Comparing the Health Care Proposals

Would include mandate.

Penalty: 2.5 percent of adjusted gross income over a certain level, which is $9,350 for singles and $18,700 for couples.

Exempt those with incomes below the above-mentioned thresholds, American Indians, people with religious objections and people who can show financial hardship.

Would include mandate.

Penalty: Up to $750 a person a year.

Exempt American Indians and those who can show financial hardship.

Would include mandate.

Penalty would be phased in gradually: $200 a person in 2014; $400 in 2015; $600 in 2016; and $750 in 2017.

Exempt American Indians, people with religious objections, those who can show financial hardship, households with incomes lower than 133 percent of the federal poverty level ($29,327 for a family of four) and people who would have to pay more than 8 percent of their income to buy the lowest cost plan available to them.

Open to a mandate as long as people who cannot afford insurance are exempt. During the campaign, President Obama proposed mandates for children only.

“I am open to your ideas on shared responsibility. But I believe if we are going to make people responsible for owning health insurance, we must make health care affordable. If we do end up with a system where people are responsible for their own insurance, we need to provide a hardship waiver to exempt Americans who cannot afford it.” (Letter to Senate leaders, June 3)

America’s Health Insurance Plans, the insurers’ lobby, supports individual mandates. But the trade association says the penalties for going without coverage are modest under the Senate Finance Committee’s bill. This creates “a powerful incentive for people to wait until they are sick to purchase coverage,” and could drive up insurance premiums, the group has warned.

Drug companies and insurers could benefit from mandates, which could provide millions of new customers.

Labor unions and consumer groups support mandates for individuals as long as employers are required to help pay for coverage.

Would require employers with annual payrolls of $500,000 or more to provide health insurance or pay a new federal tax.

Employers would have to contribute at least 72.5 percent of the premium cost for individuals and 65 percent for families for the lowest cost plan that meets the minimum benefit requirements set by the government.

Penalty: Up to 8 percent of wages in payroll taxes. Employers with payrolls of $500,000 to $750,000 would pay 2 percent to 6 percent of wages, and those with payrolls above $750,000 would pay the full 8 percent.

Employers that offer health insurance must automatically enroll employees into the lowest cost plan available. But employees may opt out of employer coverage.

Would require employers with more than 25 workers to contribute at least 60 percent of the premium costs, or

Pay a $750 penalty for each full-time worker and $375 for each part-time worker.

Would not require employers to provide coverage. Employers with more than 50 workers would have to reimburse the government for some or all of the cost of subsidies provided to full-time employees who work 30 or more hours a week and buy insurance on their own through the exchanges.

Penalty: Up to $400 for each worker in the company, whether they are receiving subsidies for insurance or not.

Employers with 200 or more employees must automatically enroll employees into health insurance plans offered by the employer. Employees may opt out of employer coverage, however, if they are able to demonstrate that they have coverage from another source.

Individuals who qualify for Medicaid could choose to leave an employer’s insurance plan and enroll in Medicaid, in which case the employer would not be required to pay a fee.

Employers who buy coverage for their employees through the proposed exchanges must offer a plan with a deductible that does not exceed $2,000 for individuals and $4,000 for families, unless they contribute funds to offset deductibles above these limits.

Open to employer mandates as long as there are provisions to exempt small businesses.

“While I believe that employers have a responsibility to support health insurance for their employees, small businesses face a number of special challenges in affording health benefits and should be exempted.” (Letter to Senate leaders, June 3)

Many business groups strongly oppose employer mandates. But Wal-Mart, the nation’s largest private-sector employer, agreed to support a requirement that big companies insure their workers, a move that left the National Retail Federation “flabbergasted.” In exchange, Wal-Mart said it wanted a guarantee that the bill would not “create barriers to hiring entry-level employees” — in effect, insisting that lawmakers abandon the idea of requiring employers to pay part of the cost for workers covered by Medicaid.

