Will the CVS-Aetna Merger Give Aetna Freedom to Kill?

The United States has a worldwide reputation for litigiousness. And it seems like just about everyone the world over is familiar with that anecdote about the woman who won millions after suing McDonalds because their coffee was too hot. (Never mind that coffee is expected to be hot as molten lava.)

But there’s one thing we never see in our notoriously litigious country: Patients and their families suing their health insurance companies over their profit-driven decisions to deny potentially life-saving treatments.

That is, we never used to, until a recent case turned that notion on its’ head.

Recently, a jury in Oklahoma City ordered insurance giant Aetna to pay $25 million to the family of Orrana Cunningham, an Aetna customer who died of cancer after the company refused to cover radiation therapy. “The jury ruled that Aetna recklessly disregarded its duty to deal fairly and in good faith with Cunningham,” according to a Nov. 10 article by the Associated Press.

Cunningham was diagnosed with Stage 4 nasopharyngeal cancer, a rare type of head and neck cancer that starts in the upper reaches of the throat. Her physicians prescribed proton beam therapy, a form of radiation that would attack the tumor accurately enough to reduce her risk of serious complications, such as blindness. 

The treatment had been approved by the Food and Drug Administration and was covered by Medicare.  However, Aetna declined to cover it, after three separate medical directors alleged this treatment was “experimental.” To save the love of his life, Orrana’s husband of 28 years, Ron Cunningham, a retired Oklahoma City firefighter, mortgaged their home and set up a GoFundMe page to raise the $92,082.19 needed to pay for the treatment. But it was too late. Before the family raised that prodigious sum, Orrana Cunningham died of a viral brain infection on May 30, 2015.

But before passing away, Orrana filed suit against Aetna for “bad faith,” as part of her fruitless attempt to force the insurer’s hand. After her death, Ron decided to proceed with the suit, taking Aetna to court. 

At trial, all three medical directors acknowledged they’d spent more time preparing for the lawsuit than they had on the decision to deny Ms. Cunningham’s life-saving medical treatment. Still, Aetna’s attorney, John Shely, thanked the medical directors personally for denying Orrana’s coverage and in closing arguments, went so far as to say he was proud of their decision.

While Aetna has vowed to appeal the ruling, Ron Cunningham’s attorney, Doug Terry, said he hoped the case would prove a watershed. “We believe this case pulled the curtain back on what goes on at a health insurance company when claims are being denied,” he told reporters.

One can only hope, as, tragically, Orrana Cunningham’s case is anything but unusual.

Insurers in the U.S. deny coverage for life-saving treatments on a daily basis, and our legislation doesn’t hold the insurance companies or their medical directors -- those who make the ultimate decision after coverage denials are appealed--accountable. 

Take any run-of-the-mill practicing physician like me, for example. If an improper medical decision on my part results in the death of my patient, I could have my medical license suspended or even revoked – not to mention facing the possibility of a malpractice suit.

Ironically, medical directors at insurance companies ––almost invariably licensed medical doctors -- face no consequences when their poor medical decisions harm or even kill patients. It may seem like common sense that physicians employed by insurance companies should be charged with unprofessional conduct when the medical decisions they make fail to meet the standard of care, but the fact is they rarely, if ever, are.

That’s because, unfortunately, health insurers fall outside the jurisdiction of state Medical Boards and are overseen by the Office of Insurance Commissioner (OIC) in each state, an entity with more bark than bite. 

Last year, California's Office of the Insurance Commissioner launched an investigation on Aetna after learning their former medical director, Dr. Jay Iinuma, admitted under oath that he never reviewed patients’ medical records when deciding to approve or deny care for patients.  Despite the outrageous admission by the medical director, California signed off on the Aetna-CVS merger last week, meaning there will be little more than a slap on the wrist for Aetna or their employed physician.

Insurance companies and the paper-pushing physicians in their employ have a clear conflict of interest: They’re job is to watch out for the company’s bottom line by signing off on the denial of costly treatments, regardless of whether those treatments could save patients’ – their customers’ - lives.

