Several comprehensive bills have been introduced on the topic of health reform in the 111 th Congress, such as H.R. 3962 (the Affordable Health Care for America Act), S. 1679 (Affordable Health Choices Act), and S. 1796 (America's Healthy Future Act of 2009). On November 3, 2009, an additional health reform proposal was made public: Amendment in the Nature of a Substitute to H.R. 3962 Offered by Mr. Boehner of Ohio ("the Amendment"). If adopted, the Amendment would replace the substantive text of H.R. 3962 with the text of the Common Sense Health Care Reform and Affordability Act. According to the Congressional Budget Office and the Joint Committee on Taxation, enacting the Amendment would result in a net reduction in federal deficits of $68 billion over the 2010-2019 period. This report summarizes the contents of the proposed Amendment. The Amendment consists of seven divisions. Division A provisions are intended to improve affordability of health insurance through the development of state reinsurance programs and high-risk pools, private insurance reforms, state innovation programs, and administrative simplification. Division B provisions are intended to improve access to health insurance for small businesses. These include the establishment of Association Health Plans. Division B would also establish requirements to improve interstate purchasing of health insurance coverage and expand tax preferences for health savings accounts and high-deductible health plans. Division C would establish national medical malpractice laws that would effectively preempt existing state medical malpractice laws, with certain exceptions. Division D is focused on the doctor-patient relationship and comparative effectiveness research. It would provide that the Act would not affect the doctor-patient relationship or the practice of medicine, and would repeal a federal council on comparative effectiveness. Division E focuses on employee wellness programs and would specify how a group health plan or a health insurer offering group health coverage could vary premiums and cost sharing based on participation in a standards-based wellness program. Division F focuses on fraud, waste, abuse, and abortion. Division G focuses on licensure of biosimilar products and would provide a pathway for such licensure. This report discusses each of the broad topics addressed in the Amendment. Each discussion consists of an overview of the issue and current law followed by a summary of provisions of the Amendment. Regulation of the private health insurance market is primarily done at the state level. State regulatory authority is broad in scope and includes requirements related to the issuance and renewal of coverage, benefits, rating, consumer protections, and other issues. Federal regulation of the private market is more narrow in scope and applicable mostly to employer-sponsored health insurance (i.e., through the Employee Retirement Income Security Act of 1974 (ERISA)). States have taken the initiative to propose and enact health care reforms to address perceived problems related to health insurance coverage, health care costs, and other issues. Each state has implemented a unique set of reform strategies to address concerns about health insurance and the health care delivery system. However, most health reform discussions, at both the state and federal level, focus primarily on insurance. Under this broad policy area, coverage and cost concerns are paramount. A couple of strategies that states have undertaken to address the twin concerns regarding cost and coverage are implementing reinsurance programs and high-risk pools. Typically, state reinsurance programs reimburse insurers that have experienced greater than average claims in a given year. states may finance reinsurance programs through assessments on all insurers in a particular market, as well as general revenue and the collection of premiums from participating insurers. To compensate insurers that may end up enrolling a sicker, more expensive population, the state may withhold a portion of premiums collected and distribute the withheld funds at a later time according to the actual risk enrolled by each participating insurer. In an effort to expand the options for health coverage, 35 states have established high-risk health insurance pools. These programs target individuals who cannot obtain or afford health insurance in the private market, primarily because of pre-existing health conditions. Also, many states use their high-risk pools to comply with the portability and guaranteed issue provisions of the Health Insurance Portability and Accountability Act of 1996 (described below). In general, state high-risk pools tend to be small and enroll a small percentage of the uninsured. The Health Insurance Portability and Accountability Act (HIPAA), which amended ERISA, requires that coverage sold to small groups (2-50 employees) must be sold on a guaranteed issue basis. That is, the issuer must accept every small employer that applies for coverage. (Guaranteed issue rules do not address premiums.) HIPAA also guarantees that each issuer in the individual market make at least two policies available to all HIPAA eligible individuals ("guaranteed availability"). In addition, HIPAA guarantees renewal or continuation of group coverage at the option of the plan sponsor (e.g., employer) and individual coverage at the option of the individual, with some exceptions. Insurers may not renew coverage