Monday, June 2, 2014

A response to my post on Boonstra/AFP

A conservative friend of mine whom I deeply respect as both an intellectual and moral thinker has written a response to my post on Boonstra. He raises some more-than-fair objections to a number of my assumptions and interpretations. I plan to respond to his post in full at a later date, but for now I just wanted to get it up and out there for the world to see, lest I be accused of being unwilling to face criticism and, in some cases, outright embarrassing corrective. Much to my friend's chagrin, I haven't changed my overall conclusion about the ad AFP made, but I do believe that his points are solid and that I did indeed make some mistakes which you can read all about below.

Let me be clear that my posting his response is not an endorsement of his opinion or anything he says within. I'm just sharing it because I think it is only fair to let readers see what turn out to be some valid objections to some of my previous statements.

Here is his response in full:

Let me start off by agreeing with the main thrust of your first five paragraphs. Let me continue by agreeing with you that it is detestable that many liberals, after reading Kessler's post, attacked Boonstra, accusing her of being a liar and/or mocking her. A critic of her ads basically has to treat Boonstra one of two ways: as a liar or as a poor, addlebrained cancer patient with no moral agency whatsoever duped and taken advantage of by the Koch brothers-backed AFP. You’ve settled mostly on the latter, but I’m not really sure one is a whole lot better than the other. Boonstra would probably find your explanations of how you could have navigated her health needs better than she can patronizing and probably wouldn’t much appreciate your sympathy in light of your using her situation throughout your post as a cudgel with which to bludgeon those who gave voice to her grievances, and even her to some extent. Though I suppose we’ve already established it doesn’t really matter what she thinks…

Paragraph six is where you lose me, for reasons that will be clear once you’ve finished reading this comment. For the sake of clarity, I’m going to follow your lead and break up your list of grievances, trying to stick to your numbering and pointing out the errors you made along the way:

0) Calabrese is a hypocrite for criticizing Kessler for not speaking directly with Boonstra, and his claims don’t pass the smell test.

If Calabrese’s complaint were solely that Kessler didn't talk *directly* to Boonstra, I agree with you that would be silly. But his complaint is primarily not that Kessler's failing isn't that he was unable to get in touch with Boonstra or anyone at AFP but that Kessler a) took the insurance company's word (not even a written contract) as gospel, b) did nothing more than look at a bunch of price lists, c) more importantly, ignored the fact that Boonstra already had to forgo treatment in the meantime as she attempted to figure out what her plan will cover (quick note on this in the next paragraph*), and d) also more importantly, upon becoming aware of additional facts, failed to give these facts a fair hearing. Kessler at no point, as far as I can tell, updates his post to account for Calabrese’s column; his only response to these facts is a credulous endorsement of “a very detailed look at Boonstra’s situation by Uri Manor, a postgraduate fellow at the National Institutes of Health,” which he appears not to have read with any care despite implying the contrary with his endorsement (the Kessler standard is apparently that false implications get you Two Pinnochios) and which this post will poke significant holes in. A self-proclaimed “fact checker” like Kessler ought to account for all the facts, not just the ones that can be spun a certain way. To the extent Calabrese’s claims "didn’t pass your smell test," I fear it may be because your sinuses are infected by Kessler’s original proclamation that Boonstra is a liar, and perhaps by other political or ideological biases as well.

*Quick note as promised: You comment early on in your post that you “don’t know of any doctor or hospital that would refuse to let a cancer patient make multiple smaller payments on a bill,” so her concerns about upfront affordability can be dismissed. (You wrote “by her, not us” but I’m assuming you meant “by us, not her.”) But if her previous plan covered a particular procedure, such as a regular schedule of bone marrow biopsies (which we’ll get into in further detail below), but it’s unclear whether her new plan will cover the same frequency of biopsies, she must either take the chance on a procedure that can cost in the high thousands or forgo it. Working out an installment plan with the provider, and the hospital, and the lab, assuming for the sake of argument that’s even as simple as you say it is, still leaves her deep in the hole. Which means this argument lacks merit with regard to demonstrating that AFP’s ad was misleading. I strongly question the assertion that we should ignore the perspective of the person paying the bills in a conversation about the affordability of those bills anyway. If she can't ignore her concerns about upfront affordability, neither can we.

