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.

• Find the full text of the law here (984 pages)

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Where's the hate you speak of? Wow, health care should be a right, looks like you are living in the wrong country, definetly not what our founding fathers had in mind.

I would like everyone to have medical treatment as needed, but reality sets in. We have 16 Trillion in debt and 1 trillion PLUS added every year lately, and no end in sight. Our politicians don't want to reform Social Security and/or Medicare etc, so the problem is just going to be exacerbated and the people will suffer, not the politicians.

My understanding is that scoring by the CBO is done the way politicians want it done, both sides do it, so its not a really good measuring stick, unless the expectations/models used are accurate, and we know people change their behaviour based on costs. Like politicians think they can keep raising taxes on cigarettes etc.., and they will just collect more money, but people change there behaviors, or find a way around these things, so less money comes and it just gets compounded.

From Thom Hartmann:

I mean, it's time to wake up to the fact that there are very real human values that are part of a successful experience of life, liberty and the pursuit of happiness.

When Thomas Jefferson wrote those words into the Declaration of Independence,we were the first nation in the history of the world to have the word happiness in our founding document.

And consider it for a minute. You cannot have life if you don't have a social safety net, if you don't have a national healthcare program, if you don't have, if you don't know that whatever happens whether you have a job or whether you don't, whether you're born into a rich family or a poor family, no matter what, you can't have life if you don't have access to those things.

You can't have liberty if you don't have those things. As Franklin Roosevelt said so famously in 1936, in June of 1936, he said, "a necessitous man is not a free man". You're not free if you're homeless. You're not free if you're sick and you can't pay for it. You're not free if you're jobless.

And the pursuit of happiness? How can we pursue happiness when we're constantly concerned about survival. That is a pure dysfunction. If we want to get back to life, liberty and the pursuit of happiness in the United States, we need to be seriously looking at the way they've done it in other countries that actually works.

 

Yes, it passed with only Democrats votes. Now to see if it stands, Nov. 2012 will be the ultimate judge.

GG

PS I feel bad that everyone that does not have insurance, has less access. but my impression of Drs iin this area that treat CFS, do not take insurance. So I don't think this will be a major help to most patients. We really need to get more Drs educated on CFS and some real treatments, otherwise it's not very helpful for the CFS community. Hope I am wrong in this regard.

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...

 

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.

 

Guys, it is probably a good idea to take the discussion about the financial system and monetary policy elsewhere.

Darn it.

 

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...

Yes, that is correct.

Drs that "don't take insurance" simply don't bill directly to the insurance. The patient has to pay up front, submit the bills to their insurance company and get reimbursed directly by the insurance company. It does not mean the insurance company doesn't pay. The resources necessary for a clinic to bill directly to insurance are very high. It is expensive to the clinic in terms of manpower and paperwork and therefore adds to the cost of services from the clinic. It also takes quite a long time for a relatively new clinic to get the paperwork in place to be able to bill insurance directly, which is one reason some of our ME/CFS doctors don't have that capability (yet).

This can be very difficult for patients without a good cash flow because you have to have enough money to pay the bills up front. Even if you get reimbursed later, you are without several thousand dollars for many months. If you don't have that kind of cash to play with, you don't get to see the doctor you need.

This kind of arrangement is not a problem for well-to-do Texas Tea-Partiers, since they have money to throw around, and they don't care about the rest of us middle-class schmucks who either can't work because of our illness, or have to try to survive in this conservative-created middle-class economic crisis while paying for, say, the medical bills (including supplements and expensive not-covered-by-insurance off-label meds) for multiple family members with ME/CFS.

 

My experience with MDs that don't bill the insurance companies directly but rather present you with a superbill to submit is that the insurance covers 10%-20% max. of the bill, and that is if you're lucky. While theoretically the MDs have not opted out of insurance, practically they have, and there is only one reason for it, and that is that they make more money, and even more important, they get their money faster (cash-flow!) because they don't have to wait for the insurance companies to approve.

 

My experience with MDs that don't bill the insurance companies directly but rather present you with a superbill to submit is that the insurance covers 10%-20% max. of the bill, and that is if you're lucky.

My experience is similar but I find the reimbursement rate is generally less than 10%.

I have been able to negotiate cash discounts often with doctors and labs that have saved me a lot of money. The amount they bill insurance is usually at least three times higher than what they will accept as payment in full. It's a pain to call and deal with the billing office but totally worth it in most cases as the savings can be significant.

