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In a recent tweet from Alexandria Ocasio-Cortez, she claims that this letter which recommends a fundraising effort of $10,000 for medical care, 'comes from an insurance group'.
Well-known conservative Ben Shapiro claims that this letter actually "comes from a medicaid group".

While they're not stating that the letter literally comes from either group, Ocasio-Cortez is suggesting that the insurance group refused to provide for the treatment, while Shapiro suggests that the medicaid refused to provide for the treatment(?).

I could not find supporting evidence for either claim although, as this claim was brought to light by Ocasio-Cortez, it seem plausible that this was used as a political weapon in favour of Ocasio-Cortez healthcare goals.

Letter referenced by Ocasio-Cortez (relevant part transcribed below)

Dear Ms. Martin,

Your medical situation was presented to our multidisciplinary heart transplant committee on Tuesday October 20, 2018. The decision made by the committee is that you are not a candidate at this time for a heart transplant due to needing more secure financial plan for immunosuppressive medication coverage. The Committee is recommending a fundraising effort of $10,000.

[...]

Katie S Vandenakker, RN
SPECTRUM HEALTH RICHARD DEVOS HEART AND LUNG TRANSPLANT CLINIC[S]

—letter to Ms. Hedda Elizabeth Martin

Is there any evidence to suggest that this letter 'comes from an insurance provider' or 'comes from a medicaid group'?

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    [Here's a long take down of the whole thing.](https://twitter.com/mattbc/status/1066414876027994112) Informative and I'd say mostly correct, but it's not sourced, so I offer it only as a comment. Further, here's [a snap of Ocasio-Cortez's tweet.](https://i.stack.imgur.com/rfLrR.jpg) Add this to your question if you want, or in case it's deleted. –  Nov 29 '18 at 21:45
  • @SQB I approved your edit but now notice that the first link goes to the tweet, not the person. Please fix. (Also, side note: https://meta.stackexchange.com/questions/319189/preferred-link-reference-format-in-questions-and-answers) –  Nov 30 '18 at 11:03
  • Medicaid is a government health insurance payor. Within the government there are policy areas or "groups" that handle that aspect of administering the program, but that's not what we're looking at here. What is a "Medicaid Group" supposed to mean, according to Shapiro? I can't really say whether something is or isn't a certain thing if that thing has no actual meaning. Can anyone shed some light on this for me? – PoloHoleSet Nov 30 '18 at 20:43
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    I'm wondering why it (the attribution) matters, really. Ocasio was not attacking the "insurance group" in her Tweet, but was talking about what she perceived to be fundamental shortcomings of our health care ***system***. Whether it is an insurance group, evaluation panel, or "Medicaid Group" makes zero difference to the point she was making. Not a knock on the question, by the way. People are making a lot of noise about the issue, so it's good to get the facts. – PoloHoleSet Nov 30 '18 at 20:52
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    @polo She says "insurance groups are recommending GoFundMe." She's clearly blaming private insurance. Her point means less if government run Medicaid does the same thing, especially since "single payer" is the common phrase for "expand Medicaid to cover everyone". –  Dec 01 '18 at 21:48
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    @fredsbend - No, not at all. While she mis-attributing in the letter, she's also not blaming **this insurance company (as she see's it),** she is blaming the private, for profit-driven *system* for the decision. As I said, if she makes the correct attribution, what changes in her message, since she is talking about the system that is in place, and not this specific company? – PoloHoleSet Dec 03 '18 at 15:28
  • @polo *"Private insurance wouldn't cover everything, so they told this woman to use GoFundMe. We should expand Medicaid to cover everyone."* **vs** *"Medicaid wouldn't cover everything, so they told this woman to use GoFundMe. We should expand Medicaid to cover everyone."* The difference A) slashes any meaningful point she hoped to make, and B) demonstrates she's pretty clueless about the issue. If she had said simply *"This is no good, we can do better"*, then she at least wouldn't look so clueless. But she didn't. She blames private companies exclusively, hinting Gov will fix it all. –  Dec 03 '18 at 16:21
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    @fredsbend - But it's not Medicaid denying it. This is a treatment panel, saying that the gap in insurance coverage for the drugs means they can't approve it. If you take the **correct** attribution - "the treatment panel at this facility is telling a patient they need to use GoFundMe to make sure they get the coverage they need" - it does not change the core message, at all. The fact that you keep talking about Medicaid when no one, anywhere, except Ben Shaprio, talked about it suggests that you shouldn't be casting "clueless" stones on this topic. – PoloHoleSet Dec 03 '18 at 16:32
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    Nowhere has she ever suggested that a universal, single-payer plan should be implemented with huge gaps in coverage requiring massive out-of pocket payments, so I'm not sure why you are claiming that she should be saying that. – PoloHoleSet Dec 03 '18 at 16:34
  • @polo Her core message is not simply "medical coverage is not good enough". That at least would be sensible. Instead, her message is "private insurance does x, universal Medicaid will fix it." That's not sensible because Medicaid also fails to do x. Her indicating this letter is from an insurance company is just further indication she doesn't understand what's going on. In other words, her core message is nonsense. Not only is it not right, it's not even wrong. That's irrelevant to what reality is, that this letter is from a treatment panel. I think it's clear we both understand that. –  Dec 03 '18 at 18:25
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    @fredsbend - No one is proposing Medicaid, as it currently is, as the alternative, so, no, that's not her "core message." She's proposing changing from our for profit patchwork of hundreds of healthcare payors to a single, unified government-run system. It's most **like** Medicaid or Medicare, and they use the term "Medicare for all" to make it easy for people to envision, but no one is proposing a system that keeps all the warts of the current patchwork. So, yes, the current for-profit system has had these issues for a long time, and the proposed Universal system would not have them. – PoloHoleSet Dec 03 '18 at 19:24
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    And, again, she ***NEVER EVER*** uses the word "Medicaid," or "Medicare" in her Tweet, so your trying to force those words into her mouth is fundamentally dishonest. She says "single payer healthcare." – PoloHoleSet Dec 03 '18 at 19:28
  • @polo That phrase, "single payer", was popularized by Sanders during his 2016 presidential campaign bid, of which Ocasio-Cortez was a volunteer. Sanders' use was limited to mean "expand Medicaid to cover all". Further Ocasio-Cortez has said just as much many times. If they really mean "like Medicaid, but so much better" perhaps they should rebrand their ideas, since Medicaid has well known issues. I'm sorry, but rarely have I seen the supporters of "single payer" recognize that the government insurance we have now has nearly the exact same issues as private insurance, plus a few more. –  Dec 03 '18 at 19:52
  • Let us [continue this discussion in chat](https://chat.stackexchange.com/rooms/86565/discussion-between-fredsbend-and-poloholeset). –  Dec 03 '18 at 19:53

