David Armstrong

Inside UnitedHealthcare’s effort to deny coverage to chronically ill patient: 'We’re still gonna say no'

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In May 2021, a nurse at UnitedHealthcare called a colleague to share some welcome news about a problem the two had been grappling with for weeks.

United provided the health insurance plan for students at Penn State University. It was a large and potentially lucrative account: lots of young, healthy students paying premiums in, not too many huge medical reimbursements going out.

But one student was costing United a lot of money. Christopher McNaughton suffered from a crippling case of ulcerative colitis — an ailment that caused him to develop severe arthritis, debilitating diarrhea, numbing fatigue and life-threatening blood clots. His medical bills were running nearly $2 million a year.

United had flagged McNaughton’s case as a “high dollar account,” and the company was reviewing whether it needed to keep paying for the expensive cocktail of drugs crafted by a Mayo Clinic specialist that had brought McNaughton’s disease under control after he’d been through years of misery.

On the 2021 phone call, which was recorded by the company, nurse Victoria Kavanaugh told her colleague that a doctor contracted by United to review the case had concluded that McNaughton’s treatment was “not medically necessary.” Her colleague, Dave Opperman, reacted to the news with a long laugh.

“I knew that was coming,” said Opperman, who heads up a United subsidiary that brokered the health insurance contract between United and Penn State. “I did too,” Kavanaugh replied.

Opperman then complained about McNaughton’s mother, whom he referred to as “this woman,” for “screaming and yelling” and “throwing tantrums” during calls with United.

The pair agreed that any appeal of the United doctor’s denial of the treatment would be a waste of the family’s time and money.

“We’re still gonna say no,” Opperman said.

More than 200 million Americans are covered by private health insurance. But data from state and federal regulators shows that insurers reject about 1 in 7 claims for treatment. Many people, faced with fighting insurance companies, simply give up: One study found that Americans file formal appeals on only 0.1% of claims denied by insurers under the Affordable Care Act.

Insurers have wide discretion in crafting what is covered by their policies, beyond some basic services mandated by federal and state law. They often deny claims for services that they deem not “medically necessary.”

When United refused to pay for McNaughton's treatment for that reason, his family did something unusual. They fought back with a lawsuit, which uncovered a trove of materials, including internal emails and tape-recorded exchanges among company employees. Those records offer an extraordinary behind-the-scenes look at how one of America's leading health care insurers relentlessly fought to reduce spending on care, even as its profits rose to record levels.

As United reviewed McNaughton’s treatment, he and his family were often in the dark about what was happening or their rights. Meanwhile, United employees misrepresented critical findings and ignored warnings from doctors about the risks of altering McNaughton’s drug plan.

At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication. Another time, a doctor paid by United concluded that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by a company doctor who rubber-stamped the recommendation of a United nurse to reject paying for the treatment.

United declined to answer specific questions about the case, even after McNaughton signed a release provided by the insurer to allow it to discuss details of his interactions with the company. United noted that it ultimately paid for all of McNaughton’s treatments. In a written response, United spokesperson Maria Gordon Shydlo wrote that the company’s guiding concern was McNaughton’s well-being.

“Mr. McNaughton’s treatment involves medication dosages that far exceed FDA guidelines,” the statement said. “In cases like this, we review treatment plans based on current clinical guidelines to help ensure patient safety.”

But the records reviewed by ProPublica show that United had another, equally urgent goal in dealing with McNaughton. In emails, officials calculated what McNaughton was costing them to keep his crippling disease at bay and how much they would save if they forced him to undergo a cheaper treatment that had already failed him. As the family pressed the company to back down, first through Penn State and then through a lawsuit, the United officials handling the case bristled.

“This is just unbelievable,” Kavanaugh said of McNaughton’s family in one call to discuss his case. ”They’re just really pushing the envelope, and I’m surprised, like I don’t even know what to say.”

The Same Meal Every Day

Now 31, McNaughton grew up in State College, Pennsylvania, just blocks from the Penn State campus. Both of his parents are faculty members at the university.

In the winter of 2014, McNaughton was halfway through his junior year at Bard College in New York. At 6 feet, 4 inches tall, he was a guard on the basketball team and had started most of the team’s games since the start of his sophomore year. He was majoring in psychology.

When McNaughton returned to school after the winter holiday break, he started to experience frequent bouts of bloody diarrhea. After just a few days on campus, he went home to State College, where doctors diagnosed him with a severe case of ulcerative colitis.

A chronic inflammatory bowel disease that causes swelling and ulcers in the digestive tract, ulcerative colitis has no cure, and ongoing treatment is needed to alleviate symptoms and prevent serious health complications. The majority of cases produce mild to moderate symptoms. McNaughton’s case was severe.

Treatments for ulcerative colitis include steroids and special drugs known as biologics that work to reduce inflammation in the large intestine.

McNaughton, however, failed to get meaningful relief from the drugs his doctors initially prescribed. He was experiencing bloody diarrhea up to 20 times a day, with such severe stomach pain that he spent much of his day curled up on a couch. He had little appetite and lost 50 pounds. Severe anemia left him fatigued. He suffered from other conditions related to his colitis, including crippling arthritis. He was hospitalized several times to treat dangerous blood clots.

For two years, in an effort to help alleviate his symptoms, he ate the same meals every day: Rice Chex cereal and scrambled eggs for breakfast, a cup of white rice with plain chicken breast for lunch and a similar meal for dinner, occasionally swapping in tilapia.

His hometown doctors referred him to a specialist at the University of Pittsburgh, who tried unsuccessfully to bring his disease under control. That doctor ended up referring McNaughton to Dr. Edward Loftus Jr. at the Mayo Clinic in Minnesota, which has been ranked as the best gastroenterology hospital in the country every year since 1990 by U.S. News & World Report.

For his first visit with Loftus in May 2015, McNaughton and his mother, Janice Light, charted hospitals along the 900-mile drive from Pennsylvania to Minnesota in case they needed medical help along the way.

Mornings were the hardest. McNaughton often spent several hours in the bathroom at the start of the day. To prepare for his meeting with Loftus, he set his alarm for 3:30 a.m. so he could be ready for the 7:30 a.m. appointment. Even with that preparation, he had to stop twice to use a bathroom on the five-minute walk from the hotel to the clinic. When they met, Loftus looked at McNaughton and told him that he appeared incapacitated. It was, he told the student, as if McNaughton were chained to the bathroom, with no outside life. He had not been able to return to school and spent most days indoors, managing his symptoms as best he could.

McNaughton had tried a number of medications by this point, none of which worked. This pattern would repeat itself during the first couple of years that Loftus treated him.

In addition to trying to find a treatment that would bring McNaughton’s colitis into remission, Loftus wanted to wean him off the steroid prednisone, which he had been taking since his initial diagnosis in 2014. The drug is commonly prescribed to colitis patients to control inflammation, but prolonged use can lead to severe side effects including cataracts, osteoporosis, increased risk of infection and fatigue. McNaughton also experienced “moon face,” a side effect caused by the shifting of fat deposits that results in the face becoming puffy and rounder.

In 2018, Loftus and McNaughton decided to try an unusual regimen. Many patients with inflammatory bowel diseases like colitis take a single biologic drug as treatment. Whereas traditional drugs are chemically synthesized, biologics are manufactured in living systems, such as plant or animal cells. A year’s supply of an individual biologic drug can cost up to $500,000. They are often given through infusions in a medical facility, which adds to the cost.

McNaughton had tried individual biologics, and then two in combination, without much success. He and Loftus then agreed to try two biologic drugs together at doses well above those recommended by the U.S. Food and Drug Administration. Prescribing drugs for purposes other than what they are approved for or at higher doses than those approved by the FDA is a common practice in medicine referred to as off-label prescribing. The federal Agency for Healthcare Research and Quality estimates 1 in 5 prescriptions written today are for off-label uses.

There are drawbacks to the practice. Since some uses and doses of particular drugs have not been extensively studied, the risks and efficacy of using them off-label are not well known. Also, some drug manufacturers have improperly pushed off-label usage of their products to boost sales despite little or no evidence to support their use in those situations. Like many leading experts and researchers in his field, Loftus has been paid to do consulting related to the biologic drugs taken by McNaughton. The payments related to those drugs have ranged from a total of $1,440 in 2020 to $51,235 in 2018. Loftus said much of his work with pharmaceutical companies was related to conducting clinical trials on new drugs.

In cases of off-label prescribing, patients are depending upon their doctor’s expertise and experience with the drug.“In this case, I was comfortable that the potential benefits to Chris outweighed the risks,” Loftus said.

There was evidence that the treatment plan for McNaughton might work, including studies that had found dual biologic therapy to be efficacious and safe. The two drugs he takes, Entyvio and Remicade, have the same purpose — to reduce inflammation in the large intestine — but each works differently in the body. Remicade, marketed by Janssen Biotech, targets a protein that causes inflammation. Entyvio, made by Takeda Pharmaceuticals, works by preventing an excess of white blood cells from entering into the gastrointestinal tract.

As for any suggestion by United doctors that his treatment plan for McNaughton was out of bounds or dangerous, Loftus said “my treatment of Chris was not clinically inappropriate — as was shown by Chris’ positive outcome.”

The unusual high-dose combination of two biologic drugs produced a remarkable change in McNaughton. He no longer had blood in his stool, and his trips to the bathroom were cut from 20 times a day to three or four. He was able to eat different foods and put on weight. He had more energy. He tapered off prednisone.

“If you told me in 2015 that I would be living like this, I would have asked where do I sign up,” McNaughton said of the change he experienced with the new drug regimen.

When he first started the new treatment, McNaughton was covered under his family’s plan, and all his bills were paid. McNaughton enrolled at the university in 2020. Before switching to United’s plan for students, McNaughton and his parents consulted with a health advocacy service offered to faculty members. A benefits specialist assured them the drugs taken by McNaughton would be covered by United.

McNaughton joined the student plan in July 2020, and his infusions that month and the following month were paid for by United. In September, the insurer indicated payment on his claims was “pending,” something it did for his other claims that came in during the rest of the year.

McNaughton and his family were worried. They called United to make sure there wasn’t a problem; the insurer told them, they said, that it only needed to check his medical records. When the family called again, United told them it had the documentation needed, they said. United, in a court filing last year, said it received two calls from the family and each time indicated that all of the necessary medical records had not yet been received.

In January 2021, McNaughton received a new explanation of benefits for the prior months. All of the claims for his care, beginning in September, were no longer “pending.” They were stamped “DENIED.” The total outstanding bill for his treatment was $807,086.

When McNaughton’s mother reached a United customer service representative the next day to ask why bills that had been paid in the summer were being denied for the fall, the representative told her the account was being reviewed because of “a high dollar amount on the claims,” according to a recording of the call.


With United refusing to pay, the family was terrified of being stuck with medical bills that would bankrupt them and deprive McNaugton of treatment that they considered miraculous.

They turned to Penn State for help. Light and McNaughton’s father, David, hoped their position as faculty members would make the school more willing to intervene on their behalf.

“After more than 30 years on faculty, my husband and I know that this is not how Penn State would want its students to be treated,” Light wrote to a school official in February 2021.

In response to questions from ProPublica, Penn State spokesperson Lisa Powers wrote that “supporting the health and well-being of our students is always of primary importance” and that “our hearts go out to any student and family impacted by a serious medical condition.” The university, she wrote, does “not comment on students’ individual circumstances or disclose information from their records.” McNaughton offered to grant Penn State whatever permissions it needed to speak about his case with ProPublica. The school, however, wrote that it would not comment “even if confidentiality has been waived.”

The family appealed to school administrators. Because the effectiveness of biologics wanes in some patients if doses are skipped, McNaughton and his parents were worried about even a delay in treatment. His doctor wrote that if he missed scheduled infusions of the drugs, there was “a high likelihood they would no longer be effective.”

During a conference call arranged by Penn State officials on March 5, 2021, United agreed to pay for McNaughton’s care through the end of the plan year that August. Penn State immediately notified the family of the “wonderful news” while also apologizing for “the stress this has caused Chris and your family.”

Behind the scenes, McNaughton’s review had “gone all the way to the top” at United’s student health plan division, Kavanaugh, the nurse, said in a recorded conversation.

