of Food and Drugs, headed by a director appointed by the Director. This office is intended to advise the Commissioner on issues relating to women's health. This section also clarifies numerous limitations that this office can't do. Page 479, Sec. 3510 - Alters another bill, the Public Health Service Act. It looks like this section extends from 2010 through 2014 something called a "Patient Navigator Program". The most straightforward definition for that term I could find was here: "Patient navigators help patients and their families navigate the fragmented maze of doctors’ offices, clinics, hospitals, out-patient centers, payment systems, support organizations and other components of the healthcare system". So, this is essentially extending a program to help patients find the services they need. Page 480, Sec. 3511 - Authorizes the Secretary of Health and Human Services to appropriate funds for this part of the bill. Page 480, Sec. 3511 - Directs the Comptroller General of the United States and the Government Accountability Office to conduct a study to see whether some of the new requirements of this bill might result in new legal claims against health care providers. This report was to be submitted to Congress by 2012. That report can be seen here. Their answer, in short, is that no, it won't. Page 481, Sec. 3601 - Says that nothing in this bill will reduce guaranteed Medicare benefits, and any savings this bill makes to Medicare will be reinvested back into Medicare to extend its solvency, reduce its premiums, or increase its benefits. Page 481, Sec. 3602 - (So short I might as well copy-paste it here) - Nothing in this Act shall result in the reduction or elimination of any benefits guaranteed by law to participants in Medicare Advantage plans. Page 482, Sec. 4001 - Directs the President to establish a National Prevention, Health Promotion and Public Health Council, headed by the Surgeon General and staffed by various Secretaries ranging from the Secretary of Health and Human Services to the Secretary of Homeland Security . This council is to coordinate national health care strategy, and provide recommendations to the President regarding ways to promote healthy lifestyles. The President is also directed to establish an Advisory Group on Prevention, Health Promotion, and Integrative and Public Health, comprised of 25 Presidential appointees who are health care professionals. This group is to develop policy

recommendations for the Council. From July 1, 2010 through January 1, 2015, the Council is to report yearly to Congress on their efforts, goals, plans, and programs. The Secretary of Health and Human Resources and the Comptroller General of the United States are to conduct reviews at least every 5 years to evaluate these programs' effectiveness. Page 485, Sec. 4002 - Establishes a Prevention and Public Health Fund to finance programs in the Public Health Service Act. This fund is to get appropriated $500,000,000 in 2010, gradually ramping up every year until 2015 and every subsequent year, where the fund will appropriate $2,000,000,000. Page 485, Sec. 4003 - Alters another bill, the Public Health Service Act, to establish the US Preventative Services Task Force, an independent panel of health experts, whose job will be to review the scientific evidence related to the effectiveness, appropriateness, and cost-effectiveness of preventive services, and to develop recommendations for improvement to the health care community. They are also to submit yearly reports to Congress on gaps in scientific research on preventive services. This section also alters another bill, the Public Health Service Act, to add the following section. Page 487, Sec. 399U - Directs the Director of the Centers for Disease Control and Prevention to convene an independent Community Preventive Services Task Force. Their job is similar to the US Preventative Services Task Force described in the previous section, except their focus is on the community level. Page 488, Sec. 4004 - Directs the The Secretary of Health and Human Services to develop a plan by 2011 to raise public awareness of the importance of preventive care and healthy living standards. The campaign will be independently evaluated every 2 years, and reports of these evaluations will be made to Congress. The information this plan seeks to spread will be done both with the cooperation of health care providers, as well as through a website with a "personalized preventive plan tool" that calculates your personal statistics and then formulates recommendations for changes in your lifestyle. I believe http://www.healthfinder.gov/ is the website in question. It is specified that no more than $500,000,000 in funding is to be set aside for this section. Every three years, from January 1, 2011 through January 1, 2017, the Secretary is to report to Congress on the status of this section. Page 490, Sec. 4101 - Directs the Secretary of Health and Human Services to award grants to schools that establish School-Based Health Centers, with a preference towards those that would serve a large population of children. $200,000,000 is set aside for these grants for 2010-2013. This section also alters another bill, the Public Health Service Act, to add the following section. Page 491, Sec. 399Z - Clarifies the definitions of terms and specifics regarding the implementation of the School-Based Health Centers mentioned in the previous section. Page 495, Sec. 4102 - Alters another bill, the Public Health Service Act, to add the following section. Page 495, Sec. 399LL - Directs the Secretary of Health and Human Services to establish a 5-year public education campaign on oral healthcare prevention and education. This campaign shall be implemented no later than 2012. Page 495, Sec. 399LL-1 - Directs the Secretary of Health and Human Services to award grants to community dental offices that demonstrate effective use of research-based disease management activities. Page 496, Sec. 399LL-2 - Alters another bill, the Public Health Service Act, to extend eligibility for the above grants to US territories (in addition to the States and Indian tribes). The Secretary of Health and Human Services is directed to coordinate with the States, territories, and Indian Tribes on issues of dental health. Incidentally, this section has what I personally find to be one of the most amusing subsections I've come across, labeled "UPDATING NATIONAL ORAL HEALTHCARE

