The lifesaver that is the Affordable Care Act

Health care in our country is a very political animal. Because of the huge amount of money there is to be made, namely by the health insurance industry, there are many special interests trying to claim their piece of the pie, and in doing so they have created the mess that is health and care in this country.

What other democratic and industrialized nation in this world has the process of health care delivery sitting before a court that may well decide that people like my husband don’t deserve to be able to purchase affordable insurance to live? The answer is none.

And why do people who have no idea what it is to have a life-altering or threatening disease, through no fault of their own, feel the need to try and take away health care from those who need it?

I have no answer for that but it is something this family is faced with every single day. From people on Twitter who regularly harangue me for speaking out in favor of the Affordable Care Act to yes, family members who are against it, I have to remind them all that the Affordable Care Act is saving lives. I also remind them that getting sick is part of the human condition and some of us get more sick than others.

And without the Pre-Existing Condition Insurance Plan, my husband and many others would die. It is that simple a truth; that black and white.

We pay a premium every month, just like those who have insurance through their employer. Until 2014 when the law is fully enacted (depending on the Roberts court, of course) and the health insurance exchanges are set up, your employer is the only access point for affordable health care.

The PCIP is a pool of people who the health insurance industry won’t insure. Why? Because the health insurance industry does not like to spread their risk pool out to people with diseases like Multiple Sclerosis or cancer because they know they will have to pay claims for these people. It’s the same with Medicare, the health insurance industry got rid of their most expensive risk pool, those over 65, when Medicare was created.

All insurance is a risk pool, we all pay into that pool to cover each other. I may never have a claim because I am healthy but my money goes to cover those who do and vice versa–that’s how insurance works. Imagine if we just opened up the Medicare risk pool to everyone, cradle to grave, and we all had the chance to pay into it. We’d solve all our problems, both with Medicare solvency and with insuring all our citizens.

The next time you hear someone, anyone, claim the Affordable Care Act is not affordable, ask them if they think it’s all right in this country of ours to allow one industry the right to deny care over and over again while taking in billions in profit.

Ask them if health care is not already “rationed” by the health insurance industry, because it is. Just ask the parents of Kyler Van Nocker or Nataline Sarkisyan.

Ask them if my husband, and other citizens of this country, have the right to be able to see their children grow up by having access to medications.

Ask them if denying access to affordable care isn’t infringing on your personal liberty.

Ask them if they even know that Medicare is a government run program that saves senior citizens from bankruptcy and death.

See what they say and the answer you receive will tell you everything you need to know about their morals and their character. Everything.

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Your Money Lost; MetLife’s Long-Term Disability Scam in MetLife v Glenn

We write a lot here about group long term disability policies and what bogus products they are. So much so, it is financially unsound to trust these policies to take care of you should you become injured, sick or disabled.

A particularly egregious example of just how worthless group policies are is seen in a case that made it to the Supreme Court (please note how the dissents fall in strict Citizen’s United lines) in Metropolitan Life Insurance Company v Glenn where MetLife was both the insurer and administrator of the group plan that insured Ms. Glenn–a huge conflict of interest. It’s like having the fox watch the hen house.

The plan grants MetLife (as administrator) discretionary authority to determine whether an employee’s claim for benefits is valid; it simultaneously provides that MetLife (as insurer) will itself pay valid benefit claims. App. 181a–182a.

MetLife sought Supreme Court review because of an earlier decision that forced MetLife to pay Ms. Glenn her benefits. MetLife spent a lot of money on this because of the precedent it set: An insurance company had to make good on a long-term disability claim and pay benefits to a person who became too disabled to work full time.

Ms. Glenn was a Sears employee who was diagnosed with severe dilated cardiomyopathy. She had dutifully paid her premiums and now she needed to use her benefits since she was too sick to work due to heart failure.

Respondent Wanda Glenn, a Sears employee, was diagnosed with severe dilated cardiomyopathy, a heart condition whose symptoms include fatigue and shortness of breath. She applied for plan disability benefits in June 2000, and MetLife concluded that she met the plan’s standard for an initial 24 months of benefits, namely, that she could not “perform the material duties of [her] own job.” Id., at 159a–160a. MetLife also directed Glenn to a law firm that would assist her in applying for federal Social Security disability benefits (some of which MetLife itself would be entitled to receive as an offset to the more generous plan benefits).

MetLife directed Ms. Glenn to a law firm to make sure she got Social Security so they could off-set her benefits. CIGNA and all the other insurers do the same. See my earlier blog postings at Illness and Insurance Hell. Just follow the money.

MetLife received the bulk of those retroactive benefits due to offsets written into the language of the policies themselves. These group disability policies are, in essence, bogus products; don’t waste your money.

The Social Security Administration consequently granted Glenn permanent disability payments retroactive to April 2000. Glenn herself kept none of the backdated benefits: three-quarters went to MetLife, and the rest (plus some additional money) went to the lawyers.

After the first two years of Ms. Glenn’s policy, MetLife decided to reverse themselves:

To continue receiving Sears plan disability benefits after 24 months, Glenn had to meet a stricter, Social-Security-type standard, namely, that her medical condition rendered her incapable of performing not only her own job but of performing “the material duties of any gainful occupation for which” she was “reasonably qualified.” App. 160a. MetLife denied Glenn this extended benefit because it found that she was “capable of performing full time sedentary work.” Id., at 31a.