The family’s relief was short-lived. A month later, United started another review of McNaughton’s care, overseen by Kavanaugh, to determine if it would pay for the treatment in the upcoming plan year.

The nurse sent the McNaughton case to a company called Medical Review Institute of America. Insurers often turn to companies like MRIoA to review coverage decisions involving expensive treatments or specialized care.

Kavanaugh, who was assigned to a special investigations unit at United, let her feelings about the matter be known in a recorded telephone call with a representative of MRIoA.

“This school apparently is a big client of ours,” she said. She then shared her opinion of McNaughton’s treatment. “Really this is a case of a kid who’s getting a drug way too much, like too much of a dose,” Kavanaugh said. She said it was “insane that they would even think that this is reasonable” and “to be honest with you, they’re awfully pushy considering that we are paying through the end of this school year.”

MRIoA sent the case to Dr. Vikas Pabby, a gastroenterologist at UCLA Health and a professor at the university’s medical school. His May 2021 review of McNaughton’s case was just one of more than 300 Pabby did for MRIoA that month, for which he was paid $23,000 in total, according to a log of his work produced in the lawsuit.

In a May 4, 2021 report, Pabby concluded McNaughton’s treatment was not medically necessary, because United’s policies for the two drugs taken by McNaughton did not support using them in combination.

Insurers spell out what services they cover in plan policies, lengthy documents that can be confusing and difficult to understand. Many policies, such as McNaughton’s, contain a provision that treatments and procedures must be “medically necessary” in order to be covered. The definition of medically necessary differs by plan. Some don’t even define the term. McNaughton’s policy contains a five-part definition, including that the treatment must be “in accordance with the standards of good medical policy” and “the most appropriate supply or level of service which can be safely provided.”

Behind the scenes at United, Opperman and Kavanaugh agreed that if McNaughton were to appeal Pabby’s decision, the insurer would simply rule against him. “I just think it’s a waste of money and time to appeal and send it to another one when we know we’re gonna get the same answer,” Opperman said, according to a recording in court files. At Opperman’s urging, United decided to skip the usual appeals process and arrange for Pabby to have a so-called “peer-to-peer” discussion with Loftus, the Mayo physician treating McNaughton. Such a conversation, in which a patient’s doctor talks with an insurance company’s doctor to advocate for the prescribed treatment, usually only occurs after a customer has appealed a denial and the appeal has been rejected.

When Kavanaugh called Loftus’ office to set up a conversation with Pabby, she explained it was an urgent matter and had been requested by McNaughton. “You know I’ve just gotten to know Christopher,” she explained, although she had never spoken with him. “We’re trying to advocate and help and get this peer-to-peer set up.”

McNaughton, meanwhile, had no idea at the time that a United doctor had decided his treatment was unnecessary and that the insurer was trying to set up a phone call with his physician.

In the peer-to-peer conversation, Loftus told Pabby that McNaughton had “a very complicated case” and that lower doses had not worked for him, according to an internal MRIoA memo.

Following his conversation with Loftus, Pabby created a second report for United. He recommended the insurer pay for both drugs, but at reduced doses. He added new language saying that the safety of using both drugs at the higher levels “is not established.”

When Kavanaugh shared the May 12 decision from Pabby with others at United, her boss responded with an email calling it “great news.”

Then Opperman sent an email that puzzled the McNaughtons.

In it, Opperman claimed that Loftus and Pabby had agreed that McNaughton should be on significantly lower doses of both drugs. He said Loftus “will work with the patient to start titrating them down” — or reducing the dosage — “to a normal dose range.” Opperman wrote that United would cover McNaughton’s treatment in the coming year, but only at the reduced doses. Opperman did not respond to emails and phone messages seeking comment.

McNaughton didn’t believe a word of it. He had already tried and failed treatment with those drugs at lower doses, and it was Loftus who had upped the doses, leading to his remission from severe colitis.

The only thing that made sense to McNaughton was that the treatment United said it would now pay for was dramatically cheaper — saving the company at least hundreds of thousands of dollars a year — than his prescribed treatment because it sliced the size of the doses by more than half.

When the family contacted Loftus for an explanation, they were outraged by what they heard. Loftus told them that he had never recommended lowering the dosage. In a letter, Loftus wrote that changing McNaughton’s treatment “would have serious detrimental effects on both his short term and long term health and could potentially involve life threatening complications. This would ultimately incur far greater medical costs. Chris was on the doses suggested by United Healthcare before, and they were not at all effective.”

It would not be until the lawsuit that it would become clear how Loftus’ conversations had been so seriously misrepresented.

Under questioning by McNaughton’s lawyers, Kavanaugh acknowledged that she was the source of the incorrect claim that McNaughton’s doctor had agreed to a change in treatment.

“I incorrectly made an assumption that they had come to some sort of agreement,” she said in a deposition last August. “It was my first peer-to-peer. I did not realize that that simply does not occur.”

Kavanaugh did not respond to emails and telephone messages seeking comment.

When the McNaughtons first learned of Opperman’s inaccurate report of the phone call with Loftus, it unnerved them. They started to question if their case would be fairly reviewed.

“When we got the denial and they lied about what Dr. Loftus said, it just hit me that none of this matters,” McNaughton said. “They will just say or do anything to get rid of me. It delegitimized the entire review process. When I got that denial, I was crushed.”

A Buried Report

While the family tried to sort out the inaccurate report, United continued putting the McNaughton case in front of more company doctors.

On May 21, 2021, United sent the case to one of its own doctors, Dr. Nady Cates, for an additional review. The review was marked “escalated issue.” Cates is a United medical director, a title used by many insurers for physicians who review cases. It is work he has been doing as an employee of health insurers since 1989 and at United since 2010. He has not practiced medicine since the early 1990s.

Cates, in a deposition, said he stopped seeing patients because of the long hours involved and because “AIDS was coming around then. I was seeing a lot of military folks who had venereal diseases, and I guess I was concerned about being exposed.” He transitioned to reviewing paperwork for the insurance industry, he said, because “I guess I was a chicken.”

When he had practiced, Cates said, he hadn’t treated patients with ulcerative colitis and had referred those cases to a gastroenterologist.

He said his review of McNaughton’s case primarily involved reading a United nurse’s recommendation to deny his care and making sure “that there wasn't a decimal place that was out of line.” He said he copied and pasted the nurse’s recommendation and typed “agree” on his review of McNaughton’s case.

Cates said that he does about a hundred reviews a week. He said that in his reviews he typically checks to see if any medications are prescribed in accordance with the insurer’s guidelines, and if not, he denies it. United’s policies, he said, prevented him from considering that McNaughton had failed other treatments or that Loftus was a leading expert in his field.

“You are giving zero weight to the treating doctor’s opinion on the necessity of the treatment regimen?” a lawyer asked Cates in his deposition. He responded, “Yeah.”

Attempts to contact Cates for comment were unsuccessful.

At the same time Cates was looking at McNaughton’s case, yet another review was underway at MRIoA. United said it sent the case back to MRIoA after the insurer received the letter from Loftus warning of the life-threatening complications that might occur if the dosages were reduced.

On May 24, 2021, the new report requested by MRIoA arrived. It came to a completely different conclusion than all of the previous reviews.

Dr. Nitin Kumar, a gastroenterologist in Illinois, concluded that McNaughton’s established treatment plan was not only medically necessary and appropriate but that lowering his doses “can result in a lack of effective therapy of Ulcerative Colitis, with complications of uncontrolled disease (including dysplasia leading to colorectal cancer), flare, hospitalization, need for surgery, and toxic megacolon.”

Unlike other doctors who produced reports for United, Kumar discussed the harm that McNaughton might suffer if United required him to change his treatment. “His disease is significantly severe, with diagnosis at a young age,” Kumar wrote. “He has failed every biologic medication class recommended by guidelines. Therefore, guidelines can no longer be applied in this case.” He cited six studies of patients using two biologic drugs together and wrote that they revealed no significant safety issues and found the therapy to be “broadly successful.”

When Kavanaugh learned of Kumar’s report, she quickly moved to quash it and get the case returned to Pabby, according to her deposition.

In a recorded telephone call, Kavanaugh told an MRIoA representative that “I had asked that this go back through Dr. Pabby, and it went through a different doctor and they had a much different result.” After further discussion, the MRIoA representative agreed to send the case back to Pabby. “I appreciate that,” Kavanaugh replied. “I just want to make sure, because, I mean, it’s obviously a very different result than what we’ve been getting on this case.”

MRIoA case notes show that at 7:04 a.m. on May 25, 2021, Pabby was assigned to take a look at the case for the third time. At 7:27 a.m., the notes indicate, Pabby again rejected McNaughton’s treatment plan. While noting it was “difficult to control” McNaughton’s ulcerative colitis, Pabby added that his doses “far exceed what is approved by literature” and that the “safety of the requested doses is not supported by literature.”

In a deposition, Kavanaugh said that after she opened the Kumar report and read that he was supporting McNaughton’s current treatment plan, she immediately spoke to her supervisor, who told her to call MRIoA and have the case sent back to Pabby for review.

Kavanaugh said she didn’t save a copy of the Kumar report, nor did she forward it to anyone at United or to officials at Penn State who had been inquiring about the McNaughton case. “I didn’t because it shouldn’t have existed,” she said. “It should have gone back to Dr. Pabby.”

When asked if the Kumar report caused her any concerns given his warning that McNaughton risked cancer or hospitalization if his regimen were changed, Kavanaugh said she didn’t read his full report. “I saw that it was not the correct doctor, I saw the initial outcome and I was asked to send it back,” she said. Kavanaugh added, “I have a lot of empathy for this member, but it needed to go back to the peer-to-peer reviewer.”

In a court filing, United said Kavanaugh was correct in insisting that Pabby conduct the review and that MRIoA confirmed that Pabby should have been the one doing the review.

The Kumar report was not provided to McNaughton when his lawyer, Jonathan Gesk, first asked United and MRIoA for any reviews of the case. Gesk discovered it by accident when he was listening to a recorded telephone call produced by United in which Kavanaugh mentioned a report number Gesk had not heard before. He then called MRIoA, which confirmed the report existed and eventually provided it to him.

Pabby asked ProPublica to direct any questions about his involvement in the matter to MRIoA. The company did not respond to questions from ProPublica about the case.

A Sense of Hopelessness

When McNaughton enrolled at Penn State in 2020, it brought a sense of normalcy that he had lost when he was first diagnosed with colitis. He still needed monthly hours-long infusions and suffered occasional flare-ups and symptoms, but he was attending classes in person and living a life similar to the one he had before his diagnosis.

It was a striking contrast to the previous six years, which he had spent largely confined to his parents’ house in State College. The frequent bouts of diarrhea made it difficult to go out. He didn’t talk much to friends and spent as much time as he could studying potential treatments and reviewing ongoing clinical trials. He tried to keep up with the occasional online course, but his disease made it difficult to make any real progress toward a degree.

United, in correspondence with McNaughton, noted that its review of his care was “not a treatment decision. Treatment decisions are made between you and your physician.” But by threatening not to pay for his medications, or only to pay for a different regimen, McNaughton said, United was in fact attempting to dictate his treatment. From his perspective, the insurer was playing doctor, making decisions without ever examining him or even speaking to him.

The idea of changing his treatment or stopping it altogether caused constant worry for McNaughton, exacerbating his colitis and triggering physical symptoms, according to his doctors. Those included a large ulcer on his leg and welts under his skin on his thighs and shin that made his leg muscles stiff and painful to the point where he couldn’t bend his leg or walk properly. There were daily migraines and severe stomach pain. “I was consumed with this situation,” McNaughton said. “My path was unconventional, but I was proud of myself for fighting back and finishing school and getting my life back on track. I thought they were singling me out. My biggest fear was going back to the hell.”

McNaughton said he contemplated suicide on several occasions, dreading a return to a life where he was housebound or hospitalized.

McNaughton and his parents talked about him possibly moving to Canada where his grandmother lived and seeking treatment there under the nation’s government health plan.

Loftus connected McNaughton with a psychologist who specializes in helping patients with chronic digestive diseases.

