Monday, March 02, 2015

SCOTUS, ACA, King v Burwell ...Here we go again...

This week, on Wednesday, the Supreme Court is to consider the case known as King v. Burwell — a challenge to that part of the Affordable Care Act (aka Obamacare & ACA) which deals with subsidies.

The ACA created a subsidy system for low and some middle income families to help in the purchase of health insurance through insurance exchanges "established by the state". The law sets a cap on the amount of insurance premium that individuals and families will have to pay for the second cheapest Silver plan based upon that person/family's income in relation to the Federal Poverty Level.

States were given the option of establishing their own exchanges or allowing the Health and Human Services Department to run a state marketplace for them. The administration would argue that both types of exchange count as having been "established by the state" (i.e. a state with a federally run exchange having made their choice to "establish" that exchange in their state.) Lawyers will argue day and night on this point, I dare say!

The case turns, I think, on just those four words of the Act: "established by the state".

Plaintiffs attest that subsidies should be available only to people buying coverage on exchanges “established by the state,” i.e. state-run marketplaces. 34 states don’t have their own exchanges. Residents rely on federally run marketplaces - the course opted for by their state representatives. If the court rules in favor of the plaintiffs, subsidies in the form of tax credits would end in those 34 states. Subsidies have made insurance affordable for millions of people who would otherwise have remained uninsured.

The whole point of ACA was to make health care affordable to everybody, not simply to those in states where the state had opted to run their own exchange. If this had not been so, wording would have been clear on this point (or ought to have been!)

There's a somewhat dodgy argument by some lawyers that proposes the real reason for not making the subsidy available in relation to both types of exchange was a way of forcing reluctant states to get on board and establish their own exchanges - or lose availability of subsidies for residents of their state. I can easily imagine that some states would not have wished to get into the exchange/marketplace thing because of the extra worries and risks involved - so much easier to let the government deal with it all! The option and the decision on this did remain with each individual state. States' rights an' all that.

It doesn't seem likely, to me, that there was ever an intention to lock people out of subsidies depending on their type of health exchange. That would have been counterproductive. The aim was to bring in as many insured people as possible, to make the system work as intended.

If SCOTUS finds for the plaintiffs, outlaws subsidies in states with federally run exchanges, the people of those states who become unable to afford health insurance will be rightly incensed. Governors of such states should be under immediate pressure to establish state run exchanges tout de suite! Would they though? Would the people rise up and demand? Would the state representatives comply? Oh.... hmm...and could this possibly be a ploy to force states into running their own exchanges? No, that doesn't feel right....a bit conspiracy-ish for me.

I doubt that those potential eventualities will come about, unless the Justices are feeling particularly obtuse and bloody-minded, with intent to bring down the whole caboodle. Couldn't they have done that on the last opportunity - that time in 2012 when Chief Justice Roberts, for once, saved the day for ACA?(SEE HERE)


mike said...

Texas, under Rick Perry at that time, refused the ACA state exchange, because it would require a Medicaid expansion. The federal contribution would have tremendously offset the TX costs for ten years. Perry thought the future, projected, economic burden would be too great. Ironically, we county tax payers (home owners) pay a portion of our taxes toward "indigent care", which is typically paid to hospital districts providing care through their emergency rooms, which is the Republican's preferred method of indigent care. ER services are horrendously expensive compared to doctor-clinic visits and do not provide preventative care.

"Absent a change of heart by Perry, supporters of Medicaid expansion will be left to weigh their options. By refusing Medicaid expansion, Texas will leave an estimated $100 billion in federal money on the table. Under the ACA, the federal government initially would have covered the entire cost of adding 1.5 million poor Texans to the Medicaid rolls. The state would have to kick in part of the cost beginning in 2017.

By 2023, Texas would have received $100 billion in federal money in exchange for a contribution of $15 billion."

Fortunately, I did not require indigent medical care prior to receiving my Social Security benefits. I did not qualify here in TX, because I had zero income, and proof of income is required for individuals without dependent children (payment for services provided on a sliding-scale). Many states have this rule. Draconian antipathy at its best!

Sonny G said...

I've tried everything I know to procure Obamacare.. However, unless I go and live in the street, I'm inelligable. heck if your in the street and don't have any address- ya cant get it either. here in NC the repubs have it all under the strict control and they arent letting go.. Our new "Govenor Asshole" is about the worst we've even had for such things..long as his buddies are getting their way and profit levels increase for THEM, the rest of us are screwed~!!! I looked and do'nt have enough SS numbers and so not sure what happens next year when I turn 65..and also dont have a clue who to ask for help on my very limited income.
ps , Annie- I put a link in saturdays comments for my chart.. asking you for any help you could offer- high or low points ya saw and what to watch for... I know Mike said I should learn on my own but my brain just can get it all right now and my emotions are in too much off a turmoil.. so Yes I am asking for help from you.
I have to report document saved but the only way to get it to you is via email...
mine is-( copy/paste it))

if you could please email me I will reply and add the doc. to it.. thanks so much in advance.

