The storyline seems clear enough:
A pretty 17-year-old California girl needed a liver transplant, but her insurance company, CIGNA (based right here in Philadelphia), said they would not pay for it.
The public caught wind of this, and the public protested. As a group of nurses and other citizens rallied outside CIGNA's office in Glendale, California, on December 20, the company decided to reverse its decision.
But it was too little, too late.
Nataline Sarkisyan died just a few hours after CIGNA's reversal, after having spent weeks of her short life in a vegetative state.
The question is clear -- why should some bureaucrat hundreds of miles away with no medical training whatsoever determine whether people get badly-needed medical treatment rather than families and doctors based on the best medical evidence? Opponents of universal healthcare say that it would simply be a tradeoff -- we would simply have the government making these decisions rather than corporations. But a lot of the time, the argument confuses two different things -- the fact that we have finite resources with the question of who gets to decide life and death matters for people.
We all agree that there is only a finite amount of resources to go around. But there are two points to make in response to that. The first is that we could have a lot more resources just by getting out of Iraq and by cracking down on tax cheats who do not pay their taxes (costs about $300 billion per year) along with getting rid of the Bush tax cuts. The second, which the Sarkisyan case brings up, is the fact that families and doctors should be allocating these finite resources, not some bureaucrat in some far-off office looking at nothing but charts and figures.
But there is more to it than that. First of all, this post from Blogger News Network details the facts of the case as presented. Nataline had been in the hospital following complications from a successful bone marrow transplant.
UCLA doctors put her on a list for a liver transplant Dec. 6 and a liver became available four days later, the family said. Her doctors told Cigna in a letter that patients in similar situations had a 65% chance of living six months if they received a liver transplant.
Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin, Madison, says transplantation is not an option for leukemia patients because the immunosuppressant drugs used in such procedures tend to spur the growth of cancer cells (he was not commenting specifically on Nataline’s case).
But this, apparently, is a matter for medical debate, given the fact that qualified medical professionals at different institutions disagree on the viability of the treatment in question. But the author of the piece and the doctor at Wisconsin were not directly involved in the case, whereas the UCLA doctors were. We should, therefore, take the word of the doctors who were working on the specific case as opposed to people who are simply commenting in general. Doctors have a medical duty to do everything that they can to save peoples' lives, including treatments of this nature. When something of this nature is a matter of medical debate, then it should be up to the doctors and the family to make these sorts of medical decisions, rather than some insurance bureaucrat in some far-off office with no medical training whatsoever.
THIS article goes into all the complications of having acute liver failure. Did this girl have problems with toxins from the damage liver making her brain swell, or causing bleeding? Did the doctors use an artificial liver to clear the toxins? What was the chance of her own liver repairing itself? Was her bone marrow working well enough to risk major surgery? Was the new bone marrow working enough to prevent bleeding and infections from the stress of major surgery? And would the medicines to keep her new liver alive lead to her leukemia coming back?
Even Reyes, the author of this piece, disagrees with this link; after all, the question is not whether the patient should have been approved of a liver transplant, but who should decide on these things. The fact of the matter is that she was already approved. And as for the questions raised, once again, the UCLA doctors and the family knew the answers to these questions and made their informed choice. Reyes and other such armchair quarterbacks do not.
But then, Reyes goes on to argue that universal government-run healthcare would lead to rationing:
And Dr Michael Dixon, chairman of the NHS Alliance, which represents NHS trusts, added: "Rationing is the great unspoken reality.
"The only people who refuse to mention the ‘r-word’ are the media and the politicians, who continue to want to promise everything for everyone in order to win elections."
But the rationing in question involves elective treatments, not the kind of emergency treatments in question here. She concludes:
Actually, I do support universal health care via private insurance companies, but mainly because it is easier to argue with them than with a government clerk, and also because I’ve worked as a doctor in Federally run hospitals. Any activist who touts Federally run health care as the answer needs to spend some time looking at these facilities before they point fingers at insurance companies.
But this is simply anecdotal information that is not based on hard facts. And the hard facts are that lifespans in countries that have universal healthcare are, for all the r-words thrown around by opponents, longer than they are here in this country. This is simply a subjective call that means nothing. Why not let the American people decide?
That is the genius of John Edwards' healthcare plan -- he would set up the government as a competitor with the private companies, and then the American public would decide. He has driven the debate on this issue to the point that the other two main candidates on our side have both adopted something similar. For every person like Nataline, there is another who is totally happy with their current healthcare plan.
