Florida Woman Dies After Medicaid Program Outsourced To Private Insurers Denies Her Liver Transplant

By Zaid Jilani One of the most destructive practices of private health insurance companies is the practice of denying care to customers for frivolous reasons. Earlier this year, the Department of Health and Human Services started including denial rates on its information section about health insurance companies on HealthCare.gov, in an effort to inform the public about this practice by the industry.

It was this practice of frivolous denials that ended up costing Jacksonville, Florida woman Alisa Wilson her life. For months, Wilson, her family, and the surrounding community had been pleading with her HMO to approve coverage for a liver transplant. Although Wilson was enrolled in the state’s Medicaid program, she was not guaranteed care because she was “forced to join a private plan as part of a Gov. Jeb Bush-era experimental overhaul of the program,” meaning she had to deal with a private, for-profit insurance company to get her care, not a government agency accountable to the public.

Bush’s overhaul made “Florida the first state to allow private companies, not the state, to decide the scope and extent of services to the elderly, the disabled and the poor, half of them children,” the New York Times reported in 2005, as the move was being considered. “[N]o one is proposing changes as far-reaching and fundamental as” Bush, the Times noted.

After “scores of e-mails and…the help of a Florida state legislator,” the HMO, Sunshine State Health, finally gave in and approved coverage for Wilson two weeks ago. Yet her health was too severe for surgery by then. On Friday evening, Wilson passed away:

Alisa Wilson, 37, died Friday at 8:50 p.m. after a lengthy battle with an undisclosed liver disease, said her father, Eric Wilson. “Her liver was gone,” Wilson said. “There was no more left. She needed that transplant two weeks ago.”

About a week and a half ago, attorneys working on Wilson’s behalf said the insurance obstacles had been worked out. By then, however, her health was too shaky to risk going under the knife. “If they did it months ago, my daughter would be alive now,” her father said.

Representatives for Sunshine State and the Florida Agency for Health Care Administration, which manages Florida’s Medicaid program, said they couldn’t speak to the specifics of the case, citing privacy laws.

Unfortunately, it has become increasingly common for states to outsource their Medicaid programs to be administered by private health insurance companies that have little accountability to the public compared to public programs like Medicare. A 2010 Kaiser Family Foundation report found that “All states except Alaska and Wyoming have some portion of their Medicaid population enrolled in managed care” — where Medicaid pays out to private organizations like Managed Care Organizations that contract with HMO’s — and “managed care is the dominant care delivery system in most state Medicaid programs. Forty-six states and DC have more than half their enrollees in managed care; in 20 of these states, over 80% of the Medicaid population is enrolled in some form of managed care.”

While the recently passed health care law is doing much to curb some of the worst abuses of the health insurance industry, one of the best ways to help people avoid these practices of the private health insurers is to offer them an alternative like a Medicare-style public health insurance option. As a part of her deficit reduction plan, Rep. Jan Schawkowsky (D-IL) proposed a robust public health insurance plan that would be offered to Americans. Not only would it operate cheaper and not committ the same abuses as the private insurance industry, it could cut the deficit by as much as $10 billion during its first year of implementation alone.

Woman With Breast Cancer Turns To Pasta Fundraisers To Finance Chemo After Insurers Deny Her Coverage

By Zaid Jilani One of the worst abuses of the private insurance industry is its practice of excluding people with certain pre-existing conditions from coverage, effectively denying them the right to get adequate health care coverage because covering them is not profitable enough.

Iowan grandmother Deb Robben knows what life is like with a pre-existing condition. Four years ago, she shopped the insurance market, looking for a company that would cover her. Unfortunately, after a lengthy search, she was unable to find a single insurer that was willing to offer her coverage; the companies denied her coverage because they considered the benign cysts in her breasts to be a pre-existing condition.

Last December, Robben was diagnosed with colon cancer. Because she has been unable to obtain insurance, she has had to pay the costs for treatment out-of-pocket. For chemotherapy treatment alone, Robben expects to pay almost $2,000 a month. “She’s only two months into chemo and already she’s at $50,000. Oh my, what is another four months going to bring,” says Melissa Gradischnig Nelson, a friend of Robben.

In desperation, Robben’s friends and family have turned to local fundraisers to try to pay for her treatment. Over the weekend, they held a $5-a-plate pasta dinner in the hope of putting “a dent” in Robben’s massive health care bills.

Local news station WHO-TV recently interviewed Robben, who told them, “It’s kind of hard when you can’t get insurance. To say, lady you’re going to die or figure out how to come up with the money. It’s not right.” Watch it:

As Think Progress has reported previously, women face especially high barriers to being approved for coverage by health insurers. The insurance industry has in the past refused to cover maternity care, disqualified women from coverage who’ve had a Caesarean-section pregnancy, and considered domestic abuse a pre-existing condition.

It is worth noting that the United States is the only developed country without a universal, cradle-to-the-grave health care system. Nowhere else in the industrialized world would a woman have to turn to holding pasta fundraisers to get the money to pay for her chemotherapy.

Insurer Denies Life-Prolonging Treatment To Five-Year-Old Boy With Cancer

By Zaid Jilani One of the worst abuses of private insurance companies is the practice of using spurious reasons to deny claims for medical treatments, which are often necessary for saving patients’ lives.

Kyler Van Nocker’s story shows that even 5-year-old kids are not exempt from this insurance company abuse. Van Nocker has neuroblastoma, which is a very rare form of childhood cancer that targets the nervous system and creates tumors throughout the body.

Due to successful treatment in 2007, Van Nocker’s cancer went into remission, giving him 12 months of pain-free life. Unfortunately, in Sept. 2008, the cancer returned, and Van Nocker was once again in need of treatment. Unfortunately, his health insurer, HealthAmerica, refused to pay for one form of treatment doctors believe could save his life (MIBG treatment) because they consider it “investigational/experimental” since it has yet to be approved by the FDA.

Yet in April 2008, the insurer approved cheaper treatment for Van Nocker that was also “experimental,” prompting Philadelphia Daily News columnist Ronnie Polaneczky to ask, “So why, pray tell, is HealthAmerica playing the ‘experimental therapy’ card in the case of the MIBG treatment Kyler now needs? Gee, money couldn’t have anything to do with the decision, could it?”

Van Nocker’s parents are suing HealthAmerica, citing the fact that the company has apparently been dishonest about its criteria for the types of treatment it will cover and is denying payment for treatment in this case because of the high cost of the procedure — $110,000 pays for only two rounds of MIBG treatment. “These companies have to be brought to the courthouse to get them to do the right thing,” says the VanNockers’s family attorney. “This child needs this treatment, or else.”

The sad truth is that Van Nocker is certainly not alone in having his claim denied by a major health insurer. The California Nurses Association (CNA), a nurses’ union and health care advocacy group, recently released a comprehensive study of claims denials across California. The study found that the six largest insurers in California rejected 47.7 million claims in the first half of 2009, nearly 22 percent of all claims submitted.

The United States is the only industrialized nation without cradle-to-the-grave, universal health care. In no other developed country would a child with cancer have to go without care because an insurance company decided it was not profitable enough to cover him.