Would create a national exchange. Allows states to opt out and operate their own exchange if they follow federal rules.

Open to people who do not have qualifying coverage through an employer or a public program.

Open to employers with 25 or fewer employees in the first year, 50 or fewer in the second year and 100 or fewer in the third year. The exchange could be expanded to larger employers over time, “with the goal of allowing all employers access.”

Until the exchange is established, a temporary program would provide health coverage to “those who have been uninsured for several months or denied a policy because of pre‐existing conditions.”

Would create state-based exchanges. Allows states to form regional exchanges.

Open to people who do not have qualifying coverage through an employer or a public program.

Open to employers with 50 or fewer employees.

Would create state-based exchanges for individuals and small employers by 2010.

Open to citizens or legal immigrants who do not have qualifying coverage through an employer or a public program. Verification of legal immigration status would be required to buy insurance through a new exchange.

For the first five years, the exchanges would be open to employers with 50 or fewer employees, but states could choose to allow companies with 100 or fewer workers to participate .

Starting in 2015, states must allow businesses with 100 or fewer workers to buy insurance through the exchange. States can choose to allow larger businesses to participate in the exchanges starting in 2017.

Starting in 2015, states would be permitted to opt out of certain requirements set by the legislation through a waiver process, as long as the state plan does not add to the federal deficit and provides coverage that is as comprehensive as the coverage required under an exchange plan.

Supports creation of a health insurance exchange. Verification of legal immigration status would be required to buy insurance through the exchange.

Illegal immigrants would be able to buy insurance in the regular private market, as they can now.

Many illegal immigrants now seek treatment in emergency rooms, which by law cannot turn them away, and the federal government reimburses hospitals $250 million a year for unpaid bills. The White House said those reimbursements would continue.

The insurers’ lobby, America’s Health Insurance Plans, has urged lawmakers “to allow health plan choices to be offered to individuals outside of the exchange” and to make subsidies available to people outside the exchange. The group also believes that larger employers should not be allowed to buy coverage for their employees through the exchange because “such a proposal would incentivize large employers with younger and healthier workers to self-fund, while those larger employers with older and less healthy workers would join the insurance pool — significantly driving up premiums for individuals and small employers."

Would create a new government insurance plan that would negotiate rates with doctors and hospitals, rather than using Medicare rates set by the government.

The public plan would have to offer different levels of benefits, covering between 70 to 95 percent of health care expenses.

Like private plans, the public plan must offer the same benefits, comply with the same insurance market reforms, follow provider network requirements and other consumer protections. The plan would not provide abortion coverage.

Health care providers would not be required to participate in the plan. But the bill assumes that providers participating in Medicare are participants of the public plan, unless they opt out.

The government would allocate $2 billion in start-up money but the public plan must be financially self-sustaining. The bill would require premiums, paid by beneficiaries, to cover the plan’s cost. The government would also provide loans to start up non-profit insurance cooperatives to compete with private insurers and the public plan.

The legislation would also create a public long-term-care program that would provide cash assistance — not less than an average of $50 per day — to people who become disabled. The program would be financed through premiums deducted from paychecks of people who choose to participate. Workers would have to contribute for at least five years before they can collect benefits.

Would create a new government insurance plan that would negotiate rates with doctors and hospitals.

The plan must offer the minimum package of benefits prescribed by the government, but states can choose to offer additional benefits.

Like private plans, the public plan must offer the same benefits, comply with the same insurance market reforms, follow provider network requirements and other consumer protections.

Health care providers would not be required to participate in the plan.

The public plan’s cost must be covered by premiums.

The legislation would also create a public long-term-care program that would provide cash assistance to people who become disabled. The program would be financed through premiums deducted from paychecks of people who choose to participate.

Would create private, nonprofit, consumer-run insurance cooperatives in states.

The co-ops would be required to meet the same guidelines as private plans regarding benefit levels, insurance market reforms and other consumer protections.

The co-ops must use their profits to lower premiums and improve benefits and the quality of health care provided to members.