SURVEILLANCE ACTIVITIES", which brings to mind tinfoil hat conspiracies about the government eavesdropping on you using your metal fillings. However, what it seems to do is direct the Secretary to expand the Pregnancy Risk Assessment Monitoring System to cover dental care as well. Also, the Secretary is to use funds as necessary to expand the tracking of data on dental care to all fifty States, territories, and the District of Columbia. Page 497, Sec. 4103 - Alters another bill, the Social Security Act, to have Medicare cover the creation of plans that include an annual "Personalized Prevention Plan Service", where a doctor will determine, based on a patient's medical history and other factors, what health conditions the patient is most at risk of, and recommend lifestyle changes to offset that risk. This is to be done by January 1, 2011. Also, by 2011, the Secretary will make such services available by phone or internet. Page 501, Sec. 4104 - Alters another bill, the Social Security Act. From what I can tell, this clarifies some language to make more kinds of preventive care more accessible to Medicare recipients. This goes into effect January 1, 2011. Page 502, Sec. 4105 - Alters another bill, the Social Security Act, so that starting on January 1, 2010, the Secretary of Health and Human Services may modify Medicare coverage of preventive services if the United States Preventive Services Task Force recommends it (and if such modification won't affect the coverage of diagnostic or treatment services), and if the United States Preventive Services Task Force rates said service low enough, the Secretary may withhold funding for it altogether. Page 503, Sec. 4106 - Alters another bill, the Social Security Act, so that starting on January 1, 2013, covered Medicaid preventive services expand to include those recommended by the U.S. Preventive Services Task Force, as well as any recommended to a patient by a doctor within the scope of that doctor's practice. Page 504, Sec. 4107 - Alters another bill, the Social Security Act, so that Medicaid covers counseling for pregnant women to quit tobacco use. Page 505, Sec. 4108 - Starting on January 1, 2011, the Secretary of Health and Human Services will award grants to states, so the states can in turn provide incentives to Medicare beneficiaries who enroll in a program to reduce their health risks by making healthy changes to their lifestyle (quitting tobacco, losing weight, etc.). The results of these state programs are to be tracked, and by January 1, 2014, the Secretary is to report to Congress on their effectiveness and whether these programs should be renewed for another two years. The Secretary is to make another report to Congress by July 1, 2016 on their effectiveness, along with recommendations for legislation regarding those results. $100,000,000 is to be set aside for this section from January 1, 2011 to January 1, 2016. Page 508, Sec. 4201 - Directs the Secretary of Health and Human Services to award grants to state and local agencies and community organizations for "evidence-based community preventive health activities". It gives a few examples of what sort of activities it means, like creating healthier schools, increasing access to exercise and healthy food options, etc. The states and agencies are to then report back on the results. The Secretary is also to make available training for proven ways to establish these health activities. There's a bit about none of the grant money going to fund videogames (no Dance Dance Revolution? Aw, sad), or anything that might raise obesity and inactivity. The Secretary is authorized to set aside funds as needed for this section from 2010 through 2014. Page 511, Sec. 4202 - Directs the Secretary of Health and Human Services to award grants to State or local health departments and Indian tribes to carry out 5-year pilot programs regarding "public health interventions" for people aged 55 to 64. Despite the different name, it sounds similar to the last section - programs to encourage and improve access to healthy living standards. Participating states are to

locate problem areas and report on their progress. The Secretary is authorized to set $50,000,000 for this section from 2010 through 2014. Both the Secretary and the Administrator of the Centers for Medicare & Medicaid Services are to evaluate these programs, both overall and as they pertain to Medicare and Medicaid. By September 30, 2013, the Secretary is to report to Congress on these programs. Page 515, Sec. 4203 - Alters another bill, the Rehabilitation Act of 1973 by adding the following section. Page 515, Sec. 510 - Directs the Architectural and Transportation Barriers Compliance Board to create standards for medical equipment used in hospitals. Page 515, Sec. 4204 - Alters another bill, the Public Health Service Act, to allow the Secretary of Health and Human Services to negotiate contracts for buying vaccines (instead of just buying them directly). This section also establishes a Demonstration Project to give grants to states that improve their immunization coverage. States that get these grants is to report back within 3 years regarding their progress. Within 4 years, the Secretary is to report to Congress on the effectiveness of this Demonstration Project. This section also reauthorizes a perviously-existing immunization program. Additionally, this section directs the Comptroller General of the United States to conduct a study to determine how well patients on Medicare can access vaccines through Medicare Part D. This report is to be submitted to Congress by June 1, 2011. $1,000,000 is set aside to fund this section. Page 518, Sec. 4205 - Alters another bill, the Federal Food, Drug, and Cosmetic Act, to require chain restaurants (restaurants with 20 or more locations) and vending machines owned by vendors with 20 or more machines, to list health information about their foods to customers. This doesn't apply to temporary menu items and condiments. This information is to be displayed in a uniform fashion. If you've been in a McDonalds and see that their menu now has calorie counts listed next to all their foods, that's essentially what this section did. Page 521, Sec. 4206 - Alters another bill, the Public Health Service Act, to direct the Secretary of Health and Human Services to start up a pilot program to try out "individualized wellness programs" in up to 10 at-risk communities. These individualized wellness programs are more or less diet and exercise programs custom-designed for the individual. Page 522, Sec. 4207 - Alters another