I'm Just Sayin'

I've been following the story of Nataline Sarkisyan. Seventeen year old Nataline was a victim of leukemia. She had a bone marrow transplant which , as this procedure often does, led to other complications including liver and kidney failure. Her brother donated a kidney and she was now needing the liver replacement. Her family's insurance company, Cigna, refused coverage for the liver transplant...the reason... this procedure was classified by Cigna as "experimental". Liver replacement is a relatively common procedure...I don't have any numbers, but I'll bet it's in the hundreds per year in the U.S. ...maybe more. Anyway...the story went public, as they say...very public. The people, via the power of the internet, which allows folks to not only be informed, but to react and be heard, demonstrated how outrageous they thought this decision was on the part of Cigna. Public outcry overwhelmed Cigna...there was a big protest march.. so they decided to reverse the "death sentence" decision and pay for the operation. Nataline died before the operation could take place.  

So, did Cigna hand young Nataline a death sentence? Maybe they did or maybe she would have died anyway. The "maybe she would have died anyway" argument is not really the point here... the point is whether we should allow accountants to decide what medical practices will be covered... paid for with Cigna (share holder) money and for whom. I'm not taking up for the insurance industry here, but a lot of factors and considerations overlap in this situation...and this situation is not unique. "Risk management" is the rather broad term often used to describe the process of an insurer deciding how much to payout in certain situations. The idea is of course, as far as the insurer is concerned, is to take in as much as possible in premiums and pay out as little as possible in claims. No insurer will stay in business it they don't pay claims and no insurer will stay in business if they pay too much money out. If they raise their premiums to pay out more claims, they will lose business. There is a constant attempt to balance this tug on the dollar. If Cigna had decided that Nataline didn't stand much of a chance of living, even with the liver transplant, then it would seem wasteful to pay for the operation. This shouldn't be Cigma's call , but it is. Now consider something else...what if Cigna had paid for the transplant and Nataline had lived? Great news for Nataline and her family and loved ones, but for Cigna, Nataline's medical expenses would not be over, they would be just beginning. Depending on how much continuing care she would need and for how long, Cigna's aftercare pay outs would far exceed the money already paid for her care up to this point.

But that is why we buy health insurance. The insurance company makes a bet with us. They bet we will stay well, we bet we will get sick or injured.  It's pretty darn scary to think that health insurance companies in some cases, would really rather see you dead than alive. There may be some comfort in the fact that your life insurance company would rather see you live. Another angle in this debate...the insurance companies don't really make their money on the differences in the premiums and the pay outs...not all of it. Your premiums are used by the insurance company to make investments. The insurance companies are not really in business to insure folks against financial losses, they are in business to gather money, your premiums, so they can invest that money to make more money. You are simply a source of funding for a group of investors. This isn't evil or duplicitous. In fact, your premiums would be higher if the insurance companies couldn't do this investing. These investments are low risk and usually guaranteed by our government...government bonds for example. The insurers are good at investing. They have never had a losing year...as an industry. The government makes sure the insures have enough cash to cover pay outs and the investments also have to have a fairly liquid nature in case the insurer needs to cover a large payout, such as after a natural disaster.

What this all means...what this under scores... is that we are all just numbers on a balance sheet as far as medical coverage goes. Our health care system isn't just broken...it's all fucked up. I don't know how to go about fixing the system. I don't know how to discuss ethics with a company, Cigna, who pays it's CEO, H. Edward Hanaway an annual compensation of over twenty eight million dollars. I don't know how to reason with a government who has borrowed billions of dollars from insurance companies...remember those government bonds I told you about? The government protects the insurance companies... they want to keep that money source open...buying bonds. I don't know how to deal with hospitals that charge $130 for throw away pajamas and still can't make money. I really don't know where begin to start with regards to the drug companies. AND I really can't see any major changes for the better...coming any time soon. I don't think we have even bottomed out as far as how bad health care and the health care system can be in the United States.

I think we would be well advised to consider the health care and insurance industry issues as of primary importance as we discus and decide on our presidential candidates.

This story isn't quite over. It seems that Cigna could now be charged with murder. Attorney Mark Geragos siad that Cigna "maliciously killed her" and has asked the DA to file charges against Cigna. What does this mean? Nothing. Cigna gets sued and charged with stuff  all the time. It's part of their overhead and your premium. Cigna lawyers love it when Cigna gets sued or charged with something.It's part of the process. It's been considered in the "risk management" calculations. You call this a system?