UPDATE #3: Emilie Speaks! (Be sure to read the original diary and first 2 updates to get the full story)
The Tennessean newspaper did a good story about about Emilie with lupus from Lawrence, TN. We hear a lot about the political implications of the AFP ads starring this unfortunate young lady, and then there is this paragraph:
When Lamb fell from a horse in 2007, CoverTN took care of her seven surgeries over the next 3½ years, she said. Lamb said one surgical bill ran $125,000, but the insurer apparently negotiated a much lower price, allowing her to stay under the $25,000 maximum. Her total cost for the hospitalizations, she said: $100.
So let's unpack this data and see how it squares with what we have learned about Emilie and her insurance.
First, we find that Emilie's major health issues are not lupus-related, as we have been led to believe in the TV ads, but caused by a fall from a horse. My ACA-dar is really alerting here.... remember the original press release quoted her about '...numerous emergency room visits and several major surgeries...'. Are we really to believe that those were lupus-related and the horse fall stuff was in addition? And that her horribly sub-standard 'non-catastrophic' insurance covered everything?
Second, CoverTN - Emilie's previous insurance - had a limit of $10,000 per year for hospital in-patient services (the $25,000 is the annual limit for ALL services). So Emilie is asking us to believe that her $125,000 surgery, which was undoubtedly in-patient, somehow got shoe-horned into a $10,000 annual limit.
Third, we are asked to believe that her 7 surgeries over 3.5 years somehow fit into either the in-patient hospital limit of $10,000/year or the outpatient limit of 2 surgeries per year, and that all of this surgical stuff, PLUS her lupus-related medical care, PLUS any other medical care she needed during this period, fit neatly into all of the limits of CoverTN (like $1,000 per year for prescriptions), so that her TOTAL medical expenses never exceeded $25,000 per year?
Fourth, her TOTAL cost for her hospitalizations was $100! So she had up to 7 hospital admissions, and NONE of them had a cost over $10,000. Has anyone reading this ever had in-patient surgery and come out with a bill less than $10,000?
Now, let's look at the next paragraph:
Lamb said her medical costs were always manageable, despite frequent doctor visits and medication for her lupus. Her out-of-pocket costs, including premiums, were slightly more than $1,000 last year, she said. She expects her out-of-pocket costs will top $6,000 a year under her current BlueCross BlueShield of Tennessee plan.
As we know from the ads, Emilie paid $53 in premiums X 12 = $636/year. That leaves her less than $500 for out-of-pocket expenses. CoverTN charges a $15 copay for doctor visits (limit 12 per year), $10 for 30-day prescription (limit $1,000 per year), and $25 for out-patient surgery (limit of 2 per year).
Another little tidbit:
Today, she’s paying $373 a month, even with a small federal subsidy.
By a little backwards math, we now know that Emilie earns about $29,800/yr and her subsidy is about $16 per month. (Isn't it scary how little clues can be use to ferret out stuff like this?)
And let's not forget that Emilie has a Platinum plan with ZERO deductible and $1,500 OOP max. This is the best insurance in the country that I've seen. Of course, since Emilie appears most concerned with her up-front costs - and totally unfazed by
the possibility of running up disastrous back-end bills - she might have chosen one of the lower-premium Gold or Silver plans, but, of course, she didn't.
So where does all this leave us? Here are the choices I see for what's going on with Emilie:
1. She somehow managed to navigate the serious limitations of her CoverTN plan and, despite multiple major surgeries, minor surgeries, numerous visits to the emergency room, lots and lots of doctor visits, and all those prescriptions, and found a way to stay within those limits each and every year since 2006.
2. Emilie's lupus is the less serious version (DLE). This is a skin disease and, while still a serious, incurable condition, as far as I can tell DLE isn't likely to require nearly as much medical care.
Everything I've written so far is taking Emilie at her word. The other possibility, of course, is that Emilie is lying about some of this. I don't really believe she is, but as each piece of the puzzle comes out, we find out things she didn't tell us about before.
Bottom line: I stand by my original assessment: Emilie is one of the big winners of Obamcare. She has spent years teetering on the edge of financial ruin, and now she has some of the best health insurance available anywhere.
And she's aiding and abetting the people who want to get rid of Obamacare and replace it with...... something?
