Earlier today, Nebraska lawmakers gave final approval to LB594, legislation that would require providers to inform women of any and all potential risk factors associated with abortion — including any physical, psychological, emotional, demographic, or situational factors — at least 24 hours before performing the procedure. At least one hour before the procedure, the legislation requires that a qualified provider assess whether the pregnant woman was being pressured into having an abortion, and evaluate “physical, psychological, emotional, demographic, or situational” risk factors cited by peer-reviewed medical journals. “This is just a legal way to harass doctors,” CAP’s Jessica Arons said about the bill. “It’s another way to chill the provision of abortion services, because who is going to want to perform these abortions if a woman can later change her mind and sue them?”

The legislation is unique in the amount of detail it includes. “Except in the case of an emergency situation, consent to an abortion is voluntary and informed only if: (1) The woman is told the following by the physician…at least twenty-four hours before the abortion”:

(a) The particular medical risks associated with the particular abortion procedure to be employed including, when medically accurate, the risks of infection, hemorrhage, perforated uterus, danger to subsequent pregnancies, and infertility;

(b) The probable gestational age of the unborn child at the time the abortion is to be performed;

(c) The medical risks associated with carrying her child to term; and

(d) That she cannot be forced or required by anyone to have an abortion and is free to withhold or withdraw her consent for an abortion. [...]

(3) If an ultrasound is used prior to the performance of an abortion, the physician who is to perform the abortion, the referring physician…shall….Simultaneously display the ultrasound images so that the woman may choose to view the ultrasound images or not view the ultrasound images. The woman shall be informed that the ultrasound images will be displayed so that she is able to view them….If the woman requests information about the displayed ultrasound image, her questions shall be answered [...]

The most condescending portion of the legislation is the section dealing with the legal recourse for providers who don’t follow the above requirements. “Except in the case of an emergency situation, if a pregnant woman is provided with the information required by section 28-327 less than twenty-four hours before her scheduled abortion, the physician shall bear the burden of proving that the pregnant woman had sufficient reflection time, given her age, maturity, emotional state, and mental capacity, to comprehend and consider such information.” Moreover, the bill “does not sufficiently put physicians on notice for what they must screen for and might be liable for,” Arons says. “Under this bill, a doctor would have to screen a woman for a ‘risk factor’ even if it appeared only once in the medical literature and even if there is no medical consensus that it’s a genuine risk.”

Last week, Nebraska passed another bill (LB1103) aimed at shutting down one of the country’s few late-term abortion providers. That measure “asserts that fetuses feel pain at 20 weeks of pregnancy” and “would be the first nationally to bar women from citing mental health problems as a reason to have an abortion after 20 weeks.” The legislation “sailed through the second of three votes needed for it to become law” on Friday and is expected to pass later this week.

The bill is “created almost entirely as a vehicle for getting anti-choice legislation challenged and potentially reviewed by the Supreme Court,” RH Reality Check’s Robin Marty observes. “Unlike every other anti-choice law that has so far passed in this country, LB 1103 refuses to provide an exemption for a mother’s mental health, regardless of the fact that prior to 20 weeks a pregnant woman’s mental health was so valuable that the state wants to advocate mandatory screenings to protect it.”

Health and Human Services Secretary Kathleen Sebelius has written a letter to the National Association of Insurance Commissioners (NAIC) requesting their assistance in defining medical loss ratio (MLR) standards in the new health care law and has issued two formal requests for public comment on how best to define the term and implement reform’s rate review provisions.

The new health care law requires that insurers spend at least 80% of customers’ premiums on medical care in the individual insurance market, and 85% in the employer/group market until 2014 and pay rebates to enrollees if they does not meet minimum standards. The bill also tries to prevent insurers from increasing rates before 2014 by requiring that insurers “submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase, and prominently post this information on their Internet websites.” States can also keep insurers with “unreasonable” rate hikes from participating in the new exchanges.

On the medical loss ratio provisions, the Secretary is asking the insurance commissioners to develop:

- Definitions relating to the activities that health insurance issuers offering individual and group coverage must report under Section 2718(a) (clinical services, activities that improve health care quality, and all other non-claims costs and the nature of such costs); and

- Standardized calculation methodologies relating to the above mentioned activities, ensuring that they account for the special circumstances of smaller plans, different types of plans, and newer plans.

I’ve argued that MLR and rate review are really the only ways to prevent insurers from increasing premiums in the interim period, when Americans are just getting their first impressions of the new health care law. Therefore, it is absolutely critical that these rules don’t allow insurers to game the system or simply reclassify costs to meet the new requirements. Already, WellPoint has announced that it intends to re-label administrative costs as ‘medical care’ in order to meet the new MLR requirements and health policy wonks have argued that insurers could avoid the MLR guidelines by paying more for certain services (to meet the benchmark) or excluding certain benefits from coverage (benefits which would attract a sicker risk pool). Insurers could also circumvent the premium rate review by shifting more costs into deductibles and co-payments.

