Would Universal Health Coverage Have Saved Nataline?

The death of Nataline Sarkisyan, the 17-year old leukemia patient who needed a liver transplant, is being blamed by many on Cigna, her family's health insurer, and its too-late-to-save-her decision about whether to cover the cost of the transplantation surgery.

Nataline's death is sad, no matter what the cause, but her name will live on for the impetus it has given to the private health insurance vs universal healthcare debate in the US.

Here are some facts:

• Nataline had been battling leukemia for a number of years, had already received a bone marrow transplant from her brother, and the drugs she needed caused her liver to fail.
  
  
• The liver failure, and other problems, had put her into a vegetative state.
  
  
• Doctors from the UCLA Medical Center where she was being treated recommended she undergo the liver transplant and sent a letter to Cigna requesting such on December 11, 10 days before she died. They said her chances of survival from the transplant would be 65 percent.
  
  
• Cigna at first refused to pay for the liver transplant, saying the treatment would not work in her case, and was partially experimental.
  
  
• After immense public pressure, Cigna reversed its decision.
  
  
• Nataline died after her life support machines were turned off, one hour after Cigna's reversal.

Here is some follow up information:

• Not all doctors agree that the liver transplant would have helped Nataline. Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin at Madison, said in a USA Today interview that the post surgery drugs would only have caused her cancer to get worse. He believes this type of surgery would have been futile.
  
  
• Questions have been raised about timing and outcome. Did Cigna only approve the surgery, knowing that she would die before she could be operated on anyway?
  
  
• Outcries from those would believe universal healthcare in the US would have made this a moot question are being heard. They believe that if the US covered everyone's healthcare, like the systems in Canada and Great Britain, then Nataline would have received her needed surgery.

But here are some questions and answers I am not hearing -- raised by this event and provided here as food for thought. If you have some ideas, I invite you to discuss them in the Patient Empowerment Forum:

• I don't believe it's up to us to second guess either the doctors or Cigna healthcare.

  The doctors were looking at Nataline's medical condition and making the only recommendation they could to save her. Whether or not the surgery would have been experimental, her options were limited. She could have surgery -- and maybe live or maybe die. Or she could not have surgery, and die for sure.

  The insurance company was looking at the odds of her living a long and strong life. The surgery might, or might not provide that. They needed to balance the cost vs the probability of a good outcome, and they deemed that Nataline's life would not have been worth the cost to them.

• While we mere mortals would love to throw stones at Cigna for their original decision not to cover the cost of the surgery, we need to remember that it's not really Cigna that would pay the cost. Where does Cigna get its money from? It gets it from its insured customers. Granted, it makes huge profits (they all do!) but those profits are their first interest, so the pot of money the surgery would have come from would not have been the profit pot -- it would have been the pot that is built by all the other insured customers.
  
  
• Do you have Cigna insurance? Would you have written a check out of your pocket to pay for this surgery which may or may not have saved Nataline's life? Could you afford the thousands of Natalines who are out there who need the same type of surgery?

  That's the way you need to think about it. Because as soon as Cigna, or any other insurance company, covers a major expense like the liver transplant surgery would have been, it comes out of the money you, and other insurance customers pay in -- and you will eventually be tapped to replenish that pot through higher premiums.
  

• And what about that liver itself? Knowing the odds were probably not in Nataline's favor, does it make any sense to consider weighing the idea of giving the liver to someone who could have survived a long healthy life with that liver, vs Nataline who might never have been healthy with it?
  
  
• Is Universal / Socialized healthcare the answer? Not necessarily. We hear about the wait times and the need for paying out of pocket for specialized types of care -- norms in countries that use a socialized system. Just because it CAN be done, doesn't mean the system is set up to support it.

Like all of us, in the perfect world, I would have wanted the surgery to go forward, and like in a TV movie, watch Nataline recover to live a long, full, happy life. But in our real world, those chances were slim.

The questions raised above are ethical questions -- there aren't easy answers, and I am not providing ANY of the answers, because I don't know them either. I'd be pleased to hear opinions.

As I try to do at all times, however, I will make a suggestion for others of you who are having trouble getting approval for a treatment or procedure from your insurance company: Fight for it! You'll find that it requires thinking like a consumer, and not like a patient -- but you may be able to prove your point, get it approved, and find better medical outcomes if you do.