Hopefully, the stunning Orrana Cunningham decision has put us on a path toward increased insurer accountability. With Aetna’s $69 billion megamerger with pharmacy giant CVS Health expected any day now, the stakes have never been higher.

Why Affordable Housing Matters in Health Care.

Whether we recognize it or not, we’re in a housing affordability crisis.  Over a third of households in the U.S., carry a shelter burden that is beyond the standard of affordability – that is, costs usurp more than 30% of monthly income.  Locally, rents have increased by 50% over the last 5 years and more startling, the number of evictions has grown by 90% in the last 3 years.   Wages aren’t keeping up with costs.  The tipping point of housing instability comes when there is a health crisis, loss of employment or reduction in hours, rent increase, expensive car repair, or any combination of these unanticipated or unwanted life events.

Why do I, a columnist usually sharing a perspective from my medical expertise, bring these statistics up? Because if we cannot provide an adequate supply of safe, affordable housing in this community, we are wasting time trying to reform health care.

Health care and other social services can improve life outcomes for individuals and families, but stable and affordable housing must be the platform where it begins.  Research supports a critical link between affordable housing and health outcomes.  In 2016, the Providence Center for Outcomes Research and Education found that health care costs were 12% lower after individuals moved into affordable housing; study subjects were 20% more likely to go see their primary care physician and 18% less likely to visit the emergency room. 

The Olympic Region -which includes Kitsap County- leads the state in number of Medicaid patients visiting the Emergency Department unnecessarily.  While the state average is 436.8 visits per 1000 patients, the average in the Olympic region is 617.6 per 1000, fully 41% higher.  

Is this a result of poor-quality health care?  No.  We believe it is a direct result of food insecurity combined with a dearth of affordable housing in our community.

Affordable housing frees up financial resources for nutritious food, adequate clothing for growing bodies, and ultimately results in a healthier mothers and children – saving money for both the family and society in the long-term.    

Critics say government-subsidized housing is detrimental to the economy and individual freedom. However, this column’s co-author, Kurt Wiest of Bremerton Housing Authority, and I have seen the lives of families literally transformed by obtaining a stable residence.  We have also witnessed the fear on a child’s face when they are told they must sleep in a car one more night.  We cannot impact the health of a child without placing it in the context of stable housing.

Affordable housing --where the cost of shelter is at or below 30% of household income-- reduces family stress and related adverse childhood experiences (ACEs).  Children who move frequently, are forced to double up in small living spaces, or face eviction can be traumatized by the experience. Studies demonstrate these children are more likely to suffer from mental health disorders, developmental delay, learning disabilities, and are hospitalized for illness more often.  Children experiencing housing instability are four times more likely to be sick than their same-aged counterparts. 

Well-constructed and maintained housing reduces the health problems by reducing the risk of overcrowding and in turn, decreasing the spread of infectious diseases.  In Kitsap County, there are many families living in homes overrun with mold, dust mites, or rodents. Those without the option of affordable housing often face substandard living situations with increased risks of accidental injury to children.  Affordable housing can improve health outcomes for those with chronic disease simply by providing a consistent environment in which to deliver health care.

Finally, affordable housing allows women and children to leave abusive situations.  Domestic violence is one of the leading causes of homelessness for women and their children.   The rate of women returning to their abusers is inversely correlated with the availability of affordable housing.  Adverse childhood experiences, such as physical or emotional abuse, have life-long impact on health and life expectancy. 

The gap between survival and self-sufficiency continues to widen.  The federal poverty line for a family of 4 is $24,600, however, “self-sufficiency” in Kitsap County during 2017 required $59,075.  The average monthly rent in Kitsap County is now $1,350.  To meet the 30% threshold, a householder must earn nearly $25 per hour, working 40 hours a week, 52 weeks a year. 

For those adults with children working minimum wage jobs, public supports, such as child care assistance and federally subsidized housing, can help families meet their basic needs.  If we are to make a difference in the health of individuals and families in Kitsap County, we must address the supply of safe, decent, and affordable housing.   Health outcomes and housing stability are inexorably connected. Without investing in affordable housing first, quality health care that’s available to all is just a pipe dream.