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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?

Cheers.

ORIGINAL DIARY

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?

Intro

You must enter an Intro for your Diary Entry between 300 and 1150 characters long (that's approximately 50-175 words without any html or formatting markup).

Funny you should ask! According to Emilie herself in one of her ads, her insurance premium has gone from $53 to $373 per month.

Now, you might ask, what kind of insurance does that get you in Emilie's county, Lawrence County, TN?

Funny you should ask! Here it is:

That's with no subsidy, BTW. Emilie's TV ad also mentions that her total health insurance cost had increased to $6,000 per year. That matches with the total cost of this policy: 389 x 12 = $4,668 + $1,500 max OOP = $6,168.

That, folks, is about as good as it gets. I've been researching ACA policies for several months, and that is the best non-subsidized policy I've EVER seen. And keep in mind that this is platinum-level insurance - no annual max, no life-time max, no 'sorry, that's not covered'.

So if Emilie really does have a major operation - which will certainly cost WAY more than her previous $25,000 limit - it will be paid for. And she can't be rescinded or dropped. And she won't be one 'bad state legislative day where they just had to cut a few million from middle-class benefits to pay for tax cuts to millionaires' from not being able to get ANY insurance.

Let me close with just one more example of the astounding ability of Republicans to be hypocrites. Here is a descriptionof one of the main principles of the latest Republican Senate 'Obamacare Alternative':

In essence, the plan attempts to lower health care costs by making people shoulder a greater share of those costs—or "sensitizing" consumers to the actual cost of health care, as Senate aides put it in a meeting with reporters on Monday.
Isn't that exactly what happened to Emilie?

I wonder what Emilie's plan used to be in the event she had exceeded the $25,000 annual coverage limit, especially because she has a serious condition.

Did she pay for a catastrophic policy? It's doubtful she could have gotten one, given her pre-existing condition.

Did she save money for those costs?

Did she pray for good health?

Did she spend every day of the past 8 years scared to death that she would be wiped out financially by a single emergency?

Did she worry every night that her extended family might have to step in to help pay for her medical care, exposing them to financial ruin?

I suspect she did all of those - except for the first one.

And today she does none of them. Emilie has affordable, adequate health care with a solid platinum policy that can't ever be taken away from her.... unless the Republicans she now chooses to support manage to somehow repeal Obamacare..... because every alternative plan I've seen would once again allow insurance companies to decide that Emilie is uninsurable, or impose limits on coverages, etc. etc. etc.

UPDATE #1: About that insurance Emilie had.

I answered a question in the comments about what type of state-sponsored insurance Emilie had, and then went on a bike ride for the first time this week - it's been raining all week. There's no better time to think things through, IMHO! Here's what occurred to me.

We know from above that Emilie had a policy known as CoverTN. Here's the link to the details of that now-discontinued program:
Link to CoverTN

It's a very limited plan. We know about the $25,000 max annual benefit, but there are also co-pays, and other limits, like 2 emergency room visits per year, and a total of $10,000 for hospital expenses. Hunh???

Does this look anything like a policy that someone suffering from a serious debilitating disease like lupus, who by her own admission needed 'numerous emergency room visits and several major surgeries' would choose? Ummm, what about prescriptions? Let's take a look:

My ACA-dar strikes again! If you watched the TV ad, one poignant moment while Emilie prattles on about 'Obama's broken promises' is her standing at the sink facing her collection of prescription medication bottles. Lots of them, as you'd expect for someone with a serious, debilitating disease that requires expensive drugs like corticosteroids, immunosuppressive drugs, anti-malarials, etc., etc., etc.

And this woman thinks, by her own words, that a plan which limits prescription coverage to $250 per quarter, is 'stellar and affordable'?

And, of course, she is so angry and disappointed with President Obama for making a REAL, affordable insurance policy available to her, that she goes on national television to complain about it?

This is outright fraud, perpetrated by the Koch-funded astro-turf group Americans For Prosperity, who created the ad and are paying to broadcast it.

A couple of other factors that I should deal with, anticipating questions to be raised in the comments:

Which type of lupus does Emilie have? We don't know, but as far as I've been able to ascertain (and I'm soliciting better information from those who know it), the skin-only form of lupus (discoid or DLE) isn't as serious as the other form (systemic or SLE). Without taking away from the seriousness of DLE, it doesn't appear to be a likely candidate for causing 'numerous trips to the ER and several major surgeries'.