The psychologist, Tiffany Taft, said McNaughton was not an unusual case. About 1 in 3 patients with diseases like colitis suffer from medical trauma or PTSD related to it, she said, often the result of issues related to getting appropriate treatment approved by insurers.

“You get into hopelessness,” she said of the depression that accompanies fighting with insurance companies over care. “They feel like ‘I can’t fix that. I am screwed.’ When you can’t control things with what an insurance company is doing, anxiety, PTSD and depression get mixed together.”

In the case of McNaughton, Taft said, he was being treated by one of the best gastroenterologists in the world, was doing well with his treatment and then was suddenly notified he might be on the hook for nearly a million dollars in medical charges without access to his medications. “It sends you immediately into panic about all these horrific things that could happen,” Taft said. The physical and mental symptoms McNaughton suffered after his care was threatened were “triggered” by the stress he experienced, she said.

In early June 2021, United informed McNaughton in a letter that it would not cover the cost of his treatment regimen in the next academic year, starting in August. The insurer said it would only pay for a treatment plan that called for a significant reduction in the doses of the drugs he took.

United wrote that the decision came after his “records have been reviewed three times and the medical reviewers have concluded that the medication as prescribed does not meet the Medical Necessity requirement of the plan.”

In August 2021, McNaughton filed a federal lawsuit accusing United of acting in bad faith and unreasonably making treatment decisions based on financial concerns and not what was the best and most effective treatment. It claims United had a duty to find information that supported McNaughton’s claim for treatment rather than looking for ways to deny coverage.

United, in a court filing, said it did not breach any duty it owed to McNaughton and acted in good faith. On Sept. 20, 2021, a month after filing the lawsuit, and with United again balking at paying for his treatment, McNaughton asked a judge to grant a temporary restraining order requiring United to pay for his care. With the looming threat of a court hearing on the motion, United quickly agreed to cover the cost of McNaughton’s treatment through the end of the 2021-2022 academic year. It also dropped a demand requiring McNaughton to settle the matter as a condition of the insurer paying for his treatment as prescribed by Loftus, according to an email sent by United’s lawyer.

The Cost of Treatment

It is not surprising that insurers are carefully scrutinizing the care of patients treated with biologics, which are among the most expensive medications on the market. Biologics are considered specialty drugs, a class that includes the best-selling Humira, used to treat arthritis. Specialty drug spending in the U.S. is expected to reach $505 billion in 2023, according to an estimate from Optum, United’s health services division. The Institute for Clinical and Economic Review, a nonprofit that analyzes the value of drugs, found in 2020 that the biologic drugs used to treat patients like McNaughton are often effective but overpriced for their therapeutic benefit. To be judged cost-effective by ICER, the biologics should sell at a steep discount to their current market price, the panel found.

A panel convened by ICER to review its analysis cautioned that insurance coverage “should be structured to prevent situations in which patients are forced to choose a treatment approach on the basis of cost.” ICER also found examples where insurance company policies failed to keep pace with updates to clinical practice guidelines based on emerging research.

United officials did not make the cost of treatment an issue when discussing McNaughton’s care with Penn State administrators or the family.

Bill Truxal, the president of UnitedHealthcare StudentResources, the company’s student health plan division, told a Penn State official that the insurer wanted the “best for the student” and it had “nothing to do with cost,” according to notes the official took of the conversation.

Behind the scenes, however, the price of McNaughton’s care was front and center at United.

In one email, Opperman asked about the cost difference if the insurer insisted on only paying for greatly reduced doses of the biologic drugs. Kavanaugh responded that the insurer had paid $1.1 million in claims for McNaughton’s care as of the middle of May 2021. If the reduced doses had been in place, the amount would have been cut to $260,218, she wrote.

United was keeping close tabs on McNaughton at the highest levels of the company. On Aug. 2, 2021, Opperman notified Truxal and a United lawyer that McNaughton “has just purchased the plan again for the 21-22 school year.”

A month later, Kavanaugh shared another calculation with United executives showing that the insurer spent over $1.7 million on McNaughton in the prior plan year.

United officials strategized about how to best explain why it was reviewing McNaughton’s drug regimen, according to an internal email. They pointed to a justification often used by health insurers when denying claims. “As the cost of healthcare continues to climb to soaring heights, it has been determined that a judicious review of these drugs should be included” in order to “make healthcare more affordable for our members,” Kavanaugh offered as a potential talking point in an April 23, 2021, email.

Three days later, UnitedHealth Group filed an annual statement with the U.S. Securities and Exchange Commission disclosing its pay for top executives in the prior year. Then-CEO David Wichmann was paid $17.9 million in salary and other compensation in 2020. Wichmann retired early the following year, and his total compensation that year exceeded $140 million, according to calculations in a compensation database maintained by the Star Tribune in Minneapolis. The newspaper said the amount was the most paid to an executive in the state since it started tracking pay more than two decades ago. About $110 million of that total came from Wichmann exercising stock options accumulated during his stewardship.

The McNaughtons were well aware of the financial situation at United. They looked at publicly available financial results and annual reports. Last year, United reported a profit of $20.1 billion on revenues of $324.2 billion.

When discussing the case with Penn State, Light said, she told university administrators that United could pay for a year of her son’s treatment using just minutes’ worth of profit.


McNaughton has been able to continue receiving his infusions for now, anyway. In October, United notified him it was once again reviewing his care, although the insurer quickly reversed course when his lawyer intervened. United, in a court filing, said the review was a mistake and that it had erred in putting McNaughton’s claims into pending status.

McNaughton said he is fortunate his parents were employed at the same school he was attending, which was critical in getting the attention of administrators there. But that help had its limits.

In June 2021, just a week after United told McNaughton it would not cover his treatment plan in the upcoming plan year, Penn State essentially walked away from the matter.

In an email to the McNaughtons and United, Penn State Associate Vice President for Student Affairs Andrea Dowhower wrote that administrators “have observed an unfortunate breakdown in communication” between McNaughton and his family and the university health insurance plan, “which appears from our perspective to have resulted in a standstill between the two parties.” While she proposed some potential steps to help settle the matter, she wrote that “Penn State’s role in this process is as a resource for students like Chris who, for whatever reason, have experienced difficulty navigating the complex world of health insurance.” The university’s role “is limited,” she wrote, and the school “simply must leave” the issue of the best treatment for McNaughton to “the appropriate health care professionals.”

In a statement, a Penn State spokesperson wrote that “as a third party in this arrangement, the University’s role is limited and Penn State officials can only help a student manage an issue based on information that a student/family, medical personnel, and/or insurance provider give — with the hope that all information is accurate and that the lines of communication remain open between the insured and the insurer.”

Penn State declined to provide financial information about the plan. However, the university and United share at least one tie that they have not publicly disclosed.

When the McNaughtons first reached out to the university for help, they were referred to the school’s student health insurance coordinator. The official, Heather Klinger, wrote in an email to the family in February 2021 that “I appreciate your trusting me to resolve this for you.”

In April 2022, United began paying Klinger’s salary, an arrangement which is not noted on the university website. Klinger appears in the online staff directory on the Penn State University Health Services webpage, and has a university phone number, a university address and a Penn State email listed as her contact. The school said she has maintained a part-time status with the university to allow her to access relevant data systems at both the university and United.

The university said students “benefit” from having a United employee to handle questions about insurance coverage and that the arrangement is “not uncommon” for student health plans.

The family was dismayed to learn that Klinger was now a full-time employee of United.

“We did feel betrayed,” Light said. Klinger did not respond to an email seeking comment.

McNaughton’s fight to maintain his treatment regimen has come at a cost of time, debilitating stress and depression. “My biggest fear is realizing I might have to do this every year of my life,” he said.

McNaughton said one motivation for his lawsuit was to expose how insurers like United make decisions about what care they will pay for and what they will not. The case remains pending, a court docket shows.

He has been accepted to Penn State’s law school. He hopes to become a health care lawyer working for patients who find themselves in situations similar to his.

He plans to reenroll in the United health care plan when he starts school next fall.

Dying on the waitlist: Doctors forced to decide who gets lifesaving COVID-19 care — and who doesn’t

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.This story was originally published by ProPublica.

Series: Coronavirus

The U.S. Response to COVID-19

In early December, Miguel Fernandez lay unconscious in the intensive care unit at a Los Angeles area hospital. A mechanical ventilator pumped oxygen into his lungs, which had been ravaged by COVID-19. The 53-year-old was dying.

The best, and likely only, chance of Miguel surviving was a therapy calledextracorporeal membrane oxygenation, better known as ECMO. It would allow his lungs to rest while a machine infused his blood with the oxygen he needed. But PIH Health Whittier Hospital, where he had been admitted, didn't have any ECMO machines or the highly trained staff needed to run them. Only a handful of hospitals in southern California did, and they were overrun with COVID-19 cases.

Since the beginning of the pandemic, public health experts had been warning about the need to “bend the curve" — to prevent the number of COVID-19 cases from spiking so hospitals wouldn't get overwhelmed.

But starting in early November, the daily number of COVID-19 hospitalizations surged in Los Angeles County, rising eightfold between then and the wave's crest, which arrived just after New Year's Day. Within weeks, overflowing hospitals faced exactly the types of care-rationing decisions experts had feared. Hospitals set up tents to increase capacity, and ambulances circled for hours as they waited for beds to open. By early January, Los Angeles County emergency medical personnel were directed to conserve supplemental oxygen by only administering it to the neediest patients, and to stop transporting to hospitals cardiac arrest patients who couldn't be revived in the field. State officials dispatched refrigerated trucks and thousands of body bags to the region.

Inside the hospitals, for patients like Miguel, a dire situation unfolded out of public view. Critically ill patients who might survive with ECMO could not get the treatment. Doctors had to choose who received the therapy based on who they thought had the best chance to survive. Some were approved, but had to be put on a waitlist. Many patients died waiting.

“I don't think we ever thought we'd get to this point, not in California," said Dr. Jack Sun, who oversees the program that includes ECMO at UCI Health in Orange County, 30 miles southeast of Los Angeles. “You know if you don't have a bed for somebody, they are going to die."

In some parts of the country, doctors can tap into centralized systems to quickly find any available bed for ECMO at any hospital in the region. That's not the case in Los Angeles. Miguel's caregivers and family would have to hack through red tape and navigate an opaque, disconnected and sometimes unfair system to try to save his life.

Miguel, the oldest of seven siblings in a family of Mexican immigrants, was always the one who fixed things. If someone needed a job, he would help them find work. If a car broke down, he would repair it. His sister, Margarita Rodriguez, described him as a “big cuddly bear" who gave her hugs and always made her smile. Just before he was hospitalized, he had stopped by to patch a leak in her roof.

Now the family had to find a way to fix Miguel.

They scoured the internet with searches like “What do you do when a ventilator fails?" One night, Margarita found a success story from San Diego about the use of ECMO. An ECMO machine takes over the work of a patient's lungs. It extracts blood from the body and circulates it through an artificial lung that removes carbon dioxide and adds oxygen before returning the blood to the body. One study of patients at 68 U.S. hospitals found that critically ill COVID-19 patients like Miguel “had a considerably lower risk of death" if they received ECMO during their first seven days in an ICU.

Miguel was relatively healthy other than having COVID-19. He didn't smoke or have any preexisting illnesses like diabetes. He was overweight, but below weight cutoffs used by ECMO centers to determine eligibility. Across the country, patients like Miguel who had been near death on a ventilator one day were alive and leaving a hospital weeks later after undergoing ECMO.

Miguel's oldest son, Miguel Jr., knew from his conversations with doctors that his dad wasn't going to get better by staying on the ventilator. “ECMO was his last hope, his best chance to survive," Miguel Jr. said. “It was ECMO or death."

A Desperate Search

Miguel and his family had tried to protect themselves from the virus. Three of his four adult children live in his home, and when they got infected in the fall, the family isolated as much as possible. Miguel stayed distanced on some nights by sleeping in an old RV he had in the backyard.

The pandemic had forced the extended Fernandez clan to cut back on family gatherings. Before COVID-19, Miguel had often organized get-togethers at his home on the southeastern side of Los Angeles, for birthdays or graduations, or to watch football or grill. After his only daughter, Jeannette, was accepted by UCLA last year, he proudly walked around her send-off bash in a “UCLA Dad" T-shirt.