Emilie, as many of us have seen on the AFP tv ads, is a young woman from Tennessee who suffers from the terrible disease of lupus. I have great sympathy for her, and I feel sad that she's had to suffer both from the disease and from the disruption of her health insurance. My purpose in this diary is to explore the story behind these highly provocative ads and present a fuller picture of whether her claims are true, as well as whether her issues really are caused by Obamacare/ACA.
Emilie was diagnosed in 2002, and my awareness of her health insurance situation begins in 2006, from this press release authored by Rep. Marsha Blackburn R-TN. An excerpt:
Emilie, like so many Americans, works in the backbone of our nation’s economy: small business. It was cost prohibitive for her employer to purchase a companywide plan, so Emilie needed to obtain an individual health care plan. Emilie found a plan that was affordable for both her and her employer. Since 2006, Emilie has called it “stellar and affordable” and it has helped her cope with the high costs of numerous trips to the emergency room and several major surgeries. - See more at: http://energycommerce.house.gov/...
Ok, let's stop right there. Ms. Blackburn implies that Emilie has been on the individual health care market, with what Emilie calls 'stellar and affordable' insurance, since 2006.
ACA-dar alert! In one of her TV ads, Emilie says her premium before her policy was cancelled was $53 per month.
Looking around a bit more, I found a slightly different press release from Ms. Blackburn that reveals the truth of Emilie's health insurance:
Emilie, who suffers from Lupus, is one of millions of Americans who had her health insurance plan cancelled because of Obamacare. Since 2006 Emilie received health insurance through CoverTN, which provided her with the affordable care she required for the numerous Emergency Room visits and surgeries she has had to endure to treat her chronic illness. Left without any other choice, Emilie signed up for Obamacare and as a result her monthly insurance premiums increased by 700 percent. Congressman Blackburn has been fighting to help Emilie find a better solution to ensure she continues to receive the care she needs and deserves. - See more at: http://blackburn.house.gov/...
OK, that's better, why did this wonderful health insurance, provided by the state of Tennessee at a cost of $53 per month, get cancelled? From The Tennessean
The letter states that as a limited-benefit plan, CoverTN does not cover all the services required by the federal law and will no longer exist as of Jan. 1. CoverTN had a $25,000 annual limit on benefits. The federal health law does not allow yearly expenditure caps.
So Emilie really got all of her treatment, including 'numerous trips to the emergency room and several major surgeries' and all those medications we see in her TV ad, for less than $25,000 per year? Really?
But why did Emilie's policy - and those of the other 16,000 needy Tennesseans - get cancelled? Simply put, because they were junk policies, by any definition of the term.
The state of Tennessee, faced with the requirement to bring the CoverTN program into ACA compliance, just folded the entire plan, completely washing its hands of the needs of all those people.
What could they have done differently? Well, first off, they could have turned these policies into real insurance policies, and stopped making these people either pay out of their own pockets for additional, high-deductible coverage, or just hope their costs were low for the year so they didn't get wiped out financially.
Another option would have been that the state could have taken the money they were spending on the CoverTN - my guess is perhaps as much as $25 million - and turned it into some sort of premium support for these 16,000 people. I don't know if that's allowable under ACA, but it's at least a possibility. Did the state try to help these people, having known since mid-2010 that this requirement would take effect on 1/1/2014? There's no sign of that.
Compounding this problem, although presumably not for Emilie because she's employed, is, of course, Tennessee's refusal to participate in the Medicaid expansion program, that is completely paid for by the federal government for 3 years and at least 90% after that.
People unlucky enough to be caught in what I'm now calling the 'Roberts-hole' - those between the top amount for pre-ACA Medicaid qualification and the ACA maximum income for Medicaid - get no subsidy at all. For Tennessee, that is between $0 and $15,282. Anyone in that hole gets no subsidy. That's right, in Tennessee adults in most cases can't qualify for Medicaid at all, and now the people who need it most can't get an Obamacare subsidy. That's perverse to the point of being evil.
So let's summarize: Emilie had junk insurance paid by the state, PPACA outlawed junk insurance almost 4 years ago effective 1/1/14, her state did nothing all that time, then sent her a letter last September cancelling her policy and doing nothing at all to help her. Who's to blame? I'm going to reserve judgement on that until I see what others are thinking. Have at it, folks.
Now, you might ask, what's Emilie doing now?