On a call with reporters, Jeanne Lambrew — Director of the HHS Office of Health Reform — didn’t provide any specifics into the new standards, emphasizing that the agency wanted to give all the different stakeholders — insurance commissioners, insurers and the general public — an equal opportunity to contribute to the process. “We want to know more about what criteria states and other entities use to improve health care quality. What criteria should be used when determining whether a medical loss ratio should be adjusted, due to potential market volatility? What methods are currently used to enforce medical loss ratio related requirements?” Lambrew also said the agency wanted to know if certain health plans should be excluded from the rate review process and how best to define an unreasonable rate increase. Both comment periods will be open for 30 days.

Georgia’s insurance commissioner John Oxendine, a Republican who is also running for Governor, said that the state won’t participate in the first phase of a new federal health care law which requires that states establish interim high-risk pools to provide coverage for individuals cannot find affordable coverage in the individual health insurance market. Oxendine’s decision is somewhat ironic, however. By opting out of the program, Oxendine is inviting the federal government to directly contract for the provision of services within the states, thus bringing about the very kind of federal intrusion that Republicans seek to avoid.

In a letter to HHS Secretary Kathleen Sebelius, Oxendine said that the new program would burden Georgia taxpayers:

“I have no confidence in any federal assertion that this so-called temporary program will not burden the taxpayers of Georgia,” Oxendine said. “I am concerned that the high risk insurance program will ultimately become the financial responsibility of Georgians at a time when our state is furloughing teachers, laying off employees, and cutting public safety and education funding.”

In other words, when given the choice between building a state-based program or having the federal government come in and contract for services with private insurers, Oxendine set the standard for conservatives across the nation and invited the federal government into the state. As Jeanne Lambrew said today during a conference call with reporters, “if the officials in Georgia chose not to participate in the high-risk pool program, our Department will work to ensure that people in George, as well as other states that don’t participate have access to affordable insurance.”

And given Georgia’s high uninsurance rate and the prevalence of chronic conditions, it’s good thing that it will. 17.8% of Georgians were without health insurance coverage in 2008. Approximately 10% of the population has diabetes, 36.9% of the population is overweight, and 27.8% are obese. 18.5% of adults are also limited in any activities because of physical, mental, or emotional problems.

We’ll see if other states choose to establish their own high-risk insurance pools, but for now it’s important to note that Republicans are seeking to win election by outsourcing the job of covering the uninsured to… the federal government.

In the final days of the health care debate, Rep. Paul Ryan (R-WI) argued that had the CBO used different methods and models to calculate the effects of reform and included different provisions in the final legislation, the Democrats’ bill would have increased the deficit and cut into the Medicare trust fund. This argument descended into the bizarre when Ryan convinced the CBO to produce a report that estimated what would happen if certain provisions of the legislation — like the tax on high-premium insurance plans and recommendations from the Independent Payment Advisory Board — were never implemented and if the SGR fix were added to the final package. To nobody’s surprise, the CBO reported that adding more spending and less offsets, increased the deficit.

Well today, CBO head Douglas Elmendorf revisited this topic and directly responded to some of Ryan’s most frequent criticisms of the legislation. Elmendorf stressed that CBO scores “the law as written” and addressed charges that the budget office double counted savings from the Medicare program by appropriating the same funds to the trust fund and to offset the costs of coverage expansion:

Cost estimates focus on the effects of legislation on the unified (total) budget. The health reform legislation improves cash flow in the HI trust fund by more than $400 billion over 10 years. Higher balances in the fund will give the government legal authority to pay Medicare benefits longer, but most of the money will pay for new programs and will not enhance the government’s economic ability to pay Medicare benefits. (There is a much smaller effect of this sort on Social Security.)

In other words, Elmendorf is suggesting that from the perspective of the CBO’s unified budget accounting rules — which consider the spending and revenues of the entire federal budget over a 10 year period — the new health care law will increase the cash flow into the Medicare Trust Fund. However, that fund is part of the larger federal budget and some of the funds could be used on other legislative priorities.

Conservatives like Ryan, however, were ignoring these long-standing accounting rules to argue that were the agency to suddenly embrace different standards, like trust fund account rules — which look at changes over a much longer period of time – it would find that the law did not extend the life of the trust fund. But this argument is fundamentally disingenuous and it changes the rules in the middle of the game. Every member knows that the CBO’s scores are “god” and that members of both parties rely on the budget office’s scores and models to move legislation. Were Democrats to draft a health bill that comported to trust fund accounting rules, rather than unified budget accounting rules, they could have produced a poor CBO score and Republicans would have undoubtedly assailed them for increasing the deficit. Instead, they demanded that the Democrats’ bill also score well under a completely different accounting standard. What’s frustrating in all of this is that the CBO is willing to entertain these kinds of requests from Ryan and actually produce reports to estimate how much the bill would cost if provisions that were purposely taken out of the bill (to adhere to certain standards of fiscal responsibility) were still part of the legislation.

Last week, Elmendorf said he was “very comfortable” with his estimates. “There are a number of people who expressed concern that we were being gamed, and I worried about that throughout the year,” Elmendorf said. “But I don’t think we were gamed — or at least not in the sense that people seemed to be using that word.”