Thursday, November 20th, 2014

Does an Americans for Prosperity ad about a woman with lupus tell the whole story?

An ad from Americans for Prosperity attacks the federal health care law.

Emilie Lamb, a 40-year-old Tennessean who suffers from lupus, is front and center in a new 60-second ad created by Americans for Prosperity, the conservative advocacy group supported by Charles and David Koch.

"I thought that Obamacare was going to be a good thing," Lamb says in the ad. "Barack Obama told us we could keep our health insurance if we liked it. And we can’t. I got a letter in the mail saying that my health insurance was over, that it was gone, it was canceled because of Obamacare. My premiums went from $52 a month to $373 a month. I’m having to work a second job to pay for Obamacare."

Ads featuring testimonials are hard to fact-check, especially when they focus on personal health details, but we expect to keep seeing them throughout the 2014 primary season. Here at PolitiFact, we plan to track the ads and write reports about how the stories told in the ads compare with what we know about how the health care law works.   

In addition to the ad, Lamb was invited to the State of the Union on Jan. 28 as the guest of Rep.  Marsha Blackburn, R-Tenn., who told Lamb’s story in an op-ed piece for The Tennessean and during a House Energy and Commerce Committee hearing. Lamb also penned her own op-ed for the New York Post describing her health situation in more details.

We tried to reach Lamb through Blackburn’s office and through other means, but were unsuccessful.

We don’t dispute Lamb’s troubles and we certainly don’t wish to diminish her plight. We’re not fact-checking her account or putting her on our Truth-O-Meter. Instead, we wanted to explore the issues that her story raises.

We expect people who see the ad will want to know if her experience is typical of the overall law. What we found was that her case represents a very specific set of challenges that are not exactly common for those purchasing coverage on the individual market.

What is lupus and what kind of care does it require?

As she says in the ad, Lamb suffers from lupus, a chronic, autoimmune disease. It most often appears in women during their childbearing years and affects about 1.5 million Americans. In a healthy person, the immune system is programmed to attack foreign forces that might make us sick. In a lupus patient, the immune system is out of balance and often attacks internal organs, mistaking them for invaders.

The organs that are affected differ for every individual. Some cases are mild and easier to manage, while others require constant medical attention. As a result, the cost of care for a patient with lupus varies wildly.

A review of studies from 2002 to 2012 on medical expenses for lupus patients found that costs on average range from $12,000 to $17,000 a year, as long as kidney issues did not surface. If the kidney is involved, costs jumped to $29,000 to $63,000 a year.

The lupus community has been generally supportive of several parts of the Affordable Care Act, said Duane Peters, spokesman for the Lupus Foundation of America, though the organization has not endorsed the overall legislation.

Lupus is a lifelong illness with no known cure, and annual treatment to manage the disease is costly. So those afflicted with lupus were often denied health care coverage on the individual market because of a pre-existing condition. Obamacare prevents that from happening.

The law also bans annual caps on benefits and allows children to stay on their parents’ insurance policies until age 26, which Peters said the foundation also supports.

What kind of insurance did she have before the health care law?

Even though Lamb has lupus and her employer did not offer insurance, she was able to get coverage through a program called CoverTN, a public-private health program that offered coverage by putting together funding from the state, employers and patients.

CoverTN was first offered in 2007 after the state decreased its Medicaid rolls by 170,000. Only businesses with 50 or fewer full-time equivalent employees were eligible to participate if half those employees earned less than $55,000 a year. Total enrollment in the program was 14,255 on Dec. 31, 2013, the last day the plan was operational.

Under the plan, the cost of coverage was split evenly between an employee, his or her employer and the state. That’s a big reason why the cost to Lamb was so low; the state subsidized one third of it and her employer picked up another third. In 2013, the state budget for CoverTN was $16.9 million.

The individual cost of the premium varied between $37 to $109 a month, but the average was about $61; Lamb said in the ad that she paid $52. Co-pays for doctor visits were $15-$20, and generic drugs cost $8-10 per prescription. An emergency room visit cost $100.

The inexpensive plan was helpful to Lamb, who makes frequent doctor and specialist visits and often finds herself in the emergency room, she said in the Post op-ed.

In exchange for the low costs, policyholders received relatively few benefits. There was a $25,000 cap on annual benefits, and coverage was pretty basic. For example, policyholders could make 12 primary care visits per year and five or six specialist visits. Only generic drugs were covered and individuals were limited to two emergency room visits per year and hospital stays were capped at $10,000-$15,000 a year.