The co-ops could negotiate collectively for better prices, but they would be “explicitly prohibited from setting payment rates for health care facilities and providers.”

The government would provide $6 billion in loans and grants by 2012 to help doctors, hospitals, businesses and other groups form the cooperatives.

Strongly favors a public plan but will not rule out cooperatives.

“Any plan I sign must include an insurance exchange: a one-stop shopping marketplace where you can compare the benefits, cost and track records of a variety of plans — including a public option to increase competition and keep insurance companies honest.” (Weekly address, July 18)

The public option “shouldn’t be something that’s simply a taxpayer-subsidized system that wasn’t accountable, but rather had to be self-sustaining through premiums and that had to compete with private insurers. ... In theory you can imagine a cooperative meeting that definition. ... There are concerns that in the past, attempts at setting up co-ops have not been successful because they just haven’t been able to get off the ground; sort of the start-up energy involved may not exist if you’re doing a state-by-state co-op effort as opposed to a broad national plan.” (Time magazine, July 28)

Insurers say a public plan could drive them out of business as the government uses its purchasing power to demand lower prices from doctors and hospitals. Insurers have also expressed resistance to cooperatives, especially if the government has a hand in running them.

In a letter to the Senate Finance Committee in June, the American Medical Association said it would oppose “any public plan that forces physicians to participate, expands the fiscally challenged Medicare program or pays Medicare rates.” A month later, the doctors’ group endorsed the House bill (a House committee had dropped a proposal to tie public plan payments to Medicare rates). Many doctors, including a half-dozen state medical societies, still oppose the public plan.

Business groups generally do not support a public plan. The U.S. Chamber of Commerce said a public plan “whether based on Medicare, run by an appointed panel, backed by entitlement financing or created in some other way, would lead to serious adverse consequences for employer-sponsored health insurance."

Would provide credits for premium costs and other health care expenses to citizens or legal immigrants who buy insurance through the exchange. Verification of legal immigration status would be required to receive subsidies.

Households with incomes up to 400 percent of the federal poverty level ($88,200 for a family of four) would be eligible to receive premium credits, if they pay specified percentages of their income toward the premium. Premium contributions would range from 3 percent to 12 percent depending on the income. People with insurance from employers would be eligible for the credits if the cost of their premium exceeds 12 percent of their income.

The proposal would also offer cost-sharing subsidies and reduce out-of-pocket spending limits for those under 400 percent of the poverty level.

Would provide credits for premium costs to citizens or legal immigrants who buy insurance through the exchanges.

Households with incomes up to 400 percent of the federal poverty level would be eligible, with those at the lower end receiving more.

People with insurance from employers would be eligible for the credit if the cost of their premium exceeds 12.5 percent of their income.

Would provide credits for premium costs and other health care expenses to people who buy insurance through the exchanges. Only citizens or legal immigrants can buy insurance through the exchanges.

Beginning in 2013, households with incomes between 134 and 300 percent of the federal poverty level ($29, 547 to $66,150 for a family of four) would be eligible, with those at the lower end receiving more.

Starting in 2014, households with incomes between 100 and 133 percent of the poverty level ($22,050 to $29,327 for a family of four) would be eligible for the credits.

People with incomes between 300 and 400 percent of the poverty level ($66,150 to $88,200 for a family of four) would not have to pay more than 12 percent of their income in premiums.

The proposal would also make cost-sharing subsidies available for households with incomes between 100 and 200 percent of the poverty level ($22,050 to $44,100 for a family of four) and reduce out-of-pocket spending limits for those under 400 percent of the poverty level.

Supports sliding-scale credits for low-income households.

The insurer’s lobby, America’s Health Insurance Plans, has urged lawmakers to make credits available to people outside of the exchange.

Some employers are concerned that the proposed credits would encourage healthy workers to drop out of employer-sponsored plans and buy insurance through the exchange. An analysis by the Congressional Budget Office also predicted that the subsidies could lead to a drop in people participating in employer-sponsored health coverage.

