Monday, April 7, 2014

My thoughts on Americans For Prosperity, Julie Boonstra, Dave Lamb, and the rest of Obamacare’s winners and losers. Or: How political spin defaces a true story of loss, and tarnishes a story of hope for millions of people.

What’s happened, and is still happening, to Julie Boonstra is incredibly upsetting, to say the least.

Julie has been suffering from leukemia for 5 years (which, incidentally, just killed a friend of mine). Julie was happy with her previous insurance plan (a Blue Care Network plan), which provided all the care she needed with low out-of-pocket costs (in exchange for a higher, $1100 monthly premium), and she lost that plan in spite of Obama’s now infamous “lie of the year”. Undoubtedly, Obamacare has its fair share of both winners and losers, and Julie Boonstra is one of the losers, if for no other reason than because she was forced off of a great insurance plan she knew and felt was giving her exactly what she needed while in the midst of fighting an ongoing battle with cancer. Anyone who doesn't feel for this woman doesn't have a soul, and I do believe that everyone who promised her she'd be able to keep her old plan owes her an apology.

Like so many other redistributionist policies, the Affordable Care Act (aka "ACA" and "Obamacare") reminds me of the trolley dilemma where you have to decide whether to save 5 people’s lives by pushing one person into the path of a train. Studies show that if you can do this by just pushing a button, you’re much more likely to do so than if you have to physically push the person with your own hands. In a sense, politics and public policy decisions can be similarly grotesque in that they allow the perpetrators to be somewhat removed from the individuals whose lives their policy reforms will be disrupting - N. Gregory Mankiw gave an overview of this dilemma in the New York Times, and similarly compared it to economic policies that "fail the do-no-harm test".

But the absolutely worst part about Boonstra and many, many others' situation is that not only did Obama push them into the proverbial tracks, but he did it with trickery. Instead of just pushing them into the tracks, it is as if he told them that he was taking them out for ice cream, and then, when they weren't looking, he shoved them into the tracks. Of course, as it turns out these victims will most likely not die because of this, but I'm not exactly eager to explain this reasoning to them myself, and regardless of the extent of the damage done unto them, there is no denying that damage has indeed been done.

As someone who believes that government has the capacity and obligation to help those who need it, I consider Obama’s deception a terrible stain on the history of liberalism.

However, two wrongs don’t make a right. Americans for Prosperity (AFP, backed by the Koch brothers) have unfortunately opted to channel Boonstra’s (any several others') well-deserved outrage and upset into grossly misleading anti-ACA propaganda for the sake of disrupting Rep. Gary Peters' (D-Mich.) campaign for the Senate. Viewers of AFP's ad, starring Boonstra, are led to believe that Boonstra lost her doctor, that she has to pay unaffordable costs, and that her prescription drugs for her cancer treatment are no longer covered. The Washington Post’s “Fact Checker” (Glenn Kessler) examined the ad and granted it two “Pinocchios” at first glance, and then downgraded it to three Pinocchio’s when it was reported that her new plan (Blue Cross Blue Shield Michigan’s Gold Premier Plan) actually has lower out-of-pocket maximums than originally assumed. She might have to pay higher out-of-pocket costs in the beginning of the year (even though her monthly premium payments are $529 lower now), but as soon as her $5100 out-of-pocket maximum is reached, her insurance would cover everything. Most importantly, it was found that, assuming she stays in-network, she would save $1200 per year.

Incidentally, I don't know of any doctor or hospital that would refuse to let a cancer patient make multiple smaller payments on a bill, so I honestly believe that while her worries about unmanageable up-front out-of-pocket expenses are sincere, they are best ignored (by her, not us). I do realize that this is easier said than done, and I certainly realize that I am in no position to tell her what she should or shouldn't do - I am just trying to explain why I believe that AFP's ad was misleading. 

