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

Posted by Cort Johnson

Obama signs health care crop

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.


  • 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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