bill, the Fair Labor Standards Act of 1938 so that employers with 50 or more employees must give female employees with a child under a year old unpaid breaks to "express breast milk". I assume this means that she's putting it in a bottle or something and not actually feeding the baby at work. These employers need to designate a private place other than the bathroom that this can be done in. Page 523, Sec. 4301 - Directs the Secretary of Health and Human Services to fund research into the cost and effectiveness of public health services. The Secretary is to report to Congress on this on a yearly basis. Page 523, Sec. 4302 - Alters another bill, the Public Health Service Act, to add the following section. Page 523, Sec. 4302 - Directs the Secretary to ensure that by 2012, all federal health programs collect demographic data (age, race, gender, etc.), which is then shared with numerous government health departments. This section forbids the use of any of this information in a way that could adversely affect any individual. The data is also to be secured and protected. This section also amends the Social Security Act to ensure that demographic data collected by Medicare meets the requirements of this section. This section also amends the Social Security Act to add the following section. Page 527, Sec. 1946 - Directs the Secretary of Health and Human Services to evaluate the information

collected in the last section and within 18 months of the passing of the Act, report to Congress on the collection of that demographic data, along with recommendations to improve collecting that data. Within two years, the Secretary is to make those improvements. Every four years, the Secretary is to report to Congress on health care disparities based on that demographic data and recommendations to improve on them. Page 528, Sec. 4308 - Alters another bill, the Public Health Service Act, to add the following section. Page 528, Sec. 399MM - Directs the Director of the Centers for Disease Control and Prevention to offer employers tools and resources for evaluating the employers' wellness programs. Page 528, Sec. 399MM-1 - Within 2 years of the passing of the Act, the Director of the Centers for Disease Control and Prevention is to start taking regular surveys to assess employer-based health policies and programs, and report to Congress with recommendations for implementing effective ones. Page 529, Sec. 399MM-2 - Directs the Secretary of Health and Human Services to evaluate Centers for Disease Control programs before evaluating private programs, unless a private company specifically requests otherwise. Page 529, Sec. 399MM-3 - The recommendations of the last few sections are not to be used to mandate requirements for those employers' workplace wellness programs. Page 529, Sec. 4304 - Alters another bill, the Public Health Service Act, to add the following section. Page 529, Sec. 2821 - Directs the Secretary of Health and Human Services to establish a program to award grants to state and local governments to improve hospital laboratories' capacity to detect and prevent the spread of infectious diseases. $760,000,000 is set aside for this for 2010 through 2013. Page 530, Sec. 4305 - Directs the the Secretary of Health and Human Services to convene a conference addressing the topic of pain management and treatment. A report on the conference is to be submitted to Congress by June 30, 2011. This section also alters another bill, the Public Health Service Act, to add the following section. Page 530, Sec. 409J - Encourages the Director of the National Institute of Health to expand research on the treatment of pain. Directs the Pain Consortium (if I ever get a band, I'm naming it Pain Consortium) to give the Director recommendations on initiatives to take regarding this. This Consortium is to be created by the Secretary of Health and Human Services. This section also directs the Secretary to create an Interagency Pain Research Coordinating Committee to coordinate all of this pain research. This section also alters another bill, the Public Health Service Act, to add the following section. Page 532, Sec. 759 - Gives the Secretary of Health and Human Services the option to award grants to medical schools and hospitals to develop education and training in the area of treating pain. Page 532, Sec. 4306 - Alters another bill, the Social Security Act, to extend an existing demonstration project addressing childhood obesity. $25,000,000 is set aside for this from 2010 through 2014. Page 533, Sec. 4401 - It looks like this section has since been repealed. Apparently it had something to do with the Senate and CBO Scoring. Page 533, Sec. 4402 - Directs the Secretary of Health and Human Services to evaluate Federal health programs to determine that they are actually effective in meeting their goals. The Secretary is to report to Congress on the results of this evaluation. Page 534, Sec. 5001 - This section just explains the purpose of the upcoming sections. These sections

are intended to improve access to care for the poor and minorities through various means. Page 534, Sec. 5002 - This section is just listing definitions that are going to be used for upcoming sections. It look like it's using many of the same definitions as previous bills regarding these sorts of issues. This section also alters another bill, the Public Health Service Act, to add more detailed information regarding definitions of health professionals. Page 538, Sec. 5002 - Establishes the National Health Care Workforce Commission, to coordinate the efforts of numerous Federal agencies in regards to identifying what the job market requires of health professionals and enhancing and streamlining school and training to meet these needs. This commission is to be comprised of 15 health care experts appointed by the Comptroller General no later than September 30, 2010, representing various areas of the health industry. Starting in 2011, the commission is to submit yearly reports to Congress by April 1 on high-priority topics regarding health care workforce supply and demand, and by October 11 they are to present Congress with another yearly report making recommendations for ways to meet current demands. The commission is also to report to Congress on the State Health Care Workforce Development Grant in the next section. They are also to report to Congress with recommendations on improving safety and health conditions for health care workers, and report to a bunch of other government agencies on