The Luis Lang story – an update and my own thoughts

Last week, Ann Doss Helms wrote an article for the Charlotte Observer about Luis Lang, a SC man with diabetes who will go blind if he doesn’t get eye surgery in the near future.  In a nutshell, Luis Lang is a Republican who opted to ignore the ACA’s individual mandate in 2014, and he also let the second open enrollment period go by without signing up for coverage.  It was only in February – after open enrollment had ended for 2015 – that he tried to get health insurance.  And that was prompted by a serious health crisis:  a series of strokes and diabetic retinopathy.  He needs surgery to save his vision, and the estimated cost is somewhere between $15,000 and $30,000.

Luis Lang has already run through his savings, has no equity in his home, and his wife doesn’t work.  His vehicle was repossessed and he only got it back thanks to the kindness of a neighbor.  He hasn’t been able to work since December because of his failing eyesight, and he didn’t have any way to pay for the surgery to save his eyes.  So he turned to GoFundMe.  A few weeks later, Helms’ article about Lang’s plight went viral, and the GoFundMe page started to rake in money.  As of today, he’s received over $21,000 – almost certainly enough to put him well on the road to saving his sight.

There are lots of GoFundMe pages asking for help paying medical bills, and they certainly don’t all do as well as Lang’s has.  It’s likely that one of the reasons his story went viral is that – ironically enough – in his initial interview with Helms he essentially laid the blame for his predicament squarely at the feet of President Obama and the Democrats who passed the ACA.  His wife also made herself a lightning rod for negative publicity when she said that Lang “should be at the front of the line, because he doesn’t work and because he has medical issues… we call it the Not Fair Health Care Act.”

Luis Lang currently has no income, so he would qualify for Medicaid if he lived in one of the 30 states (including DC) where Medicaid has been expanded under the ACA.  Unfortunately, he lives in South Carolina, and his state’s leadership has essentially turned their backs on low income residents, blocking Medicaid expansion for more than a year and a half now.  That decision was made entirely by the Governor and the Republican majority in the state legislature.  Obamacare called for every state to expand Medicaid.  But in 2012, the Supreme Court ruled that states couldn’t be compelled to expand Medicaid, despite the fact that the federal government would cover the entire cost of doing so, through 2017.  After that, the states’ portion will gradually increase to 10% by 2020, and will remain at that level.  Medicaid expansion is a huge financial win for the states – particularly those like SC that have a significant percentage of low-income residents (SC is ranked 42nd in terms of median household income in the US).

The Luis Lang situation has been the subject of many a blog post over the last few days. There’s been plenty of speculation as to whether or not the outpouring of support from the liberal community would help him see the ACA for what it really is:  a law designed specifically to help people like himself.

If you’re among those who have been waiting for a new update on Lang’s situation, the wait is over.  My healthinsurance.org colleague, Harold Pollack, interviewed Luis Lang and you can read or listen to the whole thing for some insight into his thoughts on the whole situation.

For some additional thoughts on the story, another healthinsurance.org colleague, Charles Gaba, posted a response to Pollack’s interview with Luis Lang.  I highly recommend reading or listening to Lang’s conversation with Pollack, and reading Gaba’s follow-up commentary.

For those of us who live and breathe healthcare reform and the ACA, the Luis Lang interview is an excellent look into how the law is perceived, particularly by those who are resistant to it based on their politics and their information sources. Rush Limbaugh probably isn’t going to be a reliable source for information about a law that was championed by a Democratic president and passed by a Democratic congress – and yet, for a lot of Americans, he is certainly a primary information source.  There is absolutely an uphill battle in terms of getting accurate information out to the people who need it the most, and Lang’s interview – more than a year and a half after the first Obamacare open enrollment period began – is testament to the fact that there’s still a long way to go.

Most of what I’d write about this situation has already been covered by others, but there were a few things about the Luis Lang interview that stood out to me:

• One of the reasons Luis Lang presents for his reluctance to enroll in subsidized coverage was the fact that subsidies get reconciled when enrollees file their income tax returns.  During open enrollment, you project your income for the coming year, and your subsidies are based on that projection.  When you file your taxes after the year has ended, the IRS looks at what you actually earned, and they calculate your subsidy based on that amount.  If the subsidy you got throughout the year was too high, you’ll owe back a portion of the overpayment (the amount you have to pay back is capped, unless you end up earning more than 400% of the poverty level and not qualifying for subsidies at all).  If the subsidy you got during the year was too low, you’ll get the additional amount refunded to you when you file your taxes.  Lang pointed out in his interview that projecting income is relatively easy for people who have steady income, but much more difficult for those of us who are self-employed and have income that fluctuates from one month to another (my husband and I have been in that situation since 2002; we love being self-employed, although accurately predicting income is certainly challenging).  But here’s the thing… the exchanges have accounted for this.  You don’t have to just sit by all year with an inaccurate income projection on the books, waiting until tax time to correct the error.  If you realize mid-year that the income you projected isn’t matching up with reality, you update the exchange with your corrected income projection, and they adjust your subsidy as needed.  You can wait until tax time if you want, but you’re not required to – that’s important for people to know if they’re hesitant to enroll because of uncertainty about their income.

