What I’m Politicing: The Distinction Between Subtitles A, B, and C is Important!

Rep. Joe Wilson bought himself a good fifteen minutes on the national stage and a nice bump in his campaign coffers by shouting “YOU LIE!” to Pres. Obama during the president speech to a joint session of Congress a few days ago.

The contention by many lefties is that Rep. Joe Wilson was rude to interrupt the President and that Rep. Wilson was wrong.  Here are two such examples from the SoDak blogosphere:

• Obama’s Right: No Benefits for Illegal Immigrants in H.R. 3200 [Madville Times]
• Joe Wilson’s Diarrhea Of The Mouth [SD Humanist]

They should both know better.  The distinctions between Subtitle A, B, and C of Title I in America’s Health Choices Act of 2009 are important.

The Contention: No Illegals Get Health Care via Reform Bill

BWJunior argues that Rep. Wilson had every right to shout (I agree, sir!), but that Rep. Wilson forgets the good old Ronnie Reagan helped craft legislation that forces hospitals to treat people no matter the status of their citizenship (we’ll get to that later).  Further, he maintains that nothing in “America’s Affordable Health Choices Act of 2009″ gives illegal aliens more access to health care:

Nothing in HR3200 gives illegal immigrants more access to healthcare than they already enjoy. In fact it specifically restricts them from benefiting from it. (though enforcement of such restrictions is questionable)

Heidelberger is a bit more affected.  He is upset at the “grossly indecorous” Joe Wilson’s contention that Pres. Obama lied when he claimed that his (we’re coming back to that point in a bit) health care plan would not apply to illegal immigrants.  Heidelberger cites “America’s Affordable Health Choices Act of 2009,” claims he’s disproved Rep. Wilson, and then excoriates his readers that they must demand chapter and verse from the 1,000+ page bill whenever they hear folks speaking about it?  Why?  Because, Heidelberger claims, those people will prove themselves wrong by the very text they cite:

p.s.: A corollary to the health care debate: when someone cites page numbers in H.R. 3200, call their bluff. Demand a hyperlink. Make them read you the actual text, word for word. Nine times out of ten, they’ll prove themselves wrong, just by reading the very bill they think they are citing.

Like a mosquito in a nudist colony, I don’t know where to begin here, dear readers.

Let’s Start at the Beginning

I’ve been reading this health care bill for the latter part of the summer.  Why?  Because I’ve been curious about all the accusations flying around.  I’ve heard pundits tell me that it gives the federal government the power to kill my grandma.  I’ve heard bloggers say that’s all right-wing rage.

Rather than get my news and analysis through some pundit’s lens, I decided to read it for myself.  I didn’t want to be one of those people who just read a column by a favorite pundit and then use whatever that pundit snipped from the bill as my basis for analysis about the legislation.  I’ve only made it about 350ish pages into the bill, and I’ve posted about my concerns and questions here.

To be quite honest, the question of whether or not illegals were funded had never, ever crossed my mind.  When I started thinking about Pres. Obama’s claims that no illegal would get health care and Rep. Wilson’s holler, I went back to my notes.

There is no language in the bill – as far as I have read – that explicitly says, “Here you go, illegal alien, have some health care on the American taxpayer.”  However, in Title II, Subtitles A & B  – the part of the bill that establishes the public option and the health insurance exchange – there is no language that explicitly says, “Hey, illegal alien, you can’t have health care insurance on the American taxpayer.”

As I understand the bill, the legislation creates new programs while simultaneously revising different sections of the tax code, Medicare, and Medicaid.  The table of contents will help clarify this point as you can see the various sections:

(I know this is a looong list – click here to skip ahead to the rest of my argument.)