And one commentor hits the nail on the head:
Please explain—in detail, not using vague platitudes—how "universal health care via private insurance companies" would A) Cover every single citizen, B) Cover people without enough money to buy a policy, C) Cover ill people or people with a pre-existing condition, D) Still deliver an acceptable return on investment and fat salaries for the executives at the private insurance companies.
These are totally fair questions that opponents of universal healthcare have to answer. Corporations have to make decisions based on what their best financial interests would be. That is fine; that is how our system works. But the problem is that they have special rights to steal our money and make exhorbant profits and let their CEO's fly all over the world in jet planes while many more people like Nataline are suffering. Human life should not be for sale.
Matthew Holt raises some more arguments about the Sarkisyan case.
First of all, Holt points to this Forbes article which argues that UCLA could have performed the operation without getting the operation approved.
The mysterious part of the narrative is whether a liver was truly ready to be transplanted. If there was a liver, why was it held up? It's not enough for the insurer to deny coverage. The doctors and the hospital--especially a nonprofit institution like UCLA--must decline to work for free.
"There have been occasions where UCLA has performed a transplant without compensation," says Roxanne Moster, a spokeswoman for the hospital. She says, cryptically: "The physicians at UCLA Medical Center base decisions on the medical condition of the patient." She also mentions that money is an issue with transplant patients because even if UCLA pays for the procedure, there is a lifetime of expensive aftercare.
Cigna's medical director Jeffrey Kang, a physician who used to be a high-ranking official with the Centers for Medicare & Medicaid Services, says there is no way that Cigna can stop doctors from performing a liver transplant. A national organization called the United Network for Organ Sharing manages the waiting lists. One of UNOS' principles is that patients should get transplants regardless of their financial means. "Some people have said we denied a liver," Kang says. "But the reality is we only denied paying for it."
So, what this argument boils down to is that the family is going after the wrong target. But the problem with that argument is that if UCLA were to perform operations for free without being paid, at some point, they would have to close their doors. Their people have to make a living somehow; they have bills to pay and mouths to feed at some point. Cigna has the money; they have record profits, while if UCLA were to approve every last request for free care, they would become broke.
Then, Holt argues that if Edwards' plan was approved and was signed into law, it would result in more, not less Nataline cases:
Meaning that if Edwards' ideas about health care are adopted and become law there may well be more people being denied last-chance, possibly life-saving operations than there are now.
All health systems and all societies everywhere somehow ration what’s available to patients. Otherwise we’d all have full time nursing care every time we get a cold. However, compared to other countries the American health system has gotten particularly out of whack by delivering unnecessary, expensive and futile care, especially at the end of life.
This is bizarre to say the least. First of all, most other countries in the world have the kind of universal healthcare system that we are debating about right now; therefore, if universal healthcare systems are better at rationing care than we are, then we should go for it. Edwards' plan is similar to plans that most other countries around the world have, so Holt's arguments are confusing to say the least -- should we have universal healthcare so that we can ration resources intelligently, or should we not have it because it is just a bunch of pandering on election year?
The question is, who gets to decide what is "unnecessary," "expensive," or "futile?" My answer, along with all advocates of universal healthcare, is that families and doctors should determine that, not some far-off bureaucrat in some office hundreds of miles away. The way the system should work is that if a doctor determines that some sort of therapy is wasteful and unnecessary, then that doctor should be able to communicate that with the family. Doctors should present options to the family and the family should be able to make an informed choice.
Holt then launches into Republican talking points about lawsuit abuse:
To some extent, this state of affairs is the result of the work that trial lawyers - like Edwards - have done on behalf of grieving families like the Sarkisyans. It's been an effective cudgel but not particularly good medicine. And it's been going since the early 1990s when another insurer, HealthNet, had a multi-million dollar judgment against it for denying payment for a bone-marrow transplant for a woman with end-stage breast cancer. Ten years, billions of dollars, and thousands of literally agonizing procedures later, the clinical trial results finally arrived. The procedure didn’t work and did more harm than good.
But the actual NYT article, from his own link, shows that HealthNet lost the case because they violated the terms of their own contract. The problem that we are facing is that we are dealing with health insurers who routinely deny coverage in breach of their own contracts as opposed to fulfilling their contractual obligations to pay for claims. Even if the procedure doesn't work as Holt claims, it is better to err on the side of making every possible effort to save peoples' lives than it is to err on the side of trying to determine whose lives are worth saving more than others.
