Special treatment for ‘high profile’ patients; exasperation for the rest of us

Introduction

Like many others, I’ve heard President Obama talk about his mother’s insurance problems during her final months in 1995. The memory of his mother having to devote precious time and energy pleading with her insurer to pay her mounting medical bills fueled Obama’s determination to focus on passing health care reform.

But I didn’t realize until reading a new book about the president’s mother that the insurer she was pleading with was CIGNA, the one I used to work for. I wish I had known at the time. In my role as PR man for the company, I might have been able to help.

One of the reasons I stayed in the insurance industry so long — nearly 20 years — was because occasionally I was able to help people who had been denied coverage.

One of my responsibilities was to advise company executives of the potential public relations consequences of certain decisions, such as refusing to pay for doctor-ordered care if a policyholder had sought help from the media or from an elected official.

I know from experience that when a reporter or politician contacts an insurance company on behalf of a policyholder, firm executives will elevate the case to “high profile” status and handle it differently. To keep a story out of the media, or to stay in a politician’s good graces, insurance company bureaucrats will often do an about face and agree to pay for coverage they previously had denied.

Although I grew doubtful over the years that insurance companies really “added value” to our health care system, I often patted myself on the back for playing a role in getting a denial reversed. I slept better at night if I could tell myself that I might have helped save someone’s life that morning, even though millions of other people were being forced into the ranks of the uninsured because of the industry’s underwriting practices.

During the time that Obama’s mother was battling both cancer and her insurance company, I was battling a managed care backlash. Soon after the Clinton reform plan failed in 1994, insurance companies offered up managed care as a “private sector solution” to the country’s health care crisis. Government involvement would be unnecessary, we argued, because the invisible hand of the market and the techniques of managed care would simultaneously bring down both costs and the number of people without coverage.

Employers bought it. By the end of the decade, they had moved almost all of their workers into HMOs or similar types of managed care plans.

But for many people, managed care turned out to be more of a nightmare than a solution. One of the ways insurance companies controlled costs was by refusing to pay for care for a variety of reasons. HMO patients were out of luck, for example, if they received care, even unknowingly, from a doctor or hospital outside of their HMO’s network. Many women were especially disadvantaged. Citing actuarial data as justification, their HMOs refused to pay for more than a 24-hour stay in the hospital after a woman delivered a baby or had a mastectomy.

Insurance companies also became especially vigilant in searching for evidence that a policyholder’s medical treatment might be related to a “preexisting condition,” as the president’s mother, Ann Dunham, found out.

In August 1995, according to Janny Scott’s book, “A Singular Woman,” Dunham received a letter from the CIGNA subsidiary that had been hired by her employer to provide short-term disability benefits. Dunham assumed the company would reimburse her for expenses related to her treatment for uterine cancer.

The letter from CIGNA dashed her hopes. The company was refusing to pay because it had reason to believe the cancer had started before she enrolled in the policy. Scott wrote that the company based its decision on notes it obtained from a gynecologist Dunham had seen months earlier for abdominal pain.

Even though the doctor did not tell Dunham she might have cancer, she made a note in Dunham’s medical record that the pain she was experiencing might be the result of a malignancy.

Scott wrote that while undergoing chemotherapy and dealing with the accompanying hair loss and sickness, Dunham had to devote enormous amounts of time communicating with CIGNA in an effort to get the company to reconsider.

Making no headway on her own, she finally informed the company she was turning over her case to “my son and attorney, Barack Obama.”

Obama was indeed a lawyer by then, but his name would have meant little to CIGNA in 1995. He was still serving as a civil rights attorney and lecturer at the University of Chicago law school. He simply was not important enough to really help his mother.

If Obama had been elected to the Senate before his mother got sick, her story might have had a different ending. A call from Senator Obama undoubtedly would have elevated her case immediately to high profile status. I had joined CIGNA two years earlier, so I probably would have been brought in to assess the situation and offer counsel from a public relations perspective.

Insurance company executives insist that their coverage decisions are not influenced by the threat of bad publicity, that they are made solely on the basis of medical necessity (as determined by them) and the limitations of a particular policy (also as determined by them).

Don’t believe it for a minute. Denials are reversed as a matter of routine after a PR guy — someone like me — informs the CEO of a call from a reporter or politician.

Indeed, Obama’s mother might have had one thing less to worry about during her final weeks if she had been able to get the media interested in her case. Or if she had just waited until her son was a little more influential to get sick.

Have you or your family had problems with health insurance companies? Tell Wendell Potter your story: wpotter@publicintegrity.org