We have shown (Physical Review Letters, 90, 228101 (2003)) that the thermal fluctuations of red blood cells can be accounted for by a model of a nearly-free, but confined bilayer membrane with a finite tension; both the confinement and tension arise from the coupling of the membrane with the cytoskeleton. Recently, we have shown that these relatively gentle effects of the cytoskeleton-membrane couplings on the membrane fluctuations are due to the dilute nature of the coupling molecules. To quantify this, we predict the fluctuation amplitude for a microscopic model of the inhomogeneous coupling of a fluid membrane and a fixed cytoskeleton. We find that there is indeed, an effective surface tension and confinement of such a membrane, in accord with our phenomenological model, and relate these quantities to the strength and periodicity of the microscopic coupling. Finally we address the role of ATP activity on the cytoskeleton-driven fluctuations and the equilibrium shape of the cell. We examine in detail the role of spectrin disconnections as the main ATP-activated network defects on the global cell shape and membrane fluctuations. Lastly, we relate cytoskeleton defects to membrane function.