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Tuesday, May 31, 2011

Health Insurance Agents and Brokers in the Reformed Health Insurance Market


Mark Newsom
Specialist in Health Care Financing

Health insurance agents and brokers, collectively called “producers” by insurance companies, assist consumers and small employers in choosing and enrolling in health insurance products. Producers are licensed and regulated by the states. Traditionally, the federal government has had no role in regulating producer activities outside of federal programs such as Medicare Advantage. The Patient Protection and Affordable Care Act (P.L. 111-148, PPACA), as amended, creates a limited federal role in developing standards for the use of producers in the health insurance exchanges, which are competitive regulated markets effective January 1, 2014. The additional regulation of producers and alternative health insurance information (e.g., the online insurance portal) and assistance services available to consumers may limit the traditional demand for producers’ services.

PPACA also has a minimum medical loss ratio provision requiring plans to pay rebates to their members if a certain percentage of their premiums are not spent on medical costs. This provision may provide an incentive for health insurance companies to reduce their compensation to and/or utilization of producers as they seek to reduce their administrative costs in relation to their medical costs.



Date of Report: May 13, 2011
Number of Pages: 11
Order Number: R41439
Price: $29.95

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Tuesday, May 24, 2011

Stem Cell Research: Ethical and Legal Issues


Erin D. Williams
Specialist in Public Health and Bioethics

Edward C. Liu
Legislative Attorney

Judith A. Johnson
Specialist in Biomedical Policy


Current federal policy permits federal funding for research using established embryonic stem cell (ES) lines, but not for the establishment of ES lines. The validity of this policy was questioned in the court case Sherley v. Sebelius, causing the temporary suspension of federal funding for all embryonic stem cell research (ESR). The decision by the United States Court of Appeals for the D.C. Circuit in the Sherley case appears to have resolved the issue, for the time being, so that federal funding under the current policy may continue. Neither the Sherley case nor the affected federal policy restricts or regulates ESR conducted solely with private, local, and/or state government funding, or with funding from other non-federal sources.

Since 1996, federal funding for research that involves the creation or destruction of human embryos has been prohibited. This prohibition is due to the Dickey Amendment, a rider placed on Health and Human Services’ (HHS) annual appropriation each year since FY1997. Federal policy allowing research on established ES lines was based on an interpretation of Dickey, issued in 1999 by then-HHS General Counsel Harriet Rabb (HHS 1999 Opinion). The HHS 1999 Opinion concluded that Dickey prohibited the use of HHS funds to establish ES lines (which involves embryo destruction), but not to conduct research using ES from established lines (on the theory that ES themselves are not embryos). In the context of the HHS 1999 Opinion, the Obama Administration created its ES policy, which permits federal funding for research using established ES lines that meet certain ethical requirements. The Obama ES policy is articulated in two 2009 documents: Executive Order 13505 (Obama EO), and National Institutes of Health guidelines issued pursuant to the EO (NIH 2009 Guidelines). In Sherley, the D.C. Circuit held that the Dickey Amendment did not unambiguously prohibit federal funding of ESR, and that HHS’s distinction between research establishing ES lines and research using ES lines was a reasonable one. Consequently, the D.C. Circuit held that HHS should not be enjoined from permitting federal funding of ESR to continue under the NIH 2009 Guidelines.

In light of the D.C. Circuit’s decision, Congress has four policy options. First, it could explicitly sanction or expand federal funding for ESR by eliminating or modifying the Dickey Amendment, or by passing other legislation. Second, Congress could encourage possible alternatives to ESR through research funding or tax incentives for activities that do not involve the destruction of human embryos (e.g., S. 88). Third, it could restrict or prohibit federal funding of ESR. (Enactment of a law banning or limiting federal ESR funding would supersede the D.C. Circuit’s decision in Sherley.) Fourth, Congress could take no action, which would permit federal ESR funding to continue until such time as the Sherley case is reversed or overruled.

Many opinions about the ethics of ESR have been published. The positions could be broadly categorized as for or against ESR; however, there is an array of finer distinctions that reveal more subtle variation in ethical, moral, and factual beliefs. Breaking down ESR arguments according to these finer distinctions demonstrates both the complexity of the issues and the points of resonance among the opinions. The broadest discussion involves the balance of embryo destruction and relief of human suffering. More subtle issues focus on the relative importance of embryo viability, the purpose of embryo creation, new versus existing ES lines, donor consent, egg procurement, possible alternatives, and federal funding. This report presents background concepts, outlines legal arguments related to Sherley, and details the ethical arguments that surround ESR.



Date of Report: May 10, 2011
Number of Pages: 24
Order Number: RL33554
Price: $29.95

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Traumatic Brain Injury Among Veterans


Erin Bagalman
Analyst in Health Policy

Traumatic Brain Injury (TBI) has been defined as “an alteration in brain function, or other evidence of brain pathology, caused by an external force.” In the general population, TBI results mainly from falls, motor vehicle/traffic accidents, assaults, and other instances in which the head is struck by or strikes against an object. In military servicemembers, TBI may also result from improvised explosive devices, mortars, grenades, bullets, or mines.

Traumatic brain injury has become known as a “signature wound” of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), because the incidence of TBI is higher in these conflicts than it has been in previous conflicts. As of FY2010, 1.25 million OEF/OIF veterans have left active duty and became eligible for Department of Veterans Affairs (VA) health care; half of them have obtained VA health care; and 45,606 have been diagnosed with TBIrelated conditions at VA medical facilities. The total number of OEF/OIF veterans with TBI is not known, in part because some OEF/OIF veterans have not accessed VA health care services.