1 Answers1

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The letter is from the Heart and Lung Clinic of Spectrum Health, a healthcare provider based out of Grand Rapids Michigan. It is not from either an insurance provider or a Medicaid group. In other words Spectrum is in the business of providing healthcare (and getting paid for it). It is not deciding who gets - or does not get - money to cover their healthcare needs.

More specifically the letter is from the heart transplant committee, a group of doctors who decide who is eligible for heart transplants and who is not, based on their medical judgement. They are declaring that the patient is not eligible to receive a heart transplant.

So if this is a medical judgement by a healthcare provider, why are they talking about money?

Because the immunosuppressive medication the letter talks about is a critical part of the treatment. It would appear that the patient has coverage for the transplant but not the associated drugs. Put simply, if the patient got the heart transplant but not the immunosuppressive drugs, that would not help them very much. The body's immune system would reject the new heart. Heart donors are rare, and to give a donated heart to a patient who could not take the immunosuppressive drugs (for whatever reason, including being unable to afford them) would be a waste of a heart that might save the life of someone else. So the committee removed the patient from the transplant list.

So why the talk about a GoFundMe compaign?

We don't know the reasoning, but it makes sense that this is intended to be a helpful suggestion about how the patient might raise the money if neither their insurer or Medicare will pay for the treatment.

So to summarize:

This is not a money provider refusing to pay for a treatment. It is a medical organization saying they will not provide a partial treatment (which otherwise could save the life of another patient) to someone who does not have funding for the entire treatment needed for success.

Nothing in the letter indicates whether the coverage that the patient does have is from an insurer or from Medicare (or similar). Commentators have pointed out that Medicare has a drug treatment exclusion/copay that can leave patients in this situation, but we don't know if that is the case. We can only deduce (with some confidence) that their coverage provides for a heart transplant operation but not the drugs necessary to make it successful, and draw our own conclusions about the logicality of that. And yes, the end result is going to be that the patient will probably die unless they can manage to raise $10,000, and that this problem is caused by the policies of whoever provides her coverage.

You can see a much deeper analysis of this situation on this Twitter conversation (for which thanks to @fredsbend), which also includes some of the author's political take.

DJClayworth
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