various other improvements that could be made. Page 545, Sec. 5102 - Establishes the State Health Care Workforce Development Grant program, which awards grants of up to $150,000 to State boards comprised of various members of the health industry whose purpose is to analyze the labor market for high-demand health care jobs and find ways to meet this demand. Any state board receiving a grant is to match 15% of the funds awarded in the grant with their own funds. Within a year of receiving a grant, these boards must report back to The Health Resources and Services Administration, which must in turn report to Congress, on the use of these funds. This section sets aside $8,000,000 for "planning grants", probably to establish these State boards, and $150,000,000 for "implementation grants", probably to implement the plans of the State boards. Page 550, Sec. 5103 - Alters another bill, the Public Health Service Act, to direct the Secretary of Health and Human Services to establish the National Center for Health Workforce Analysis, to develop ways to measure the information required by the previous sections, as well as evaluating the programs in this part of the bill on a yearly basis. The Secretary is directed to award grants to states and medical schools to assist with this. $12,000,000 is set aside for this section for 2010 through 2014. This section also alters another bill, the Public Health Service Act, in numerous places to add in the use of the evaluations this section creates. Page 553, Sec. 5104 - Establishes the Interagency Access to Health Care in Alaska Task Force, who are to assess access to health care for beneficiaries of Federal health care systems in Alaska, and develop a strategy to improve it. Within 45 days of the enactment of the ACA, the Secretary of Health and Human Services is to appoint this task force's members, to be comprised of representatives of various government health programs. Within 180 days of the enactment of the ACA, the task force is to submit a report to Congress on its findings and strategy. The task force is then terminated. This report can be read here. Page 554, Sec. 5201 - Alters another bill, the Public Health Service Act, to alter student loans for medical students. First, medical students receiving Federal loan assistance must practice medicine for the first 10 years out of medical school, or conversely, until they repay their loan. Students who fail to comply with this, or who default on their loan, will owe interest at a 2% higher rate than the loan they were paying (as I understand it, prior to this a default caused interest to accrue at 18%, and this new rate is much more reasonable). It also directs that the Secretary of Health and Human Services will not

factor your parents into decisions about your own financial needs - your needs will be determined by your school's loan officer. Also, this section notes that Congress intends for money from student loans repaid under this section to go back into the student loan program. Page 554, Sec. 5202 - Alters another bill, the Public Health Service Act, to increase the maximum size of loans granted to nursing medical students, and revises a few dates pertaining to them. Page 555, Sec. 5203 - Alters another bill, the Public Health Service Act, to add the following section. Page 555, Sec. 775 - Directs the Secretary of Health and Human Services to establish and carry out a pediatric loan repayment program. The recipient of the loan must agree to be employed full-time for at least 2 years in the pediatric health field. In return, that recipient will get up to $35,000 a year for up to 3 years of that service in payments on interest of education loans. $150,000,000 is set aside to pay for this section for 2010 through 2014. Page 557, Sec. 5204 - Alters another bill, the Public Health Service Act, to add the following section. Page 557, Sec. 776 - Directs the Secretary of Health and Human Services to establish the Public Health Workforce Loan Repayment Program. This is much like the pediatric program in Section 555 above, but for medical graduates in any field. The graduate must agree to work full-time in the field they studied for at least 3 years. In return, the Secretary will pay up to a third of the student loans that the graduate owes, up to $35,000. The Secretary will also make additional payments to cover any tax liability in regards to the loan (up to 39% of the loan repayments). $195,000,000 is set aside for this section in 2010, and the Secretary is directed to appropriate funds as necessary for 2011 through 2015. Page 559, Sec. 5205 - Alters another bill, the Higher Education Act of 1965, to include "Allied Health Professionals" in the list of professions that qualify for that bill's loan forgiveness program (which reduces student loan amounts owed by $2000 for every year that person works full-time). Page 559, Sec. 5206 - Alters another bill, the Public Health Service Act, to move a few things around for the next section. This section also alters another bill, the Public Health Service Act, to add the following section. Page 560, Sec. 777 - Allows the Secretary of Health and Human Services to award grants to medical schools so that they can award scholarships so that medical professionals who already have a career can get additional training. $60,000,000 is set aside for this section for 2011 through 2015. Page 560, Sec. 5207 - Alters another bill, the Public Health Service Act, to fund the Public Health Service Corps from 2010 onward, starting at $320,461,632 in 2010 and gradually ramping up to $1,154,510,336 per year for 2015 and later. Page 561, Sec. 5208 - Alters another bill, the Public Health Service Act, to add the following section. Page 561, Sec. 330A-1 - Directs the Secretary of Health and Human Services to award grant money to Nurse-managed Health Clinics. $50,000,000 is set aside to fund these grants in 2010, and "such sums as may be necessary" for 2011 through 2014. Page 562, Sec. 5209 - Alters another bill, Department of Health and Human Services Appropriations Act, 1993, to lift the cap of the number of people that can be in the United States Public Health Service Commissioned Corps, which allocates enlisted health professionals to the uniformed services such as the US Coast Guard. These professionals have largely been deployed in times of crisis, such as during Hurricaine Katrina and the Haiti earthquake. Previous to this, no more than 2800 people could be enlisted in this service, but now there is no limit.