While your attempt to actually address (rather than ignore, as Kessler chose to) the facts raised by Calabrese is to be commended, your blogpost is based on a series of assumptions—flawed, as I’ll demonstrate in a moment—that I think could only have been made were you taking for granted that Boonstra—er, sorry—that AFP was lying, and that therefore any additional facts from Herman Cain employee and AFP mouthpiece Dan Calabrese must also be lies. Frankly, if this reasoning were any more circular, it would come with coupons.

Flawed Assumptions about Boonstra’s Prior Coverage

You write that you assume, on the basis of Julie Boonstra’s marriage to Mark Boonstra, who is now a Michigan judge, that Boonstra’s old plan was the 2013 Blue Care Network plan for Michigan judiciary employees, or that that plan is at least a “useful upper limit estimate” for her previous plan. (Unclear why you note that he is the former chair of the Washtenaw County Republican Party, since it’s not actually relevant to her plan. Most lefty bloggers cited that fact for the purpose of undermining Boonstra’s credibility, and there isn't really any other reason to mention it. Doesn't quite sync up with your decision to treat Boonstra as a moron rather than a liar.) There isn’t a particularly strong basis for declaring the Michigan judiciary plan the upper limit of coverage she simply must have had; in fact, I don’t think you really have any well-founded basis for assuming what she was getting for her $1100/month at all; in all likelihood she would have chosen a plan that best served her own particular needs rather than those of the Michigan judiciary. Making assumptions about her plan that confirm your allegations is circular reasoning that reeks of foregone conclusions and/or bias. I think it severely undermines your fact check from the start. Particularly since Boonstra’s previous plan could not possibly have been the Michigan judiciary plan you identified, for several reasons:

a) Mark Boonstra was appointed to the Michigan Court of Appeals in March 2012, just over two years ago. Boonstra says she purchased her canceled plan shortly after being diagnosed with leukemia five years ago.

b) Even if Mark had been appointed five years ago, Julie Boonstra is actually Mark Boonstra's ex-wife, not his wife, as a number of articles about her mention. Once they were divorced, she could no longer be on his plan, which is the one you assume she was on. (At least not through him. The only way for her to have remained on that plan is through COBRA, but that doesn’t make sense either, since COBRA runs out after 36 months for former spouses. I don’t know when the divorce was, but her account suggests she’s been on her plan longer than 36 months, so it presumably would have run out by now on its own. COBRA is also not typically the best idea for people who can obtain a private plan.)

c) Even without getting into that, in the second ad you can see the letter from BCBS canceling her plan due to the so-called ACA’s new coverage requirements. These new coverage requirements don’t even apply to employer-provided plans yet, so it’s surprising you would assume her old plan was an employer-provided plan and that Kessler wouldn’t have noticed the glaring error. The many who have lost employer-provided plans up until now have lost them because of their employers' responses to Obamacare's incentives, not its coverage requirements.

d) Along similar lines, Boonstra’s 13 March 2014 letter to the Detroit News says the first thing she did when she was diagnosed with leukemia five years ago was find a “Cadillac” plan that covered 100 percent of her expensive treatments. Expensive, but it gave her peace of mind so she could focus on her health and see the specialists and doctors she needed. A person can’t just walk out and purchase an employer-provided plan—she is obviously referring to a plan on the individual insurance market. I think this error is equally glaring.

e) Her plan had no deductible and basically no co-pays for brand name drugs, she told the Detroit News. (Per Politifact: "While the cost of the plan was expensive at $1,100 per month, there were no co-pays or deductibles. Basically, her out-of-pocket expenses were nonexistent, she said." The original article appears to be behind a Detroit News paywall.) This is not true of the plan you identified, and obliterates your assumption that that plan represents a useful upper limit on her coverage. Amazing the poisonous deceptions you can see through with even a basic Internet connection, amiright?

