Edwards Refuses to Negotiate -- With Insurance Companies

The Los Angeles Times covers a medical case they portray as extremely complex and difficult -- one where doctors and an insurance company were forced to decide whether to provide a liver transplant to a leukemia-stricken 17 year old girl. The expensive procedure had a fair chance of extending the girl's life for at least 6 months, but there were no guarantees.

Cigna ultimately reversed their initial decision and elected to cover the procedure, but by the time the approval letter reached the family, they had taken their daughter off of life support:

Doctors treating Nataline told the family and Cigna in a letter that patients in similar situations have a 65% chance of living six months if they receive a liver transplant. Doctors had qualified Nataline for a transplant Dec. 6 and a liver became available four days later, the family said. But the transplant was not performed because Cigna had refused to approve and pay for the procedure, they said.

Cigna turned down the transplant, calling the procedure experimental because it was not supported by enough medical literature as safe or effective in such cases. The family's benefit plan does not cover experimental treatments. But this week, after receiving an appeal from the family and UCLA doctors, the company reconsidered.

Arlys Stadum, a Cigna spokeswoman, said the insurer submits all transplant requests to physicians with transplant expertise for review. Every request that is refused has been seen by at least one expert physician, she said.

In explaining the reversal, she said, "It was really just looking at how complex the decision was..."

"We are making this decision on a one-time basis, based on the unusual circumstances of this matter, although the treatment, if provided, would be outside the scope of the plan's coverage and despite lack of medical evidence regarding the effectiveness of such treatment," Garnsey wrote.

Dr. John Roberts, chief of the transplant service at UC San Francisco, said Cigna faced a difficult decision in the case, based on the facts presented by the UCLA team.

Roberts said his center generally will not accept a patient without a 50% chance of living five years. According to UCLA's letter to Cigna, patients like Nataline had a 65% chance of living six months.

"The problem that they got into is, here's a situation where she didn't have very long to live," he said. "Probably in this situation, they're probably better off to say, 'The transplant center really feels like this is the right thing to do, let them go ahead.' "

The standard of care for this particular situation is "going to be pretty hard to know," Roberts added. "I think it's a very difficult decision for both the transplant center and the insurance company."

This sounds like a terrible case. As a parent, there's no doubt that I would want for my daughter any procedure that might save or extend her life. I'd protest, blog, call my Congressman, go to the news -- do whatever it took to try to get the necessary treatment for my child.

By the same token, no medical system can afford to provide every conceivable procedure to ever needy patient. At some point, caregivers need to assess the chance of success, the risks, the cost of a given procedure, and decide when a given procedure simply doesn't have enough of a chance of success to warrant providing it. This is the way it is in the real world.

But that's not the way it is in John Edwards' world. When John Edwards is President, it seems that any patient will be entitled to any procedure he or she wants. And Edwards won't 'negotiate' with the people who try to control cost and keep the system solvent. It seems he'll rule by fiat:

Nataline Sarkysian died last night at UCLA Medical Center after complications arose from a bone marrow transplant to treat her leukemia. Her insurance provider, CIGNA Healthcare, first denied the potentially lifesaving transplant, but relented after a loud public protest and outrage. By that time, though, Sarkysian passed away before the procedure could be performed.

"Are you telling me that we're gonna sit at a table and negotiate with those people?" asked a visibly angered Edwards, challenging the health care companies. "We're gonna take their power away and we're not gonna have this kind of problem again."

Edwards also told the audience of about a hundred people at the Score Pavillion in Nevada, Iowa, that it will take a fighter (i.e. him) - and not a negotiator (ii.e. Obama) - to take on large insurance companies like CIGNA.

We've all heard horror stories from Britain, Canada, Japan, or some other wealthy nation with national health care. Experience shows pretty clearly that single-payer systems have plenty of flaws -- with health care rationing high on the list. As the Cato Institute explained it:

Wherever national health insurance has been tried, rationing by waiting is pervasive, putting patients at risk and keeping them in pain. Single-payer systems tend to leave rationing choices up to local bureaucracies that, for example, fill hospital beds with chronic patients, while acute patients wait for care. Access to health care in single-payer systems is far from equitable; in fact, it often correlates with income—with rich and well-connected citizens jumping the queue for treatment. Democratic political pressures (i.e., the need for votes) dictate the redistribution of health care dollars from the few to the many. In particular, the elderly, racial minorities, and those in rural areas are discriminated against when it comes to expensive treatments. And patients in countries with national health insurance usually have less access to critical medical procedures, modern medical technology, and lifesaving drugs than patients in the United States.

Far from being accidental byproducts of government-run health care systems that could be solved with the right reforms, these are the natural and inevitable consequences of placing the market for health care under the control of politicians.

It makes intuitive sense that many decisions about care for people near death will be difficult and painful. Regardless of whether it's the insurance company or the taxpayer paying the bill, at some point a decision needs to made as to when to cease curative therapies. Leave it to an ambulance-chasing shuyster like John Edwards to claim that it will suddenly be easy.

A final comment: the LA Times article mentions that one of the reasons the case attracted so much attention is that the family turned to a DailyKos contributor to help publicize it. (I have no argument with that; as I mention, I too would do whatever it took.) Any surprise that Edwards is attentively reading DailyKos?