The Wall Street Journal-20080111-Edwards and Organ Transplants
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Edwards and Organ Transplants
Campaigning in the primaries, former Sen. John Edwards is leveraging the tragic story of Nataline Sarkisyan -- the 17-year-old California woman who recently died awaiting a liver transplant -- to press his political attack on insurance companies and argue for European-style, single-payer health care. But the former trial lawyer, accustomed to using anecdotes of human suffering to frame his rhetoric, is twisting the facts. Organ transplantation, like many areas of medicine, provides a poor basis for his political thesis that single-payer health care offers a more equitable allocation of scarce resources, or better clinical outcomes.
Late last year, Ms. Sarkisyan developed liver failure, apparently a result of blood clotting that stemmed from the high doses of chemotherapy and a bone marrow transplant she had received to treat relapsed leukemia. She was put on life support as her doctors at the University of California-Los Angeles tried to get her a new liver, and asked CIGNA, the insurer that was acting as administrator to her father's employer-provided, self-insured health plan, to pay for the transplant. CIGNA deemed the transplant unproven in its medical benefit and ineffective as a treatment. It recommended that her father's employer not cover the procedure.
After an appeal, CIGNA hired an oncologist and transplant surgeon to review the case. According to CIGNA, these experts agreed that the transplant exceeded appropriate risk-taking, with little support from existing medical literature.
CIGNA never reversed its administrative decision. But after significant pressure from the California Nurses Association, a powerful union lobby -- and legal threats -- it made a clumsily- announced concession, a one time "exception" to pay for the transplant itself, despite sticking to its judgment that the procedure constituted an experimental use of a scarce organ. But CIGNA's concession came too late. The same day it was made Ms. Sarkisyan was taken off life support and died.
From here, facts are in dispute. Her family says a liver became available while CIGNA wrung its hands over the matter. Some news accounts question this turn, since institutions like UCLA would typically proceed with transplants, even before insurance plans are settled, once an organ becomes available.
Mr. Edwards seized on the case. "We're gonna take their power away and we're not gonna have this kind of problem again," he said on Dec. 21. "These are living and breathing examples of what I'm talking about and there are millions more just like them," Mr. Edwards told reporters on Jan. 6. An edited video of his attacks on CIGNA has posted on YouTube.
Research provides little support to Mr. Edward's underlying premise that single-payer health-care systems would do better. On balance, data suggests that in the U.S. transplant patients do quite well compared to their European counterparts, with significantly more opportunities to undergo transplant procedures, survive the surgery, and benefit from new organs.
Some of the best data pits the U.S. against the U.K. and its National Health Service. A study published in 2004 in the journal Liver Transplantation compared the relative severity of liver disease in transplant recipients in the U.S. and U.K. The results were striking. No patient in the U.K. was in intensive care before transplantation, one marker for how sick patients are, compared with 19.3% of recipients in the U.S. Additionally, the median for a score used to assess how advanced someone's liver disease is, the "MELD" score, was 10.9 in the U.K. compared with 16.1 in the U.S. -- a marked gap, with higher scores for more severe conditions. Both facts suggest even the sickest patients are getting access to new organs in the U.S.
On the whole, the U.S. also performs more transplants per capita, giving patients better odds of getting new organs. Doctors here do far more partial liver transplants from living, related donors, but also more cadaveric transplants (where the organ comes from a deceased donor). In 2002 -- a year comparative data is available -- U.S. doctors performed 18.5 liver transplants per one million Americans. This is significantly more than in the U.K. or in single-payer France, which performed 4.6 per million citizens, or in Canada, which performed 10 per million.
What about the differences in outcomes between ours and single-payer systems, an issue Mr. Edwards hasn't directly addressed? One recent study found that patients' five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Irleand than the U.S. The same study also found that in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.
These findings aren't confined to transplanted livers. A study in the Journal of Heart and Lung Transplantation compared statistics on heart transplants over the mid 1990s. It found patients were more likely to receive hearts in the U.S., even when they were older and sicker. The rate was 8.8 transplants per one million people, compared to 5.4 in the U.K. Over the same period, about 15% of patients died while waiting for new hearts in the U.K. compared to 12% in the U.S. In 2006, there were 28,931 transplants of all organ types in the U.S., 96.8 transplants for every one million Americans. There were 2,999 total organ transplants in the U.K., 49.5 transplants for every one million British citizens.
What about Mr. Edwards's implicit thesis, that U.S. organ allocation is dictated by someone's ability to pay? When it comes to livers, the majority of U.S. transplants are for chronic liver disease, usually resulting from hepatitis C or alcoholism. These are diseases disproportionately affecting lower-income Americans who predictably comprise a comparatively higher number of people getting new organs.
Ideally, everyone who can benefit from an organ transplant would receive one, especially a young patient like Ms. Sarkisyan. But with more patients than available organs, some form of allocation procedure involving administrative judgments is inevitable. In Ms. Sarkisyan's case, that judgment was made by CIGNA, in an advisory capacity to her father's employer, interpreting the terms of the employer's health- insurance contract. In the U.K. and other European systems -- and in the U.S. single-payer system favored by Mr. Edwards -- those judgments are made solely by a government agency. The available data suggests that the government allocation procedures do a somewhat worse job, as far as health outcomes are concerned, than private allocation procedures in the U.S.
As in all events, the inevitable trade-offs and ethical dilemmas cannot be wished away. Our system in the U.S. for allocating scarce resources remains imperfect. But taken as a whole, statistics show that organ access, our willingness to transplant the sickest patients, and our medical outcomes are among the best in the world. Probably superior to the single-payer systems that Mr. Edwards would have Americans emulate -- and certainly better than the facts that Mr. Edwards wants us to believe.
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Dr. Gottlieb is a practicing physician and resident fellow at the American Enterprise Institute.