• When Pollack asked Lang about his motivations for taking his story public, Luis Lang notes that “the main reason was to call awareness to the gap or as the media calls, the Affordable Healthcare Act doughnut hole.”  Just to clarify, the doughnut hole is part of Medicare Part D, and the ACA is actually getting rid of it.  Luis Lang is talking about the Medicaid coverage gap, and oh my goodness… a whole lot of us have been calling attention to it, as loudly and as often as we can, from every rooftop and blog we can find.

• Medicaid expansion was one of the cornerstones of the ACA.

• Medicaid expansion was a huge part of how the law would expand access to healthcare for as many Americans as possible, particularly those with limited resources.  Lang goes on to note that he thinks “the Affordable Healthcare and Medicaid should have been combined in one. So that way, the states … take it out of the state’s hand…” Yes.  That would have been great, and it’s how the law was written.  I can’t emphasize that enough.

• The ACA did not leave it up to the states to decide whether or not to expand Medicaid.  That was the Supreme Court’s decision.  And in the states where Medicaid still hasn’t been expanded, it’s because state leadership has refused expansion.

• That Supreme Court ruling – and subsequent rejection of Medicaid expansion by Republican state leadership – has resulted in millions of Americans remaining uninsured.  They don’t qualify for subsidies in the exchanges, since the law was written with the assumption that they’d be on Medicaid; they also don’t qualify for Medicaid because SCOTUS made Medicaid expansion optional, and 21 states still haven’t expanded coverage.

• Luis Lang has diabetes.  Prior to 2014, there is no way he’d have been able to obtain health insurance in the individual market, for any amount of money.  There were a handful of states where coverage was guaranteed issue prior to 2014, but SC wasn’t one of them; neither was Colorado – all of our clients had to go through medical underwriting prior to 2014.  The ACA changed that.  Thanks to the ACA, Luis Lang can now obtain health insurance in the individual market, although coverage is only available during open enrollment (the next one is November 1, 2015 to January 31, 2016) or during a special enrollment period triggered by a qualifying life event.  It doesn’t matter that he has diabetes – and that’s a pretty big change from the way things were before the ACA, when diabetes would always result in an application being declined.

• Attempting to self-insure is a fool’s errand, unless you’re among the wealthiest of the wealthy.  Nobody can predict when disaster might strike, and the medical bills can be shockingly large, to say the least.  Luis Lang is a 49-year-old diabetic smoker who chose to remain uninsured even in 2014 when he was able to work.  It’s not hard to see how that is likely to result in problems.  But my point about self-insuring applies even to the healthiest 30-year-olds… don’t do it.  Unless you’ve got a million dollars in liquid assets lying around and you wouldn’t mind spending it on healthcare.  But for everyone else, don’t do it.  For just about all of us, it’s a matter of when, not if, we’ll need healthcare.  And most crowdfunding attempts aren’t nearly as successful as Lang’s.

• In the original Charlotte Observer article about Luis Lang, it’s mentioned that he knew the law required him to have health insurance, but that he chose to skip it and “thought help would be available in an emergency.”  This is an incredibly common misconception.  It’s true that EMTALA requires hospital emergency rooms to evaluate everyone who comes through their doors, and to provide stabilization treatment for people with “emergency medical conditions.”  That means they can’t leave you bleeding to death in the doorway because you can’t pay for your treatment.  But all they’re required to do is stabilize you.  There is no doubt that Lang’s condition is dire, but eye surgery to fix diabetic retinopathy isn’t something that’s going to be provided in the ER to stabilize a critical patient.  If a patient has cancer, the emergency room isn’t going to provide chemotherapy.  Clearly, EMTALA is better than leaving patients to die.  But it’s not a substitute for health insurance.  President Bush once noted that “people have access to health care in America. After all, you just go to an emergency room.”  That wasn’t really true back in 2007, and it’s not really true today.  For the vast majority of healthcare needs people have – including Luis Lang’s eyesight – emergency stabilization doesn’t go very far.

I’m truly hopeful that Luis Lang’s GoFundMe success will translate to a successful eye surgery and restored vision.  And I hope that he’ll then be able to return to work and qualify for a special enrollment period to sign up for health insurance in the SC exchange (starting this year, HHS adjusted the rules so that people like Luis Lang can qualify for a special enrollment period if their income increases to at least the poverty level and makes them eligible for a subsidy in the exchange.  The new special enrollment period helps people get out of the coverage gap; otherwise, a change in income is normally not a qualifying event).  Or maybe SC will move to expand Medicaid.  There are an awful lot of non-famous people in the same situation as Luis Lang – although many of them would garner a lot more sympathy – but they don’t have money pouring in through GoFundMe.  They’re desperate for Medicaid expansion.  Hopefully lawmakers in states like SC are paying attention.