03/18/2014 01:39 pm ET Updated Mar 18, 2014

How This Anti-Obamacare Ad Misses The Bigger Health Care Picture

Beneath all the partisan fury about Obamacare lies a surprisingly fundamental question: Just what exactly counts as health insurance?

A recent ad produced by an anti-Obamacare organization illustrates the issue. The Americans for Prosperity video features a Tennessee woman named Emilie Lamb whose monthly health insurance premium under Obamacare rose to $373 from $52.

Lamb, a 40-year-old accountant from Lawrenceburg who suffers from the chronic, incurable auto-immune disease lupus, is unhappy about the price hike. "I thought that Obamacare was going to be a good thing. Instead of helping, Obamacare has made my life almost impossible," she says in the Americans for Prosperity video.

To pay for the increase, Lamb took a second job doing bookkeeping on weekends and now works more than 50 hours a week, she wrote in an email to The Huffington Post. She's also published an op-ed in the New York Post, was the subject of another anti-Obamacare op-ed by Rep. Marsha Blackburn (R-Tenn.) in The Hill, and was Blackburn's guest at the State of the Union address in Washington, D.C., last month.

Yet, it's debatable whether Lamb was ever really "insured" under her old plan, a subsidized Tennessee state program called CoverTN, for people who earn up to $55,000 a year.

That policy only covered Lamb's medical costs up to $25,000 a year. Had she gone over that amount and incurred thousands of dollars in hospitalization costs -- a real possibility for someone with her condition -- she would've been thrown into debt like so many other Americans in the pre-Obamacare landscape. Her old plan also limited how many times she could see a doctor in a year and capped hospitalization benefits.

If real health insurance were available for $52 a month, that's what everyone would have. BlueCross BlueShield of Tennessee, which administered Lamb's policy, didn't even call it "insurance," instead describing it as a "limited-benefit plan," the pro-Obamacare group Families USA noted in a 2009 report critical of CoverTN.

Lamb's new insurance, a top-notch "platinum" plan from the health insurance exchange, offers unlimited annual coverage, has no deductible, limits out-of-pocket expenses to $1,500 a year and comes with a rich benefits package as mandated by the Affordable Care Act. Lamb qualified for a tax credit that reduces her premiums by about $15 a month.

Her old plan is now illegal under Obamacare and is off the market. Much in the way that it's no longer legal to buy a car with no seat belts, it's no longer possible to buy health insurance that doesn't provide basic access to health care services and a high level of security against medical debt. Likewise, most states require a car owner to carry a minimum level of liability coverage -- not for the sake of that driver, but to protect anyone who might be harmed in a crash.

While consumers like Lamb are opposed to the changes forced by the law, larger societal and economic factors are at work. If patients are free to choose health policies that won't cover major medical expenses, that affects everyone else. Doctors and hospitals won't get paid, and those costs get spread throughout the health care system -- and passed on to taxpayers, who pick up a share of the cost of unpaid hospital bills every year through funding streams built into Medicare and Medicaid.

But this is a complex, difficult reality of the health care system that's not easy to simplify for a 60-second political advertisement set to sad music, and not as compelling as the personal story of a sick woman with limited means who's angry about changes she can't control.

Another person in Lamb's position could reasonably come to the opposite conclusion: that the Affordable Care Act's guarantee of coverage for people with pre-existing conditions, its comprehensive benefits package and the financial assistance it provides are tailor-made for a low- to middle-income person with a chronic medical condition like lupus. Under the old rules, a lupus patient could have been turned down for coverage or kicked off their plans when they got sick, and could have been charged higher prices than a healthier person.

It's worth noting that Lamb opted for a high-value and higher-cost platinum plan, instead of a cheaper bronze, silver or gold plan. She did so because a patient with ongoing health needs can save money by spending more on premiums and less on out-of-pocket costs, she told the Washington Post. A cheaper premium might well result in higher annual costs when deductibles and co-payments are figured in.

By Lamb's estimate, her annual costs will be about $4,500 higher with her new coverage, although she originally wrote in the New York Post and told other news outlets that number was $6,000. Is it worth it? Not in her opinion.

But consider a hypothetical alternative situation in which CoverTN still existed and Lamb still had its benefits. Depending on the severity of the disease and therapies prescribed, the average annual cost of lupus treatments ranges from $13,735 to $62,651, according to the Lupus Foundation of America. A bad year could drive her medical bills above $25,000.

"I am sure that my health care needs will change over the years. I know that I am not getting any younger, and every day I feel the effects of lupus a little more," Lamb wrote to HuffPost. Her current symptoms include patchy skin, fatigue, chronic joint and muscle pain, and kidney infections and stones, she wrote.

Lamb isn't worried about excess costs, though. When she racked up a $125,000 in medical costs after a horseback riding accident in 2007, CoverTN wound up footing most of her bills and keeping her below the $25,000 cap. She speculates that her medical providers would be willing to slash her bills again or set up a payment plan.

Philanthropy from an insurance company and a hospital isn't something most Americans would expect to rely on, though.

Ask anyone whose medical bills are in the hands of a collections agency, or who had to file for bankruptcy. What if the insurer couldn't drive the price down or the hospital refused to accept less than it was owed? Odds are Lamb would be financially devastated by medical bills that she'd never be able pay off, leaving health care providers and taxpayers holding the bag.



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