Amanda K. Sarata, Coordinator
Specialist in Health Policy
Nancy Lee Jones
Legislative Attorney
Jennifer Staman
Legislative Attorney
Upon the enactment of the Patient Protection and Affordable Care Act (PPACA), as amended, certain questions have been raised about how PPACA might affect existing law. One such existing law, the Genetic Information Nondiscrimination Act (GINA), is a civil rights statute and has as its purpose the prohibition of discrimination against individuals on the basis of genetic information. In order to effectuate this prohibition, GINA not only contains certain requirements for health insurance and a general prohibition of employment discrimination provisions, but also has strong privacy protections. On the other hand, PPACA is comprehensive health care legislation that is intended to, among other things, enhance consumer protections in the private health insurance market. Both GINA and PPACA contain provisions affecting certain elements of health insurance, as well as employment-based wellness programs. PPACA, the more recent statute, does not specifically amend GINA and also does not reference GINA’s requirements. The two laws serve different but complementary purposes, and there is no explicit conflict or contradiction in their terms. Still, the interaction of these two acts may be analyzed.
This report provides a brief overview of GINA, an overview of relevant PPACA and GINA provisions relating to the provision of health insurance through the private market and the implementation of employer wellness programs, and statutory analysis of the potential interactions between the related provisions in both laws.
Date of Report: December 13, 2010
Number of Pages: 15
Order Number: R41314
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Paulette C. Morgan, Coordinator
Specialist in Health Care Financing
Patricia A. Davis
Acting Section Research Manager/Specialist in Health Care Financing
Barbara English
Information Research Specialist
Jim Hahn
Analyst in Health Care Financing
Mark Newsom
Specialist in Health Care Financing
Julie Stone
Specialist in Health Care Financing
Sibyl Tilson
Specialist in Health Care Financing
Medicare is a federal insurance program that pays for covered health services for most persons 65 years of age and older and for most permanently disabled individuals under the age of 65. Part A of the program, the Hospital Insurance program, covers hospital, post-hospital, and hospice services. Part B, the Supplementary Medical Insurance program, is optional and covers a broad range of complementary medical services including physician, laboratory, outpatient hospital services, and durable medical equipment. Part C provides private plan options for beneficiaries enrolled in both Parts A and B. Part D is an optional outpatient prescription drug program.
Medicare has established specific rules for payment of covered benefits. Some, such as physician services and most durable medical equipment, are based on fee schedules. Some payments are based, in part, on a provider’s bid (an estimate of the cost of providing a service) relative to a benchmark (the maximum amount Medicare will pay). Bids and benchmarks are used to determine payments in Medicare Parts C and D. Payments for some items of durable medical equipment in specified locations are to be based on competitive bidding, starting in 2011. Many services, however, including inpatient and outpatient hospital care, are paid under different prospective payment systems (PPSs). In general, the program provides for annual updates to these payment amounts. The program also has rules regarding the amount of cost sharing, if any, which beneficiaries can be billed in excess of Medicare’s recognized payment levels. Unlike other services, Medicare’s outpatient prescription drug benefit can be obtained only through private plans. Further, while all Part D plans must meet certain minimum requirements, they differ in terms of benefit design, formulary drugs, and cost-sharing amounts.
Medicare payment policies and potential changes to these policies are of continuing interest to Congress. The Medicare program has been a major focus of deficit reduction legislation since 1980. With certain exceptions, reductions in program spending have been achieved largely through regulating payments to providers, primarily hospitals and physicians. The Balanced Budget Act of 1997 (P.L. 105-33, BBA) modified some existing payment policies, including changing underlying payment methodologies and updates to payment amounts. Subsequent legislation increased Medicare funding to mitigate the financial impact of some BBA provisions. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173, MMA), too, modified payment methods and established payment increases for some providers. Most recently, the Tax Relief and Health Care Act of 2006 (P.L. 109-432, TRHCA); the Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. 110-173, MMSEA); the Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275, MIPPA); the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5); the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148, PPACA), as modified by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152); and the Medicare and Medicaid Extenders Act of 2010 (P.L. 111-309) have affected Medicare’s payments.
This report provides an overview of Medicare payment rules by type of service, outlines current payment policies, and summarizes the basic rules for program updates.
Date of Report: December 29, 2010
Number of Pages: 51
Order Number: RL30526
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L. Elaine Halchin
Specialist in American National Government
For many years, it was said that National Football League (NFL) players who had sustained concussions were “dinged,” or “had gotten their bell rung.” Out of a sense of loyalty to their teammates, a desire to win, or concern that sitting on the bench with an injury would hurt their chances to make the team, players would—and, perhaps, were expected to—play through their injuries, including concussions.
Beginning around 2006 or 2007, the NFL, the NFL Players Association (NFLPA), and others increased their efforts to safeguard active players and assist former players (although there has been no explicit, public acknowledgment by the league that repetitive brain injuries cause dementia and related illnesses in retired NFL players). It should be noted, however, that one milestone predates this time period. The NFL established its Mild Traumatic Brain Injury (MTBI) Committee in 1994; its successor, the Head, Neck and Spine Medical (HNS) Committee, was formed in 2010. As for the NFLPA, it established the Mackey-White Traumatic Brain Injury Committee in 2009.