Page 562, Sec. 5210 - Alters another bill, the Public Health Service Act, to alter a section of that bill to appear as the following section. Page 562, Sec. 203 - Establishes the Regular Corps and the Ready Reserve Corps. Both will have officers appointed by the President, though the Regular Corps officers must be approved by the Senate. These officers can be called into active duty at any time by the Surgeon General. When the ACA passed, the Reserve Corps was incorporated into the Regular Corps. The Ready Reserve Corps is intended to be sort of on-call emergency personnel for the public Health Service Commissioned Corps (like the National Guard, but for national medical emergencies). It looks like the gist of this is that there is to ensure that we have a staff of trained medical professionals on-call if we find ourselves facing another disaster. Okay, a lot of the following stuff has to do with grants for medical schools, student loans, and just in general trying to make it easier for more medical students to get through school, and for helping them to pay off the loans they had to take out to pay their way through school. The reasoning undoubtedly being that more doctors and nurses means better health care, and making it easier for people to afford medical school means more doctors and nurses. Here we go... Page 563, Sec. 5301 - Alters another bill, the Public Health Service Act (note - this was a bit difficult to find. The actual bill only says "Part C of Title VII"), to replace one section of that bill with the following section. Page 563, Sec. 747 - Directs the Secretary of Health and Human Services to make grants to public or nonprofit hospitals and medical schools to develop training programs (with financial assistance) for family medicine. Grants are limited to 5-year periods. $125,000,000 is set aside for this section for 2010, and "such sums as may be necessary" for 2011 through 2014. an additional $3,750,000 is set aside for 2010 through 2014 for "programs that integrate academic administrative units", which sounds like it includes some sort of management training. Page 566, Sec. 5302 - Alters another bill, the Public Health Service Act, to add the following section. Page 566, Sec. 747A - Directs the Secretary of Health and Human Services to schools partnered with nursing homes to create training programs for workers in those nursing homes. $10,000,000 is set aside for this section from 2011 through 2013. Page 567, Sec. 5303 - Alters another bill, the Public Health Service Act, to move around and relabel a few sections, and to add the following section. Page 567, Sec. 748 - Gives the Secretary of Health and Human Services the option to give grants or enter into contracts with medical schools and hospitals to create training programs for dentists. $30,000,000 is set aside for this section for 2010, and "such sums as may be necessary" for 2011 through 2015. Page 569, Sec. 5304 - Alters another bill, the Public Health Service Act, to add the following section. Page 569, Sec. 340G-1 - Gives the Secretary of Health and Human Services the option to give grants to schools and hospitals to establish a demonstration program for the training of a variety of different kinds of dental professionals. Page 571, Sec. 5305 - Alters another bill, the Public Health Service Act, to add that the Secretary of Health and Human Services is directed to award grants to geriatric health centers to fund a fellowship program for short-term education programs in the field of geriatrics. $10,800,000 is set aside for this from 2011 through 2014. The Secretary is also to award grants to various types of medical professionals who agree to teach or practice in the field of geriatrics, long-term care, or chronic care

management for at least 5 years. $10,000,000 is set aside for this from 2011 through 2013. This section also expands the types of professionals able to receive grants for training in geriatrics, and extends those grants through 2014. Page 574, Sec. 5306 - Alters another bill, the Public Health Service Act, to shuffle a few sections around and add the following section. Page 575, Sec. 756 - Gives the Secretary of Health and Human Services the option to give grants to schools to recruit more students in social and psychiatric health programs. $30,000,000 is set aside for this section for 2010 through 2013. Page 577, Sec. 5307 - Alters another bill, the Public Health Service Act, to expand one of that bill's programs pertaining to various areas of public health, and extending the program in that section through 2015. It's hard to tell just what exactly this public health program is, but it looks like it has to do with training health care workers to work with people who have disabilities. Page 578, Sec. 5308 - Alters another bill, the Public Health Service Act, to change one section to specify that the grants awarded in that section to nurse and midwife training programs must go to programs accredited by the American College of Nurse-Midwives Accreditation Commission for Midwifery Education. Page 578, Sec. 5309 - Alters another bill, the Public Health Service Act, to shuffle around and rename a few things in a section pertaining to nursing education grants, to extend that grant program through 2014, and to add the following section. Page 579, Sec. 831A - Gives the Secretary of Health and Human Services the option to give grants to nursing schools to increase the number of nurses to meet the needs of the work force. Page 580, Sec. 5310 - Alters another bill, the Public Health Service Act, by shuffling around a lot of sections. Page 580, Sec. 5311 - Alters another bill, the Public Health Service Act, by changing the nursing loan program to specify that the attended school be accredited, by increasing the size of the loan from $30,000 to $35,500, and by extending the program through 2014. This section also alters another bill, the Public Health Service Act, to shuffle a few sections around and add the following section. Page 581, Sec. 847 - Gives the Secretary of Health and Human Services the option to enter into agreements with nursing students to pay off up to $80,000 of any loans they took to get their nursing degree. Nurses who enter this agreement must become a full-time member of a nursing school's faculty for at least 4 years. Page 582, Sec. 5312 - Alters another bill, the Public Health Service Act, by changing a portion of that bill to be read as the following section. Page 583, Sec. 871 - Authorizes the Secretary of Health and Human Services to use $338,000,000 to carry out the previous sections. Page 583, Sec. 5313 - Alters another bill, the Public Health Service Act, by changing a portion of that bill to be read as the following section. Page 583, Sec. 399V - Directs the Director of the Centers for Disease Control and Prevention to award grants to states, public health departments, and free clinics, for community health workers and outreach health programs in areas with less health care. Page 585, Sec. 5314 - Alters another bill, the Public Health Service Act, by adding the following section.