 

My experience with MDs that don't bill the insurance companies directly but rather present you with a superbill to submit is that the insurance covers 10%-20% max. of the bill, and that is if you're lucky. While theoretically the MDs have not opted out of insurance, practically they have, and there is only one reason for it, and that is that they make more money, and even more important, they get their money faster (cash-flow!) because they don't have to wait for the insurance companies to approve.

I don't disagree with this overall. My experience, however, is that insurance has paid no less (so far) than 80% of the bill. I suppose that depends on your insurance company. The whole medical industry is terribly inconsistent.

 

I would like everyone to have medical treatment as needed, but reality sets in. We have 16 Trillion in debt and 1 trillion PLUS added every year lately, and no end in sight. Our politicians don't want to reform Social Security and/or Medicare etc, so the problem is just going to be exacerbated and the people will suffer, not the politicians.
.

It doesn't follow that universal healthcare increases costs. I believe that the US spends around 17% of GDP on healthcare which is just about the highest in the world. This compares with 9.6% for the UK in 2010 of which I believe 8% is spent on the NHS and 1.6% on private provision.

 

With Medicare, I don't think you can send them the bill yourself if the doctor doesn't accept Medicare. Seems to work differently from private insurance.

Sushi

 

Talking to doctors will really help everyone understand. This will not help anyone. We have seen what happens to other countries.

I think health care in the UK is very good, although getting worse due to recent budget cuts and reorganisations.

If anyone is really interested in comparisons there is a lot of data on:

http://www.oecd.org/document/30/0,3746,en_2649_37407_12968734_1_1_1_37407,00.html

 

As a famous baseball player said, it's hard to make predictions, especially about the future. But I'm not optimistic about the results of the new law. Extremely poor people who live in states governed by actual human beings will likely benefit from Medicaid coverage. I certainly hope that includes Merry. But I live in Maine, where the foot-in-mouth governor just rammed through a law to dump FORTY THOUSAND people off Medicaid. It's not likely his handlers will allow him to change his mind and accept the new program. He's too busy cutting the state income tax rate for the highest earners.

We can be assured that the insurance companies will benefit. This law is for them, not us. The fact that some working class people might benefit is a happy accident. It's important to remember that the US, like most of the world, is a subsidiary of the FIRE sector - Finance, Insurance, Real Estate. We exist to serve them. Until the FIRE sector completely wrecks the economy (shouldn't be many more years) no substantial structural changes will happen. They will just keep piling bricks on a foundation of sand.

I have never seen or heard any discussion of just what the premiums will be. That is remarkable. Presently we have no idea whether or not working people will be able to actually pay for these policies. I predict many will not. So not only will they continue to not have real access to the medical industry, they will be assessed penalty 'taxes' for being poor. As usual.

How many of the new Medicaid patients will be able to find a doctor that will accept Medicaid? I have see no discussions of this. In Maine, most Medicaid patients are dumped into an HMO-type plan. They literally have to get permission to change providers. Fortunately I have Medicaid due to disability, so I don't have these restrictions. My biggest problem is that I can not see out-of-state providers, so I will never have the oppurtunity to see a real CFS specialist.

Someone mentioned the fact that insurance companies prefer to sell insurance through employers, and really stick it to individual policy holders. There is a simple reason for that: one has to be relatively healthy to keep a job; these are the customers the insurance companies want.

The last time I bought individual insurance in Maine, there was only one company, Anthem, selling those policies. All the others dropped their customers, including me. I have seen nothing that suggests this will change, just a lot of blather about 'insurance exchanges', in other words, a web site listing phone numbers to call and wait on hold for hours.

As always, the devil is in the details, and in the bureaucrats that interpret the regulations that no one can understand, and whether those bureaucrats expect to leave 'public service' for a cushy job in the insurance industry. God I hate being so cynical all the time. There really is bliss in ignorance.

 

There really is bliss in ignorance.

It doesn't last long if people are not informed. That is how all of this began.

 

Part of the act was to fund a website with information and facts about the plan. A good place to start for information.

http://www.healthcare.gov/

 

I don't disagree with this overall. My experience, however, is that insurance has paid no less (so far) than 80% of the bill. I suppose that depends on your insurance company. The whole medical industry is terribly inconsistent.