Upon reading Kessler's analysis, many liberals attacked Boonstra, accusing her of being a liar. I’m sure you can imagine the outrage from conservatives. Dan Calabrese, who works for Herman Cain, wrote an article defending Boonstra and attacking Kessler, and his article has been cited by many other right-wing sources including National Review. Calabrese accused Kessler of drawing conclusions without ever bothering to speak with Boonstra herself, and criticized him for instead opting to base his conclusions exclusively on statements from her insurance provider. 

As it turns out, Kessler did try to contact both Boonstra directly, as well as AFP (whom she has designated as her spokesperson), but neither of them answered when he pressed for more information, repeatedly. In an email, Kessler elaborated on his experience with AFP:

"Clearly AFP’s strategy from the beginning was to challenge anyone from questioning a cancer victim who felt aggrieved (witness the very first statement they gave me) and certainly they have used that to damage the Democratic candidate. But they never responded with any level of detail to answer my questions. It’s a classic tactic to avoid hard questions and then run to a highly sympathetic voice (Calabrese) who will unquestioningly reprint your spin.

I don’t take it personally, and in fact have good relations with the AFP folks. (I am equally tough on the ridiculous things Democrats say about the Koch Brothers.)  When they think they have a good case, they answer my questions. When they don’t, they avoid them. Since they avoided them in the Boonstra matter, I was fairly certain there were holes they did not want exposed.
My main goal in writing about these ads is to help readers understand what information is missing. Obviously, if you are going to overhaul 1/6th of the economy—and mandate a certain minimum level of benefits—there are going to be some losers in the new system. Even if it is just one percent of the people in the individual market—and certainly it’s much higher—that’s more than 10,000 victim stories. The Obama administration’s error was in asserting that everyone would be a winner, creating an opening for ads like this."

Calabrese also claims to have unearthed more information about Boonstra’s plan, based on her statement of benefits. Given that he didn’t actually get this info directly from Boonstra himself (making him a hypocrite for criticizing others for not speaking directly with Boonstra), but rather from a spokesperson for AFP, I was not prepared to take his (actually, AFP’s) word for it, especially since much of what he said didn’t pass any “smell test” (although at least a couple points he made were indeed valid). I’m going to break up his list of grievances, and respond to each one with my own findings:

1) Long-term care and nursing care are not covered. Since Boonstra’s leukemia diagnosis five years ago, she spent two-and-a-half years bed-ridden. If that happens again, she’s got a big problem.

MOST (if not all) insurance plans don’t cover long-term care – you have to buy that separately. Since she refuses to share the details of her previous plan (for privacy reasons), we can’t be certain what her previous plan covered. However, I have heard that she is (if not previously married)  related to and co-owns property with Mark Boonstra (a former chair of the Washtenaw County Republican Party, and now a Michigan judge), and I also found an amazing 2013 Blue Care Network plan for judiciary employees in Michigan, so I’m going to assume that this was her previous plan – if nothing else, this state employee plan would be expected to be more generous than her old individual plan, and thus should serve as a useful upper limit estimate on what she used to have for coverage. While even this plan didn’t offer long-term care, it did direct people to a way to separately enroll in long-term care. I also see that this plan covered 90% of private care nursing costs (note, however, that private-duty nursing was NOT limited by her out-of-pocket maximum - meaning there is no limit to how much private-nursing would have cost her over time). Her current plan’s statement of benefits (two separate links to two different versions) does indeed list private-care nursing and long-term care as excluded. However, it does in fact cover "acute long-term care", as well as "home health care” and “skilled-nursing”, all of which we should fully expect to be able to cover whatever she needed if she went through the same 2.5 year ordeal again (God forbid).

In any case, yes, I can see how you’d be incredibly upset about losing this amazing plan with significant cost-sharing for private-duty nursing, but given that her plan does offer home health care and acute long-term care, it is very misleading to imply that she would now be shit out of luck if she had to go back to bed for 2.5 years again.

2) The statement of benefits says glaucoma is not covered. Leukemia is a disease that ravages every part of the body, so lack of coverage for glaucoma (or even dental care, which is also highly relevant for a leukemia patient and is also not covered) is a very serious issue.