Page 585, Sec. 778 - Directs the Secretary of Health and Human Services to expand existing Centers for Disease Control and Prevention fellowship programs as needed to address work force shortages. $39,500,000 is set aside for this section for 2010 through 2013. Page 586, Sec. 5315 - Alters another bill, the Public Health Service Act, by adding the following section. Page 586, Sec. 271 - Establishes the United States Public Health Sciences Track to award 850 medical degrees per year in various medical fields, with the curriculum and details of the plan to be determined by the Surgeon General. Page 587, Sec. 272 - Goes into detail on how the Surgeon General is to appoint faculty for the Sciences Track described in Section 271, and the sort of educational programs it will have. Page 588, Sec. 273 - Goes into details regarding admissions and enrollment of students for the Sciences Track described in Section 271. Page 591, Sec. 274 - Allows the secretary of Health and Human Services to transfer "such sums as may be necessary" for the Sciences Track described in Section 271. Page 591, Sec. 5316 - Directs the Secretary of Health and Human Services to establish a training demonstration program to train and employ nurses as primary care providers. The Secretary is directed to give grants to health clinics for the purposes of this training. Page 593, Sec. 5401 - Alters another bill, the Public Health Service Act, by expanding the Centers of Excellence program and designating how the money for this program is to be spent based on how much is available in any given year. $300,000,000 is set aside for this section for 2010 through 2015, and "such sums as are necessary" for subsequent years. Page 595, Sec. 5402 - Alters another bill, the Public Health Service Act, by increasing the limit of certain educational loans and scholarships. Page 595, Sec. 5403 - Alters another bill, the Public Health Service Act, to add the following section. Page 595, Sec. 751 - Directs the Secretary of Health and Human Services to award funds to medical schools, apparently for use in programs that bring minority and disadvantaged students into health professions. These schools must match these funds with at least half of the funds needed for the program in question. $625,000,000 is set aside for this section for 2010 through 2014. This section also alters another bill, the Public Health Service Act, to replace a section of that document with the following section. Page 600, Sec. 752 - Directs the Secretary of Health and Human Services to award grants and contracts to replace an older program (Health Education Training Centers) with grants to medical schools to accomplish what looks to me like a diverse set of goals ranging from increasing various types of education to increasing the number of minority faculty. $25,000,000 is set aside for this section from 2010 through 2014, and "such sums as may be necessary" for every year after. Page 600, Sec. 5404 - Alters another bill, the Public Health Service Act. I had a lot of difficulty with this one, so I had to look around to figure out just what it does. Apparently, it's re-writing a bunch of stuff in one section regarding workforce diversity grants. This document apparently says it just reauthorizes them, so without any better indication just what it does, I'm gonna' have to go with that. This is the first section of this bill that I cannot, on my own, determine what it does. Sorry. :-(

Page 601, Sec. 5405 - Alters another bill, the Public Health Service Act, to add the following section. Page 601, Sec. 399V-1 - Directs the Secretary of Health and Human Services to establish a Primary Care Extension Program. This program looks like it's intended to coordinate efforts between primary care providers and local health workers. The Secretary is directed to award grants to establish statebased Primary Care Extension Program State Hubs to facilitate this coordination. $240,000,000 is set aside for this section in 2011 through 2012, and "such sums as may be necessary" for 2013 through 2014. Page 604, Sec. 5501 - Alters another bill, the Social Security Act, to increase Medicare payments to primary care doctors and surgeons by 10%. Page 606, Sec. 5502 - This section has since been repealed. It apparently had something to do with improving Medicare Health Centers. Page 606, Sec. 5503 - Alters another bill, the Social Security Act, to shuffle a few sections around. Also, from what I can tell, it changes around the "applicable resident limit" for hospitals to allow doctors to be better distributed to hospitals they're needed at. Page 609, Sec. 5504 - Alters another bill, the Social Security Act. It looks like what this section does is to make it so that starting on January 1, 2010, resident medical staff's work time will be accounted for regardless of where that staff is working. It looks like this is at least in part to account for time spent training. Page 610, Sec. 5505 - Alters another bill, the Social Security Act. Much like the previous section, it looks like this one has to do with accounting for medical staff's time. It looks like this one accounts for time spent on vacation or in conferences and seminars. Page 612, Sec. 5506 - Alters another bill, the Social Security Act. It looks like this section makes it so that when a hospital closes, other hospitals in the area can have their "residency cap" raised to employ the medical staff who worked at the closed hospital. Page 614, Sec. 5507 - Alters another bill, the Social Security Act, to add the following section. Page 614, Sec. 2008 - Directs the Secretary of Health and Human Services to award grants to states and schools to provide financial aid to low-income students. Also, within 18 months of the ACA passing, directs the Secretary of Health and Human Services to award grants to states for training programs for home care aides. Also, one section of the Social Security Act pertaining to Family-toFamily Health Information Centers is extended through 2014. $425,000,000 is set aside for this section from 2010 through 2014. Page 620, Sec. 5508 - Alters another bill, the Social Security Act, to add the following section. Page 620, Sec. 749A - Gives the Secretary of Health and Human Services the Option to award grants to teaching health centers for new primary care residency programs. $125,000,000 is set aside for this section for 2010 through 2012, and "such sums as may be necessary" for every year afterwards. This section also alters another bill, the Social Security Act, to add the following section. Page 621, Sec. 340H - Directs the Secretary of Health and Human Services to award grants to teaching health centers for new graduate medical residency training programs. $230,000,000 is set aside for this section for 2011 through 2015. Page 625, Sec. 5509 - Directs the Secretary of Health and Human Services to establish a graduate nurse education demonstration program to reimburse up to five hospitals for the costs of nurse training. By October 17, 2017, the Secretary is to report to Congress on this program. $200,000,000 is set aside for this section for 2012 through 2015.

