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Don't be fooled by another 'Obamacare horror story'

The assertion that a woman with lupus was penalized by health care reform is misleading at best

Published: February 14, 2014 05:00 PM

Here's another Affordable Care Act horror story that's, well, too bad to be true. It’s centers on the plight of a woman from Lawrenceburg, Tenn. whose $57-a-month plan was canceled because it didn’t meet the standards of the new law, thus "forcing" her into a $373-a-month Platinum plan purchased through

The woman, Emilie Lamb, 39, was so outraged that she told her story in this video from Americans for Prosperity and again in this op-ed from the New York Post. And she was a guest of her Congresswoman, Marsha Blackburn, at the State of the Union Address last month. (Blackburn’s office was kind enough to pass along to Lamb my request to speak to her, but I never heard from her.)

Lamb suffers from lupus, a chronic inflammatory autoimmune illness that requires lifelong monitoring and treatment. Her old plan, she wrote,“was perfect for someone with my unique medical condition and limited financial means.” But the experts I spoke with say Lamb is lucky she didn’t land in bankruptcy court before her old health plan was consigned to well-deserved oblivion. Here’s why.

Her old health plan, CoverTN, may have been a well-intentioned effort by the state of Tennesee to provide minimal coverage for lower-income working people. But the most it would pay out for health care in a single year was $25,000. That’s barely enough for an uncomplicated pregnancy, and totally inadequate for a serious, unpredictable illness such as lupus that can require expensive treatments.

“Lupus is a highly variable disease,” Gary Gilkeson, M.D., a professor of medicine and lupus specialist at the Medical University of South Carolina, said. “There certainly are patients that do well on low-cost generic medications, but about 50 or 60 percent will end up needing immunosuppressants.” If lower-cost varieties don’t work, he said, “they go on to the biologics like Benlysta, which is around $50,000 a year, or Rituxan, which is about $60,000 a year.”

In addition, having lupus greatly increases a person’s risk of developing cancer, kidney failure, or heart disease, all of which can have six-figure treatment costs—well above the $25,000 limit of Lamb's old plan. Luckily, Lamb hasn't yet needed any of these expensive drugs or treatments. But there's a very good chance that she will.

Under her old plan, they would not have been covered. Under her new plan, they will be. I used’s window-shopping feature to identify what she purchased: a Platinum plan with a $1,500 out-of-pocket limit. (Here’s the Summary of Benefits and Coverage for it.) There is no deductible, 25 percent coinsurance for pretty much all services, and, most critically, no upper limit on what the plan will pay out for medical care. So if she ever has a complication of her disease, or needs one of those expensive drugs, the most she’ll have to pay out of pocket in a year is $1,500. The insurance company will pick up the rest of the tab, no matter how costly.

In other words, she now has real health insurance, not junk. The only "horror story" here was the insurance she used to have.

And remember, before the new health law went into effect, having a serious pre-existing condition such as lupus would have made it impossible for Lamb to be accepted for private health insurance at any price. But when she went to buy her new plan, she wasn’t asked a single question about her health history, because it is now officially a non-issue.

Got a question for our health insurance expert? Ask it here; be sure to include the state you live in. And if you can't get enough health insurance news here, follow me on Twitter @NancyMetcalf.

We're providing regular coverage of the new health care law. To get health insurance advice tailored to your situation, use our Health Law Helper, below.

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