• DIVISION A—AFFORDABLE HEALTH CARE CHOICES
  • TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
    • Subtitle A—General Standards
    • Subtitle B—Standards Guaranteeing Access to Affordable Coverage
    • Subtitle C—Standards Guaranteeing Access to Essential Benefits
    • Subtitle D—Additional Consumer Protections
    • Subtitle E—Governance
    • Subtitle F—Relation to Other Requirements; Miscellaneous
    • Subtitle G—Early Investments
  • TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
    • Subtitle A—Health Insurance Exchange
    • Subtitle B—Public Health Insurance Option
    • Subtitle C—Individual Affordability Credits
  • TITLE III—SHARED RESPONSIBILITY
    • Subtitle A—Individual Responsibility
    • Subtitle B—Employer Responsibility
  • TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
    • Subtitle A—Shared Responsibility
    • Subtitle B—Credit for Small Business Employee Health Coverage Expenses
    • Subtitle C—Disclosures to Carry Out Health Insurance Exchange Subsidies
    • Subtitle D—Other Revenue Provisions
• DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS
  • TITLE I—IMPROVING HEALTH CARE VALUE
    • Subtitle A—Provisions Related to Medicare Part A
    • Subtitle B—Provisions Related to Part B
    • Subtitle C—Provisions Related to Medicare Parts A and B
    • Subtitle D—Medicare Advantage Reforms
    • Subtitle E—Improvements to Medicare Part D
    • Subtitle F—Medicare Rural Access Protections
  • TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS
    • Subtitle A—Improving and Simplifying Financial Assistance for Low Income
    • Medicare Beneficiaries
    • Subtitle B—Reducing Health Disparities
    • Subtitle C—Miscellaneous Improvements
  • TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE
  • TITLE IV—QUALITY
    • Subtitle A—Comparative Effectiveness Research
    • Subtitle B—Nursing Home Transparency
    • Subtitle C—Quality Measurements
    • Subtitle D—Physician Payments Sunshine Provision
    • Subtitle E—Public Reporting on Health Care-Associated Infections
  • TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION
  • TITLE VI—PROGRAM INTEGRITY
    • Subtitle A—Increased Funding to Fight Waste, Fraud, and Abuse
    • Subtitle B—Enhanced Penalties for Fraud and Abuse
    • Subtitle C—Enhanced Program and Provider Protections
    • Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and Abuse
  • TITLE VII—MEDICAID AND CHIP
    • Subtitle A—Medicaid and Health Reform
    • Subtitle B—Prevention
    • Subtitle C—Access
    • Subtitle D—Coverage
    • Subtitle E—Financing
    • Subtitle F—Waste, Fraud, and Abuse
    • Subtitle G—Puerto Rico and the Territories
    • Subtitle H—Miscellaneous
  • TITLE VIII—REVENUE-RELATED PROVISIONS
  • TITLE IX—MISCELLANEOUS PROVISIONS
• DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
  • TITLE I—COMMUNITY HEALTH CENTERS
  • TITLE II—WORKFORCE
    • Subtitle A—Primary Care Workforce
    • Subtitle B—Nursing Workforce
    • Subtitle C—Public Health Workforce
    • Subtitle D—Adapting Workforce to Evolving Health System Needs
  • TITLE III—PREVENTION AND WELLNESS
  • TITLE IV—QUALITY AND SURVEILLANCE
  • TITLE V—OTHER PROVISIONS
    • Subtitle A—Drug Discount for Rural and Other Hospitals
    • Subtitle B—School-Based Health Clinics
    • Subtitle C—National Medical Device Registry
    • Subtitle D—Grants for Comprehensive Programs to Provide Education to
    • Nurses and Create a Pipeline to Nursing
    • Subtitle E—States Failing to Adhere to Certain Employment Obligations

Division A is creates new public programs and revises the IRS tax code.  Division B makes “improvements” on Medicare and Medicaid.  And Division C, as I understand it, gives the federal government enforcement and regulatory power.  It’s Division A, Title II, Subtitles A, B, and C that are causing all the controversy, and those are the sections that we should examine closely.

But, wait, didn’t Heidelberger, BWJunior, and a whole host of lefties cite a specific part of the bill by chapter and verse that explicitly forbids illegal immigrants from getting health care?

Yes, they cited specific sections of the legislation; however, the part of the bill that both gentlemen cite proves their claims wrong.