In sum: We can’t be certain what her previous plan was, but we can be certain it was not the one you identified, demolishing an assumption central to your post that a slightly more detailed look would have prevented and undermining your fact check before it gets off the ground.

Continuing on to Calabrese’s contested facts:

1) “Given that [Boonstra’s] new 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,” as Calabrese did by observing that long-term care and nursing care are not covered by her new plan.

Simply googling acute long-term care ought to sufficiently demonstrate why we should not "fully expect [her new plan] to be able to cover whatever she needed if she went through the same 2.5 year ordeal again (God forbid)" just because her new plan covers acute long-term care. Acute long-term care means in an acute long-term care facility, not at home, which is obviously preferable, and which is what her previous predicament called for. Acute long-term care also tends to be somewhere in the neighborhood of 2.5 to 5 weeks, not 2.5 years, depending on the severity of the medical condition. It's basically one step below the ICU.

Which leaves us with home health care, which you similarly misunderstand. Home health care is basically part-time skilled nursing care in the home. If you need more than 8 hours per day or 35 hours per week, you're “shit out of luck,” as you put it. And we (and she) have no idea what exactly her new BCBSM plan would actually cover or how long it would cover home health care for. All we know is that her previous plan covered her 2.5 years of bedrest. But since you've already decided she has no credibility and that AFP is a bunch of liars, you assume she has no idea what she's talking about and no cause for concern.

Take a closer look at the statement of benefits you linked to and you can see that for home health care, she's still paying 20% coinsurance, and if she has to go out of network that's entirely on her. For skilled nursing care, she's a) limited to 45 days per year (i.e., there’s no long-term nursing care and she’s "got a big problem" if she's on bed rest for 2.5 years again), b) the care doesn't take place at her home, but at a BCBSM-approved facility, c) BCBSM will cover her only after she reaches her deductible, plus a $500 copay, and d) she still has to shoulder 20% of the cost herself (coinsurance).

Thus, your assertion that it is very misleading for Boonstra to imply she'd be in a pickle if she were, God forbid, ever to have to return to bed rest for another 2.5 years, since her new plan covers home health care and acute long-term care, is itself misleading. Scratch that: not misleading, just plain wrong. Her new plan only partially covers home health care, unlike her old plan if we are to take her at her word. And acute long-term care—which 1) is overkill if a doctor is prescribing bed rest, 2) takes place in an acute long-term care facility rather than the comfort of home, 3) in which a patient typically stays for 2.5 weeks(!) not 2.5 years, and 4) which no insurance company would cover if the appropriate treatment is merely bed rest with some form of nursing care—is more or less irrelevant. The fact is, her new plan will not cover circumstances she has faced before as satisfactorily as those circumstances were covered by her previous plan—the one she was kicked off of by Obamacare. This is true even under the upper limit you (baselessly) assume for her previous coverage.

2) “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).”

I don’t see any explicit mention of glaucoma in the statement of benefits either, but I assume Calabrese is referring to the fact that Boonstra’s new plan does not cover vision. This was less than clear on his part. You can have this one, since he’s almost certainly wrong about glaucoma treatment not being covered.

However, your reasoning that “it is hard to believe that they would incentivize getting glaucoma screening for HMO customers, but entirely fail to treat PPO customers for glaucoma,” is flawed. You fail to realize or mention that that specific HMO is BCN Advantage, which is Blue Care Network’s Medicare Advantage plan. Just because BCBS incentivizes Medicare patients (with a coupon booklet, yippee…), who are at higher risk of glaucoma, to get a glaucoma screening covered by Medicare at no cost to Blue Cross, it doesn't logically follow as you claim that Blue Cross would pay for glaucoma treatment for non-Medicare customers out of its own pocket. If something was lost in translation and AFP/Calabrese meant glaucoma screening rather than treatment, other Blue Cross plans don’t cover glaucoma screening (see this woman’s experience, for example), notwithstanding their incentivizing Medicare patients to get one. If that's what they meant, they might have been correct, since it’s hard to tell whether BCBSM considers it covered preventive care – it certainly doesn’t count as a free preventive screening as far as Obamacare is concerned, though. If Boonstra's plan is like the aforementioned woman’s plan, it covers what is essentially a routine eye exam, i.e., the chart with the big E on top, not a comprehensive eye exam that would detect glaucoma.