But Miguel had to keep working. He and two of his brothers owned a construction business that bought and renovated homes. They had flipped hundreds of properties, starting 12 years ago with an $80,000 fixer-upper in Compton and more recently a $2.5 million project in Pasadena. Two of Miguel's three sons worked with him. Even after COVID-19 struck his family, Miguel still had to pick up supplies and go to job sites.

In early November, Miguel started to feel sick and went to a coronavirus testing site at a local recreation center. Two days later he received an email telling him what he already suspected: He had COVID-19. By Nov. 15, he had a fever and night sweats and was having trouble breathing.

Even though he was getting sicker, Miguel didn't want to go to the hospital. He knew people like him were dying. Latino Angelenos have suffered the highest COVID-19 death rate in Los Angeles County — almost twice the rate of Blacks and about three times the rate for whites.

But by Nov. 17, Miguel struggled to breathe as he walked from the bathroom to the couch. The family had purchased an oximeter, a device that measures oxygen levels in the blood when clipped onto a finger. His oxygen level had dropped to 77%, dangerously below the 95% considered at the low range of what's normal.

“We realized this was a real emergency," said Jeannette, his 21-year-old daughter. Just before midnight, two of Miguel's sons helped him into the passenger seat of the family's Ford Explorer. Jeannette took the wheel and Miguel's wife, Alejandrina, got in the back seat.

Jeannette headed to PIH Health Whittier Hospital, a 523-bed facility near their home. Outside the emergency room, the staff helped the 275-pound Miguel into a wheelchair and put an oxygen monitor on his finger. It sounded an alarm. His wife and daughter could see fear in his eyes; he didn't say a word as he was rushed into the hospital. Jeannette and Alejandrina didn't even get to say goodbye.

PIH Health declined to make caregivers available for interviews or answer questions about Miguel's care. “PIH Health will not be able to provide a statement for this story," a hospital spokesperson said in an email.

Hospital records show that Miguel was given high-flow oxygen through a face mask and put in a bed that allowed hospital staff to flip him on his belly, boosting his oxygen level to 93%. He was treated with steroids and an antiviral drug. Two days after admission, things were looking up.

Jeannette began providing updates through a group text message labeled “Familia." It included Miguel's brothers, many cousins, nieces and nephews, parents and his four children. Miguel was “doing good," she reported. Miguel spent his days reading messages on his phone, even when lying on his stomach. He sent his family photos of his food, and made special requests of the hospital staff, asking for buttered sourdough toast and prune juice with breakfast.

The family hoped Miguel would be home for Thanksgiving. But the course of COVID-19 is unpredictable.

At 11 p.m. on Nov. 22, Miguel texted his family, letting them know he expected to have a long night. He wrote in a text: “if I want to make it to thanksgiving have stay awake and restore my oxygen levels."

When Thanksgiving arrived four days later, a scan of Miguel's lungs revealed inflammation and scar tissue. Doctors started him on a 10-day course of anti-inflammation medication. “Be out by Christmas," Miguel texted.

The family responded with encouragement. “Hang in there we are all with you," wrote his sister Margarita. “Ten days go by really fast."

But eight days later, on Dec. 4, Miguel's oxygen levels plummeted. The doctors put him on a ventilator.

Miguel was now fighting for his life.

Unable to visit him, the family prayed for his recovery. Every night Miguel was in the hospital, his extended family gathered on Zoom at 7:30 p.m. Miguel's 71-year-old mother, Martha, and 73-year-old father, Salvador, would lead an hour-long prayer session while clutching rosary beads.

The separation was especially difficult for Alejandrina, who had been married to Miguel since 1991. Miguel liked to tease her when she watched her Mexican telenovelas: Why do you watch those shows when you have me? On Mother's Day earlier in the year, Miguel had surprised her by buying a pair of rings, getting down on one knee and proposing again. The couple made plans to renew their vows on their 30th wedding anniversary this summer. When he became sick with COVID-19, Miguel assured Alejandrina he would get better so they could get married again. She promised she would wait for him.

After Miguel was intubated, his family gathered in the parking lot outside the building where ICU patients are treated, to be as close to him as possible. Miguel's mother knelt on the pavement for 40 minutes, her hands clasped in prayer. She told her grandchildren that praying needed to be sacrificial. It had to hurt to be effective.

It was hard for Miguel's family to reach the doctors to discuss treatment options, in part because family members couldn't visit. It was impossible to build a relationship at the bedside or buttonhole doctors on their rounds, the way they could have in non-pandemic times. They called multiple times a day, but it was difficult to get clear information.

When a doctor did call with an update, Miguel's daughter Jeannette would patch in her brother, Miguel Jr., and Miguel's niece, Jhaimy Fernandez, a fourth-year medical student at the University of Vermont's Larner College of Medicine.

Miguel's family members said they were the ones to bring up ECMO, shortly after he was intubated. The ICU doctor treating Miguel told them ECMO was not an option, they recalled. Jhaimy requested a consultation with the palliative care team, which specializes in helping critically ill patients and their families make treatment decisions. The palliative care team, however, agreed with the ICU doctor, she said.

“They just thought it was outrageous for us to even think about ECMO," Jhaimy said of the hospital's doctors.

Miguel Jr. said it seemed as if the doctors were not familiar with his father's medical history. They asked if he had diabetes, Miguel Jr. said, which he didn't. He didn't have any preexisting conditions that typically make patients unsuitable for ECMO. Although some ECMO centers use age cutoffs, Miguel, at 53, was young enough to be considered appropriate for the therapy.

Carlos Fernandez, Miguel's younger brother and business partner, said it was frustrating that the family had to bring the ECMO option to the caregiving team.

“They just kind of wrote him off," he said, adding that it's possible the treatment team was just overwhelmed. “He's an older, Latino, overweight man. That is the demographic the coronavirus is looking for."

In a discussion with Miguel's daughter in the early afternoon of Dec. 7, a doctor called his prognosis “very poor," according to notes in his hospital record.

That update, however, was followed by more hopeful news. The family's insistence had paid off. His doctors had now decided he was, in fact, a candidate for ECMO. The family doesn't know what changed their minds, and the medical records do not describe how the doctors arrived at that decision. The medical team told the family Miguel would be transferred soon to a site where he could receive the new treatment.

A Tangled System

That afternoon, a hospital patient case manager began the effort to find Miguel an ECMO bed.

There is no central database that hospital staff can tap into to quickly figure out where in the greater Los Angeles area an empty ECMO bed might exist. Case managers typically have to call hospitals one by one, navigating each facility's particular bureaucracy and coordinating it all with Miguel's insurer.

“It is a nonsensical, haphazard collection of stakeholders, and the pandemic has found the fault lines in it," said Dr. Douglas White, a physician who directs the program on ethics and decision making in critical illness at the University of Pittsburgh School of Medicine.

A key reason ECMO is being rationed in the U.S. is a lack of regional coordination, White said. “If one hospital has no ECMO [units], but another 50 miles away has one, there needs to be a system in place to connect them," he said. “That's how you prevent the need to ration."

In Arizona, the state health department created the Arizona Surge Line early in the pandemic to coordinate care statewide for critically ill patients, said White. More than 4,000 patients, including many from hard-hit Native American reservations, have been transferred through this clearinghouse, according to White. The system is focused on capacity for all critically ill patients, so it's broader than just ECMO treatment. But it's an example of how to connect patients to the resources they need in real time, he said.

In Washington and Oregon, ECMO program directors can log in to a document that displays the availability of ECMO beds throughout the region.

In 2016, the directors of Minnesota's six ECMO centers created a consortium to help with pandemic and emergency operations, said Dr. Matthew Prekker, a pulmonologist and critical care specialist at Hennepin County Medical Center in Minneapolis. The consortium established uniform eligibility guidelines to make sure all critically sick patients get a fair chance at the therapy.

If half the state's medical centers reach capacity, it triggers an emergency conference call between the ECMO center directors, who steer patients to open beds. “We are well organized," said Prekker. “We don't work in silos."

Los Angeles has vast academic medical centers, but no real-time coordination on finding ECMO beds. Before COVID-19 there had not been a need to coordinate such a high volume of patients, said Dr. Peyman Benharash, director of the adult ECMO program at UCLA Health. He said when COVID-19 hit, ECMO doctors created an informal group chat so they could coordinate patients and resources, but it's not something case managers can access. Benharash said his center does not use a waiting list, because he wants case managers to continue searching for any hospitals that might have a bed available. If UCLA is full, it tells case managers to call back in 12 hours.

The lack of a centralized system in Los Angeles can result in a scramble for case managers and doctors as patients' lives hang in the balance.

On the afternoon of Dec. 7, Miguel's medical records show, the PIH Whittier case manager called Miguel's insurance company. There was no guarantee the insurer would agree to a therapy that can easily run into the six figures. Insurance company rejections of ECMO are not uncommon, according to ECMO directors. But in Miguel's case that didn't seem to be an obstacle. The insurer told PIH that the University of Southern California's Keck Hospital, the Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center might be options. The case manager left a message at USC and provided UCLA with Miguel's information. Cedars-Sinai came back with a no, saying Miguel didn't meet its criteria for ECMO therapy.

The case manager, after talking to Miguel's insurer, tried two more hospitals. One, UCI Health in Orange County, didn't have any ECMO beds available. A second, Providence Saint John's Health Center in Santa Monica, said it would review Miguel's records.

During the COVID-19 surge, ECMO centers were screening the growing number of patients to prioritize those with the best chances of survival. At 5:08 p.m., after three hours of working the phones, the case manager turned over the search to a colleague. Soon after, UCLA called to say it wouldn't take Miguel because he had a hematoma and blood clotting.

A Prayer Answered

As the case managers searched for an ECMO bed, Miguel's mother was back in the hospital parking lot holding a vigil for her son. This time, she hid a prayer card and string of rosary beads underneath the green leaves of a day lily to protect Miguel when she was not there.

The search for an ECMO bed did not make progress for most of the day on Dec. 8. The longer Miguel depended on a ventilator, the greater the chance he would either die or suffer complications that could disqualify him for ECMO. Even without complications, extended ventilator time could rule out ECMO. By now, he had been intubated for four days. Some programs will not take a patient who has been intubated more than a week.

“When it comes to somebody needing ECMO, they can fail very quickly," said Sun.

The next day, on Dec. 8, the palliative care team offered a grim prognosis in a telephone call with Miguel's family: “We told them that Mr. Fernandez was not likely to recover at this point," according to hospital records. The family said it still wanted the hospital to make every effort to save Miguel if his heart stopped.

Throughout the day on Dec. 8, a staffer at the Saint John's transfer center was trying to reach someone at PIH to discuss Miguel's case. At 8:33 that evening, a case worker at PIH wrote that she had received a call from Saint John's. The transfer contact said he had “been trying to get in contact with [case manager] all day and left VMs but no one called back."

The next day, a PIH case worker noted in the records that she had missed messages from Saint John's because it was her day off.

Saint John's had been calling PIH with good news: The hospital had accepted Miguel for its ECMO program and would admit him as soon as a bed became available. Over the next few hours, paperwork was faxed back and forth between the hospitals, and the insurance company was contacted for approval.

“Great news!!!" Jeannette announced in a message to the family group chat, adding a heart emoji. “My dad got accepted to St. John's hospital in Santa Monica!!"

The plan, she informed the group, was for Miguel to be moved later that day.

A Life-Saving Therapy

At Saint John's, Dr. Terese Hammond was receiving up to three requests a day to use ECMO to treat patients like Miguel. Hammond had been instrumental in starting the hospital's ECMO program after she was recruited in 2018 to oversee critical care. She had worked with the therapy at USC, where she headed up the pulmonary critical care fellowship.

Community hospitals like Saint John's don't typically have the budget or specialized staff for an ECMO program. Even in the United States — which spends about twice as much per person on health care as other developed nations — more than 90% of hospitals do not offer ECMO. In Los Angeles, the established programs are located at big academic medical centers like USC, UCLA and Cedars-Sinai.

At Saint John's, private donors came up with the money to buy a dozen ECMO units, which can cost up to $85,000 each, Hammond said. The hospital can care for as many as eight ECMO patients at once, depending on staffing.