under specified circumstances, such as nonpayment of premiums or fraud. All states require issuers to offer policies to firms with 2-50 workers on a guaranteed issue basis, in compliance with HIPAA. As of January 2009 in the small group market, 13 states also require issuers to offer policies on a guaranteed issue basis to self-employed "groups of one." And as of December 2008 in the individual market, 15 states require issuers to offer some or all of their insurance products on a guaranteed issue basis to non-HIPAA eligible individuals. Each state would be required to establish and operate a qualified reinsurance program in the small group market or a qualifying high-risk pool to offer individual coverage. The Amendment would specify the features of such programs and pools. The HHS Secretary (hereinafter referred to as "the Secretary") would be permitted to waive the requirements of this provision as deemed appropriate. The Amendment would authorize an appropriation of $15 billion for seed and operational grants to states for FYs 2010-2019, and an additional $10 billion for FYs 2015-2019. Participation in qualifying high-risk pools and qualified reinsurance program would be limited to citizens and nationals of the United States. Citizenship would be verified in accordance with §1903(x) of the Social Security Act, which requires states to obtain satisfactory documentation of citizenship. Legal permanent residents (LPRs), refugees, and other lawfully residing aliens would be not be eligible. The Amendment would impose new federal requirements on the private health insurance market. Specifically, the proposal would: expand eligibility for guaranteed availability protections in the individual market for HIPAA eligible individuals; prohibit health insurance issuers from imposing an annual or lifetime benefit limit on any health insurance coverage; prohibit health insurance rescissions in the application of guaranteed renewability protections in the individual market, except under certain conditions such as nonpayment of premiums, fraud, and other circumstances; and require issuers to provide (1) notice of a proposed nonrenewal, discontinuation, or rescission of an individual health insurance policy to the enrollee before such proposed action would take effect, and (2) the opportunity to appeal such proposed action to an independent, external third party, as specified by the Secretary. With the lack of comprehensive health care reform at the federal level, states have been engaged in innovative approaches using private expansions, subsidies and tax credits, and regulatory reforms in order to both expand coverage and keep premiums down. Often these approaches have been hampered by funding issues. For example, while the Dirigo Health Agency in Maine has been successful in enrolling an estimated 9,000 to 11,000 previously uninsured individuals, the program has had some financial struggles and operated at a net loss in 2008. Such financial struggles are common for new programs, but there is not a mechanism in current law to provide federal grants to assist states in their attempts to implement innovative health reforms. For those that argue that health care quality and cost pressures would improve if the health insurance system acted more like a competitive market, the lack of symmetric information is a problem for consumers. This phenomenon occurs when any actors in the marketplace have informational advantages over others. Consumers often have limited comparable and accessible information about health insurance plans. Current law contains no provisions for a coordinated national effort, federally or at the state level, to provide a comparative health plan finder except in the Medicare Advantage and Part D programs. The Amendment provides $50 billion in incentives to states that adopt reforms that reduce the cost of health insurance and expand coverage. The appropriations would be broken up into three components: (1) $25 billion for reductions in cost in the small group market; (2) $10 billion for reductions in cost in the individual market; and (3) $15 billion for reductions in the number of uninsured. The term "small group market" means the market for health insurance coverage through a group health plan maintained by an employer who employed on average at least 2 but not more than 50 employees on business days during a calendar year. The term ''individual market'' generally means the market for health insurance coverage offered to individuals other than in connection with a group health plan. Under the Amendment, states would have to meet targets as specified by the Amendment, for reductions in health plan premiums and the number of uninsured in order to receive funds. For premium reductions, the Secretary would determine if the targets have been met relative to a premium baseline. The premium baseline would for year one be the average per capita premiums for health insurance coverage in the state. In subsequent years, the premium baseline would be increased by a percentage calculated by a formula to be determined by the Secretary in consultation with the Congressional Budget Office and the Bureau of the Census. In determining the formula the Secretary would take into account the inflation in health care services costs in the year, historic premium growth rates, and historic average changes in the demographics of the population covered that impact the rate of growth of per capita health care costs.