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Supreme Court Lets Affordable Health Care Act Stand....Implications for ME/CFS



In a surprise, Chief Justice John Roberts joined the four liberal members of the Supreme Court to uphold most provisions of the Affordable Health Care Act including the individual health care mandate.

The implications of the Supreme Court's decision are substantial for people with chronic illnesses, in general, and for people with chronic fatigue syndrome who often have with low incomes and difficulty purchasing health care. NBC News called the decision "a major victory for millions of Americans who either can’t purchase health insurance or have chronic illnesses."

With studies suggesting that ME/CFS costs the average family about $20,000 a year in lost wages, and with a recent CDC study findings that on direct medical costs averaging almost $6,000 annually, a significant portion of which is paid out of pocket, this is a community that could use some financial relief at the doctors office.

Republican presidential candidate Mitt Romney and other Republicans have vowed to repeal the bill in its entirety. Now that the most parts of the bill have passed muster at the Supreme Court the fate of the bill may be determined by the outcome of the upcoming election.

Pre-existing Illnesses

One of the most significant aspects of the Affordable Health Care Act is its clause preventing companies from restricting or barring coverage because of a pre-existing health condition. Prior to the enactment of the bill insurance companies could refuse to sell a policy, or charge several times more for it or exclude specific conditions from coverage. Under this bill insurance companies will not be allowed to jack up rates or exclude coverage for conditions when you become ill - a situation which drove many to bankruptcy or left them unable to afford insurance coverage.

Remarkably it appears that 'most' insurance companies won't even be able to charge more for people with pre-existing conditions. The government website states

"Under the Affordable Care Act, in 2014, most health insurers will no longer carve out needed benefits, charge higher premiums, put lifetime limits on coverage of key benefits, or deny coverage due to a person’s pre-existing condition"​

The desire to cover pre-existing conditions drove the most controversial aspect the Bill, the individual mandate, which requires all Americans who can afford to, to have insurance so that the premiums for healthy people will help pay the costs of those who become ill.

The Uninsured

The law is designed to greatly reduce the number of people without health insurance - a problem afflicting many with ME/CFS. Estimates suggest that as many as 30 million people who do not now have health insurance will have it by 2014 Federal subsidies (which tap out at $44,000 a family) will enable millions of lower-income Americans who could not otherwise afford health insurance to have it.

Tax Credits Assist the Less Well Off
  • Lower-income people will be eligible for Medicaid in states that provide that option. (Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid.) The court's decision to refuse to compel states which refuse to expand Medicaid eligibility to people with lower incomes to give up their already existing Medicaid funds may blunt the laws reach in some areas. A Department of Health and Human Services (DHHS) report found that a low-income family could save up to $14,900 a year using tax credits.
  • Middle-class - Tax credits for those earning between 100% and 400% (@ $43,000) of the poverty line will be available to assist in buying insurance coverage. A Department of Health and Human Services (DHHS) report found that tax credits may help middle-class families save as much as $2,300 a year.
Insurance Exchanges

People buying individual policies and small businesses will be able to use 'insurance exchanges' to shop for policies. These exchanges will offer the same choice of health plans as congressmen or women currently have. Thus far 14 states, including California, Colorado and West Virginia, have already authorized the creation of these "exchanges". They are due to be enacted by Jan 1st, 2014. Find about more about insurance exchanges here. Check out a map on your state's progress in producing them.

The Already Insured

Companies with greater than 50 employees will be required to offer insurance or pay a penalty. If workers aren't satisfied with the options a company offers they are free to use the money the employer might have contributed to their insurance and use it to shop on the Insurance Exchanges.

It's not clear the effect the law will have on premiums. A DHHS report stated that 'all businesses' will 'likely see'reduced health care premiums of $2,000 per family by 2019.