Clearly no one trusts health insurers to make these decisions. But the process that Cigna, (and HealthNet), went through is defensible, and to some extent duplicates what happens in other countries. For single-payer (or any health system) to work and work well, someone somewhere has to say, "This is a justifiable procedure. That's literally a waste of money that could be better spent somewhere else." Any rational universal health care system is going to have to confront this problem, even while it solves many others that the current US system causes, such as the financial catastrophe visited on those who are uninsured and get very sick.
We agree with that, but once again, who gets to decide what is justifiable, and what is a waste of money? There is an element in the type of thinking that is espoused by Republicans that is more akin to anti-abortion activism or colonialism or the defense of perpetual warfare in Iraq than there is with any legitimate concern for healthcare. Let's just use Iraq as an example -- the Republican way is to say, "Let me help you." The Democratic way is to say, "I will let you."
The difference is that the first mentality is more akin to the White Man's Burden of the Civilization of All Aboriginal Races. Colonialists justified the exploitation of African countries as needed to help civilize the native tribes. Supporters of perpetual warfare in Iraq justify the occupation as needed to help a poor backward Iraqi government. Supporters of forced preganacy say that they only want to help women to see that their fetus is really a living, breathing human being.
The difference between us and them is that in all these instances, people do not need this "help" in order to function. We did not need the "help" of the British in order to form our own government. The natives did not need the "help" of the missionary societies to thrive for thousands of years before they came. Women do not need our "help" in order to make their own decisions about whether to continue their pregnancies or not. The Iraqi government does not need our "help" in order to create its own society. And people and families who are confronted with life-threatening illnesses do not need the "help" of some corporate bureaucrat in some far-off office hundreds of miles away to make informed choices with the help of their doctors.
Holt can engage in ad homenims against Edwards all he wants:
So why did Edwards bring up this debatable case? I guess it’s just that he felt that he'd get a quick political score based on a dramatic case that fits into his anti-insurer mantra. But it doesn’t obviate the main issue which is that at some point it’s humane for both the patient and the society for someone to say, "no."
But it should be the job of the doctor to say, "no." There already are fair and adequate safeguards against doctors who make decisions that are not in the best interest in the patient -- people can take doctors who routinely make medical decisions that harm patients to court and win millions of dollars in malpractice awards.
Even if the decision to go ahead with the transplant was borderline, doctors make these kinds of decisions all the time. And these were some of the best doctors in the country.
Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute in Dallas, said the operation that UCLA wanted to perform was a "very high-risk transplant" and "generally speaking, it is on the margins."
But Klintmalm said he would consider performing the same operation on a 17-year-old and believes the UCLA doctors are among the best in the world.
"The UCLA team is not a cowboy team," he said. "It's a team where they have some of the soundest minds in the industry who deliver judgment on appropriateness virtually every day."
Again, this is all the more reason why these sorts of decisions should be made by families and doctors. However, Dgrishka1 argues:
Here's an extreme hypothetical. Suppose a licensed physician recommends a surgery that will cost $500,000. The surgery is, in fact, medically appropriate. However, if the surgery is performed your life expectancy will increase by only 6 months. Under that secenario, I think, it would be legitimate to at least consider whether or not the third-party payor ought to reimburse you for the operation. (There are good arguments on either side, to be sure, and I am not necessarily advocating a particular result. What I am suggesting is that in situations like that, the payor, whomsoever it will be, will indeed have to decide whether or not the treament is not only "medically" appropriate, but also "economically" appropriate).
My point is it is simply disingenuous to suggest that with a move from private insurance to a public insurance all problems of payment and resource allocation will dissipate.
True. But on the other hand, as I mentioned above, we can bring a lot more resources into the system simply by ending the Iraq occupation as well as cracking down on tax cheats and ending the tax cuts for the rich that Bush passed. And in addition, we can free up even more money by creating a culture of preventitive care, where people are encouraged to prevent medical problems from happening in the first place. And in most universal healthcare countries, that is what people actually do -- they take responsibility for their own mental, physical, and emotional health rather than wait to call the doctor until it is too late.
And even if we ultimately have to ration healthcare in some way, it is better that the government, which acts in the best interests of the taxpayers, make these sorts of decisions than some corporation, which only exists to make profits. At least we have some sort of role in determining what is and isn't medically appropriate rather than have it determined in some corporate boardroom by people answerable to nobody.