Hammond was an early believer in using ECMO to help COVID-19 patients whose lungs were failing. Nearly every one of the COVID-19 patients treated with ECMO at Saint John's transferred in, some from more than an hour away.

“We have to validate there is benefit, and we have been able to do that," she said. “I have people alive today because of ECMO."

Miguel's family didn't have to look hard for those success stories. Los Angeles Police Department detective Michael Chang was an early ECMO patient at Saint John's whose near-death experience was featured in local news reports.

Chang had been assigned to robbery and gang investigations but was shifted early in the pandemic to working in uniform at COVID-19 testing sites, food giveaways and supermarkets. On March 30, he was admitted to a small Orange County hospital near his home with COVID-19. Six days later, he was intubated and placed on a ventilator.

As soon as Chang was intubated, his wife, Dana Chang, tapped into a network of police contacts in search of more advanced care. A captain put her in touch with an LAPD reservist who is also a surgeon, she said. That doctor told her about Saint John's and its ECMO program. He called Hammond, and a transfer was arranged.

“He was going downhill fast," Dana said of her husband. “If I left him there, he would have died."

Chang arrived by ambulance at Saint John's on April 7 and was immediately hooked up to an ECMO machine. On the evening of April 12, he was removed from the machine. He left the hospital five days later.

Michael Chang sometimes still experiences shortness of breath and bouts of a dry cough, but he credits ECMO with saving his life. “Prior to me getting it, I had never heard of ECMO," he said. “I had no idea what this thing is. The world needs to know about this."

Of the 39 COVID-19 patients placed on ECMO at Saint John's since the start of the pandemic, 15 are alive today. Hammond said most of them almost certainly would have died without ECMO.

Hammond is the first to caution that ECMO is not a miracle cure. About half the COVID-19 patients undergoing ECMO die in the hospital, according to a registry of more than 3,400 COVID-19 patients worldwide, though some centers have reported survival rates of as high as two-thirds.

Miguel's family said they knew ECMO wasn't a guarantee, just a chance, something the doctors at PIH were telling them he didn't have there. If it didn't work, they said, they would take comfort in knowing everything possible had been done to help him.

The Waiting List

The news of Miguel's pending transfer to Saint John's quickly gave way to a larger reality: There were lots of patients like Miguel in Los Angeles.

COVID-19 was surging. The number of COVID-19 patients in intensive care units had doubled in the three weeks since Miguel was hospitalized. At PIH Whittier, two weeks before he was admitted, 17 patients had COVID-19. The week Miguel arrived, that number swelled to 47. By the time he was intubated, there were 76. By Dec. 7, when the ECMO search began, there were 93.

At Saint John's, the ICU was full and unable to take in any new patients. While Hammond had approved the transfer of Miguel and had an ECMO machine to treat him, there were no beds available.

The waiting list was not something the family could see or monitor. There was no way to know who was ahead of Miguel, or why, or how fast people were moving up the list. At least at the deli counter or DMV, they could see numbers on a board, monitor their progress and make sure no one jumped the line. With Miguel's life in the balance, his family was completely in the dark.

“My dad didn't have anybody that would call to make him a priority," said Miguel Jr. “There was no way for us to hold anyone accountable for what they were saying. We just had to take them at their word."

Hammond said the waiting list is not influenced by a patient's wealth or social status, only whether they are medically qualified and “likely to survive this therapy." In the case of Miguel, she had approved him for ECMO when other hospitals said either they had no room or he didn't meet their criteria.

On Dec. 10, Miguel Jr. shared the bad news on the family chat that his father's transfer had not taken place the night before as hoped. “We have been calling my dads transfer case manager at the hospital and we even called saint johns and spoke to one of their case managers to try to speed up the transfer process but there is not much we can do but wait for a bed to open," he texted to the Familia group.

The next two days brought more waiting. “Call to Providence St Johns to follow up on ECMO spoke w/ Rachel, still no bed. no movement yet, same status," Miguel's caseworker at PIH wrote in her notes for Dec. 11.

By now Miguel had not been breathing on his own for a week and was becoming “more and more difficult to ventilate," according to hospital records.

The family didn't understand what it meant when hospitals said they had “no beds" in their intensive care units. Jeannette and Miguel Jr. called Saint John's to ask if they could buy a bed for their father. They did research to find out if donations were allowed to fund additional beds at the hospital, but were told it doesn't work that way.

Jeannette imagined ways to get inside the hospital and see with her own eyes that every one of its 266 beds was occupied. She looked into becoming a volunteer at Saint John's and found an application online.

Hammond said the phrase “not having a bed" was a euphemism for lacking enough nurses, respiratory therapists, perfusionists and doctors to care for patients who need intensive care. Saint John's expanded its ICU capacity from the normal 23 beds to 40, but adding beyond that meant stretching the staff too far.

On the morning of Dec. 12, nearly five days after the search for an ECMO bed began, the case manager told Miguel's family that he was in “the top 3" of those waiting for an ICU bed at Saint John's, according to the medical records.

Less than an hour later, a team of doctors and nurses hurried to Miguel's room at PIH. The hospital had called a Code Blue. Miguel's heart had stopped. The team started chest compressions and administered drugs to restart his heart. It worked, but Miguel had suffered damage to his kidneys and other organs.

The next day around noon, someone from the Saint John's transfer center called a nurse at PIH Whittier to say that once again no beds were available. The PIH case manager told Saint John's that Miguel was in multi-organ failure, and might not survive the ambulance ride to the other hospital. Two hours later, Saint John's informed PIH it would no longer take Miguel as a patient “due to change in condition."

At 5:23 p.m., another Code Blue alert was sounded. This time, Miguel did not survive. In his room, a hospital worker gathered items left behind after his 26-day stay: an Apple laptop, an iPhone and a pair of cracked black-rimmed glasses.

“People Are Dying Waiting"

The story of Miguel's death and his family's scramble to get him potentially life-saving care has become a familiar one for Hammond.

She said she has had as many as seven people on her waiting list at one time, all in similarly desperate situations.

“Part of the PTSD I have, the nightmares I have, are as much having to say no and having people die on a waiting list," she said. “Those are all things that represent a lot of moral injury for physicians. We know the limitations the surge placed on our ability to do the best we can. People are dying waiting."

The rationing is not limited to Los Angeles. It is playing out across the country.

In Dallas, the ECMO unit at Baylor University Medical Center receives daily requests from across Texas and neighboring states on behalf of desperately sick COVID-19 patients. Their last chance at survival could come down to whether Baylor has a bed. “A few days ago I had five patients on my waitlist," Dr. Gary Schwartz, a lung transplant surgeon who leads the ECMO program at Baylor, said in an interview. “Two passed away while waiting. It is absolutely terrible."

Schwartz said his center, one of the busiest in the country, averaged about 120 ECMO patients a year before COVID-19. In 2020, that number grew to 158, and the number would have been higher if he had had additional capacity. “Quite honestly, there was an additional 50 to 100 who were appropriate but there were no resources for them," he said.

National guidelines created by the Extracorporeal Life Support Organization, a consortium of hundreds of ECMO centers, essentially call for rationing as the demand for ECMO spikes in regions saturated with COVID-19 cases. As surge levels escalate, “we recommend that selection criteria become more stringent to use this resource for those most likely to benefit," according to the guidelines.

Some centers have moved to implement an age cutoff for ECMO, or lower the age in existing guidelines. At Baylor, the maximum age of those considered appropriate for ECMO was dropped to 60 from 75 before COVID-19, Schwartz said. He said another center in the region reduced its age range to 50 or younger because it was overwhelmed with requests. “Many of the patients in the beginning were elderly, and we were afraid that if we had lots of those people that the younger people, 30 to 40, wouldn't have that available," he said. Schwartz said he has colleagues in Europe who think an age restriction is unethical. “In a perfect world, we would be using [ECMO] for the people most likely to survive," he said.

Schwartz and the directors of other ECMO centers in Dallas created an ad hoc group chat on WhatsApp to try to keep track of where beds were available as hospitals filled to capacity. “The real question is do we learn from this and change in the future to some kind of centralized process?" Schwartz said.

Hammond said the ECMO directors in Los Angeles have a similar arrangement where they text each other to find empty beds. The surge in Los Angeles is waning, and cases throughout the country are also going down. But new variants of COVID-19 are emerging, posing a threat of fresh surges. Hammond hopes the experience with COVID-19 will prompt the creation of a formal, permanent network to coordinate the care and movement of critically ill patients in Southern California.

Miguel's niece, Jhaimy, will become a doctor in five months and has been interviewing to do her family medicine residency training in Los Angeles. She's always been aware of health care disparities, and went to medical school to find ways to improve the system.

“It just pains me to see how typical a case my uncle was," she said. “He was Hispanic, mid-50s, an essential worker, not trusting of the health care system. He fit all the checks."

On Dec. 30, Jhaimy was one of dozens of family members who gathered to bury Miguel in a sprawling cemetery near his home.

A family friend organized a fundraiser to help defray the cost of the funeral. Miguel was his family's primary source of income, and since his death, bills have mounted.

A blue and white floral arrangement spelling out “PAPA" was placed on a stand near his grave. Underneath it was a photograph of a younger Miguel, wearing a white button-down shirt and a leather jacket.

The specter of COVID-19 hung over the graveside service. Everyone wore a mask. Miguel's mother slumped over his casket, gripping it with hands covered in clear medical gloves. She wore a face shield and a cloth mask.

The burial did not bring Miguel's family members much closure. Jhaimy said she has wondered what would have happened if her uncle had not been so afraid to go to the hospital. Would he have survived if he had been treated sooner?

Miguel Jr. and Jeannette are troubled that Miguel's doctors didn't present ECMO as an option, and then resisted the idea when the family suggested it.

The family still thinks about what would have happened if an ECMO bed opened up in time.

“I believe with ECMO he would still be here today," Miguel Jr. said. “He never got the chance to fight."

Lax states are attracting shoppers and students from stricter neighbors — and sending back COVID cases

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For months after Washington state imposed one of the earliest and strictest COVID-19 lockdowns in March, Jim Gilliard didn't stray far from his modular home near Waitts Lake, 45 miles north of Spokane.

The retiree was at high risk from the coronavirus, both because of his age, 70, and his medical condition. Several years ago, he had a defibrillator implanted. So he mainly ventured out during the pandemic to shop for food.

There wasn't much else to do anyway. Gatherings in his county were limited to no more than 10 people, there was a mask mandate, movie theaters were closed and many nightclubs and concert venues were shuttered because of a state ban on all live entertainment, indoors and out.

An hour away in Idaho, life was more normal. The state left key COVID-19 regulations up to localities, many of which made masks optional. Even in places that required face coverings, enforcement was laxer than in Washington. High school sports, canceled for the fall in Washington, were on full display in Idaho. Most Idaho schools welcomed back students in person, in contrast to the remote learning prevailing in Washington. Businesses reopened earlier and with fewer restrictions. There were concerts and dances.

Weary of Washington's restrictions, thousands of residents made the easy drive over the border to vacation, shop and dine in Idaho. Gilliard resisted temptation until he learned that the annual Panhandle Bluesfest would go on as scheduled near Priest River, Idaho, on Sept. 12. A keyboardist who used to own a blues club just outside Coeur d'Alene, Idaho, Gilliard was buoyed after months of relative isolation by the prospect of hanging out with friends while listening to music on a remote mountainside surrounded by soaring pine trees and thick hemlocks. He decided to go.

A friend took a picture of Gilliard at the festival. Wearing a bandanna fashioned as a headband, a cut-off T-shirt and dark glasses, he was perched on a tree stump and pointing back at the camera. As was permitted by local regulations at the time, he was not wearing a mask, nor were about 10 people sitting together in the background.

As the number of COVID-19 cases skyrockets nationwide, the extent of the public health response varies from one state — and sometimes one town — to the next. The incongruous approaches and the lack of national standards have created confusion, conflict and a muddled public health message, likely hampering efforts to stop the spread of the virus. The country's top infectious disease expert, Dr. Anthony Fauci, said last month that the country needs “a uniform approach" to fighting the virus instead of a “disjointed" one.