Others
  • Ending Lifetime Limits - the end of lifetime limits on health care will help those most severely stricken from sliding into bankruptcy and/or losing medical care.
  • Honest Mistakes No Longer Cause for Insurance Withdrawl - for years insurance companies have found ways to deny coverage if they can find small mistakes in applications. Under the Affordable Care Act they will no longer be able to do that.
  • Premium Payments Must Primarily go to Health Care Not Administrative Overhead and Marketing - a certain portion of your insurance payments are required to go to health care not administration or marketing or a portion of your fee will be rebated. In his comment on the Supreme Court decision President Obama stated that in Oct of this year 13 million people will receive insurance company rebates because their insurance company spent more in administrative and marketing costs than allowed.
  • Medicare - Medicare recipients will keep getting discounts on prescription drugs to close a gap in coverage known as the "doughnut hole.
Improved and More Efficient Health Care

The bill provides a variety of means designed to make health care more efficient and effective. These include improvements to physician and hospital quality care reporting, development of outcome measures, a National Health Care strategy based on health care quality and testing a variety of models to improve health care delivery.


More Emphasis on Understanding and Treating Pain - Some of the less talked changes could have implications for people with ME/CFS. Section 4305, for instance, requires increased attention on treating chronic pain. Some of the requirements, which include the creation of a Pain Consortium to provide annual recommendations to the Director of the NIH, and the creation of an Inter-agency Pain Research Coordinating Committee tasked with identifying critical gaps in pain research and treatment, have already begun to be carried out.

Other programs include
  • A Value-based Purchasing Program - will provide hospitals financial incentives to increase their quality of care by providing more money to better performing hospitals. Hospitals will be required to publicly report a variety of performance results for heart attacks, infections, surgical care, pneumonia, etc. The government site reports "for the first time, hospitals across the country will be paid for inpatient acute care services based on care quality, not just the quantity of the services they provide." This program will begin in October of this year.
  • Reduced Billing Costs - the law standardizes billing and requires health plans to begin adopting and implementing rules for the electronic exchange of health information. The govt site states "Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and, most importantly, improve the quality of care." This program will come into effect Oct, 2012.
  • More Free Preventative Health Care - by Jan 1st 2013 insurance providers will be required to provide more free preventative health care services such as check ups and mammograms.
  • 'Bundling' to Save Money - The law establishes a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care. Under payment ;plan called “bundling,” hospitals, doctors, and providers are paid a flat rate care rather than using the current system where each service or test is billed separately to Medicare.
Jan 1st, 2014

If the bill is not repealed, on Jan 1st, 2014 - just 18 months from now - most of the major changes (individual mandate, creation of Insurance Exchanges, Medicaid eligibility for low-income patients, tax credits for the middle class, etc.) will kick in. Click here for a timeline.

After that a few more changes are in store. For instance, by Jan 1st, 2015 physician payments will begin to be tied to the quality of health care they provide.

As more information becomes available on the Affordable Health Care Law's effect on people with chronic illnesses such as ME/CFS we'll report on it.
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I think that's more of a social-care issue and a political corruption issue rather than a health care issue.

I don't think that the two can be separated so easily. The problems CFS has faced in the UK are a prime example of a more state driven, rather than consumer driven, approach to healthcare. The current US reforms are relatively minor, and don't move the US to anything like the UK model for healthcare, but I do think that the way in which CFS has been treated are a fine example of the problems which can be caused by the UK approach to healthcare, even if they were far from inevitable are could have been easily avoided by a more reasonable approach to patients.
 
I don't think that the two can be separated so easily. The problems CFS has faced in the UK are a prime example of a more state driven, rather than consumer driven, approach to healthcare. The current US reforms are relatively minor, and don't move the US to anything like the UK model for healthcare, but I do think that the way in which CFS has been treated are a fine example of the problems which can be caused by the UK approach to healthcare, even if they were far from inevitable are could have been easily avoided by a more reasonable approach to patients.

I don't agree. I think a state-driven approach has created a world-class first-rate health care system, at relative low cost, and the UK government set up the NHS in the first place. Not that I'm saying there isn't room for improvement.

I think that the neglect of CFS/ME comes down to two things: resources and corruption...
The corruption re ME/CFS is seen in the US system as well, where ME/CFS isn't properly recognised nationally, and it also seems to be similar throughout many of the health care systems of the world, because a lack of knowledge and ignorance allows the corrupting influences to gain a foothold.
As for resources, I don't think that's easily solved. They have issues re insurance and access to healthcare in the US.
I don't see how you can get a proper consumer-driven health care system. Are there any? Consumers only win when there is proper competitive market, which I doubt you could ever get in a health care market, just as you don't in utility companies, and rail companies.
 