3) Boonstra's prescription drugs are covered, and even if they weren’t, she can get a year’s supply of generic Loratadine for $17, “so this appears to be yet another example of AFP being incredibly misleading, coupling an anecdote about a very typical pharmacy/prescription mishap with a cancer patient's worries about losing life-saving cancer drugs. This is all obviously intended to create the impression that Boonstra's 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 (you can see in her statement of benefits that chemotherapy is covered), 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 deception. 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.”

It is important to note here that due to the disruption of her plan and her inability to purchase insurance via the dysfunctional website or any of the dysfunctional workarounds established by the administration, despite being proactive and trying for months to line up a replacement, she was still scrambling to line up new insurance days before her prior plan lapsed. Boonstra was put in an untenable (read: unaffordable) situation by Obamacare, which kicked her off her insurance plan, an insurance plan which worked for her, without a viable, functional exchange, essentially leaving her stranded. You can listen to her interview with Sean Hannity if you care to hear the specifics of her predicament in her own words. Or you can read her 13 March 2014 letter to the Detroit News, “Dexter cancer victim: I'm not lying about Obamacare.” She has quite literally been faced with the possibility that her medication and tests would not be covered and she would have to pay for it herself upfront, with or without any guarantee of reimbursement. All in line with both her ads.

You claim it’s no problem, she can just work out a plan with the hospital or the drug provider to pay any upfront out-of-pocket costs. Number one, you don’t know that. Number two, if she can’t, and has to pay a great deal of her out of pocket costs early, in the first few months of the year, she may have to pass on a test one month because she doesn't have the money up front. Under her old plan, she had the security of budgeting $1100 a month, no more, no less. Having to pay $6350 in the first month, for example, means having to come up with ~$4700 more than she had to before ($6350 minus the $1100 she would have budgeted under her old plan minus the $571 to account for her lower monthly premiums). Second month, ~$3550 more. Third, ~$2550 more. Fourth, ~$1350 more. I think you'd agree these aren't exactly pittances. I imagine for most single moms like Boonstra having to come up with that, even potentially, is accurately described as “unaffordable,” zero Pinnochios. Potentially having to pass on a test or prescription one month because she will be paying much of the out of pocket costs in the first few months of the year and won’t have the money for that test or prescription is not fair, and calling her or her defenders liars for referring to that situation as unaffordable for her is low.

Boonstra said that, costs aside, she was still concerned about the delay while transitioning from plans during the ACA going into effect. In the Dexter Leader, Boonstra stated that she faced a period of not being covered and going without the medications that are necessary to her survival due to technical issues with the ACA website and delays in reaching an ACA representative over the phone. Your comment above that “this is all obviously intended to create the impression that Boonstra's new health insurance is going to stick her with paying the full amount for incredibly expensive cancer-treatment drugs, or else she will die” is actually accurate. She was faced with this exact situation, due to Obamacare, because of the upfront out-of-pocket costs. You meant to imply this was a false impression, so in that respect you’re inaccurate, but the impression itself is accurate. By this point in the year, she may be alright. For the first several months of next year, and I suppose every year, she faces the same issue once again regarding upfront costs (though she will at least have a better sense of what's covered after she's paid those costs) and be deprived the peace of mind and ability to budget she had under her old plan. Kessler has perhaps never had to worry about such mundane concerns as these, and certainly hasn't had to recently, possibly explaining his inability to understand why this predicament is unaffordable.

Counter to Glenn Kessler’s claims that you can’t claim a plan is “unaffordable” when over the course of the year it will provide you with substantial savings, her plan will not necessarily provide her with the substantial claims he envisions, forces her to have to forgo care, and of course a plan can be unaffordable if in the short-term you face costs that are unaffordable even if in the long-term it may provide you with savings. This is not a mere “annoyance,” as Kessler puts it, or pain in the ass, as you put it.