The VA has engaged in outreach efforts to OEF/OIF veterans via mail, telephone, and television advertisements. In order to make contact with servicemembers before separation and conversion to veteran status, the VA participates in some Department of Defense (DOD) activities. Some OEF/OIF veterans may choose not to enroll in VA health care, because they have health coverage from other sources or because they do not perceive a need for health care. Others may experience barriers to accessing VA care.

Servicemembers who sustain mild TBI (also known as “concussion”), which accounts for the majority of injuries, may walk away from the event, seemingly unharmed; thus mild TBI may go unnoticed and untreated. Accordingly, VA policy requires that all OEF/OIF veterans receiving medical care in the VA health care system must be screened for possible TBI, and that those who screen positive must be offered further evaluation and specialized treatment. The VA and the DOD have jointly developed evidence-based clinical practice guidelines for treatment of mild TBI.

Servicemembers who sustain moderate to severe TBI (i.e., recognizable injuries) require immediate treatment, which begins at the site of the event and continues at a military treatment facility. Once stabilized, servicemembers may remain at a military treatment facility or be transferred to the VA Polytrauma System of Care. Transfers from DOD to VA facilities require coordination between the two systems, and several programs have been developed to facilitate coordination of care.

The VA’s FY2010 budget for “TBI and Other Neurotrauma” research was $22 million (rounded). Before applying a 0.2% rescission for most non-defense items, the full-year continuing resolution for FY2011 maintained VA’s research funding at the FY2010 level. The large number of studies conducted by the VA and the DOD, as well as the Department of Health and Human Services (HHS), raises questions for some about potential duplication of effort, gaps in the research, dissemination of research findings, and translation of research into practice.



Date of Report: May 5, 2011
Number of Pages: 23
Order Number: R40941
Price: $29.95

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The Individuals with Disabilities Education Act (IDEA): Statutory Provisions and Recent Legal Issues


Nancy Lee Jones
Legislative Attorney

The Individuals with Disabilities Education Act (IDEA) is the major federal statute for the education of children with disabilities. IDEA both authorizes federal funding for special education and related services and, for states that accept these funds, sets out principles under which special education and related services are to be provided. The requirements are detailed, especially when the regulatory interpretations are considered, and have been the subject of numerous judicial decisions. The key concept in IDEA is the requirement for the provision of a free appropriate public education (FAPE) for children with disabilities. In order to implement FAPE, IDEA requires that each child with a disability have an individualized education program. Children with disabilities may also receive related services and must receive their education in the least restrictive environment.

IDEA was originally enacted to respond to situations where children with disabilities were being excluded from school without any statutory recourse. Section 615 of IDEA provides detailed procedural safeguards for children with disabilities and their parents. Procedural safeguards are provisions protecting the rights of parents and children with disabilities regarding a free appropriate public education (FAPE) and include notice of rights, mediation, resolution sessions, and due process procedures. Section 615 has been a continual source of controversy, especially the provisions relating to the discipline of children with disabilities. IDEA also provides for attorneys’ fees in some situations, but the Supreme Court has found that parents are not entitled to expert witness fees.



Date of Report: May 11, 2011
Number of Pages: 19
Order Number: R40690
Price: $29.95

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Medicare Primer


Patricia A. Davis, Coordinator
Specialist in Health Care Financing

Paulette C. Morgan, Coordinator
Specialist in Health Care Financing


Medicare is a federal insurance program that pays for covered health care services of qualified beneficiaries. It was established in 1965 under Title XVIII of the Social Security Act as a federal entitlement program to provide health insurance to individuals 65 and older, and has been expanded over the years to include permanently disabled individuals under 65. Medicare, which consists of four parts (A-D), covers hospitalizations, physician services, prescription drugs, skilled nursing facility care, home health visits, and hospice care, among other services.

Generally, individuals are eligible for Medicare if they or their spouse worked for at least 40 quarters in Medicare-covered employment, are 65 years old, and are a citizen or permanent resident of the United States. Individuals may also qualify for coverage if they are a younger person with a permanent disability, have End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant), or have amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease). In addition, individuals with one or more specified lung diseases or types of cancer who lived for six months during a specified period prior to diagnosis in an area subject to a public health emergency declaration by the Environmental Protection Agency (EPA) as of June 17, 2009, are also deemed entitled to benefits under Part A and eligible to enroll in Part B.

In FY2011, the program will cover an estimated 48 million persons (40 million aged and 8 million disabled) at an estimated total cost of about $569 billion, accounting for approximately 3.7% of GDP. Medicare is an entitlement program, which means that it is required to pay for covered services provided to eligible persons so long as specific criteria are met.

Since 1965, the Medicare program has undergone considerable change. During the 111
th Congress, the Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (HCERA, P.L. 111-152), were signed into law. They made numerous changes to the Medicare program that modify provider reimbursements, provide incentives to increase the quality and efficiency of care, and enhance certain Medicare benefits.

However, in the absence of congressional action, the Medicare program will be unsustainable in the long run. The Part A trust fund has been estimated to become insolvent in 2029. And although the Part B trust fund is financed in large part through federal general revenues and can not become insolvent, Medicare spending growth will put increasing strains on Congress’s competing priorities.

The 112
th Congress may continue to debate the recent changes to Medicare, and may consider additional legislative action ranging from technical corrections to broader structural changes.

This report provides an overview of Medicare and will be updated to reflect any legislative changes.



Date of Report: May 9, 2011
Number of Pages: 28
Order Number: R40425
Price: $29.95

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