What the Lefties Are Citing Proves Their Contention Wrong

We are going to focus on “Division A Affordable Health Care Choice, Title II Health Insurance Exchange and Related Provisions.”  This is the part of the legislation that establishes the health insurance exchange market (Subtitle A), the public option (Subtitle B), and individual affordability credits (Subtitle C).

What Heidelberger, BWJunior, and many defenders of Pres. Obama’s plan (again, we’re going to get to that later) cite refers to “Division A, Title II Health Insurance Exchange and Related Provisions, Subtitle C – Individual Affordability Credits” (beginning on p. 128).

There is language in that section of the bill that explicitly denies these affordability credits to illegal aliens.

Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States. (pp. 143)

So, the bill does have an apparatus in it that denies these affordability credits to illegal aliens.

That same language is not in the part of the bill that establishes the Public Health Insurance Option (“Division A, Title II Health Insurance Exchange and Related Provisions, Subtitle B – Public Health Insurance Option” – beginning on pp. 116) nor is it present in the section of the bill that establishes that Health Insurance Exchange (“Title II Health Insurance Exchange and Related Provisions, Subtitle A – Health Insurance Exchange” – beginning on pp. 72).  (I had this same argument a few days ago.)

So, when Heidelberger asks for his readers and opponents to cite the bill, here, there’s nothing to cite in this case.  There’s no language that bars illegal aliens from the Health Insurance Exchange or from the Public Health Insurance Option.

Indeed, we can see as much in the table of contents for each section.

Table of contents for Title II Health Insurance Exchange and Related Provisions, Subtitle A – Health Insurance Exchange:

Sec. 201. Establishment of Health Insurance Exchange; outline of duties; definitions.
Sec. 202. Exchange-eligible individuals and employers.
Sec. 203. Benefits package levels.
Sec. 204. Contracts for the offering of Exchange-participating health benefits plans.
Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan.
Sec. 206. Other functions.
Sec. 207. Health Insurance Exchange Trust Fund.
Sec. 208. Optional operation of State-based health insurance exchanges.  (pp. 6-7)

Table of contents for Title II Health Insurance Exchange and Related Provisions, Subtitle B – Public Health Insurance Option:

Sec. 221. Establishment and administration of a public health insurance option
as an Exchange-qualified health benefits plan.
Sec. 222. Premiums and financing.
Sec. 223. Payment rates for items and services.
Sec. 224. Modernized payment initiatives and delivery system reform.
Sec. 225. Provider participation.
Sec. 226. Application of fraud and abuse provisions.  (pp. 7)

Table of contents for Title II Health Insurance Exchange and Related Provisions, Subtitle C – Affordability Credits:

Sec. 241. Availability through Health Insurance Exchange.
Sec. 242. Affordable credit eligible individual.
Sec. 243. Affordable premium credit.
Sec. 244. Affordability cost-sharing credit.
Sec. 245. Income determinations.
Sec. 246. No Federal payment for undocumented aliens. (pp. 7)

It strike me as quite strange that Subtitle C has explicit language that denies the individual affordability credits to undocumented aliens but that the both Subtitle A and B are lacking that same language.  In other words, within the bill as I have read and now re-read (ugh!) it, there is nothing within the bill that prevents illegal aliens from receiving benefits from the Health Insurance Exchange or the Public Health Insurance Option.  No proof of citizenship is required to enroll in those programs.  At all.

None.

Zip.

Zero.

Nada.

The way the legislation reads now is that an illegal alien could possibly enroll in the health insurance exchange or the public health insurance option.  He just could not receive affordability credits to use in those programs.

However, don’t just trust me: the White House is admitting as such in their Friday afternoon docu-dump.  Posted over on MSNBC First Reads:

Today, for the first time as far as we know, the administration is backing a provision that would require proof of citizenship before someone could enroll in a plan selected on the exchange.

Here, the administration also concedes that hospitals would be compensated with public funds for the care of undocumented immigrants.