No doubt her chemotherapy is covered, but your reiterated argument that the absolute maximum she can possibly pay for her chemotherapy drugs ($350), when added to her monthly premium ($571), comes to (~$900), still less than her previous monthly premium ($1100) is, first of all, silly, as if her chemo drugs are the only costs she has to worry about, and we know they aren’t. Secondly, it is based on flawed assumptions about her previous plan and its deductible: you say the deductible was $400; in fact, she had no deductible. Thirdly, her plan also says the maximum copay is actually $300, depending on whether she’s using preferred or non-preferred, which bumps you up to $450, which puts her at just about where her old premium was. But we'll generously go along with you, assume she’s using a preferred provider and therefore has a maximum copay of $200. But this copay applies to each drug each month—copayments being payments made typically at the time the patient receives the service (click the Prescriptions tab here). If she has to fill four drugs, assuming the fifth drug is Loratadine (since I'm tired and don't feel like checking whether it was five chemo drugs + Loratadine or four chemo drugs + Loratadine) with a $200 copay, that puts her at $150, plus $800 for that month. Plus her premium, which puts her several hundred dollars over her previous monthly premium, contrary to your calculation. (I believe this is a significant error on your part.) Given the cost of chemo drugs (and the supply crisis of generic chemo drugs), this can't be dismissed as an overestimate. And again, that’s not even the maximum hit for all medical expenses she may incur, just drugs. Under her old plan, she didn’t have to worry about that. Under her new plan, she appears to remain significantly exposed.

4) “Given that we now know her previous, super-awesome plan cost her a maximum of ~$18,900/year after premiums ($1100/month, according to Boonstra), out-of-pocket maximums ($1500 in-network, $3000 out-of-network, both not including deductibles), and deductibles ($400 in-network, $800 out-of-network) are all added up, 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. But that’s only assuming the worst, and only because she had an insanely awesome plan before (and only assuming I’m looking at the correct plan).”

Recall: We “know” nothing about her previous, super-awesome plan that you’ve written here aside from that her premiums were ~$18,900 a year. Everything else you’ve assumed, and demonstrably incorrectly. You have to subtract at least $1200 (since you're wrong about the deductibles), and probably another $4500 (since you're probably wrong about the OOP maximums) given her comment that her previous Cadillac plan essentially covered all expenses. That puts you at about $13,200, compared to $21,468. (Willing to take your word on the latter number.) But herein, even by your own original numbers, you demolish your post all by yourself, without any help from me even. And with my help, correcting your calculations, even moreso. This pretty much moots your and Kessler’s entire effort! (Though both were already mooted by the unaffordability of the immediate potential upfront costs.) At best, by your math, Kessler should have awarded Boonstra’s original ad one Pinnochio if you agree with him that she implied she lost her doctor, which is debatable; a reasonable viewer (i.e., one not specifically looking to discredit her ad) would likely conclude she lost her insurance plan but kept her doctor, in light of her twice mentioning she lost her insurance plan without also mentioning she lost her doctor. For the record, by the way, she kept her specialist only because she intentionally chose a plan that covered that specialist to replace the plan Obamacare kicked her off of.

You go on here to score AFP for not educating Boonstra about Obamacare's "huge money/life-savers," namely narrow networks and free bone marrow biopsies, which is particularly amusing in light of your own need for education in that regard, given several serious errors you make. I suppose shame on the AFP for not educating you about them either. So allow me:

“But there is no reason to assume the worst,” you write, because the ACA requires insurance companies to provide free preventive care (including free bone marrow biopsies). Wrong wrong wrong wrong wrong wrong wrong. Here is the list of preventive services insurance companies must cover. (That link goes to, so no guarantees it will remain functional by the time you get to it.) Surprisingly easy to track down if you have an Internet connection. You’re basically saying she’ll do just fine, because the ACA covers flu shots and some other screening services. Anything not on this list—cholesterol, diabetes, obesity, STD, HIV, and the other screenings listed there, which are probably relatively low on the list of most cancer patients' concerns—is not free. This is another significant error on your part.

