Saturday, November 7, 2009

Nicholas Kristof on "Unhealthy America" - One Grand Slam and One Stikeout

I greatly admire New York Times columnist Nicholas Kristof's reportorial thoroughness and passion for social justice. So I wasn't surprised that I agreed with the opening passage in his November 5 column on "Unhealthy America":

The moment of truth for health care is at hand, and the distortion that perhaps gets the most traction is this:

We have the greatest health care system in the world. Sure, it has flaws, but it saves lives in ways that other countries can only dream of. Abroad, people sit on waiting lists for months, so why should we squander billions of dollars to mess with a system that is the envy of the world? As Senator Richard Shelby of Alabama puts it, President Obama’s plans amount to “the first step in destroying the best health care system the world has ever known.”

That self-aggrandizing delusion may be the single greatest myth in the health care debate...
Kristof goes on to cite multiple studies that show just how mediocre our overall "system" is. This is educative journalism at its best.

Then he stumbled:

I regularly receive heartbreaking e-mails from readers simultaneously combating the predations of disease and insurers. One correspondent, Linda, told me how she had been diagnosed earlier this year with abdominal and bladder cancer — leading to battles with her insurance company.

“I will never forget standing outside the chemo treatment room knowing that the medication needed to save my life was only a few feet away, but that because I had private insurance it wasn’t available to me,” Linda wrote. “I read a comment from someone saying that they didn’t want a faceless government bureaucrat deciding if they would or would not get treatment. Well, a faceless bureaucrat from my private insurance made the decision that I wouldn’t get treatment and that I wasn’t worth saving.”

The flow of Kristof's article makes it clear that he is presenting Linda's painful story as an indictment of the inurer. But there are three basic possibilities for understanding Linda's tragic situation, only one of which is malfeasance. Kristof invites readers to see the insurer as guilty as charged, just one more example of insurer "villainy."

This is bad journalism, especially coming from a brilliant and ordinarily trustworthy reporter like Kristof. He missed an opportunity to educate his readers by making these important distinctions:

  1. The medication Linda wants is a validated, "evidence-based" form of chemotherapy and the insurer knows this, but chooses not to cover it, duplicitously claiming that it is not "medically necessary." A court that found an insurer guilty of doing this would, and should, levy hefty punitive damages.
  2. There are new findings about the medication or about Linda's particular condition that the insurer has not given proper weight to. In this situation, an appeal that documents the rationale for why the medication should be seen as effective should succeed. I have been part of an insurance appeals process and have seen numerous situations over the years in which decisions were seen in a new light when new information was introduced.
  3. The medication Linda wants is ineffective, but an uninformed or overzealous physician has told her it's what she needs. In the 1990s, bone marrow transplant for advanced breast cancer was covered on the basis of faith and hope. Insurers who refused to cover it were sued. In a famous case (Fox v Healthnet) the plaintiff's family was awarded huge punitive damages. The treatment was ultimately found to be ineffective, but only after 30,00 women had received it, often with the result of increased suffering and shortened survival. (False Hope, by Richard Rettig and others describes the the painful saga in detail.) If this is the situation Linda should receive clear explanation and compassionate care, but not agreement that the insurer has committed a moral crime. And the physicians who are misleading her should receive a combination of reeducation and chastisement for giving such bad advice.

The fact that one of our best journalists is contributing to our national failure to understand the need for clinically informed, ethically justifiable limits says a lot about how difficult the learning curve will be. As I've often said in this blog, even if Mother Theresa was in charge of an insurance plan, she would not cover every cancer chemotherapy that we petition for.

(Norman Daniels and I discuss these issues in detail in Setting Limits Fairly.)

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