The bullet points sent tonight by the White House:

• Undocumented immigrants would not be able to buy private insurance on the exchange. Those who are lawfully present in this country would be able to participate.
• Undocumented immigrants would be able to buy insurance in the non-exchange private market, just as they do today. That market will shrink as the exchange takes hold, but it will still exist and will be subject to reforms such as the bans on pre-existing conditions and caps.
• Verification will be required when purchasing health insurance on the exchange. One option is the SAVE program (Systematic Alien Verification for Entitlements) which states currently use to make sure that undocumented immigrants don’t participate in safety-net programs for which they are ineligible.
• There would be no change in the law that requires emergency rooms to treat people who need emergency care, including undocumented immigrants. There is already a federal grant program that compensates states for emergency room costs associated with treatment of undocumented immigrants, a provision sponsored by a Republican lawmaker.

What?

BTW, it might be of note, if you run a text search on the .pdf of the bill, “undocumented” only appears twice: once in the table of contents and once in the title of the sub-section.

It Doesn’t Matter to the Bigger Picture, Anyway

BWJunior was onto something more interesting by citing the Emergency Medical Treatment and Active Labor Act (a smaller part of the COBRA 1986 – full text of the bill here) and invoking the specter of Ronald Reagan.

We might want to note that this legislation only applies to hospitals participating in government programs:

The Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395dd, EMTALA) is a United States Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act. It requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.

EMTALA applies to “participating hospitals”, i.e., those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program. However, in practical terms, EMTALA applies to virtually all hospitals in the U.S., with the exception of the Shriners Hospitals for Children, Indian Health Service hospitals, and Veterans Affairs hospitals. The combined payments of Medicare and Medicaid, $602 billion in 2004,^[1] or roughly 44% of all medical expenditures in the U.S., make not participating in EMTALA impractical for nearly all hospitals. EMTALA’s provisions apply to all patients, and not just to Medicare patients. [via Wikipedia]

In other words, the federal government says, “If you are going to take my money, you’re going to play by my rules.”

Further, BWJunior’s entirely correct that Pres. Reagan did sign the legislation into law, and it might make the conversation even more interesting (non-unique disadvantage or not) if we could discuss which congressmen sponsored the legislation: COBRA was sponsored by Rep. Dan Rostenkowski – a Democrat from Illinois (!).

How the legislation that BWJunior cited affects the current health care debate is an even more interesting question.  I wonder how much of the rising cost of health care and insurance can be traced to hospitals not receiving Medicare/Medicaid payments in a timely fashion and treating patients who don’t pay.  (How much would the cost of a Big Mac increase if we all took one but didn’t pay for it?)

In addition to invoking Pres. Reagan, BWJunior argued that Rep. Wilson should at least introduce legislation that bars illegal aliens from getting health care if that’s what he wants.  Says BWJunior:

The problem I have is if you are going to set a precedent by interrupting a Presidential address, please have the courtesy to be correct. If you don’t want us paying for the healthcare of illegals, introduce legislation to override the 23 year old law that allowed it in the first place instead of calling out the President because of your overactive imagination.

I agree, BWJunior.  It’s worth noting that Republicans did try to do as much with the current health care reform bill.  And Democrats voted it down.

In the House Ways and Means Committee, the Republicans tried to amend the Democrats’ health care bill to require use of the SAVE system or a similar safeguard, but their amendment was voted down on a straight party-line vote… [via Power Line]

This happened back in early August:

The House bill, as currently structured, does not offer clear guidelines to ensure that illegal immigrants cannot access taxpayer-funded health care benefits. Rep. Dean Heller (R-NV) introduced an amendment that would use two citizenship status verification systems, the Income and Eligibility Verification System (IEVS) and Systematic Alien Verification for Entitlements (SAVE) programs, to establish an individual’s eligibility to obtain the bill’s proposed affordability credits or enroll in the public insurance option. Both programs are currently used to determine citizenship status and eligibility for public assistance programs. Safeguards to guarantee that only citizens can access federal health care benefits are necessary, considering that the US Census Bureau currently estimates that 9.6 million of the uninsured are not US citizens. The first Heller amendment failed on a straight party-line vote.  [via The Foundry]

If I am reading that correctly, then, Democrats voted against a provision to verify citizenship for access to taxpayer funded health care benefits.  Wow.  (BTW, here’s the House Ways and Means Committee chaired by Charlie Rangel. Rangel’s, remember, is that guy who keeps forgetting about where he hid put his money.)