“This is similar for emergency care,” you write, i.e., no reason to expect the worst. The NewYork Times begs to differ:
Some states limit the amount that out-of-network hospitals and doctors can charge above what insurance has covered, experts said, but there are no federal curbs on balance billing. The new health care law, does, however, offer some protections for people who need emergency care: insurers cannot charge more for co-payments and co-insurance for emergency services than they would charge when you use in-network providers. Insurers must also pay out-of-network emergency providers according to a standard schedule, in hopes of lessening the likelihood that patients will be left with enormous bills. Still, there’s nothing in the law that stops health care providers from billing consumers for the balance, which is what often happens  — and exactly what the D’Andrea family experienced. “This is not an issue that the Affordable Care Act fixes,” said Timothy S. Jost, a professor at the Washington and Lee University School of Law and expert on health care laws. “It is conceivable that the problem gets worse for some people if the Affordable Care Act encourages narrower networks, which some people think it might do.”
But perhaps the most serious and glaring errors you make here are with regard to the bone marrow biopsies: First off, the free bone marrow biopsies are for people over 50, as you even note later. Boonstra is 49, as any number of articles have mentioned. Second, it’s actually a free biops-- you only get one per year, not the regular schedule of them that Boonstra had set up. Third, the free biopsies are for preventive care related to COLORECTAL CANCER, as a more careful (less careless?) reading of your own link shows (right there at the top of page 7 of the PDF), as mandated by law; in arguing that if BCBS covers a preventive bone marrow biopsy for colorectal cancer screening as mandated by law, it surely also covers them at least partially for cancer patients, you are succumbing to the same logical flaw as above with regard to glaucoma screening. Fourth, the regular schedule of biopsies that Boonstra had made with her doctor to monitor for a relapse of her leukemia would not, by any stretch of the imagination, be free under this provision of Obamacare, nor is there any reason to assume, even if one could assume that they are partially covered for cancer patients, that all the biopsies she used to get will be covered under her new plan. The government’s forcing Boonstra to bend over and receive what it considers good for her is not what's meant here by preventive colorectal care.

You also fail to understand the nature of the out-of-pocket “maximums.” See, for example, this story from the LATimes:
As a Blue Cross Blue Shield representative patiently explained to me, however, the out-of-network limit isn't really a limit. When a customer reaches that amount, the insurer will still pay only the standard out-of-network share. That's why my plan covered only 50% of the $54,755 charged by Tristate Care Flight to ferry me (by helicopter) from a car wreck in Quartzsite, Ariz., to a hospital in Phoenix. If Tristate wanted to bill me for the other half, the representative explained, it was free to do so.
The healthcare law's out-of-pocket limit suffers from the same shortcoming. Once you reach it, your insurer will cover 100% of the cost only of the essential health benefits covered by the plan, and out-of-network services are exempt (except for emergency treatments). That's a troubling thought, considering how many insurers are reducing the number of doctors and hospitals in their plans. These ‘narrow networks’ increase the chances that a doctor, therapist or clinic you'd like to use won't be subject to the annual cap.
More ominously, being treated at an in-network hospital is no guarantee that the specialists who see you there will be in your plan's network as well. If there's no emergency involved, you could be stuck paying the difference between the contracted amount and the specialist's charges, even if you've hit the out-of-pocket limit. And the difference can be staggering: In one extreme example cited by the insurance industry, an out-of-network California pathologist charged $8,100 for a tissue exam for which Medicare reimburses $128.
His story had a happy ending, but it illustrates how a person could be stuck with ridiculous bills for out-of-network services for life-saving treatments she may need for her cancer, your assurances to the contrary notwithstanding, since the “caps” on out-of-network services are not really caps. I’ve pointed this out to you before in other contexts, if memory serves, which raises the question of why I’m bothering to point it and other errors out to you in this response, the answer to which is that I’m clearly a masochist. Also that maybe other people are reading this.

