Update on Patient Protection and Affordable Care Act

Legal Issues

Update on Patient Protection and Affordable Care Act

On June 28, 2012, the last date of the current court session, the US Supreme Court issued their decision on the constitutionality of the Patient Protection and Affordable Care Act of 2010, also known as Obamacare or healthcare reform.  This decision affirmed almost every provision in this Act.  While the court declared the so-called individual mandate unconstitutional under the commerce clause of the constitution, the court found this mandate to be constitutional under the tax and spend powers of the constitution. What does this change of authority mean for us as individuals in the US who use the health care system?  It will have no change on the application or effects from the individual mandate.  It will, however, change the language proponents and opponents will use to describe their opinions of the Act.  During an election year this change has already been heard on most media outlets.


The effective application of the individual mandate is very important to people with existing diseases, such as diabetes.  The individual mandate requires that all individuals not covered under another health insurance program purchase health insurance or pay a penalty.  This means that even people who do not think they will need health care will need to purchase this insurance.  This will allow insurance companies to spread the costs of health care among the heavy users of medical care and the people who need little or no health care.  This cost sharing system should result in lower health premiums for everyone, even individuals with large needs for medical care.


The court also determined that the Federal government cannot withhold existing Medicaid benefits as an encouragement for States to expand Medicaid coverage.  However, the Federal government may withhold new funding as an incentive for states to expand coverage.  This second ruling will have a major impact for individuals who earn just above the poverty line in States that decide not to expand Medicaid.  Several States, mostly with Republican governors have already said they do not intend to expand Medicaid coverage.  In States that chose not to expand Medicaid coverage, individuals who are not poor enough to receive Medicaid coverage under the current system and are not rich enough to afford health insurance will continue to have difficulty obtaining medical care.


Besides these two provisions this law will benefit individuals with diabetes.  The law has already:

+Allowed children to stay on their parents’ insurance until they are 26.

+Prohibited insurers to deny or cancel coverage for children who have diabetes and other serious medical conditions.

+Prohibited insurers from putting lifetime limits on coverage or canceling coverage if an individual is diagnosed with a medical condition, such as diabetes.

+Reduced drug costs to seniors by providing refunds for individuals who have been affected by the “donut hole” in existing drug programs.

+Set up Pre-Existing Condition Insurance Plan (PCIP) to provide health insurance coverage to people with medical conditions, such as diabetes, who would have difficulty obtaining coverage under existing programs.


By August 2012, this law will:

  • +Require screening of pregnant women for type 2 and gestational diabetes for all insured individuals with no co-pay required.
  • +Medicare will include a new, free wellness visit to identify a senior’s health risks and establish a personalized prevention plan to reduce the risk of onset or complications of conditions such as diabetes.


By 2014, the law will further benefit individuals with diabetes by:

  • +Requiring insurers to offer the same premium to all applicants of the same age and geographical location without regard to most pre-existing conditions (excluding tobacco use).
  • +Requiring States or the Federal government to set up marketplaces where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).
  • +Poor individuals and families above the Medicaid level will receive federal subsidies if they choose to purchase insurance via a government health insurance exchange.
  • +The federal government will set minium standards for health insurance policies and lifetime coverage caps will be banned.
  • +Companies employing 50 or more people without offering health insurance will need to pay if the government has had to subsidize an employee's health care.
  • +Very small businesses will be able to receive discounted health insurance for their employees through the exchanges.
  • +There will be certain essential services that may not have co-pays for patients.

In summary, unless this legislation is overturned in future administrations, individuals with diabetes have already received  and will continue to receive many benefits from this legislation.

Update on Avandia:  Drug company GlaxoSmithKline pled guilty of failing to report safety data about the (diabetes) drug Avandia to the Food and Drug Administration.  The company also agreed to plead guilty to two counts of introducing misbranded drugs — Paxil and Wellbutrin. The company has agreed to pay $3 billion for these three counts.  According to reports, Glaxo lied to the FDA for six years about the safety of Avandia. The company failed to provide information about risks of heart failure and heart attacks that they obtained from post-marketing studies and studies undertaken in response to European regulators' concerns about the cardiovascular safety of Avandia. Many individuals have filed suits against GlaxoSmithKline about unhealthy side effects of Avandia.  This will be a subject of a future column.