Anyway, this business about illegal aliens getting health care on the taxpayer’s dime strikes me as moot.  It doesn’t matter in the overall grand scheme of this debate: “America’s Affordable Health Choices Act of 2009″ should not become law.

Further, the Democrats have had control of both the House and Senate since 2007.  In addition to controlling Congress, the Democrats now control the White House with arguably the most popular president in recent history.  All of the hysteria about some right-wing “teabaggers” or some Republican opposition is quite silly.  When the President first demanded this legislation be passed, Republicans had no political power.  There was nothing they could do to stop the President, Speaker Pelosi, or Sen. Reid.  And yet, the President still whines as though he faces a huge Republican majority that’s blocking his every move.

While the whining about opposition is silly, Pres. Obama’s constant appeals to “his plan” are irritating.

He doesn’t have one (that he’s shared with the public).

Pres. Obama made public health care a large part of his campaign, and he decided to make it an important agenda item for his first year in office.  He has spent an entire summer speaking and proselytizing for health care insurance reform.  He’s demanded that congressmen to get their bills written, insinuated that Republicans are mere obstructionists (they do have alternate plans!), and making a bizarre false dictomy between reform or status quo (which is so silly).

And yet, in all this time, while campaigning for arguably the most important item in his early presidency, Pres. Obama has never released his plan.  He left Congress to write him a bill, it’s a bad one.

I wholeheartedly agree with Heidelberger that if a fellow citizen is arguing about the health care bill, you should make “them read you the actual text, word for word.”  Why won’t the President do such with his plan?

BTW, this post by Andrew at Constant Conservative might be of interest along with this bit by Steve Hickey about Planned Parenthood and this legislation.

Update/Edit

If you’re wondering where so many leftists got their Section 246 analysis, check Media Matters.  It seemed that conglomerate start the whole section 246 movement.

Given that Section 246 so clearly is narrow and so clearly does not prove that Obama was correct in his speech, I wondered how it was that, within hours of Obama’s speech, blog comment sections and blog posts were being plastered by people quoting Section 246 as “proof” that Obama was right and Wilson was wrong. Even my own blog post received comments from people quoting Section 246.

Realistically, how many people had dug into the 1018 pages of the House Bill to find Section 246?

The answer is that at 9:51 p.m. on the night of Obama’s speech Media Matters, the Democratic media operation, issued an Action Alert claiming that Section 246 was “Proof That “You Lie!” Was A Lie” and that “in reality, Rep. Wilson is the liar.”

In addition to Media Matters’ other distribution methods, that Action Alert was sent out by Media Matters via Twitter [to over 1700 followers] and re-tweeted over 200 times.

The Media Matters meme about Section 246 has been picked up by many bloggers, including Jason Linkins at Huffington Post, who cited Media Matters as having proved that “what’s been completely glossed over by the press is the fact that the ‘You Lie!’ was itself built upon a lie.” A blogger at DailyKos declared “Healthcare Bill, HR 3200 Sec 246 proves Wilson a liar.”

But of course, the fools in the blogosphere who either did not read the words of Section 246 or chose to ignore the fact that Section 246 only applies to “affordability credits” were not to be outdone.

Keith Olbermann, the Fool-in-Chief, went on a rant last night on MSNBC about how Joe Wilson was a liar and wrong. The proof? Section 246!  [Legal Insurrection @ the Hot Air Blog]

Head over to the Hot Air blog to watch Olbermann mumble through the words “affordability credits.”

When do you think the folks who quoted Section 246 to brandish Rep. Joe Wilson a liar will publish corrections/retractions of their claims?

On a different note,  it does seem as though reading that legislation wasn’t a total waste of time: because I had read the legislation, I was able to quickly see the problem with this Section 246 business.  That kind of first hand knowledge of an issue breeds far more confidence than reposting whatever some media outlet tells me is true.  What’s that line?  Trust but verify?