I don’t see anything about glaucoma being excluded in her statement of benefits, and I’ve never heard of any insurance plan excluding glaucoma. Glaucoma is treated with prescription drugs, ALL of which are covered by her insurance plan! I do see that LASIK, RK, and PRK are excluded from her plan, but those aren’t typically used to treat glaucoma, and I’m guessing the exclusion of those types of laser surgeries is for people who want that treatment for normal eye correction, and should not be lumped together with laser treatments for those with glaucoma, which by the way are entirely different. Also, if you search BCBSM's provider network for glaucoma, you get 250 hits!!! Interestingly, I did find a different BCBSM plan (Multi-State Gold, link), which does cover dental and vision. For some reason Boonstra opted not to get this plan, which by the way is only 6%, or ~$30/month more expensive. Also, I see that for BCBSM’s HMO customers, they offer incentives for those who get screened for glaucoma. It is hard to believe that they would incentivize getting glaucoma screening for HMO customers, but entirely fail to treat PPO customers for glaucoma. The whole thing sounds very fishy to me! Without any info other than Calabrese’s (again, actually AFP’s) word, I am very skeptical of Calabrese’s claim. In any case, since glaucoma exclusion is not mentioned anywhere in the statement of benefits, I'm calling this one a lie. Again - not Boonstra's lie, but rather AFP (I'm going to assume Calabrese took AFP's word for it).

3) Boonstra is on five different medications to help deal with her leukemia. The Blue Cross PR spokesman claimed that they are all covered. But when Boonstra went to fill her prescription for Loratadine — a prescription-level equivalent of Claritin that she uses to control congestion brought on by chemotherapy — she was told that Loratadine is not covered. She has not yet attempted to restock any of her other meds but she is already having to come with strategies to deal with that problem.

Let’s pretend for a moment that her current plan doesn’t cover Loratadine. It is over the counter, and it is very inexpensive compared to the prescription drugs she’s very worried about getting (for good reason!). In fact, you can buy 1 year's supply on Amazon for $17.  Perhaps she uses a larger dose, but I can’t imagine it is much more than double the regular dose. In any case, “she was told that Loratadine is not covered” sounds suspiciously like there was a mistake of some sort, so I decided to investigate. Looking at BCBSM’s list of approved prescription drugs, I see that Loratadine is indeed listed, but only in generic form. So if she’s trying to fill a prescription for name-brand Loratadine, they will indeed decline it. Obviously, she just needs her doc to change the prescription to generic. Is that a pain in the ass? Sure. Is that also exactly what everyone who cares about rising health care costs thinks should be happening? Absolutely.

In any case, this appears to be yet another example of AFP being incredibly misleading, coupling an anecdote about a very typical pharmacy/prescription mishap with her worries about losing life-saving cancer drugs. This all is intended to create the impression that her new health insurance is going to stick her with paying the full amount for incredibly expensive cancer-treatment drugs, or else she will die. Obviously, this is not the case, and it is shameful that AFP is willing to use a cancer victim, who is probably scared out of her mind, to spread this kind of misinformation. This will ultimately end up making her look like she doesn’t know how to navigate the modern world, and all for the sake of AFP and Calabrese's political agenda.

4) The $5,100 cap on Boonstra’s out-of-pocket spending is for in-network care only. If she has to go out of network, she could spend an additional $10,200. The “fact checkers” treat this as impossible because Boonstra’s doctor is in network, but anyone who has ever dealt with cancer would know there is no way of predicting where you will have to go to find care.

Given that we now know her super-awesome previous plan cost her a maximum of ~$17,400/year after premiums ($1100/month, according to Boonstra), out-of-pocket maximums ($1000 in-network, $2000 out-of-network, both not including deductibles), deductibles ($400 in-network, $800 out-of-network), etc., it does appear that she could end up spending quite a bit more on her current plan (which adds up to a maximum of $21,468, assuming she forgoes non-acute long-term care and private nursing), but that’s only assuming the worst, and only because she had an insanely awesome plan before (assuming I’m looking at the correct one). 