Would provide tax credits to employers with 25 or fewer workers and average wages of $40,000 or less.

The credit would not be allowed for employees earning more than $80,000 a year. The amount, up to 50 percent of premium costs, phases out as firm size and average wages increase.

Would spend $5 billion from 2013 to 2015 to subsidize employer-sponsored health plans covering early retirees ages 55 to 64. The federal government would cover 80 percent of the cost of a retiree’s medical claims of more than $15,000, with a cap at $90,000 — at which point the employer’s plan would pay the rest.

Would provide tax credits to employers who have 50 or fewer workers and who pay at least 60 percent of their employees’ health insurance premiums.

Eligible employers would be able to receive the credit for only three consecutive years. The credit phases out as firm size and average wages increase.

Would subsidize employer-sponsored health plans covering early retirees ages of 55 to 64, until the proposed state exchanges are established. The federal government would cover 80 percent of the cost of a retiree’s medical claims between $15,000 and $90,000.

Would provide tax credits to employers with 25 or fewer workers and average wages of $40,000 or less. An employer would have to contribute at least 50 percent of the total premium for an employee’s coverage or at least 50 percent of the average premium cost for small businesses in the employer’s state.

The full credit would be available to employers with 10 or fewer workers and average wages of $20,000 or less. The amount phases out as firm size and average wages increase.

In 2011 and 2012, all qualifying employers could receive up to 35 percent of their contribution to a worker’s insurance premium.

Starting in 2013, only employers buying insurance through the proposed exchanges can receive a tax credit for two years that covers up to 50 percent of their premium contribution.

Would spend $10 billion over 10 years to subsidize employer-sponsored health plans covering early retirees ages 55 to 64. The federal government would cover 80 percent of the cost of a retiree’s medical claims between $15,000 and $90,000.

Supports tax credits for small businesses.

Would include all individuals with incomes up to 150 percent of the federal poverty level ($33,075 for a family of four). The program currently covers millions of low-income older Americans, people with disabilities, pregnant women, children and some parents. Childless adults are generally not eligible.

The federal government would pay all the costs for those who are newly eligible for the first two years and 91 percent of the costs after that.

The legislation would end the Children’s Health Insurance Program, which benefits children of the working poor. Children with family incomes up to 150 percent of the poverty level would receive coverage through Medicaid. Families with higher incomes would receive subsidies to buy coverage through the exchange.

Assumes expansion of Medicaid to include individuals with incomes up to 150 percent of the poverty level. The committee does not have authority over Medicare and Medicaid, which are under the Finance Committee’s jurisdiction.

Would include all individuals with incomes up to 133 percent of the poverty level, starting in 2014.

The federal government would pay most of the new costs — anywhere from 77 percent to 95 percent — with a higher share in poorer states, until 2019.

In “high-need states,” where the percentage of Medicaid enrollment is below the national average and unemployment rates were 12 percent or higher in 2009, the federal government would pay 100 percent of the new costs until 2019. Only four states meet the criteria: Michigan, Nevada, Oregon and Rhode Island.

States would have the option to create a “basic health plan” for people earning between 133 and 200 percent of the poverty level ($29,327 to $44,100 for a family of four), who are not eligible for Medicare or Medicaid and who do not receive coverage through an employer. States could develop or expand various existing insurance programs that now typically cover people who qualify for Medicaid; small states could develop joint plans. Qualifying individuals living in states that choose to operate these plans could not receive the proposed federal subsidies through the exchanges. States would receive 85 percent of the money that would have been paid as subsidies to finance the plans.

The president promised to expand eligibility for Medicaid during the campaign.

In a telephone call with senior members of the Senate Finance Committee in early August, governors from about a dozen states objected to picking up costs for new Medicaid recipients.

Would require the basic benefits package to cover 70 percent of the health care spending covered by the plan. Consumers would pay the remainder, in deductibles, co-payments and other charges. The plan would cap out-of-pocket health care spending to $5,000 for an individual and $10,000 for a family.