On one hand, MetLife forced Ms. Glenn to apply for Social Security benefits, sent her to a law firm to help receive them and took taxpayer dollars to offset the plan she paid premiums for BUT when it came time to continue paying those benefits after the first two years, MetLife “itself had to determine whether she could work, in order to establish eligibility for extended plan benefits, it found her capable of doing sedentary work and denied her the benefits.”

This was what the Social Security agency said as well, but with help from the law firm they sent Ms. Glenn to, MetLife pushed, and received, tax payer dollars in the form of Social Security dollars. They burden the Social Security system.

The Supreme Court found this questionable as well and said so:

In particular, the court found questionable the fact that MetLife had encouraged Glenn to argue to the Social Security Administration that she could do no work, received the bulk of the benefits of her success in doing so (the remainder going to the lawyers it recommended), and then ignored the agency’s finding in concluding that Glenn could in fact do sedentary work. See id., at 666–669. This course of events was not only an important factor in its own right (because it suggested procedural unreasonableness), but also would have justified the court in giving more weight to the conflict (because MetLife’s seemingly inconsistent positions were both financially advantageous). And the court furthermore observed that MetLife had emphasized a certain medical report that favored a denial of benefits, had deemphasized certain other reports that suggested a contrary conclusion, and had failed to provide its independent vocational and medical experts with all of the relevant evidence. See id., at 669–674. All these serious concerns, taken together with some degree of conflicting interests on MetLife’s part, led the court to set aside MetLife’s discretionary decision.

MetLife also did the same thing CIGNA did to us, namely pick out information that bolstered their point of view of the reality of my husband’s disease, Multiple Sclerosis:

The Court of Appeals ultimately set aside MetLife’s denial of benefits in light of a combination of several circumstances…(3) MetLife’s focus upon one treating physician report suggesting that Glenn could work in other jobs at the expense of other, more detailed treating physician reports indicating that she could not; (4) MetLife’s failure to provide all of the treating physician reports to its own hired experts; and (5) MetLife’s failure to take account of evidence indicating that stress aggravated Glenn’s condition. See id., at 674.

If you are wondering why this happens, it’s simply due to corporate greed and money–lots of money. These group policies are huge money makers for the large health insurance companies and they rake in billions in profits each year from them. Paying out claims to people with Multiple Sclerosis is not what they want to do–their interests lie in fattening the bottom line.

As financial tools, they are worthless and a waste of your hard-earned dollars. You have alternatives such as private policies. Save your money and look elsewhere. And if you think these policies need to be better regulated or ERISA should be removed or rewritten as law, write your members of Congress. That’s what we pay them for.

Your health and well-being do not matter to large corporate entities no matter how much they try to spin it otherwise. See AHIP.

Vermont now leads the way in our nation on health care!

Vermont is now leading the way in our nation towards a civilized, rational and cost-effective form of health care. The state has passed a bill establishing a Single Payer system.

That’s right, everyone in the state of Vermont will have the right of health insurance coverage, a Medicare for Everyone type of health care.

Imagine, if you will, the security of never fearing you are just one pink slip away from a health care related financial disaster or knowing that you will not have to declare bankruptcy if you lose your job and have a pre-existing condition like Multiple Sclerosis.

You will always be able to pay into a Single Payer system and be covered. And the more people in the pool, the more costs are contained.

Here’s Vermont for Single Payer dot org’s Top 10 Reasons for the Single Payer system.

Think Progress has been reporting on this and here is a link to the article. However, there still are some hurdles to a civil society:

A bigger hurdle Vermont faces is obtaining a waiver from the federal health care reform act and finding a way around federal ERISA laws — which “pre-empt states from enacting legislation if it is ‘related to’ employee benefit plans” –- that insurers could use to sue the state. The health reform law currently offers a waiver to states who meet certain standards by 2017. Rep. Peter Welch (D-VT) has introduced an amendment that would move the waiver date up to 2014 — an idea that President Obama has endorsed.

For those of  you unfamiliar with ERISA laws, be glad you are. The federal ERISA (Employee Retirement Incoms Security Act) laws were in enacted in 1974 and meant to protect employees from having their pension funds ravaged by crooked CEOs. It also covers health plans and there’s the problem. More on ERISA here, here and here. Please read these links, they explain everything in detail.

The health insurance companies like ERISA laws since it helps them NOT pay out claims or holds them liable for any wrong-doing. It’s why Nataline Sarkisyan’s parents could not sue CIGNA when they denied their 17 year old daughter a liver transplant and she died. Nataline had leukemia.

“The most important federal insurance regulation of the past generation is ERISA,” says Tom Baker, deputy dean of the University of Pennsylvania Law School in Philadelphia. “If ever a law backfired for the public, ERISA is the perfect example.”

During the debate over the Affordable Care Act two specifics were brought to the table to help the consumer. The first was get rid of ERISA for health plans. Guess what? The insurance lobby (AHIP) won on that one and we still have it.

And the second was get rid of the McCarran Ferguson Act of 1945, the one where the insurance industry is immune to Federal Anti-Trust Laws (like Major League Baseball). You guessed it, the insurance lobby won out again over the consumer.

If you are a believer in states’ rights then I urge you to write your members of Congress and tell them to do away with these two federal laws and put the rights back in the hands of your state. You’ll be healthier! And Single Payer or Medicare for Everyone.