And here's where Emilie is caught in a trap of her own construction: if she tries to claim that she has DLE, then either she's lying about how serious it is, or if it IS serious enough to require all those major medical expenses, then everything I said above still rings true.

Somebody might wonder if this was the only medical coverage Emilie could possibly have found, given that she was obviously not insurable in the barbaric pre-ACA days.... well, all I'm going to say on that right now is, NO, that is not the case. This is enough of an update for the moment, so I'll just tease you with 'wait for the next installment of....... Emilie isn't quite who you thought'!

Now, a couple of other tidbits:

First, why is Emilie walking around in her back yard in broad daylight with no hat on? I don't profess to know much about lupus - although I've learned a lot about it today - but isn't sunlight supposed to be the biggest trigger for lupus attacks?

And second, if you have watched the video of Emilie, you remember her saying that her previous policy had a monthly premium of $53. So, on her CoverTN policy, what is the only mix of circumstances that could result in a 39-year-old woman having a premium of $53?

I'm not accusing her of anything, this just caught my eye. Anyone who hasn't figured it out should go google 'what to do and not do if you have lupus'.

Finally, if anyone who voted for anything other than 'she should be grateful for it' in the poll in this diary now wants to change their vote, I understand, but I don't think it's possible.

UPDATE #2: Emilie had a choice before Obamacare

In the first update, we saw that Emilie's CoverTN policy was completely unsuited for someone with a serious disease like lupus.

So did she have options?

Glad you asked! The answer is: Yes, she did. Tennessee had a high-risk pool, called AccessTN, available to people with serious diseases/conditions. Here's a partial list of the 55 pre-approved medical conditions that required only a doctor's statement for eligibility:

Coming in at 47.... Systemic Lupus Erythematosus.

And if Emilie actually suffered from the less severe type of lupus, discoid lupus, and had been denied coverage because of it, here's the other way to qualify:

Denial by one unaffiliated insurance carrier for individual coverage due to a health-related condition
So she was eligible for AccessTN, one way or the other. There are 3 levels of coverage, so I'm going to choose the best, which is most equivalent to the Obamacare policy she seems to now have.
So, assuming she doesn't smoke (in spite of the $53 problem), she would pay $477. And what kind of insurance would that get her?
Now, that's not half-bad insurance for an uninsurable person, pre-ACA. I couldn't screen capture far enough down to show the max annual OOP of $5,000, max medical annual $250,000, max pharmacy annual benefit $100,000. The rest is pretty decent, pre-ACA... follow the link if you're interested.

My eyes zeroed in on the generic drug co-pay of $10. Remember, if you will, that her CoverTN policy had an annual limit of $1,000.

So what does this policy cost?

Gee, you keep asking all the right questions! I'll use my new notation:

Premium      $5,724
Deductible    $1,000
Co-pay         $4,000
MAX             $10,724

This is the policy that any rational person suffering from a serious debilitating, un-curable disease would choose, knowing that they would be faced with taking multiple expensive prescriptions, have numerous trips to the emergency room and facing several major surgeries. It isn't cheap, but I reckon that in the end analysis, given all the limitations on the CoverTN policy that Emily had, that it would have been comparable in terms of total out-of-pocket expenses for health care. And if not, remember, then Emilie isn't nearly as sick as she (and the Koch brothers) are leading us to believe.

Let's compare this to the ACA-compliant, Platinum plan it appears she now has:

Premium     $4,668
Deductible   $0
Co-pay        $1,500
MAX            $6,168

It occurs to me that everyone else on the Tennessee high-risk pool insurance  - there were 2,600 of them - was paying something like the first example above, and is now paying something like the second. (Please don't jump on me, there is a very wide range here - 3 levels of pre-ACA Access TN policies with age/location/smoking/weight variations and 4 levels of ACA policies with age/location/smoking variations. And no, I'm not going to post a whole bunch of them for comparison - I'm satisfied that these are reasonably representative)

Is it any wonder that none of THEM is appearing in TV ads excoriating President Obama?

Cheers.

Extended (Optional)

Originally posted to databob on Sat Feb 08, 2014 at 06:48 PM PST.

Also republished by Three Star Kossacks.

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