Page 628, Sec. 5601 - Alters another bill, the Public Health Service Act, to continue yearly grants for Federally Qualified Health Centers. $33,956,044,009 is set aside for this for 2010 through 2015, and by setting the amount of yearly grants after that to be a product of the previous year's grant and the increase in hospital expenses. Page 629, Sec. 5602 - Directs the Secretary of Health and Human Services to establish a comprehensive way to designate areas that aren't getting adequate health care services, to be published by July 1, 2010. Page 631, Sec. 5603 - Alters another bill, the Public Health Service Act, to extend funding for the Wakefield Emergency Medical Services For Children Program through 2014. $138,140,781 is to be set aside for this section for 2010 through 2014. Page 631, Sec. 5604 - Alters another bill, the Public Health Service Act, to add the following section. Page 631, Sec. 520K - Directs the Secretary of Health and Human Services to award grants to community mental health programs for a demonstration project for coordinated community-based mental health services. Within 90 days of receiving a grant, they are to report back to the Secretary on their progress. $50,000,000 is set aside for this section for 2010 and "such sums as may be necessary" for 2011 through 2014. Page 632, Sec. 5605 - Creates the Commission on Key National Indicators, whose 8 members are appointed by equal portions of the majority and minority parties in the House and Senate, and whose job responsibility is to create and maintain a system of "Key National Indicators", which appear to be common ways to measure progress on various issues. Every year, this Commission is to report to Congress and the National Academy of Sciences on their activities and recommendations. $70,000,000 is set aside for this section for 2010 through 2018. I believe this is their website. Page 636, Sec. 5606 - Gives the option for states to provide grants to health care providers that cater to under-served areas in their state. It specifies that states are not to use Medicare, Medicaid or Tricare funds for this. Page 637, Sec. 5701 - Directs the Secretary of Health and Human Services to submit yearly reports to Congress on the progress of previous sections. Page 638, Sec. 6001 - Alters another bill, the Social Security Act, so that starting in 2011, physicianowned hospitals will not be supported by Medicare. Limits are placed on the growth of currentlyexisting physician-owned hospitals, and this sort of hospital must report to the Secretary of Health and Human Resources on its activities every two years, and must disclose additional information to its patients. Additionally, starting on May 1, 2012, the Secretary of Health and Human Services will audit these hospitals to ensure that they are meeting these requirements. The limits created in this section are apparently because it is a potential conflict of interest for a physician to own the hospital they work in. Page 643, Sec. 6002 - Alters another bill, the Social Security Act, to add the following section. Page 643, Sec. 1128G - Starting on March 31, 2013, manufacturers of drugs and medical supplies must make a yearly report on who they sold products to, and the nature of their transactions. If the recipient has anything financial to gain from the sales of those products, the manufacturer is to disclose that information as well. Manufacturers that fail to comply with this section can be fined anywhere from $1,000 to $1,000,000 per year depending on the number of infractions and their severity. The Secretary of Health and Human Services is to make yearly reports both to Congress and to each State on a summary of the information gathered under this section. It looks like this section is looking for possible conflicts of interest and fraud. Page 651, Sec. 6003 - Alters another bill, the Social Security Act, to make it so that starting on January

1, 2010, doctors recommending certain types of "imaging services" (I assume some sort of X-Ray) must inform patients that they are not required to get those services from the place the doctor recommends. Page 651, Sec. 6004 - Alters another bill, the Social Security Act, to add the following section. Page 651, Sec. 1128H - Starting on April 1, 2012, drug manufacturers are to submit yearly reports to the Secretary of Health and Human Services about drug samples that they sell by mail that are paid for by Medicare, and who they're selling them to. Again, this looks like a way to stop fraud Page 652, Sec. 6005 - Alters another bill, the Social Security Act, to add the following section. Page 652, Sec. 1150A - Makes it so that pharmacies that provide prescription drugs must disclose to the Secretary of Health and Human Services what percentage of the drugs they provide are generic, what percentage are sold through retain versus mail-order, and the amount and types of rebates they offered. It looks like this information is being gathered at least in part to help states create their health insurance exchanges. Page 654, Sec. 6101 - Alters another bill, the Social Security Act, to make it so that nursing facilities working with Medicare and Medicaid must make available the names of their management staff. Page 657, Sec. 6102 - Alters another bill, the Social Security Act, to add the following section. Page 657, Sec. 1128I - Makes it so that nursing facilities working with Medicare and Medicaid must have regulations that are effective at preventing criminal, civil, and administrative violations. By 2013, the Secretary of Health and Human Services will evaluate these programs to see the changes they made. The Secretary will then report to Congress on that evaluation. Also, by December 31, 2011, the Secretary is to implement a Quality Assurance and Performance Improvement ("QAPI") program for standards these nursing facilities must meet. Page 659, Sec. 6103 - Alters another bill, the Social Security Act, to make it so that by 2011, the Secretary of Health and Human Services is to make a website available with information to help people compare Medicare-supported nursing homes. The website will provide information that includes information on hours of care provided, staff turnover, types of staff members, number of criminal violations, etc, as well as information on how to file a complaint. You can see the website here. This section also alters another bill, the Social Security Act, to direct the Secretary to conduct surveys of nursing facilities at least once every six months to collect this information. Page 666, Sec. 6104 - Alters another bill, the Social Security Act, so that starting in 2012, Medicare and Medicaid hospitals' reporting of costs must include staff pay and benefits. The Inspector General of the Department of Health and Human Services is to categorize this information and make it available upon request. Page 667, Sec. 6105 - Alters another bill, the Social Security Act, to direct the Secretary of Health and Human Services, by 2011, to create a standardized complaint form to be made available upon requests to residents or those acting on their behalf. States are to create a process to track and resolve these complaints. Page 667, Sec. 6106 - Alters another bill, the Social Security Act, so that starting in 2012, the Secretary of Health and Human Services is to create a uniform format for hospitals to submit staffing data that includes payroll data, job title, and turnover rates. Page 668, Sec. 6107 - Directs the Comptroller General of the United States to conduct a study on the Five-Star Quality Rating System for nursing homes of the Centers for Medicare & Medicaid Services. Page 668, Sec. 6111 - Alters another bill, the Social Security Act, so that starting in 2011, when a

