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Just Saying “No”


An American by choice, the last few days have made me nostalgic for British elections, with their clearly defined, disciplined parties, 80-plus percent voter turnout and three-week campaigns. After all there’s barely a ha’penny’s worth difference between the three leading Democratic candidates.

To separate himself from the Democratic front-runners former Sen. John Edwards has spent the last few days laying into insurance company, Cigna, for its failure to immediately approve a liver transplant for California teenager, Nataline Sarkisyan. That action, says Edwards, in concession speech after concession speech, is emblematic not just of the health care system’s break-down but of a failure of the current American political system.

Edwards like most Democrats wants a single payer health system and his plan is the closest of the three front-runners to providing one. But his advocacy of Natalie Sarkisyan’s case raise a question no one else seems to be asking.

First, some background. Natalie’s doctors at UCLA Medical Center had suggested the transplant as essentially the last roll of the dice to save her life. Cigna initially refused to pay for the operation. Their reasoning – and it was quite a rational reason – was that the operation would be futile. To be fair, the surgeons at UCLA disagreed. (But as the Brits like to murmur at these moments, “They would say that wouldn’t they?”)

There was an immediate outcry of the kind we’ve become accustom to as health care policy becomes increasingly political. Ten days later Cigna relented, offering to pay for the transplant itself (if it simply approved the procedure immediately, Natalie’s mother’s employer would have paid). And, of course, UCLA Medical Center, which is after all a government institution, could just have sucked it up and paid for the operation itself, but it didn’t seem to be too keen to do that.

But two things get in the way of this, perhaps commensensical, approach on Cigna’s part. And they’re getting in the way of the current debate.

First, insurers have no credibility. Their bad behavior over the past few years means that no one trusts them at all.

Second, there’s an election to win, and John Edwards decided his campaign will be the voice of the girl’s parents, a fine idea for a politician seeking office. Lousy policy.

One good reason to have a single payer system is to rationally decide what is paid for and what isn’t. 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.

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.

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.

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.”

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