A MEDICAL CASE BECOMES POLITICAL
By Vanessa Fuhrmans And Laura Meckler

Wall Street Journal -
http://online.wsj.com/article/SB1199672407876713 95.html?mod=googlenews_wsj
Jan 7 2008

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."

Nataline Sarkisyan, who died last month.

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.