Nowhere are these regulatory disparities more counterproductive and jarring than in the border areas between restrictive and permissive states; for example, between Washington and Idaho, Minnesota and South Dakota, and Illinois and Iowa. In each pairing, one state has imposed tough and sometimes unpopular restrictions on behavior, only to be confounded by a neighbor's leniency. Like factories whose emissions boost asthma rates for miles around, a state's lax public health policies can wreak damage beyond its borders.

“In some ways, the whole country is essentially living with the strategy of the least effective states because states interconnect and one state not doing a good job will continue to spread the virus to other states," said Dr. Ashish Jha, dean of the Brown University School of Public Health. “States can't wall themselves off."

A motorcycle rally in August in Sturgis, South Dakota, with half a million attendees from around the country spread COVID-19 to neighboring Minnesota and beyond, according to Melanie Firestone, an epidemic intelligence service officer for the Centers for Disease Control and Prevention, who co-authored a report on the event's impact.

South Dakota “didn't have policies regarding mask use or event size, and we see that there was an impact in a state that did have such policies," Firestone said. “The findings from this outbreak support having consistent approaches across states. We are all in it together when it comes to stopping the spread of COVID-19."

Viruses don't respect geographic boundaries. While some states require visitors, especially from high-risk areas, to be tested or quarantined, others like South Dakota have no such restrictions. Many people who are tired of strict COVID-19 measures in their states have escaped to areas where everyday life more closely resembles pre-pandemic times. There, with fewer protections, they're at risk of contracting the virus and bringing it back home.

After the Idaho concert, Gilliard started feeling ill and was diagnosed with the coronavirus. For about a week, he stayed in bed. As his condition worsened, he was admitted to a Spokane hospital and placed on a ventilator. He died on Oct. 15. His death certificate lists COVID-19 as the underlying cause.

Going to the Idaho festival likely killed Gilliard, his ex-wife, Robin Ball, said.

“If he had been wearing a mask, not shaking hands and keeping distance, he could probably be alive," she said. “He had been careful before that. He shouldn't have been up there."

The degree of coronavirus regulation tends to track political lines. President-elect Joe Biden carried blue Washington state with 58% of the vote, while President Donald Trump easily won red Idaho with 64%. Trump has helped to fuel the patchwork response to the pandemic, criticizing the approaches of some states, praising others and at times contradicting the advice of his own coronavirus task force and Fauci.

“What really struck me [is] how hard it is to take the pandemic strategy as laid out by the White House with every state on its own and ... implement it because every state is not on its own, they are all interconnected," Jha said.

Biden has said he wants to implement national standards, such as required mask wearing, to help blunt the spread of COVID-19 while acknowledging the federal government lacks little power to do so. He hopes to work with governors and local officials to establish consistent standards across the country.

A lack of such consistency is affecting eastern Washington, which appears to be absorbing some of the costs — both human and economic — of Idaho's more laissez-faire approach to the virus. The rate of new cases in and around Spokane, near the Idaho border, is far higher than in Seattle and western Washington, which experienced one of the earliest outbreaks in the country in February. Although slightly more than half of recent COVID-19 cases in Spokane spread among households or personal contacts, Spokane Regional Health District epidemiologist Mark Springer said, “people bringing back COVID-19 from larger events in Idaho" has been a problem. And with Idaho's rate of new cases now doubling Washington's, Idahoans who commute to the Spokane area pose an outsized danger. At the same time, Washington's shuttered businesses have ceded customers to their Idaho competitors.

Public schools in Washington have also suffered. After opening the school year with remote-only instruction, the Newport School District lost about one-fourth of its 1,200 students. Most of them opted either for specialized online-only programs or for nearby private and public schools across the border in Idaho, which offered in-person learning and sometimes didn't require masks or social distancing, said Newport Superintendent Dave Smith. The plunge in enrollment has led to a $1.2 million drop in funding, he said.

In early October, Newport began some in-person learning but had to return to remote instruction after a COVID-19 outbreak in the community. The source was traced to a Christian church and school only a few feet from the Washington border in Oldtown, Idaho.

“It's incredibly frustrating," Smith said. “I certainly think aligned standards across the nation would have changed our situation."

Washington Gov. Jay Inslee recently called on “Idaho leaders to show some leadership" and be more aggressive in combating COVID-19. He blamed the virus spread in Idaho for straining Washington hospitals. For their part, some in Idaho have complained that the rise of COVID-19 there has more to do with the influx of Washington residents over the summer and fall than with a lighter regulatory touch.

Many of those Washingtonians headed to Coeur d'Alene (pop. 52,400), the seat of Kootenai County and the largest city in northern Idaho. Despite some cancellations, many tourism activities went on as scheduled. The Spokesman-Review newspaper in Spokane ran a feature headlined, “A nearby escape: Coeur d'Alene Resort offers amenities for singles and families." The resort, the article noted, was offering special packages for families that include a pizza-making experience, scenic cruise tickets and discount theme park tickets. In the resort garage, most of the license plates were from Idaho or Washington.

“Yes, the coronavirus exists," the article continued. “However, the luxe Coeur d'Alene Resort is open and taking steps to make an experience as safe as possible." While employees wore masks, the article said, they were optional for guests and about two-thirds opted not to use them. The resort did not respond to requests for comment.

At a park in downtown Coeur d'Alene, a weekly concert series called Live After 5 attracted crowds all summer. Though attendance was lower than in prior years, it swelled as promoters targeted marketing to tourists, concert organizer Tyler Davis said. At one show in July, a member of the band surveyed the large gathering and said, “Look around you guys, it feels kind of normal tonight." Groups of people danced in front of the stage, food trucks lined up along one side and vendors set up tents. Masks were “encouraged but not required."

The day after that show, the Panhandle Health District encompassing five Idaho counties ordered a mask mandate in Kootenai. It required masks in indoor and outdoor public places when a social distance of 6 feet could not be maintained.

Springer, the epidemiologist, watched the flow of Spokane County residents to Idaho with concern. “The issue with Idaho is a somewhat significant one for us in that the restrictions are a pretty stark contrast between what is in Idaho and what we have in Washington," he said. “Coeur d'Alene is a sister community to us."

Jim Gilliard was a popular figure in the blues music community around Spokane and northern Idaho. In the 1990s, he operated a music club outside Coeur d'Alene called Mad Daddy's Blues. He was a talented musician himself, playing keyboards in local blues bands, even after losing a finger and badly injuring two others in a table saw accident.

Gilliard was raised in New York City and Pennsylvania. His father, E. Thomas Gilliard, was an acclaimed ornithologist who served as curator of birds at the American Museum of Natural History and was often gone for months at a time on expeditions to New Guinea. After Gilliard met Ball, the two headed to Colorado and enjoyed life as ski bums, moving from resort to resort for a couple of years before eventually settling in Coeur d'Alene, and having a son. After they divorced two decades ago, she stayed in Coeur d'Alene and he ended up in the village of Valley, Washington. (pop. 164).

Gilliard was one of nearly 300 people who paid $25 each to attend the blues festival, which was held 2 miles up a mountain road outside Priest River, Idaho, a tourist town 6 miles from the Washington border.

Bonner County, where the concert was held, is a rural pocket of defiance against government public health mandates related to the coronavirus. When the local library instituted a mask requirement for users, mask-less demonstrators, some clutching small children, protested and tried to enter the library as staff members stood their ground and explained they were only trying to prevent people from getting sick. The county sheriff wrote to the governor criticizing lockdown orders early in the pandemic, alleging that public health officials misled the public and that “COVID-19 is nothing like the plague."

Concert organizers Billy and Patty Mullaley said they waited until the end of June before deciding to go ahead with it. The only potential roadblock was getting liability insurance at an affordable price during a pandemic, which they were able to do after shopping around.

“At the time, there were not any restrictions" on events like theirs in Idaho, Patty Mullaley said. “We did not take it lightly, having the event. We really put thought into it." They bleached outhouses and the area around the concert stage offered plenty of space for social distancing, she said. Among those most grateful they went ahead, she said, were musicians who had been starved for gigs because of coronavirus-related cancellations. Featured acts included Sammy Eubanks, Coyote Kings and Tuck Foster and the Tumbling Dice.

Mullaley said the festival drew Washington residents eager for events banned in their own state. “From my experience, everyone and their dog from Washington was over here," she said. “Our COVID is probably from people coming over here from Washington."

Few of the hundreds of people at the festival wore masks and many didn't stay socially distant, according to attendees. “Part of what made it magical was people were completely free and happy and not fearful at all," said Sylvia Soucy, who had COVID-19 earlier in the summer. People danced barefoot on the soft sand and mingled with friends, she said.

Mullaley said people socially distanced “as much as possible." In the end, she said, “these were all adults" who made individual decisions. Soucy agreed. “It was completely a choice all of us made," she said. The remote setting — no cellphone service, no electricity and surrounded by hundreds of acres of undeveloped forest — added to the temporary joy of escaping from the virus, Soucy said.

Soucy said she talked to Gilliard there and he was in good spirits, “glad that people were not worried about being able to get together there on the mountain." Gilliard also chatted with other friends, including a former girlfriend, according to Soucy. Ball said the former girlfriend was diagnosed with COVID-19 shortly after the festival and notified Gilliard.

“I don't know why he let his guard down," Ball said. “I will never understand that." In the end, she thinks it had to do with “a long summer of not having a lot of stuff to do. He had been so cautious for those seven or eight months. He just didn't feel like it was going to be a problem."

The Mullaleys said they were unaware of anyone else from the concert getting COVID-19 around that time. But some Washington residents who tested positive for the coronavirus told contact tracers that they had attended the blues festival, according to Matt Schanz, the administrator of Northeast Tri County Health District, a public health agency in Washington covering counties near the Idaho border.

That doesn't definitively mean that they contracted the virus at the festival, he said. “We have 550 cases within three counties, and if you read the summary reports, a decent number of those have some affiliation with Idaho," Schanz said.

South Dakota has largely remained open for business during the pandemic. Gov. Kristi Noem, an ally of Trump's, has refused to impose a mask mandate, saying there are questions about its effectiveness. The state has not placed any restrictions on bars and restaurants and officials allowed the 10-day motorcycle rally in Sturgis. Such a rally would have been prohibited in Minnesota. Both Minnesota and South Dakota are in the top five states when it comes to rates of cases per capita over the last week.

The CDC advises that outdoor events are less risky than indoor ones. The Sturgis rally, which featured events in both settings, is now linked to at least 86 COVID-19 cases in Minnesota, including four people who were hospitalized and one death, according to a CDC report released in November. The report said the total is likely an undercount as some of those infected declined to share their close contacts with health officials.

“These findings highlight the far-reaching effects that gatherings in one area might have on another area," the researchers wrote. They added, “This rally not only had a direct impact on the health of attendees, but also led to subsequent SARS-CoV-2 transmission among household, social, and workplace contacts of rally attendees upon their return to Minnesota."

Mike Kuhle, the mayor of Worthington, Minnesota, said South Dakota's approach to the pandemic “is a source of heartburn for me and sleepless nights." His city is close to both the South Dakota and Iowa borders. In addition to worries about the virus spreading from South Dakota, Kuhle said, “during the lockdown people have gone to Sioux Falls for shopping. It's ugly for our businesses."

A similar dynamic has played out in the Quad Cities area at the border of Illinois and Iowa. There, thousands of people cross bridges over the Mississippi River every day to work, visit family and shop in each state.

As cases in Iowa began to surge this summer, Gov. Kim Reynolds dismissed mask mandates as “feel-good" measures that are difficult to enforce. Until recently, Iowa restaurants and gyms were allowed to operate at full capacity as long as social distancing measures were in place. There was no state-imposed limit on the size of social gatherings. Nicknamed “COVID Kim" by her critics, Reynolds changed course in mid-November in the face of surging cases and hospitalizations, requiring masks.

Illinois clamped down earlier and harder, instituting a mask mandate at the end of April. Movie theaters opened in Iowa before those in Illinois. Iowa never closed its golf courses when neighboring states like Illinois did.

For Illinois businesses, the gap between the two states' regulations has been crushing, said Paul Rumler, the president of the Quad Cities Chamber.

“A river runs through it but otherwise this is one community," he said. On the Illinois side, “we have retailers and restaurants who want to be responsible corporate citizens and follow the guidelines knowing they are at a disadvantage from a business literally 3 miles away."