Insurers could choose to cover or not cover abortion as they see fit. But people who receive federal subsidies to buy insurance cannot choose a plan that includes abortion coverage. Federal tax dollars can only be used for abortion as allowed by current law, in case of rape or incest or if the life of a pregnant woman is in danger.

Insurers could not deny coverage because of a person’s pre-existing conditions. Variation in premiums is limited. Maximum difference in premiums based on age is 2 to 1 (for oldest group, compared with young adults).

The legislation would also revoke the exemption from federal antitrust law that health insurance companies have long enjoyed. It would outlaw price-fixing, bid rigging and “market allocations” by companies that sell health insurance or medical malpractice insurance.

Insurance plans covering children and their parents would have to continue “dependent coverage” for children through age 26. Rules and age limits for dependents under employer plans currently vary by state.

Besides the basic plan, the legislation would create three other levels of coverage to be offered through the health insurance exchange, covering up to 95 percent of costs. The Congressional Budget Office says the actuarial value of policies bought in the individual insurance market now averages 55 percent to 60 percent.

Would require the basic benefits package to cover 76 percent of the health care spending covered by the plan. The plan would cap out-of-pocket health care spending to $5,950 for an individual and $11,900 for a family.

Insurers could not deny coverage because of a person’s pre-existing conditions. Variation in premiums is limited. Maximum difference in premiums based on age is 2 to 1.

Insurance plans covering children and their parents would have to continue “dependent coverage” for children through age 25. Rules and age limits for dependents under employer plans currently vary by state.

Besides the basic plan, the legislation would create two other levels of coverage to be offered through the exchanges, covering 84 percent and 93 percent of the costs of the plans.

Would require the basic benefits package to cover 65 percent of the health care spending covered by the plan. The plan would cap out-of-pocket health care spending to $5,950 for an individual and $11,900 for a family.

The basic plan would not be required to provide abortions but insurers could choose to cover or not cover abortion as they see fit. Health plans that chose to cover abortion could use only the premium money and co-payments contributed by beneficiaries to cover the procedure, and not any federal subsidies. Tax dollars could not be used to pay for abortions except in cases of rape or incest or if the life of a pregnant woman was in danger.

Insurers could not deny coverage because of a person’s pre-existing conditions. Variation in premiums is limited. Maximum difference in premiums based on age is 4 to 1.

Besides the basic plan, the legislation would create three other levels of coverage to be offered through the health insurance exchange, covering between 70 percent to 90 percent of costs. The proposal would also offer the option of lower-cost insurance to those 25 and younger, with protection only against the costs of catastrophic illness.

Insurance plans in the health insurance exchange should not “deny coverage on the basis of a pre-existing condition, and all of these plans should include an affordable basic benefit package that includes prevention, and protection against catastrophic costs.” (Letter to Senate leaders, June 3)

If individual mandates are passed, insurers say they will stop refusing to insure people with pre-existing conditions and will also stop charging higher premiums based on gender or health status.

About $1.05 trillion, according to the Congressional Budget Office, to provide coverage to 36 million people. The costs would be fully offset by cuts in the growth of Medicare and by new fees and taxes. The bill would reduce projected federal budget deficits by $104 billion over 10 years.

Earlier versions of the bill in the House included provisions to avert cuts in Medicare fees to doctors, scheduled to occur under existing law. Those provisions, which would cost more than $200 billion over 10 years, were put into a separate bill.

About $611 billion, according to an early, incomplete estimate by the budget office. The Finance Committee is expected to propose expansions to Medicaid that would add several hundred billion dollars to the legislation’s cost, depending on how it is designed.

About $829 billion, according to the budget office. The costs would be fully offset by cuts in the growth of Medicare and by new fees and taxes. The bill would reduce projected federal budget deficits by $81 billion over 10 years.