hospital reports a problem and fixes it within 10 days, the Secretary of Health and Human Cervices may choose to reduce any civil penalties that hospital would have received by up to 50%. Page 672, Sec. 6112 - Directs the Secretary of Health and Human Services to conduct a demonstration project in 2011 to create a program to oversee chains of nursing facilities. The Secretary is to specifically select chains with severe safety and quality control issues. Chains that contract with the Secretary under this demonstration project will be analyzed for problems and given recommendations for improvement. 180 days after this demonstration project is completed, the Secretary is to report to Congress on it. Page 674, Sec. 6113 - Alters another bill, the Social Security Act, to make it so that by 2011, hospital administrators must notify the Secretary of Health and Human Services, residents of the hospital, and numerous other parties at least 60 days before the hospital closes. After giving this notification, the hospital is not to admit any new patients. The notice must include a State-approved plan to transfer residents to another hospital. he Secretary is to make sure the residents are all relocated. Administrators that fail to comply with this can be fined up to $100,000. Page 675, Sec. 6114 - Directs the Secretary of Health and Human Services to start two three-year demonstration projects by 2011 to develop "best practices" in nursing facilities, one pertaining to the "culture change" movement (you can read more about this here), and one for improving resident care using information technology . Within 9 months of these projects' completion, the Secretary is to report about them to Congress. Page 676, Sec. 6121 - Alters another bill, the Social Security Act, in multiple places, to make it so that by 2011, nursing facilities include dementia management and patient abuse prevention training for employees. Page 677, Sec. 6201 - Directs the Secretary of Health and Human Services to establish an effective program for hospitals to run criminal background checks on new hires. States must pay for at least onefourth of the expenses for enacting this (with the Federal government paying for the rest). The Inspector General of the Department of Health and Human Services is to evaluate this program, and within 180 days after the program is completed, make a report to Congress on it. No more than $480,000,000 is to be set aside for this section for 2010 through 2012. Page 683, Sec. 6301 - Alters another bill, the Social Security Act, to establish the Patient-Centered Outcomes Research Institute (PCORI), whose job will be to improve the information we have about effective ways health conditions can be treated. After being established, they are to be completely independent from the government. They are to be headed by the Director of Agency for Healthcare Research and Quality, the Director of the National Institutes of Health, 19 people appointed by the Comptroller General of the United States representing people from various fields in the health industry. PCORI will publish the information found in their research, and submit yearly reports to the President and Congress. You can see their website here. In addition to this, this section also alters another bill, the Social Security Act, to add the following section. Page 695, Sec. 937 - Directs the The Office of Communication and Knowledge Transfer to help organize and spread the research findings of PCORI. In addition to this, this section also alters another bill, the Social Security Act, to specify that the Secretary of Health and Human services may only use research to make its Medicare coverage determinations if that research is transparent and public. The Secretary is also directed not to make determinations based on this data that value the life and wellbeing of younger patients more than the life and well-being of elderly patients, or intended to influence patients choosing between options based on their longevity versus the likelihood of living with a disability. In addition to this, this section also alters another bill, the Social Security Act, to transfer

some money from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund to PCORI. In addition to this, this section also alters another bill, the Social Security Act, to add the following section. Page 698, Sec. 9511 - This section sets aside $1,110,000,000 (in addition to the funds mentioned in the previous section) to fund PCORI from 2010 through 2019. This section lists a lot of rules and instructions for how this money is to be used and tracked, and it also alters another law, Chapter 34 of the Internal Revenue Code of 1986, by adding the following three sections. Page 700, Sec. 4375 - Adds a yearly fee to health insurance companies amounting to $2 for every person they insure. This fee doesn't apply to certain types of insurance plans (accident and disability insurance, liability, and workers' compensation, amongst others). Starting in October 1, 2014, this fee is set to rise on a yearly basis depending on national health care costs. This section expires on September 30, 2019. Page 701, Sec. 4376 - Adds a yearly fee to employers amounting to $2 for every person they insure. Starting in October 1, 2014, this fee is set to rise on a yearly basis depending on national health care costs. This section expires on September 30, 2019. Page 702, Sec. 4377 - This section adds a bunch of definitions. It also alters another law, Chapter 34 of the Internal Revenue Code of 1986, to make PCORI tax-exempt. Page 704, Sec. 6302 - Ends the Federal Coordinating Council for Comparative Effectiveness Research. Page 704, Sec. 6401 - Alters another bill, the Social Security Act, to direct the Secretary of Health and Human Services to create a screening and background check process for health care providers and suppliers working with Medicare, Medicaid and CHIP. Health care providers and suppliers must also disclose affiliations with other providers and suppliers, and if any of these affiliations looks like it might cause significant risk of fraud, abuse or waste, the Secretary may deny the application to work with Medicare, Medicaid and CHIP. If there are problems along these lines, states must comply if the Secretary passes a moratorium on enrolling new providers for these services unless that moratorium would negatively affect beneficiaries' access. Page 710, Sec. 6402 - Alters another bill, the Social Security Act, to add the following section.