Rumler said the chamber advocated for the two states to have a consistent approach to the pandemic to no avail. “If there was a federal standard, it would eliminate the confusion of our region," he said. “It would make our life a lot easier."

Debbie Freiburg, a volunteer contact tracer for the county encompassing the Illinois side of the border, said the looser restrictions in Iowa offered Illinois residents the chance to “take a break" from the virus.

“It's bad and the differences are huge, unfortunately," she said. “I can be in Iowa in 10 minutes, and there were a lot of us going shopping in Iowa."

Freiburg, who retired to the area after working as a pediatric cancer nurse in Washington, D.C., said cases in her Illinois county have been tracked to Iowa, including several from a large wedding at a hotel just over the border.

Tensions between Washington and Idaho over their divergent responses to the pandemic escalated in October. As the count of COVID-19 cases climbed, the board of the Panhandle Health District in Idaho voted 4-3 to rescind the mask order it had imposed on Kootenai County three months before. Officials in Washington were stunned. Inslee, the governor, refused to rule out restrictions on border traffic.

The move by the health board came amid growing resistance in the state to mandatory public health measures to control the virus and skepticism that COVID-19 was even real.

A group of Idaho politicians, including Lt. Gov. Janice McGeachin, appeared in a video in October urging the state to limit restrictions. Sitting in a truck with an American flag draped over the side, McGeachin placed a gun over a Bible. “We recognize that all of us by nature are free and equal and have certain inalienable rights," she said. A legislator in the video said “the pandemic may or may not be occurring."

State Rep. Tony Wisniewski, who represents Kootenai and also appeared in the video, urged the health board to make masks optional. He compared the mask mandate to what he said was a requirement in Nazi Germany to tell authorities if a neighbor was Jewish.

Health board member Allen Banks said he was “deeply suspicious" of tests for COVID-19. In an email to a senator who had criticized the board's mask mandate, he wrote, “I hope you and the legislators who support your effort will continue to stand for truth rather than the fantasy of a phony disease based on a false test."

Board member Walt Kirby, who had voted in July to approve the mask mandate initially, was the deciding vote. He opposed a mandate because people were “pretty damn nasty" to him for supporting it before, he explained. “I am not going to vote for it, I am just not because no one is wearing the damn masks anyway," Kirby said, adding that he wears a mask. As for people who ignore the advice of public health experts, he said, “I am just sitting back and watching them catch it and die and hopefully I will live through it. You know I am 90 years old already and I am not getting involved in it anymore."

Even as the requirement was rescinded, cases in Kootenai were soaring. The rate of hospitalizations in the border area in northern Idaho is nearly double the rate in the Spokane region. Overall, the number of new cases in Idaho per capita is almost twice that of Washington.

With the county mandate overturned, the city of Coeur d'Alene considered in late October whether to adopt one on its own. Mayor Steve Widmyer and the City Council were inundated with hundreds of emails and telephone calls, many from mask opponents.

“This is Idaho, not Washington or California," wrote one resident. “Let the people decide if they wish to mask up or not." Another told the city leaders, “If you want to live with a mask 'muzzle' on your face move to California or Washington."

Ball, Gilliard's ex-wife, urged Widmyer to support a mandate. “People come here so they don't have to wear a mask and fill our bars and businesses while spreading covid," she wrote.

In Coeur d'Alene, the mayor only votes to break a tie among the city councilors. Widmyer, who had complained that city officials “shouldn't have been put into this position," didn't have to vote, because the council approved the mandate 4-2 on Oct. 26. Protesters outside chanted, “No more masks, we will not comply," and the blowback has been swift. A group of residents is pushing to recall the pro-mandate councilors. The mayor did not respond to interview requests.

While Coeur d'Alene adopted a mandate, nearby Post Falls and Hayden rejected similar proposals. All three cities are less than 20 miles from the Washington border. Idaho Gov. Brad Little has also remained steadfast in opposition to the idea, unlike Iowa's Reynolds. “Idaho's health officials have been mindful of the challenges of mitigating spread of COVID-19 in border communities since the onset of the pandemic," a spokeswoman for Little said in an email. The governor's “priority at this time is mitigating the spread of COVID-19 in Idaho and preserving health care capacity for those in need."

For the Panhandle health board, however, the situation became too dire to ignore. On Nov. 19 it reversed itself again and passed a mask mandate for all five of its counties, including Bonner, the site of the blues festival. But county sheriffs have ignored enforcing the mandate or made it a low priority, according to local media.

The move came too late to save Gilliard. “Until everyone in this country can do the same thing, all states on the same page, limit crowd size and mask mandates that are enforced, this is going to happen," said Ball, his ex-wife. “It only makes sense. Because what we have been doing hasn't been working."

Pharmacists are seeing unusual and fraudulent prescribing activity as doctors hoard unproven coronavirus drugs endorsed by Trump

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

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Inside Purdue Pharma’s media playbook: How it planted the opioid 'anti-story'

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Data touted by OxyContin maker to fight lawsuits understates company's role in crisis

This story is a collaboration between ProPublica and STAT.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

Purdue Pharma has tried to refute accusations that it fueled the opioid crisis by arguing it was a small player in the U.S. market for prescription pain relievers. But a new ProPublica analysis of government data shows that the company, the maker of OxyContin, had a far bigger impact than it portrays.

Purdue’s position rests on a Drug Enforcement Administration database, made public by a court order in July, which shows Purdue sold 3.3% of the prescription opioid pain pills in the U.S. from 2006 to 2012.

Last month, when Purdue moved to dismiss a lawsuit by the Massachusetts attorney general alleging that it had downplayed the addiction risk of its potent drug, the company highlighted the DEA statistic in a slide presentation. One slide was headlined: “Purdue makes a very small fraction of opioids nationally.”

Company lawyer Timothy Blank told the judge, “The notion that Purdue has created this epidemic is a serious misconception.”

The number promoted by Purdue, however, is an inadequate measure of market share and understates the company’s role in the opioid epidemic, according to experts and the new ProPublica analysis. That’s because the percentage of sales doesn’t take the potency and dose of the pills into account. The analysis favored by Purdue treats every pain pill as the same, whether it is a 5 milligram Percocet or an 80 milligram OxyContin. It’s analogous to measuring alcohol sales by equating a 12-ounce glass of 100 proof whiskey with a similar-sized can of light beer.

ProPublica analyzed the same data set touted by Purdue but accounted for the wide variation in strengths of prescription painkillers. Besides counting the number of pills sold, the analysis measured the amount and potency of opioid that they contained. Higher doses of opioids are associated with a greater risk of overdose.

On that basis, the market share of Purdue is 16% — about five times higher than the number cited by the company. That makes Purdue the third-largest seller of opioids from 2006 to 2012, behind generic pain pill makers Actavis Pharma and SpecGx, a subsidiary of Mallinckrodt.

“All opioids are not created equal,” said Len Paulozzi, a former medical epidemiologist at the Centers for Disease Control and Prevention who researched prescription opioid overdose risk. He said it is important to adjust for potency because “the risk of an overdose, whether fatal or nonfatal, is directly related to the dosage a person receives.”

Purdue’s contention that it was a minor participant in the opioid painkiller market is both a legal and a public relations strategy. The company has been working to settle more than 2,000 lawsuits blaming it for helping to create the public health disaster, and also to protect the reputation and legacy of the Sackler family, its owners. Once praised for their philanthropy, the Sacklers have more recently been condemned by politicians and advocates for their stewardship of Purdue.

Settlement talks, which included a provision that the Sacklers contribute at least $3 billion of their own money, recently reached an impasse and Purdue is considering filing for bankruptcy, the Associated Press reported Saturday. The Sacklers have been separately sued by more than a dozen states, including Massachusetts and Connecticut, for their role in overseeing the company’s allegedly illegal marketing of OxyContin.

Purdue has long experience at countering criticism of OxyContin. The first reports that people were abusing the drug surfaced two decades ago. Since then, Purdue has repeatedly argued that its flagship drug has done more good than harm. Even when Purdue pleaded guilty in 2007 in federal court to a criminal charge of illegally marketing OxyContin by downplaying addiction risks, it blamed misstatements by employees who didn’t follow company directives. More recently, the company and representatives of the Sackler family have said that the opioid crisis is now driven by “illegal street drugs” such as heroin and fentanyl.

Purdue declined to comment on the ProPublica analysis.

By minimizing OxyContin’s market share, the per-pill sales data that Purdue prefers also muffles the drug’s outsized impact in certain states, especially in the Northeast. For example, Purdue’s lawyer told the Massachusetts judge that the company sold just 4.6% of the prescription pain pills in the state from 2006 through 2012. But when the total amount of opioid ingredient in each pill is considered, Purdue’s market share in the state is actually more than four times higher at 20.5%.

In some states, when sales are adjusted for potency, Purdue sold more painkiller medication than any other company: Purdue was the top seller in Rhode Island, with 31.2% of the opioid market, as well as in Connecticut, where it had 28.5%. In Ohio, which has consistently ranked among states with the highest rates of overdoses, Purdue had one-fifth of the market. In 13 states, Purdue was responsible for 20% or more of retail opioid painkiller sales.

The market share nationally of some companies dropped when potency was considered. SpecGx, which has 37.7% of the market on a per pill basis, fell to 29%. Actavis declined from 34.6% of the total pill market to 30.4% in the ProPublica analysis.

The analysis of the DEA data cited by Purdue was first done by The Washington Post. It partnered with the publisher of the Charleston Gazette-Mail in West Virginia in a joint legal action that prompted the release of the DEA database. The database, called Automation of Reports and Consolidated Orders System, or ARCOS, tracks every opioid pill sold in the country from manufacturer to distributor to pharmacy.

The Post limited its analysis to shipments of oxycodone and hydrocodone, which accounted for three-fourths of all pill shipments to pharmacies. ProPublica also restricted its analysis to the same two drug classes sold by retail outlets and practitioners because the numbers cited by Purdue in court are based on that methodology.

The reason Purdue’s market share is significantly larger when measuring the amount of opioid ingredient sold is because OxyContin is formulated at strengths many times higher than most other pain pills.

When Oxycontin was unveiled in 1996, Purdue’s marketing campaign touted it as providing longer pain relief while allowing patients to take fewer pills each day. To accomplish that, Purdue packed into each pill a large amount of opioid that was slowly released over a 12-hour period. Its largest dose, until it was taken off the market in 2001 amid safety concerns, was a 160 milligram pill.

Abusers quickly figured out how to crush OxyContin tablets and remove the opioid inside. Some snorted it, while others reduced it to liquid form and injected it.

In determining the amounts of opioid painkillers sold by Purdue and other manufacturers, ProPublica calculated a rate called morphine milligram equivalent, or MME, which is commonly used by public health agencies, including the Food and Drug Administration and the CDC.

The calculation standardizes different types of opioids to the same morphine equivalent. Hydrocodone, the opioid in Vicodin, has a potency that is equivalent to morphine. Oxycodone, the opioid in OxyContin, is one and a half times more potent than morphine. When converting to morphine equivalents, the amount of hydrocodone in a pill is multiplied by one, while oxycodone is multiplied by 1.5.

Using this formula, an 80 milligram pill of OxyContin has an MME of 120 while a 5 milligram Vicodin pill has an MME of 5.

The average total MME for a pill sold by Purdue in the DEA database was 61.5. By comparison, the average MME per pill sold by the largest manufacturer during this time frame, Actavis Pharma, was 11. For the second biggest manufacturer, SpecGx, it was even lower at 9.6 MME.

CDC guidelines advise against prescribing more than 90 MME per day. OxyContin users are typically directed by their doctors to take two pills per day. Based on the DEA database, the typical prescription from 2006 to 2012 would have totaled 123 MME a day — an amount 37% above the maximum recommended by the CDC.

A CDC review in 2016 concluded that higher opioid dosages are associated with increased overdose risk. One of the studies cited by the CDC found that patients taking between 50 and 100 MME of painkillers a day were up to 4.6 times more likely to overdose than those taking less than 20 MME. For patients receiving more than 100 MME a day, the risk was up to nine times higher than for the lower dose group.

