Yesterday I appeared on a four-person health care panel that was televised in New Hampshire.  The panel included a conservative who surprised me by arguing that the difference between the progressive candidates’ proposals for health care reform and the conservatives’ position on health care just isn’t that great.

Looking at the candidates’ proposals, I disagreed.  Put simply, the conservatives would like to make government smaller. They want to “outsource” many of government’s jobs to the private sector. They tried to privatize Social Security, and they have partially succeeded in privatizing Medicare by paying private insurers a steep premium to take care of seniors under Medicare Advantage. (See my post about the high cost of the program here).

Finally, the vote on SCHIP split along conservative/ progressive lines, with conservatives voting against expanding SCHIP. As President Bush explained, more funding for SCHIP would expand the government’s role in our health care system.

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I promised to return with more information about who halted the use of life-saving checklists in Intensive Care Units in Michigan and at Johns Hopkins. (For my earlier posts on this shocking story, click here and here).

The Office of Human Research Protections (OHRP) is the agency that has nixed the use of checklists. Who runs the OHRP?  Until his recent resignation (as of Sept. 30), Bernard Schwetz was the director of OHRP. Who is Schwetz? He is a veterinarian (DVM). That’s right, he’s vet, not a M.D.

What’s even more surprising is that from January 20, 2001 to February 2002, Schwetz, who is also a toxicologist (Ph.D.), was Acting Deputy Commissioner of the FDA. This was not a bright period in the FDA’s history. During Schwetz’s tenure, the FDA’s counsel, Dan Troy, was running the agency from behind the scenes. Troy, a Bush appointee, was well-known as a long-time foe of FDA regulation. In the 1990s, he represented Brown & Williamson Tobacco Corp. in its effort to fend off the FDA, and just months before joining the agency, he had defended Pfizer in another battle with regulation. As a U.S. News & World Report headline summed up his career change: “Mr. Outside Moves Inside: Daniel Troy Fought the FDA for Years; Now He’s Helping to Run it.” (I have documented Troy’s power in my book, Money-Driven Medicine).

As for Schwetz, what can one say about a vet/toxicologist who becomes temporary deputy commissioner of the FDA? “Political appointee” is the phrase that comes to mind.

I’m told that the OHRP is a “strange creature.” It was created in 2000 to replace the small, underfunded Office of Protection from Research Risks. That office reported to the NIH. OHRP, by contrast, reports directly to the Assistant Secretary of Health, putting it under the White House’s control.

OHRP began sending what only can be described as threatening letters to Michigan and Johns Hopkins last summer—on Schwetz’s watch. He announced his resignation at the beginning of August. I haven’t been able to find an explanation for the resignation or whether it is in any way connected to OHRP’s decision about the checklist.

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One of the most infamous records the U.S. holds is that of the world’s incarcerator. As of 2006, 2.2 million Americans were incarcerated, more than even China—which has over four times the population of the U.S.

California is the most cell-happy state in the union, with its prison population in midyear 2006 at over 175,000, or 11.3 percent of the total prisoners in the country.  The Golden State’s 175,000 inmates are held in 33 prisons—meaning there’s roughly 5,307 inmates per prison.

Put differently, every prison health care system has 5,307 potential patients, day in and day out. That’s quite a caseload, and it’s made much worse by the fact that prisoners are in much poorer health than the general population. Indeed, the California prison system is in the throes of a health care crisis—one that highlights why we should all care about the quality of medical services for inmates.

As you might guess, prison is an unhealthy place. Prisoners are more than eight times as likely to be infected by HIV, four times as likely to have active tuberculosis, and more than nine times as likely to have hepatitis C. According to the National Commission on Correctional Health Care, about 3 percent of the U.S. population spends time in prison or jail—but between 12 and 35 percent of the total number of people in the nation with some communicable diseases (like AIDS and Hepatitis B) pass through a correctional facility.

Commission data shows similar trends occur for mental illnesses (see the table below). Prison inmates have rates of schizophrenia and other psychotic disorders that are three to five times greater than the general population. Their incidence of bipolar disorder is up to three times greater than people outside prisons. And prisoner rates of drug and alcohol abuse are also higher.

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Perhaps you saw the headlines over the holidays:

• “CIGNA Defends Decision To Let Teen Die—On Christmas Eve”
• “As CIGNA Insurance Waffles on Liver Transplant, Girl Dies”
• “Lawyer: CIGNA’s refusal to pay for liver transplant ‘killed’ teen”
• “Teenage Girl Dies So CIGNA Execs Can Get Richer”
• Metroblog: "Merry ******* Christmas, From  CIGNA Healthcare "

Without question, this is a tragic story. Here are the bald facts: Nataline Sarkisyan, a 17-year-old who had been battling leukemia for three years, received a bone marrow transplant from her brother the day before Thanksgiving. She then suffered complications; her liver failed, and she went into a coma. At that point her doctors at the UCLA Medical Center recommended a liver transplant, saying that the transplant would give her a 65 percent chance of living another six months.  Within four days, a matching donor was found.

But on December 11th her insurer, CIGNA, refused to cover the transplant on the grounds that for a patient this sick, the transplant would be an “experimental procedure.” And her insurance policy "does not cover experimental, investigational and unproven services.” 

The doctors told the family that their only alternative would be to make a $75,000 down payment on the operation. Unfortunately, the family didn’t have $75,000. 

Observers both in the mainstream media and in the blogosphere were outraged when they heard that CIGNA had denied coverage.  Daily Kos led the protest with “Murder By Spreadsheet: CIGNA  Denies Claim and 17-Year-Old Will Die.” Responding to the firestorm, on December 20 CIGNA relented, saying that  "despite a lack of medical evidence regarding the effectiveness of such treatment,” it would cover the transplant.

The letter from CIGNA came too late. That same day, the hospital called to say that Nataline’s condition was deteriorating and her family was forced to make the decision to take her off life support.  She died within the hour.  The next day the Sarkisyan’s lawyer announced that the family planned to sue CIGNA for “malicious” murder.

This is both a tragic tale and a complicated story—far more complicated than the headlines suggest.  As Dr. John Ford, an assistant professor at UCLA’s medical school observed on his blog, California Medicine Man, “While I’m not surprised at the intensity of emotion that has arisen from this case, the utterly inflammatory and often mindless rhetoric being propagated is sobering. It seems that nuance has taken a hike, never to reveal itself.” 

Here are just a few of the questions that this vexed and vexing case raises:

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