Twilight said...

mike ~ Oklahoma's situation is much the same as that in Texas. Gov. Mary Fallin can't stand the thought of being told what to do by President Obama, of course. So no expansion of Medicaid and no state run exchange.

Our legislators had their own court case on this subsidy issue, Pruitt v. Burwell in an Oklahoma court the judge ruled in favour of the plaintiff, and said that Congress is free to amend the wording of the Act, but as it stands it means that only those purchasing insurance from state run exchanges are eligible for subsidies.

It seems that the text of the Act is so long and complex that a bit of sloppy writing here and there became inevitable.

Twilight said...

Sonny ~ Yes, Oklahoma is in much the same boat. Once you reach 65 you'll be eligible for Medicare though, won't you Sonny? That should help a lot.

I did respond to your request in the weekend's post - did you see that? Maybe you missed it.

I do think that by the end of this month you'll be feeling much stronger...take a look back at the previous post's comments.

To be honest, I'm really not equipped or experienced enough to offer much more than that from an astrological angle. And, again, being very candid, I'm not sure that going more deeply into astrology for any kind of health-related reasons would help. As I've said often, astrological doctrine is truly mainly guesswork on the part of ancient and modern astrologers. Sometimes it works, sometimes it can prove to be either quite wrong or meaningless. The fact that it works sometimes is interesting enough for me to delve into it and dabble a bit.
But looking for reliable help in natal chart placements and aspects and transits could be misleading and counterproductive to helping your emotional situation right now.

Much as I wish I could be of help - I truly am not qualified to do more than offer encouragement, and try to send a few positive vibes wherever I can.

For now, on the broadest possible astro-level, the one thing all astrologers agree on is that in general things will improve once the Uranus-Pluto series of square aspects is finished - that'll happen a bit later this month. Focus on just that for now Sonny, and we'll see whether that piece of astrology works. I'm betting, and hoping, that it will. :-)

mike (again) said...

Sonny - a slight divergence on your astrology is that your sixth house of health is highlighted favorably right now, even though it's involved in the Uranus-Pluto square.

Might I once again recommend you consider magnesium supplementation? It has been strongly correlated toward alleviating depression, bipolar, ADHD, and other mental conditions. Most daily vitamins do not contain the daily requirement...most have about 10 to 15% MDR...most contain magnesium oxide, which is the least absorbable. Stomach acid reducers inhibit absorption of magnesium. If your sleep pattern is disturbed, 2-5 mg of melatonin prior bedtime is also recommended.

This supplementation may help reduce the sharp edges of your anxiety.

Sonny G said...

thank you Annie.. your words comfort me and give me hope..

I will go and look at your former comment..

Sonny G said...

thank you so much Mike..I will read from the links you posted to decide which magnesium is the best.. of course I ordered the citrate:( guess I'll toss that..

mike (again) said...

P.S. Sonny - If you can't leave the house or can't find the glycinate, citrate, or taurinate forms of magnesium at your health food store, but have epsom salts on hand, take 1/2 teaspoon dissolved in about 1/4 cup warm water twice a day. One teaspoon epsom salts provides 320 mg elemental magnesium, which is just about the adult daily requirement. Epsom salts are sold USP (United States Pharmacopeia) and safe for internal ingestion (taken as a laxative in large quantities, but will not have laxative properties taken by the half-teaspoon).

mike (again) said...

Sonny - magnesium CITRATE is perfectly fine. Have you been taking magnesium citrate?

Sonny G said...

oh ok Mike.. yes I bought the citrate from NOW brand.. I'm willing to get to a health food store if you recommend a brand thats better quality.
I really want best there is to take..

ps- it says on the back- veggie cap , no gluten wheat sugar and such .. just let me know if you favor a specific brand I will find it and take it..

thank you both so much.

LB said...

Twilight ~ In your post, you said, "Subsidies have made insurance affordable for millions of people who would otherwise have remained uninsured."

It's important to keep in mind the subsidies you're referring to only make *insurance* affordable, NOT healthcare. There's a BIG difference.

Then too, as Sonny pointed out, lots of folks have fallen through the cracks and don't qualify for subsidies so they can purchase insurance plans that leave them without affordable healthcare.

HR676, Expanded and Improved Medicare For All continues to seem like the only viable solution if we want to provide affordable access to healthcare for EVERYONE.

Sonny ~ I've had good results with the magnesium supplement, "CALM", by Natural Vitality. Don't know if someone already mentioned that particular brand or not. It comes in powdered form (flavored or unflavored, and with or without calcium and vitamins C & D3). Just add boiling water and stir.

Good luck!

mike (again) said...