The short list of benefits did not meet the minimum requirements set by the Affordable Care Act, particularly the part of the law that said insurers couldn’t set caps on annual spending for care.  So the state had to cancel the plan. Tennessee officials requested a waiver from the Obama administration to keep it operational, but the waiver was denied.

Why did Lamb choose a more expensive plan on HealthCare.gov?

After her CoverTN was canceled, Lamb said she was directed to the federal insurance marketplace to purchase coverage. Tennessee does not operate its own portal.

She ended up selecting a platinum plan that cost $373 a month after a small subsidy, the second-most expensive plan available to her, according to the Healthcare.gov website. It had no deductible and Lamb now pays a coinsurance of 25 percent of her in-network care. There is a $1,500 limit on out-of-pocket expenses each year.

Lamb said it will end up costing her about $6,000 more a year than CoverTN.

Bronze plans were available that cost as low as $144, but the deductible was high at $4,000. And there was still a coinsurance of 50 percent for doctor and ER visits, even after the deductible was met. For someone needing constant medical care, that could get expensive.

There were silver plans that ranged between $270-$300, after a subsidy, with a deductible of $2,000-$2,500. Some of those plans had copays of $25 for a doctor visit with ER visits costing 30 percent after the deductible. The limit on out-of-pocket expenses was about $4,000, or more.

A few gold plans were in the $300 range. Some had no deductible and coinsurance rates at 35 percent, and others had deductibles but caps on out-of-pocket expenses of around $2,000.

In her op-ed, Lamb said her "frequent and expensive trips to doctors and specialists" made all the other plans too pricey.

Without knowing the number of doctor trips, prescription refills or emergency visits Lamb needs, it’s impossible calculate how much each plan would end up costing her each year.

We should note that any of these plans -- bronze, silver, gold or platinum -- would include more benefits. For example, on the plan she selected, there is no cap on the number of times a policyholder can go to the hospital, like there was with CoverTN. With the platinum plan, she also has access to non-generic drugs, rehabilitation services and basic eye and dental care, none of which were available through CoverTN.

The plans on the federal marketplace also have no cap on the annual benefits an individual can claim. This would be particularly critical for serious illness that would result in extended hospital stays. When Lamb had CoverTN, if she got really sick, from her lupus or something else, or was in an accident, her coverage would stop at $25,000. That’s not allowed anymore.

Republicans have argued that Lamb has the right to take that risk. And Lamb would have extra money in her pocket to pay those costs if she was still on the cheaper plan. Instead, those dollars are going to pay for her new policy.

But proponents of the health care overhaul say caps on benefits were a major problem before the law passed, and were a big reason why health care bills contributed to so many bankruptcies.

Why doesn’t Lamb qualify for Medicaid?

There’s one final element to explore: Would Lamb have qualified for Medicaid if Tennessee officials didn’t turn down the federal expansion under the Affordable Care Act?

Through the health care law, the federal government will reimburse states 100 percent initially and 90 percent in the future to expand Medicaid benefits to any adult making at or above about 138 percent the federal poverty level. For a family of four, that equates to a household income of about $32,913. For an individual, it’s about $16,104.

Tennessee is one of 23 states to not expand the program.

We don’t know Lamb’s salary. We can estimate it’s about $29,500 based on the amount of subsidies she received to purchase coverage on the federal marketplace.

Again, we weren’t able to speak with Lamb. She doesn’t mention having kids or being married in the ad or her op-ed, and a spokesman from Blackburn said she is single. Therefore, it is unlikely she would have qualified for Medicaid, even if Tennessee expanded the program.

Our conclusion

In the ad, Lamb said "Barack Obama told us we could keep our health insurance if we liked it. And we can’t." This appears to be true for Lamb. Despite Democratic rhetoric to the contrary, not everyone was able to keep their insurance, especially if they possessed more limited policies. Someone who needed regular health care but stayed under caps would have done better if those plans were allowed to continue.

But proponents of the law say the purpose of insurance is to protect you when you get sick and against catastrophic circumstances. Plans that capped coverage often did not meet that standard, and Lamb’s previous plan definitely capped coverage.

Testimonials are a powerful tool for ad-makers but the anecdotal evidence presented in them is often atypical. In this case, the ad doesn’t present a full picture of the law’s effects.