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A Medical Case Becomes Political
By VANESSA FUHRMANS and LAURA MECKLER
January 7, 2008 Page A1
John Edwards has been bashing big health insurers in recent days with the story of a girl who died waiting for a liver transplant. But the details of the case suggest the Democratic presidential candidate may be oversimplifying the tale.
Nataline Sarkisyan had been battling leukemia for three years. Insurer Cigna Corp. rejected coverage for a liver transplant, then reversed its decision and said it would pay. The 17-year-old died before the operation could take place.
By pushing the case so hard on the campaign trail, Mr. Edwards is raising the emotional tone of the debate on health care, which has already emerged as perhaps the leading domestic issue in the campaign. Mr. Edwards and Sen. Hillary Clinton are among the Democratic candidates attacking health insurers.
"We need a president who will take these people on," Mr. Edwards said at the Democratic presidential debate Saturday night. He said Nataline "lost her life a couple of weeks ago because her insurance company would not pay for a liver-transplant operation."
In New Hampshire yesterday, the candidate's wife, Elizabeth Edwards, put her arm around the girl's mother, Hilda, before Mrs. Sarkisyan spoke at a campaign rally.
Cigna defended its handling of the case. "I'm perplexed that this has become a campaign issue," said Jeffrey Kang, Cigna's chief medical officer. "It is highly unlikely that any health-care insurance system, nationally or internationally, would have covered this procedure."
Insurers are highly unpopular with many doctors, who complain about insurance-company bureaucracy, and with patients who don't like having medical claims denied. Left-leaning critics of the U.S. health-care system say it isn't appropriate for some insurers to be making billions of dollars in profit while tens of millions of Americans go without insurance. They would prefer the "single payer" type of system in many European nations, where the government takes the leading role in paying for care.
While none of the leading Democratic candidates go that far, they have railed against insurers' cherry-picking when they decide who is eligible for a policy. People who are sick or have pre-existing conditions find it's hard or impossible to buy coverage on their own, something the leading Democratic candidates for president all vow to change.
Mr. Edwards, a former trial lawyer and North Carolina senator, wants to offer a government-run public plan, like Medicare, that would be open to all Americans. This could be a step toward the single-payer plan that many liberals want, and Mr. Edwards has said that it's a good opportunity to test that idea's popularity. He also wants to cap insurance-company profits.
The candidates have differed over what role insurance companies should have as health-care change is hammered out. Mr. Edwards takes a harsher tone, saying they can't be negotiated with, while Illinois Sen. Barack Obama says insurance companies deserve a seat at the table.
Nataline's case could provide fuel to both sides of the argument about whether insurance companies generally do a good job covering Americans. The day before Thanksgiving, she received a bone-marrow transplant from her brother. Soon after, her liver failed, and she went into a coma. Her doctors at the medical center of the University of California, Los Angeles, recommended a liver transplant, saying that patients in such situations would have a 65% chance of living another six months.
Cigna said both its own medical experts as well as an outside transplant surgeon and a cancer doctor with transplant expertise concluded there wasn't enough evidence that the procedure would be safe or effective. But after the denial got press coverage, the company reversed the decision on Dec. 20 "out of empathy for the family." Nataline died later the same day.
A UCLA spokeswoman declined to comment yesterday on Nataline's treatment, saying her family hasn't given the university permission to discuss the case.
Cigna said it wouldn't have benefited financially from denying the transplant because it only administered the health plan of Nataline's father's employer. In reversing the decision, it said it would pay for the transplant itself.
"We are asked to make the right clinical decision by our employer customers, so it would have been unfair to make them pay for it," said Dr. Kang, Cigna's chief medical officer.
Richard Freeman, a professor of surgery at Tufts University School of Medicine who wasn't involved in the case, said such cases happen too rarely to provide statistically validated medical evidence about the benefit, if any, of a transplant.
Rather, it "boils down to a philosophical argument," he said. Some doctors want to pursue aggressive treatment of a patient who appears to be dying, believing it's worth improving the chances, however slim, and fostering medical innovation. Others say the trauma and pain of an invasive procedure such as a transplant are likely to outweigh any medical benefit and the financial costs.
John Ford, an associate professor at UCLA who wasn't involved in Nataline's case, questioned in a recent post on his blog whether the survival data for a transplant were clear-cut. "It seems highly unlikely that such data, if it exists at all, has any degree of reliability," he wrote.
Nonetheless, the case has found a natural fit with Mr. Edwards's pitch. The candidate is an experienced practitioner in the modern political art of putting an ordinary person's face on policy prescriptions. At yesterday's rally in New Hampshire, Mr. Edwards turned the microphone over to the family of Nataline. Her father, mother and brother emotionally spoke of her death and their anger at Cigna.
Her father, Grigor Sarkisyan, spoke in raw terms about his loss before a packed crowd of more than 500 people at the Franco-American Center in Manchester, N.H. He said he had promised to buy his daughter a white car when she got her driver's license. "After she passed away, I bought a coffin for her because Cigna -- they killed my daughter. I don't have a daughter any more."
He added that he didn't think he'd have to worry about this sort of issue because his family had health insurance. "That's not right -- not in America," he said, echoing Mr. Edwards' stump speech. "This is not right. Maybe someplace else, but not in America."
The Edwards campaign says the candidate had been talking about Nataline's story for weeks when, on the night of the Iowa caucuses last Thursday, the family heard him mention their daughter on television. They contacted the Armenian National Committee of America, which in turn called the campaign's headquarters.
Karen Ignani, president of America's Health Insurance Plans, the main industry lobby group, said it's addressing the desire for health-care change by making its own proposals for universal coverage. Last month, it offered a proposal for guaranteeing access to individual health insurance to anyone who applies. The industry has long opposed that idea in practice.
The group also plans to work with medical societies on how to finance or cover experimental treatments. "We're not taking a P.R. approach to this but a policy approach," she said. "People want us to solve the problem, not just discuss it."
Still, Robert Laszewski, a health-care consultant in Washington, said the industry often muffs its public-relations strategy. Cigna's delay in reversing its decision on Nataline's transplant "shows just how tone-deaf" the industry is, he said.
Health insurers have also been fighting a legal battle in California over their right to rescind the policies of members who make misstatements on their applications. Critics say the insurers sometimes use small errors as an excuse to withdraw coverage. "They don't get the critical nature of the debate," said Mr. Laszewski.