But there is no reason to assume the worst, especially since it is completely unnecessary: First, the ACA has provisions that require your insurance company to fully cover costs for preventive care (which, by the way, includes bone marrow biopsies – see below). That means that if you cannot find a provider in your network who performs the necessary preventive care, your insurance company is still required to foot the entire bill. This is also true for emergency care – if (God forbid) something terrible should happen to Boonstra and she needs an emergency procedure, she can rest assured knowing that she won’t be slapped with out-of-network bills for that service, even if she has to go to a provider that is not in her network.

The fact is that these narrower networks are a fine cost-saving measure that will bring down overall health-care spending. Even anti-ACA conservatives like Avik Roy are applauding these narrower networks. I would argue that narrower networks, coupled with the ACA’s humane provisions, create a best-case scenario: People won’t go see docs they don’t need to see, and insurance companies will be pressured to make sure they keep their networks robust, since they will end up footing big bills if their patients have no choice but to go outside their networks to find the care they need. In case insurance companies still try to get away with denying full in-network cost-sharing for out-of-network services (for non-emergency procedures, for example), the ACA has also set up a requirement to enable customers to appeal to an independent, external board to review their disputes.

So, once again, it seems that while I can totally understand Boonstra’s distress, especially if she didn’t know about these provisions (I have a strong suspicion that AFP didn’t go out of their way to educate her about these huge money/life-savers), I find AFP/Calabrese to be grossly misstating the reality of her situation. She will not be stuck with ridiculous, out-of-network bills for life-saving treatments she may need for her cancer.

Having said all of that, I do wish that Congress would pass a law (wishful thinking, I know) requiring that insurance companies a priori charge in-network rates for any procedure a patient needs (not just life-saving), and yet cannot find a provider for that procedure within their network. I am still investigating whether there isn't already some provision in the law that already effectively makes this the case, e.g. the preventive, emergency, or external appeals provisions (please contact me or comment below if you know of anything that could help my investigation!). If so, then a lot of people will be able to sleep better at night, including defenders of the ACA. The fact is that potentially having to resort to an appeals process is the last thing a cancer patient like Boonstra should have to be thinking about. That said, it seems that her odds for success in any attempt to appeal are very, very high.

5) When Boonstra was first diagnosed, she had to go through a painstaking process to get approval for her chemotherapy drugs to be covered. When she finally found insurance she liked, she had no problem with the chemo drugs. She now says that process is starting all over again.

I’m sure this is a major pain in the ass. No disputing that here, although I can't help but wonder if Boonstra isn't doing this unnecessarily, given the irrational response to the Loratadine incident (she apparently went out and bought a prescription card).

6) Boonstra has already had to cut back on her bone marrow biopsies, which she was having on a regular schedule she had worked out with her doctor, because she doesn’t have clarification on whether these will be covered.

As you can see in what I wrote in (4), bone marrow biopsies are not only covered – they’re FREE for people 50 years old or older - I cannot imagine they're completely uncovered otherwise. I am willing to accept that Boonstra may not have known this, and perhaps even AFP/Calabrese didn’t know this, but the fact is that she did not have to cut back on her biopsies. I hope she figures this out sooner rather than later.


As I said, what’s happening to Julie Boonstra is incredibly upsetting and I wish this wasn’t happening to her - I wouldn't wish this upon anyone. But I don’t believe that excuses the AFP’s intentional misinformation campaign against the entire ACA. Worse, their using Boonstra as a political pawn, putting her in the public eye, has only caused her great grief, while tarnishing their own credibility. Of course, none of that changes the fact that their propaganda campaign may still prove effective in defeating many Democratic candidates who not only have to battle very real challenges the ACA poses, but now many very false ones as well. 

Most sadly, AFP's campaign probably discouraged many people who would have greatly benefited from buying insurance on the exchanges, due to completely unfounded fears of poor coverage and insurmountable costs.