Sonny - the NOW brand is reputable and you shouldn't have any concern. I'm not sure what dosage you purchased, but follow label directions and don't exceed that dosage per day. From your brief description, I think you are taking the capsules; 3 capsules/day equals 500 mg magnesium.

Also consider taurine supplementation. Taurine is an interesting biochemical found naturally in meat & seafood, and the supplements are readily available as synthetic taurine, and is chemically identical. Vegetarians have critically low levels of taurine, as it's not found in plants. Taurine serves many physiological functions, one being the ionic and osmotic regulation of potassium, calcium, magnesium, and zinc. It plays a significant role in neurotransmission and neuroregulation.

Please read these two links and decide whether you want to supplement with taurine. It's very inexpensive and should be readily available:

Turmeric or its active ingredient, curcumin, has been shown to be beneficial for mood disorders:

Sonny, I take magnesium and melatonin for my sleeping disorder and it has been very beneficial. I take taurine for borderline hypertension and it has reduced my BP to normal range. Taurine is good for so many health concerns! I started curcumin a number of years ago, due to a horrid case of numular dermatitis on both legs that were resistant to western medicine. The dermatitis disappeared with curcumin, but returns without. Curcumin is like taurine: good for so many things. A friend with type 1 diabetes started taurine two years ago and was so amazed...constant thirst & urination stopped immediately and a month later, the insulin requirement was reduced to one injection every five or six days, and with no hypoglycemic episodes (the most dangerous)...a1c is now normal and no more hyperlipidemia.

mike (again) said...

Hello, LB! I was busy typing when you commented. I agree with your comment. I'm advantaged to have the Native American provision AND the low income subsidy. Without these two bonuses, my $357/mo low-end, bronze plan has a $6,500/year deductible, so it's essentially catastrophic coverage with tremendous out-of-pocket for the average insured person.

That said, a friend's wife was diagnosed with cancer back in October and just completed round 3 chemo, with many more to go. They have racked-up incredible expenses that would have bankrupted them without the ACA. Adding injury to insult, he is scheduled for torn meniscus knee surgery in a week.

LB said...

Hi mike ~ I'm genuinely glad you're better off than you were before. Sorry about your friend, but hope they continue to benefit as well so they can concentrate on what's most important without having to worry about costs.:)

Twilight said...

LB ~ Well - yes, I agree, but in this post I was writing about the case coming before SCOTUS on Wednesday, not debating the positives and negatives of ACA in general. I think we've done that before. Single payer was the ideal, and it wasn't going to happen. Best that can be hoped for now is to get the wrinkles out of what there is available - this case is one wrinkle being used by the Republicans to cause trouble and maybe even put a nail in ACA's coffin. If ACA dies there'd be a whole lot more people without any help.

I was clarifying, also, in my own mind what this SCOTUS case is about. :-)

LB said...

Twilight ~ I understand. There are people (like mike and the friends he mentioned) who seem to have benefited from the ACA.

While I wouldn't wish anyone to lose these (apparent) gains, I only wanted to give a voice to some of the millions of people who, although now paying lower premiums for health insurance, will NOT be substantially better off, if at all, than they were before the ACA ~ as well as all those who are now worse off because of it.

Even with insurance, millions of people will continue to go bankrupt or become homeless each year because of medical bills. It doesn't take much. Just one long-term or catastrophic health issue, maybe far less.

How many low-income folks can afford to pay out-of-pocket for doctor's visits with a 5 or $10,000 deductible and MANY necessary medical expenses left uncovered?

The ACA wasn't designed to provide affordable healthcare ~ it was designed under the pretense of making *insurance* more affordable because of subsidies, subsidies not everyone qualifies for.

Twilight said...

LB ~ No argument from me that ACA was, in general, a bad deal and not what most people had wished for - but it's what we got, sadly, due in part to Democrats not fighting hard enough for better.

I came from a country with a National Health Service, I know the benefits of that system (and its flaws) better than most. I could tear my hair out thinking about the injustice of what has gone on in the US for years, and why the people didn't rise up long ago because of it.

My husband had to re-mortgage his house to pay for a $30,000 operation some years ago (before I knew him) - because at an age just before retirement he gave up work to look after his mother (Parkinson's disease had struck her)
and he could not get any kind of health insurance at that time - couldn't wait for Medicare in a year or so or he'd have risked death.

But...ACA is what we've got We might not have it much longer if Republicans retain control of both houses and we get a Republican president in 2016.

If SCOTUS rules that states with federally run exchanges are not eligible for subsidies, then it could be a death blow for the ACA as a whole, and the group of people it has helped will be back without help once again.

We'll not get better health care system without a total overturn of the political system here - money out of politics to begin with, end of the duopoly Rs and Ds...and on.
It'd take a bloody revolution or a terrible environmental calamity.