Significant changes in the league’s return-to-play guidelines and ongoing efforts to change or refine the rules of the game are a couple of the initiatives undertaken by the league. These changes, and others, have been accompanied by renewed efforts to inform players of the signs and symptoms of concussions and alert them to the possibility of long-term consequences. A rigorous, established evaluation methodology could aid in ascertaining whether such efforts have been successful.
Benefits available to former players who suffer from dementia or neurological conditions include the 88 Plan and the neurological care program. An eligible retired player may apply for total and permanent (T&P) disability benefits on the basis of problems or illnesses related to brain injuries. If his application is approved, however, the cost of the required level of care might exceed the amount of his T&P benefit.
Congressional interest in NFL players and concussions has been manifested in several hearings held by the House Committee on the Judiciary. Hearings were held during the 111th Congress on the following dates: October 28, 2009; January 4, 2010; February 1, 2010 (this gathering was labeled a forum); and May 24, 2010.
As the NFL, NFLPA, and others continue their efforts to safeguard active players or assist retired players, Congress may choose to monitor these efforts. Specific issues that may interest Congress include, for example, certification standards for football helmets, NFL policy and rule changes, benefits for retired players suffering from dementia or related illnesses, and, though beyond the scope of this report, whether changes at the professional level influence the policies in college, high school, and youth football.
Date of Report: January 3, 2011
Number of Pages: 37
Order Number: R41555
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Vivian S. Chu
Legislative Attorney
On October 12, 2010, the Supreme Court heard oral arguments for Bruesewitz v. Wyeth, a case involving the scope of the National Childhood Vaccine Injury Act. The Supreme Court faces consideration of whether 42 U.S.C. § 300aa-22(b)(1) of the act precludes all vaccine design defect claims even if the vaccine’s side effects were avoidable, or whether the vaccine manufacturer has to show on a case-by-case basis that the side effects could not have been avoided by some alternatively designed vaccine. Both parties have fundamentally differing interpretations of the statute’s plain meaning and of Congress’s intent. This report provides an overview of the structure of the Vaccine Act and the relevant facts of the Bruesewitz case. It then examines the district court and court of appeals decisions before discussing the arguments made by the parties before the Supreme Court. Finally, the report looks at some of the potential consequences that might result from the Court’s decision in favor of either the Bruesewitzes or Wyeth. This report will be updated pending the Supreme Court’s decision.
Date of Report: December 20, 2010
Number of Pages: 18
Order Number: R41538
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Carmen Solomon-Fears
Specialist in Social Policy
In 2008, U.S. teen births accounted for 10.4% of all births and 22.2% of all nonmarital births. The birth rate for U.S. teenagers (ages 15 through 19) increased in 2006 and 2007 after a steady decline since 1991. However, in 2008 the teen birth rate dropped 2% below the 2007 teen birth rate, reversing the two-year upward trend. Although the birth rate for U.S. teens has dropped in 15 of the last 17 years, it remains higher than the teenage birth rate of most industrialized nations. In recognition of the negative, long-term consequences associated with teenage pregnancy and births, the prevention of teenage and out-of-wedlock childbearing is a major goal of this nation.
The Adolescent Family Life (AFL) program, created in 1981 (Title XX of the Public Health Services Act), was the first federal program to focus on adolescents. It was created to support demonstration projects that provide comprehensive and innovative health, education, and social services to pregnant and parenting adolescents, their infants, male partners, and their families. From 1998 to 2009, federal teen pregnancy prevention efforts in the AFL program and in general relied heavily on using abstinence-only education as their primary tool.
It appears that a consensus is now growing around the viewpoint that success in the teen pregnancy prevention arena does not necessarily have to be an “either-or” proposition in which abstinence-only education programs are pitted against comprehensive sex education programs. P.L. 111-117 (the Consolidated Appropriations for FY2010) included a new discretionary Teen Pregnancy Prevention (TPP) program, funded at $110 million for FY2010, which provides grants and contracts, on a competitive basis, to public and private entities to fund “medically accurate and age appropriate” programs that reduce teen pregnancy.
P.L. 111-148 (the health care reform law) established a new state formula grant program and appropriated $375 million at $75 million per year for five years (FY2010-FY2014) to enable states to operate a new Personal Responsibility Education Program (PREP), which is a comprehensive approach to teen pregnancy prevention that educates adolescents on both abstinence and contraception to prevent pregnancy and sexually transmitted diseases. PREP also provides youth with information on several adulthood preparation subjects (e.g., healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, and healthy life skills).
The Title V Abstinence Education Block Grant to states was authorized under P.L. 104-193 (the 1996 welfare reform law). The Title V Abstinence Education program is formula grant program, specifically for abstinence-only education, funded by mandatory spending. The program’s funding expired on June 30, 2009, but P.L. 111-148 reauthorized the Title V Abstinence Education program and restored funding to it at the previous annual level of $50 million for each of FY2010-FY2014.
There are many other federal programs that can provide pregnancy prevention information and/or services to teens. They include Title X Family Planning, Medicaid family planning, the Maternal and Child Health block grant, the Title XX Social Services block grant, the TANF block grant, and several other Department of Health and Human Services (HHS) programs. This report briefly examines some of the data collected by the National Center for Health Statistics on teenage childbearing, offers potential reasons for high teen pregnancy and birth rates, and provides basic information on federal programs whose purpose, in whole or part, is to prevent teen pregnancy and reduce teen births.
Date of Report: December 17, 2010
Number of Pages: 18
Order Number: RS20301
Price: $29.95
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