The government would spend $11 billion to avert the scheduled cuts in Medicare fees to doctors.

In a speech to Congress on Sept. 9, President Obama said the total cost of his plan to overhaul the health care system would be “around $900 billion.” He also insists that the bill not add to the federal debt and that it should “bend the cost curve” by slowing the growth of health spending in the long term.

Would raise $460 billion over 10 years by imposing an income surtax on high-income people — couples with adjusted gross incomes over $1 million a year and individuals over $500,000 — at a rate of 5.4 percent.

Would raise about $100 billion with various other revenue provisions, which include a 2.5 percent excise tax on the medical devices sold for use in the United States, a $2,500 cap on contributions to health care flexible spending accounts and elimination of the tax deduction for employers who receive federal subsidies for providing retiree prescription drug coverage.

Does not include financing proposals. The health committee does not have authority over taxes, Medicare or Medicaid.

Would impose $13 billion in new annual fees on some sectors of the health care industry. The fees, allocated by market share, would include: $6.7 billion a year on insurance companies, $4 billion a year on manufacturers of medical devices and $2.3 billion a year on drug makers.

Impose an excise tax of 40 percent on insurance companies and insurance administrators for any health insurance plan that is above $8,000 for individuals and $21,000 for families, applied to premium amounts over the threshold.

Proposed raising $318 billion in revenue over 10 years by limiting the tax benefits of itemized deductions—like charitable contributions, state and local taxes, and mortgage interest—for households earning more than $250,000. The plan met resistance in Congress, with the Democratic chairmen of the House and Senate tax-writing committees, among others, objecting that it could depress tax-deductible charitable contributions.

Mr. Obama has signaled that he might be willing to consider the House plan to increase taxes if it applied “to families whose joint income is a million dollars."

Administration officials have signaled support for the excise tax on high-end insurers. On July 24, Mr. Obama discussed the “possibility of penalizing insurance companies who are offering super, gold-plated Cadillac plans” in a PBS interview. “I haven’t seen the details of this yet, but it may be an approach that doesn’t put additional burdens on middle-class families,” he said.

Would raise more than $400 billion over 10 years by trimming Medicare payments to hospitals and most other health care providers. Cut nearly $200 billion in subsidies for insurers that offer the elderly private plans through Medicare Advantage. (The government pays about 14 percent more for the private plans than it would pay for the same people in traditional Medicare.) Demand better prices from drug makers participating in Medicare and Medicaid.

The Institute of Medicine at the National Academy of Sciences would conduct two studies and recommend changes to the current Medicare reimbursement system. In the first, the institute would analyze geographical disparities in Medicare rates and send recommendations to be implemented by the secretary of health and human services. The other would assess whether to tie Medicare payments to quality of care. Those recommendations would be subject to a vote in Congress.

Does not include financing proposals. The health committee does not have authority over taxes, Medicare or Medicaid.

Would reduce Medicare payments to hospitals and most other health care providers. Cut subsidies to private Medicare Advantage plans.

The proposal would link Medicare payments to the quality of care provided, under a new system of “value-based purchasing."

Proposed trimming $622 billion from Medicare and Medicaid by 2019, mostly by eliminating subsidies for insurance plans in Medicare Advantage, reducing Medicare and Medicaid reimbursements to health care providers and demanding better prices from drug makers for the programs.

Insurers oppose proposals to cut subsidies for private Medicare Advantage plans, but physician groups support the measure, in part because it might free up additional money that could go toward doctors’ pay.

Major hospital associations have reached a deal with the House to give up more than $155 billion in Medicare and Medicaid payments over 10 years.

Drug companies have promised to help narrow a gap in Medicare coverage of prescription drugs that is known as the doughnut hole. They would give most beneficiaries a 50 percent discount on brand-name medicines bought when they hit the gap in coverage. White House officials recently assured drug makers that the administration stood by a behind-the-scenes deal to block any Congressional effort to extract cost savings from them beyond the agreed-upon $80 billion.