I am also not sure that a 39-59 percent, or essentially 50-50, chance of reversal on appeal (that rate comes once again from your own link) constitutes "very, very high" odds for success. 80% or 90% constitutes very, very high; 50-50 is a coin toss. I know a certain fact checker at the Washington Post who might have awarded you a Pinnochio for that had he bothered to give your “very detailed look” an even slightly detailed look. But it’s AFP’s spin that’s misleading… On top of that, this link you posted notes that "the number of payment disputes for these emergency services is likely to rise" due to the shrinking networks you attributed to Obamacare.

5) Boonstra having to go through the painstaking process of getting her chemo drugs approved again is a major pain in the ass but not actually necessary, and her response to the Loratadine incident is overblown.

Given the timeline—with all the problems with and its various workarounds (as a result of which the implementation of the entire act should have been delayed until ready but wasn't, with callous disregard for those who were hurt by it), Boonstra was only finally able to purchase replacement insurance coverage days before her plan was set to expire—her "overblown" response to the Loratadine incident was nothing of the sort. If you were on meds that you had to take, that had been working for you, and that you might now have to pay an exorbitant amount out of pocket for since you're not yet sure whether your insurance will cover the specific drugs you've been on and need, in the particular amounts you need, went to the pharmacy and were told you had to pay counter to what you thought about your plan, and didn't have time to find out since you need your meds immediately and who knows how long the approval process takes, you would likely do the same. (We’ll note here also that you don’t know what meds she’s on, in what dosages, or what tier they fall into under her new plan, so you’re making presumptions here that you lack basis for making. Under her old plan she didn't have to worry about that, as her plan covered brand-name drugs without co-pays.) You would also likely take issue with anyone who told you you were acting irrationally by doing so. It’s not just a major pain in the ass. It’s having to budget for those expenses yourself in the meantime, out of your own pocket. There’s a word for that in the English language as pertains to people who are not as liquid as you or I may be and who "do not have $5,000 or $6,000 dollars in the bank," as she has claimed. That word: "unaffordable."

6) “Bone marrow biopsies are not only covered – they’re FREE” thanks to Obamacare, and “the fact is she did not have to cut back on her biopsies.” Boonstra has cut back on them out of ignorance, but at least you are graciously willing to concede the possibility AFP/Calabrese may not have known this either and are not intentionally screwing her over on this particular aspect of her care.

I covered the particulars of this above. Not only are unlimited bone marrow biopsies not free for anyone (you get one a year (not a regular schedule of them) if you’re over 50 (which Boonstra is not) for colorectal cancer prevention (Boonstra is already fighting, not preventing, leukemia, not colorectal cancer), there is no reason to assume, as you do here, that just because Obamacare mandates a free preventive colorectal cancer screening, it follows logically that out of the goodness of their hearts, BCBS will cover the same regular schedule of bone marrow biopsies Boonstra had worked out previously with her specialist under her old plan. You claim “the fact is she did not have to cut back on her biopsies,” but the actual fact is that you have no idea what bone marrow biopsies her new plan will cover. Until she finds out, she’s potentially on the hook for those costs, which for each biopsy are in the thousands (physician fees, lab fees, etc). How gracious of you to point out that if this is an issue for her, she can no doubt work out a plan with her provider to pay in installments over time. Going forth with a previous course of action simply because one "cannot imagine" one's previous medical regimen will not be covered is rightly described as assuming significant financial risk upon oneself. Just because you've been making foolish assumptions doesn't mean Boonstra should…