In any case, Boonstra is still much better off than the millions of sick and poor Americans who were uninsured before the ACA was enacted. In fact, I’m willing to bet that there are many poor, uninsured people with cancer who would deem her newfound issues of potentially increased costs and narrower networks “1st world problems”.

Don’t believe me?

Let’s assume that only 8 million additional people get insurance via the ACA (note that this is likely to turn out to be an underestimate, especially over several years). Out of 8 million people, ~3.2 million people will get cancer at some point in their lives. That's a lot of people who would have had to face cancer without any insurance at all if it weren’t for the ACA. And that’s just cancer – never mind the huge number of other diseases or injuries that could bankrupt or even kill someone if they don’t already have reliable coverage. Never mind the people who were paying insanely high premiums because of pre-existing conditions, who now can afford to pay off some of their medical bills due to the ACA. I'm not sure how many people's premiums were reduced, but if someone can direct me to a source, I'll gladly link to it - I personally know at least 3 families whose premiums went down, and that's without subsidies.

Even more appropriate, think about my friend, Dave Lamb, who just died from his battle with leukemia. He did not have insurance before the ACA, leading him and his family to amass enormous debt, causing them to have to ask for donations. Fortunately, since he was a well-loved musician with a following, he was eventually able to amass the amount necessary for his treatments. But the bills kept climbing for his follow-ups, and they are still at least $40,000 below their target (please donate!!!). More importantly: Who knows whether he would be alive today if he had been able to immediately go in for treatment, instead of having to wait until they had enough money for his much needed transfusions, bone-marrow transplant, and follow-up appointments without worrying about his astronomical medical bills? If the exchanges had opened two years ago, none of those things would have been an issue for him or his family.

One fair question is: “how many Boonstras are there”?, and I don’t know the answer to that question. We know that about 4.8 million insurance plans were canceled, but we know that some people benefitted from better plans, and that most people ended up with nearly identical plans anyway. Thus, I would still argue that there are very likely to be many more winners than losers in this scenario. But most importantly, the “winners” in this case are people who’ve gone from no coverage to at least some coverage, whereas the losers like Boonstra are most often people going from absolutely incredible coverage to really great coverage (along with a lot of headache, which for Boonstra happened at the worst possible time). Reasonable people can disagree on whether that tradeoff is justified, but to me this seems like an inevitable consequence of any major reform, be it sponsored by Democrats or Republicans, or smeared by Fox or MSNBC.

In a concise response to Mankiw's diatribe against utilitarian economic policies like the ACA, The New Republic's Isaac Chotiner has this to say:

"We already had a healthcare system that made all kinds of trade-offs. And many people, of course, never really "voluntarily agreed" to the system, even if they were lucky enough to have had insurance. Was paying high premiums because of pre-existing conditions a choice? Was taking the plan from your employer a choice? In Mankiw's world, however, things only became disruptive after Obamacare. 
The status quo, whether in terms of the minimum wage or healthcare, was not just some completely fair system that is now being messed with by statist liberals. Our system of government and economy have been "disruptive" for a very long time."
In any case, I really, really hope that Boonstra doesn’t find everything about her new plan to be as horrible as she expects it to be. I only want her to find out that everything is just fine, so that she can relax and get back to living her life as she did before.

AFP and Calabrese, on the other hand, have some major soul searching to do, in my opinion. To take a legitimately bad story, and stain it with poisonous deception that is so transparent that anyone with an internet connection can see through it, is using Boonstra’s tragic situation for their own ideological/political agenda. The amount of publicity and negativity they subjected her to, by using her as a political symbol, is undoubtedly not good for her already fragile health. The truth is that I am personally worried about publishing this article for fear of only contributing more to that negativity. So let me say it once again: Boonstra did nothing wrong, and everyone should hold her in their prayers. AFP, on the other hand, should think long and hard about what they've done, and should probably spend more energy trying to help those like Boonstra, instead of making them and everyone else fear for their well-being.

For shame.