Most European countries have a mixed system of private insurance and government involvement.

I think that there is a big cultural difference in the UK, where many doctors and patients see their relationships as the benevolent doctor being kindly willing to provide some free treatment, rather than that of a professional being paid to provide a service. The sort of mistreatment seen by many CFS patients in the UK is less likely to occur when patients themselves have more power.

There are different problems which can occur in a more consumer driven approach to healthcare, but fact that CFS seems to have been treated particularly badly in the UK, and the nature of the UK healthcare system, does seem very likely to be related to me.
 
Most European countries have a mixed system of private insurance and government involvement.

I think that there is a big cultural difference in the UK, where many doctors and patients see their relationships as the benevolent doctor being kindly willing to provide some free treatment, rather than that of a professional being paid to provide a service. The sort of mistreatment seen by many CFS patients in the UK is less likely to occur when patients themselves have more power.

There are different problems which can occur in a more consumer driven approach to healthcare, but fact that CFS seems to have been treated particularly badly in the UK, and the nature of the UK healthcare system, does seem very likely to be related to me.

I can't remember the details, but I think the new NHS bill is supposed to give us freedom to choose our doctors, and gives doctors the freedom to chose service providers. So maybe that will address some of those concerns, if the new system works at all. But I can't help feeling it will be a total disaster.

I agree with what you say about the patient-doctor relationship in the UK. We are often stuck with one doctor (who can dictate our health care) who we see as an authority figure, and who we don't like to argue with in case we upset them and they turn against us. This means that it's an unbalanced relationship, giving the doctor too much power.

I noticed the contrast with the private sector, recently, when my cat had an emergency. I knew she had a stomach problem, relating to fur balls, but I didn't know exactly what the problem was. I went to a vet who couldn't diagnose the problem but wanted me to pay £500 for an investigation into cancer, which I new was highly unlikely to be related to her issues, so I declined the cancer investigation, thinking it was a rip-off. I went back to the vet a second time and they still couldn't diagnose her. So I suddenly realised that unlike the NHS, I could chose another vet! Wow! That's amazing, I thought! I have a choice! How refreshing! (I don't know why I had thought otherwise... I just got confused because it was health care!) So I went to a second vet, but the outcome was exactly the same, and he also wanted me to pay loads for a cancer investigation. Neither of them could offer my cat an endoscopy, for whatever reason I couldn't understand, which I thought would be a simple procedure. Luckily, after years of ME, I don't trust health-care providers any more, so I trusted my own instincts, and observations, more than the vets'. I wouldn't have done so a few years ago. So, feeling a little defeated, and very worried, I finally went to one more vet. "Oh, she might have stomach inflammation", the vet said. "Treat her with this medicine." And guess what... The cat was better in three days.

So that's my only experience of private health care! (Apart from dentists.) The individual vets were useless, but I could shop around.

But I don't think private health care for people works in the same way. It equates to a monopoly, and the system seems to be rigged against the consumer, and the costs are enormous.

Unfortunately, I don't know anything about the European systems, so we might be able to learn something from them. But I still believe that the UK system is one of the best in the world, and one of the cheapest in developed countries. So personally, I think it's a case of "the grass is always greener on the other side", and that each system has pros and cons.
 
I live in one of those "other countries", and things are quite good here. My insurance after getting sick now costs half of what it did in the US prior to getting sick. It's a very similar situation to Obamacare - there are private insurers that are required to offer certain services. No one can opt out, people that can't afford it are covered, etc.

I'm not sure what horrible things you think are happening in Europe and elsewhere. Waiting times here to see doctors about the same, as is appointment length. All doctor visits and prescribed meds are fully covered. There's a "deductible" of something like 100 euros for the entire year, except it's actually in the form of a refund if it isn't used. No one takes out their checkbook or debit card in a doctor's office, or a drug store, or a hospital. It's an amazing and safe feeling.

The money to pay for the system comes from all the lucky, currently healthy people, who are also forced to pay into the plan. Then one day they'll be the old sick people, and younger folks will be helping keep their rates low.

So what, exactly, is bad about any of this?


Unlikely you'll get an answer, you're messing up the mess argument.
 
So personally, I think it's a case of "the grass is always greener on the other side", and that each system has pros and cons.