As an aside, you claim that every plan, Democrat or Republican, would result in similar losers to Boonstra. Under GOP plans, a lot of people would likely be dropped from their current plans. But I don't know of any Republican proposals that would forcibly kick people off their current insurance without adequate time to identify and evaluate alternative coverage as happened with Obamacare. They would be able to purchase replacement plans they like more cheaply, not that bureaucrats like more expensively. Many proposals are also being reexamined in light of Obama's lies to minimize the disruption. Oh yeah—the GOP has also not attempted to hoodwink the public about their proposals, and one can read their proposals end to end and come to an informed decision. There is only one plan that passed (if you can call it that) only because the American people were lied to about it (and continue to be lied to about it) over and over and that forcibly kicked people off their insurance plans despite those false assurances to the contrary, because that plan introduced new mandates for coverage, and because the administration executing that plan (frequently less than faithfully and less than legally, in which respect its execution follows in the spirit of its passage) chose to take a particularly narrow definition of the “grandfather” clause, kicking multitudes off plans they were happy with, and failed to delay this disruption until a functional marketplace had been established. With more on the way. There was no need to break a few million Boonstras in order to make this particular Obamelet. (Particularly one that many people are finding doesn’t actually get them access to care, i.e., a product that doesn’t work and/or that raises their expenses, significantly.) And it was reckless and inexcusable to break those few million Boonstras without a functional system in place for them to purchase replacement insurance, putting those few million Boonstras in a position in which they were literally scrambling (no pun intended) to obtain some form of insurance to meet their needs, even if that meant having to cut back on their own health care in the meantime. That alone is an untenable, unaffordable position, and that alone would render your entire blogpost moot and Kessler’s multiple fact checks incorrect on their face, even if it weren’t possible to pull his and your reasoning apart on their own terms, as I’ve done above.

The accusations you level against AFP throughout this post are so scathing and sanctimonious it seemed fitting to go back and read your conclusion in light of the errors in your own post. I recommend you go back and see if those accusations—intentional misinformation campaign, using Boonstra as a pawn (which you do here repeatedly, using her as a cudgel with which to beat those who gave voice to her grievances and contributing to the effort to shut her up and scare away others), causing her grief while tarnishing their own credibility, diminishing her sincere complaints and making them seem less significant—can’t legitimately be turned around on you now that your errors, egregiously flawed assumptions, and knowledge gaps have been pointed out and the supposedly malicious, deceptive AFP and Calabrese and the confused, feebleminded Boonstra have been shown to be correct throughout, with one or two exceptions that are at best sidepoints. You have been shown to be incorrect regarding the one claim that matters, namely that Boonstra’s new plan is not, as Kessler claims, more affordable than her old plan: because of the upfront costs she cannot afford (both due to the deductible and due to the uncertainty of coverage) and the tests or medications she must forgo or change, because she does not necessarily come out ahead even in the long-term, because she is not similarly covered for circumstances she has already experienced (2.5 years of bed rest), and because of her increased exposure to financial risk.

In light of this, who has major soul searching to do? Who has “taken a legitimately bad story and stained it with poisonous deception so transparent that anyone with an internet connection can see through it”? The answer is not AFP. (This last criticism is especially rich in light of my frequent use of your own links and the errors you make that a quick googling would have avoided.) I wouldn’t refer to your post as a “poisonous deception,” since I think these are mostly errors rather than the intentional deception you accuse your political/ideological opponents of perpetrating, but they were arrived at due to bias toward a particular outcome. And while I don't think your errors deceitful, some of your accusations are, particularly this fantasy that AFP is deliberately withholding information from Boonstra that is preventing her from seeking treatment to which she is entitled. As above, I think she would probably take umbrage at your concern for her already fragile health in light of your accusing those who highlighted her story of subjecting her to the negativity that in actuality you, Kessler, and the lot have subjected her to unjustifiably. AFP will no doubt continue to spend energy and money trying to help those like Boonstra, and the Democrats will no doubt spend a significant amount of energy and money trying to tear her down and scare people like her from coming forward and convince the base that the Koch brothers rather than Obamacare are getting in the way of her well-being.

I think you owe Boonstra and AFP a retraction. I think you also owe Glenn Kessler an apology for exposing him as a credulous fraud. (Also Mark Robison of the Reno Gazette-Journal, who cited you by name and affiliation with the NIH but didn’t link to your blog so you may have missed it.)

I rate your blogpost Three Pinocchios.

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