It might also depend on how you look at it...My insurance was *meant* to pay 80% out of network. But that was only 80% of what they considered reasonable and customary and not 80% of the actual bill. So in actuality that 80% coverage ended up being about 10% of the total charge.

But of course, as you say, experiences vary as widely as the policies.

It's a racket any way you slice it.

 

Very interesting to read the comments about this from our US members. I can't comment on Obamacare, because I'm in the UK. But it's interesting to hear that some people on this forum are against it. From what I've heard about it, in the UK, I imagined that all people with CFS would be in favour of it. From a UK perspective, I've mainly heard that it was a long-overdue and well-needed bill. So it's interesting to hear people on this forum think otherwise. I imagined that most people would have @Merry's perspective on the issue. Anyway, I'm not expressing a view, because I don't know enough details, and I'm not a US citizen, so it doesn't affect me.

Hi Bob,

I think quite a few of the US citizens on the forum are going to avoid posting on this thread as it could turn easily turn into a political debate. Just to say that the yays and nays here may not statistically reflect opinions.

Sushi

Amen. I did post in this thread ... and would like to hit undo on that. Politics gets, err, odorous.

 

I would like everyone to have medical treatment as needed, but reality sets in. We have 16 Trillion in debt and 1 trillion PLUS added every year lately, and no end in sight. Our politicians don't want to reform Social Security and/or Medicare etc, so the problem is just going to be exacerbated and the people will suffer, not the politicians.
.

It doesn't follow that universal healthcare increases costs. I believe that the US spends around 17% of GDP on healthcare which is just about the highest in the world. This compares with 9.6% for the UK in 2010 of which I believe 8% is spent on the NHS and 1.6% on private provision.

Excellent point.

The only real reason we don't have universal healthcare is that our politicians have to raise fantastically large sums of money, increasingly so every year, and creating a bill did nothing for the profits of those who fund their campaigns -- big HMOs, big Pharma, etc. -- is basically impossible for the Democrats or the Republicans because their jobs depend on giveaways to their funders.

That's why I vote Green Party, which takes no corporate donations. The Green US presidential candidate is Dr. Jill Stein, a Harvard-trained physician and a leading advocate for single-payer Medicare for All who twice ran against Romney in Massachusetts

Here's what she had to say about the Supreme Court decision on her website:

Stein noted that "Obamacare is based on Romneycare, and as with so much else, Obama implemented a Republican scheme to impose mandates that are a regressive tax on working people. The Roberts Court may call it constitutional, but the mandate is still bad news for our suffering millions. Romneycare has meant that the working poor have seen a health cost increase ten times that of the wealthy. As a physician, I've seen Romneycare in action in my home state of Massachusetts. Forty percent of the people who need health coverage find that it's still too expensive for them. And a quarter of the people who seek payments get denied by their private insurers. It has failed to control costs, and as a result they are raising co-pays and attacking public employee health plans. It's a fiscal and administrative nightmare which has gutted public services in Massachusetts. Schemes developed by health industry lobbyists to enrich themselves will never take care of our real needs.”
http://www.jillstein.org/romneycare_and_obamacare

When Jill debated Romney during the Mass Governor's race, the Boston Globe described her as "the only adult in the room." -- http://www.c-spanvideo.org/program/173128-1

 

It might also depend on how you look at it...My insurance was *meant* to pay 80% out of network. But that was only 80% of what they considered reasonable and customary and not 80% of the actual bill. So in actuality that 80% coverage ended up being about 10% of the total charge.

But of course, as you say, experiences vary as widely as the policies.

It's a racket any way you slice it.

A racket indeed.

I suppose I'm either fortunate in my insurance or in my choice of physicians. I'm also not in an HMO, which may be beneficial in this case.

However you slice it, though, the medical industry is making money hand over fist and patients are suffering for it.

 

Talking to doctors will really help everyone understand. This will not help anyone. We have seen what happens to other countries.

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?

 

I don't think that many people in the UK would swap our system for anything else either, and definitely not for the US system.
Sure, it's not perfect, and we complain about it a lot, but overall it really does look after us from birth to death when we really need it.
Personally, I think it's the best thing about our country, and I hold it in very high regard.
Yes, CFS patients are neglected, but I think that's more of a social-care issue and a political corruption issue rather than a health care issue.