Yeah - I think that the UK system is, overall, definitely better than the US system. I was just pointing out what I see as one of the problems with it. It's also possible for people to slip in to being proud of the way their country does things, and over-look the problems that there are with it.
 
In theory, U.S. patients can choose their providers, but in practice, well, it frequently doesn't happen. In rural areas there are few providers to choose from, and the number seems to be shrinking, especially for dental care.

I don't know how it is in other areas, but where I live, trying to see a new provider is like applying for a job. I'm not kidding. If the doctor sees something they don't like in one's file (chronic pain, narcotics prescriptions, etc.), that person doesn't get in. According to the Americans With Disabilities Act, this sort of blatant discrimination is illegal, but there is no one to enforce it, so they get away with it.

And it literally takes months to be 'approved'. First they send a fax to the old provider for records. Then they wait for the records. And wait. And wait. When one calls to find out what the delay is, one will be told, "Well, you can't expect us to inconvienence the old provider by bugging them." I offered to send copies from my own files. Nope. The records *Must* come directly from the previous provider. The Medicaid people offered to send records from *their* files. That too was unacceptable. After waiting several months, what arrived was so incomplete as to be useless. At that point, they finally allowed me to bring in records from my own files.

Anyway, after nine years of getting sicker and sicker, I still don't have a diagnosis. My own personal story hardly seems like a ringing endorsement of the U.S. model of the 'free market'. Apparently the U.S. model works for some people, maybe even a few people on this forum, but they are few and far between.
 
That's a good point. I don't think most do. (Dr. Peterson is a standout in that he actually takes Medicare!) but I don't think that means patients can't get reimbursed by insurance; I think it means they have to give the doctors bills to their insurance companies directly. Does anybody know? Its been a long time since I saw a doctor for ME/CFS...
Drs. Enlander and Natelson in New York accept Medicare too.
Good to hear that a few CFS drs take Medicare.

GG
 
I have to admit that I was a little appalled to hear some of the stuff that people were informally spreading around about healthcare in other countries. Seemed like a pretty disgusting (and TOTALLY misleading) scare tactic. There are tons of countries that have made government involvement in health care work great, and sustain it just fine.

I am Canadian. I have great quality healthcare. I get all the tests, doctor's appointment, specialist referrals, etc. that I need. Cancer, or childbirth, or other recognized health conditions won't cost me a penny. No worries, no additional stress, no bankruptcy from medical bills. Having a pre-existing condition doesn't matter at all. Nobody is denied coverage, and nobody is going broke trying to pay for insurance. Nobody is dying because they can't get access to tests or top notch care.

I myself have needed a number of MRI's, appointments with top specialists, etc., and have been seen promptly and been given everything they had to give me. Many doctors still struggle here with how to approach ME in particular, but that seems to be true around the world. Our wait times are very reasonable, particularly when you take into consideration that the most urgent needs take precedence. That's totally fine with me. If you're actively bleeding from the head, I am happy for you to go first. :) When I've had problems that needed more urgent answers (e.g. sudden hearing loss, or signs of a possible tumor), I've gotten the appropriate testing right away.

Much of the rest of the world is very confused about how someone could be opposed to your new healthcare bill, and sees it as a long overdue step in the right direction. I feel like there are a lot of active misinformation campaigns that go on in the U.S., designed to sway people over to the views that would most benefit a small group of wealthy and influential individuals, at the cost of what would truly be best for other people. I hope that if anyone has questions about what healthcare is really like in other countries, they will be able to find someone here to ask. Because everyone I know here thinks it's great, including several people who moved here from the U.S. and love it.
 
I also wanted to add that I worked briefly in healthcare in a two systems in the US where everyone I saw was covered by insurance already. So payment was mostly a non-issue for most patients. On my side, I merely marked the diagnosis, time spent, procedures done, etc. electronically and sent them off into the system. I had no staff who needed to call multiple insurance companies, most of my decisions were not questioned, and the rare times it was, I got to speak to an expert MD who at least understood where I was coming from rather than lower-level personnel or even worse, a clerk with no medical training at all. [It happens.]

I imagine this is the norm for most MDs working outside the US in countries with a national health insurance system. It definitely makes it easier for the clinicians and I can see how paperwork dealing with multiple insurance companies can drive up cost.