“If Purdue sold a lot of 80 milligram pills, they are going to have proportionately more of the market on an MME basis,” said Gary Franklin, the medical director for the Washington State Department of Labor and Industries. “That is an important point to get out. People are dying from these higher doses.”

Franklin, who is an unpaid expert for the state of Washington in its lawsuit against Purdue, cautioned that other factors increase overdose risk as well. For instance, people who take benzodiazepines, such as Xanax, at the same time as opioids can fatally overdose on lower doses of painkillers.

The FDA, in a staff report this year, also found that a higher daily dose of opioid pain relievers “likely contributes causally to increased risk of intentional and unintentional opioid overdose.” The agency noted that other factors influence overdose risk and that a substantial portion of overdose victims either did not have a prescription for the pills they took or were prescribed a lower daily dose.

Until 2010, according to the DEA’s National Drug Threat Assessment Summary, OxyContin was “by far” the most commonly abused prescription painkiller in the country. In 2010, Purdue introduced a reformulated version of OxyContin that is harder to abuse. The new version can still be abused if crushed or taken orally, but it does not provide as potent a high as the older version, according to the agency.

In the Massachusetts hearing last month, Purdue relied on the lower per pill market share in oral arguments before the judge and in the accompanying slide presentation of data. One slide stated, “DEA Data Refute the Commonwealth’s Allegations.”

“What the commonwealth has done is create an extraordinary misperception in the community, and it is a dangerous misperception,” Purdue’s attorney Blank told the judge at the Aug. 2 hearing, according to a transcript of the proceeding. “The attorney general says it is all on Purdue. It is not all on Purdue.”

“All those prescriptions are not equal,” responded Assistant Attorney General Sandy Alexander. “Some of those prescriptions are for two pills of the lowest dose opioid. Purdue specialized in the most dangerous prescriptions because they were the most profitable.”

The Massachusetts lawsuit cites internal Purdue records in alleging the company pushed higher doses because they were the most profitable. Authorities also allege that the company knew patients taking more of the drug were more likely to overdose. One Massachusetts doctor, who was paid more than $80,000 by Purdue to give talks to other physicians, prescribed 24 of the highest dose OxyContin pills a day for a single patient, according to the state complaint.

“Purdue specialized in getting patients on the highest doses for the longest periods of time,” Alexander told the judge. “Those prescriptions, when you count them, they’re not all equally valuable to a drug company and they’re not all equally dangerous to the people of Massachusetts.”

Purdue’s market share from 2006 to 2012 would have likely been even higher save for an anomaly in the history of the drug. For a brief time, including the years 2006 and 2007, OxyContin had generic competition. Its sales slumped from $1.3 billion in 2005 to $752 million in 2006 and $1 billion in 2007, according to health care data firm IQVIA. Purdue sued the generic makers and gradually eliminated competition from them so that by 2008, OxyContin sales more than doubled from the prior year to $2.3 billion.

By that measure, dollar sales, Purdue has long been the market leader for prescription opioids. Internal Purdue records indicate OxyContin had more than 28% of the total market share in gross sales each year from 2008 through 2018. Since 1996, sales of OxyContin have totaled more than $35 billion. The Sackler family received at least $8 billion in company profits during that time, according to court records.

ProPublica news apps developer Mike Tigas contributed to this report.

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Watch Richard Sackler deny his family’s role in the opioid crisis

This story is a collaboration between ProPublica, STAT and ABC News.

Four years ago this week, Dr. Richard Sackler sat in a conference room at a law office in a Louisville, Kentucky, office park. Lawyers for the Kentucky attorney general’s office were taking his deposition as part of the state’s lawsuit alleging that the family business, Purdue Pharma, illegally marketed the opioid painkiller OxyContin by understating its addictive properties.

Sackler, who has been at various times Purdue’s president and co-chairman of its board, testified for more than eight hours. The lawyers asked him about his role at the company, what decisions he was involved in and whether he believes Purdue played any part in the opioid crisis that has resulted in more than 200,000 overdose deaths related to prescription drugs since 1999.

Despite hundreds of lawsuits against Purdue stretching back well over a decade, that August 2015 deposition, which was recorded on video, is believed to be the first time any member of the Sackler family was questioned under oath about their role in the marketing of OxyContin.

Four months after the deposition, Purdue agreed to pay Kentucky $24 million to settle the case. The company fought a legal battle for more than three years to keep the deposition secret. After the news organization STAT won a court decision in 2016 ordering its release, Purdue appealed all the way to the Kentucky Supreme Court. The court declined on Wednesday to hear the case, letting STAT’s lower court victory stand.

This past February, ProPublica obtained and published a transcript of the deposition. In a statement then, Purdue stood behind Sackler’s testimony. The video, however, remained unavailable. In April, comedian John Oliver called on his HBO show for its public release, saying it wasn’t “something that Purdue gets to bury.”

Now ProPublica has obtained the video and selected significant passages. Here are those excerpts:

Sackler was questioned about how much money he and his extended family have made from sales of OxyContin.

Profits From OxyContin Sales

Sackler was both a board member and an executive of Purdue, in addition to an owner. His role in conceiving, launching and overseeing the marketing of OxyContin is discussed here.

“It is Almost That I Dedicated My Life to It”

Lawyers for the state of Kentucky asked Sackler about emails showing Purdue created OxyContin for fear that its existing painkiller, MS Contin, would soon face generic competition.

Generic Threat Pushes Purdue Pharma to Create OxyContin

Sackler was questioned about how Purdue incentivized its sales force to sell OxyContin and whether he thought the company’s marketing was appropriate.

Incentives for OxyContin Sales Reps

OxyContin Marketing Too Aggressive?

A 1997 email exchange, read to Sackler at the deposition, shows that he supported a decision by Purdue executives not to correct a misperception among doctors that OxyContin is weaker than morphine. In fact, OxyContin is twice as potent as morphine. Purdue pleaded guilty in federal court in 2007 to falsely promoting OxyContin by understating the risk of addiction to the drug, including failing to alert doctors that it was a stronger painkiller than morphine. In these clips, Sackler is questioned about the failure to tell doctors about the relative strength of OxyContin and how that may have benefited the company.

Oxycontin More Potent Than Morphine

Do Doctors Perceive Oxycontin as Weaker Than Morphine?

Sackler was asked about comments he made describing the U.S. Food and Drug Administration’s rapid approval of OxyContin.

OxyContin Gets Speedy FDA Approval

At the deposition, Sackler disputed some of the findings in the 16-page statement of facts related to Purdue’s 2007 guilty plea. He also said that he never read the full statement.

Statement of Facts About Purdue Pharma’s Misconduct

Sackler Challenges Meaning of 2007 Settlement

Sackler quibbles over whether patients could develop a tolerance to OxyContin, as stipulated in the 2007 agreed statement of facts.

Health Care Providers Told OxyContin Patients Wouldn’t Experience Withdrawal Symptoms

Sackler said “I don’t know” more than 100 times during the deposition, including in response to this line of questioning about Sackler-owned businesses.

Sackler Questioned About His Positions at Company

Near the end of the deposition, Sackler was asked if Purdue was responsible for the epidemic of opioid addiction in Kentucky.

Sackler Denies Purdue Pharma Conduct Caused Increase in Opioid Addiction in Kentucky

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OxyContin maker explored expansion into 'attractive' anti-addiction market

Not content with billions of dollars in profits from the potent painkiller OxyContin, its maker explored expanding into an “attractive market” fueled by the drug’s popularity — treatment of opioid addiction, according to previously secret passages in a court document filed by the state of Massachusetts.

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

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OxyContin company considered capitalizing on the 'addiction treatment boom' — while trying to boost sales of opioids at the same time

This story was co-published with STAT.

Not content with billions of dollars in profits from the potent painkiller OxyContin, its maker explored expanding into an “attractive market” fueled by the drug’s popularity — treatment of opioid addiction, according to previously secret passages in a court document filed by the state of Massachusetts.

In internal correspondence beginning in 2014, Purdue Pharma executives discussed how the sale of opioids and the treatment of opioid addiction are “naturally linked” and that the company should expand across “the pain and addiction spectrum,” according to redacted sections of the lawsuit by the Massachusetts attorney general. A member of the billionaire Sackler family, which founded and controls the privately held company, joined in those discussions and urged staff in an email to give “immediate attention” to this business opportunity, the complaint alleges.

ProPublica reviewed the scores of redacted paragraphs in Massachusetts’ 274-page civil complaint against Purdue, eight Sackler family members, company directors and current and former executives, which alleges that they created the opioid epidemic through illegal deceit. These passages remain blacked out at the company’s request after the rest of the complaint was made public on Jan. 15. A Massachusetts Superior Court judge on Monday ordered that the entire document be released, but the judge gave Purdue until Friday to seek a further stay of the ruling.

The sections of the complaint already made public contend that the Sacklers pushed for higher doses of OxyContin, guided efforts to mislead doctors and the public about the drug’s addictive capacity, and blamed misuse on patients.

Citing extensive emails and internal company documents, the redacted sections allege that Purdue and the Sackler family went to extreme lengths to boost OxyContin sales and burnish the drug’s reputation in the face of increased regulation and growing public awareness of its addictive nature. Concerns about doctors improperly prescribing the drug, and patients becoming addicted, were swept aside in an aggressive effort to drive OxyContin sales ever higher, the complaint alleges.

Among the allegations: Purdue paid two executives convicted of fraudulently marketing OxyContin millions of dollars to assure their loyalty, concealed information about doctors suspected of inappropriately prescribing the opioid, and was advised by global consulting firm McKinsey & Co. on strategies to boost the drug’s sales and burnish its image, including how to “counter the emotional messages” of mothers whose children overdosed. Since 2007, the Sackler family has received more than $4 billion in payouts from Purdue, according to a redacted paragraph in the complaint.

“The payments were the motivation for the Sacklers’ misconduct,” the complaint says. “And the payments were deliberate decisions to benefit from deception in Massachusetts, at great cost to patients and families.”

In 1998, two years after OxyContin was launched, Dr. Richard Sackler, a son of Purdue co-founder Raymond Sackler, instructed executives in an email that its tablets were not merely “therapeutic” but also “enhance personal performance,” like Viagra. Fifteen years later, he complained in another email that a Google alert he set up for OxyContin news was giving him too much information about the drug’s dangers.

“Why are all the alerts about negatives and not one about the positives of OxyContin tablets?” he asked a company vice president. Staff immediately offered to replace Sackler’s alert with a service that supplied more flattering stories, according to the complaint.

The redacted paragraphs leave little doubt about the dominant role of the Sackler family in Purdue’s management. The five Purdue directors who are not Sacklers always voted with the family, according to the complaint. The family-controlled board approves everything from the number of sales staff to be hired to details of their bonus incentives, which have been tied to sales volume, the complaint says. In May 2017, when longtime employee Craig Landau was seeking to become Purdue’s chief executive, he wrote that the board acted as “de-facto CEO.” He was named CEO a few weeks later.

In a statement today in response to questions about the redacted material, the company said that Massachusetts “seeks to publicly vilify Purdue, its executives, employees and directors by taking out of context snippets from tens of millions of documents and grossly distorting their meaning. The complaint is riddled with demonstrably inaccurate allegations.”

Purdue acknowledged in the statement that it was considering acquiring the rights to sell drugs that combat addiction or reverse the effects of an overdose. It criticized the state for “casting in a negative light” the company’s exploration of a potential acquisition of an addiction treatment that was already on the market, “even though the company never actually made the acquisition.”

Purdue also pointed out that OxyContin is approved by the Food and Drug Administration. It said that most opioid overdoses “now result from heroin and illicit fentanyl.”

The Sackler family was once best known for its philanthropy. Its name is engraved on museums and university buildings across the world. A group of activists has called on organizations to stop accepting Sackler donations and for the family name to be stripped from some institutions. Aggressive marketing of OxyContin is blamed by some analysts for propelling the crisis that has resulted in 200,000 overdose deaths related to prescription opioids since 1999.

After its 1996 launch, OxyContin rapidly became a top seller. But reports of patients abusing the drug soon followed. OxyContin contained more pain relief medication than older drugs, and crushing and snorting it was a simple way to get high fast. In 2007, Purdue pleaded guilty to federal charges of understating the risk of addiction and agreed to pay $600 million in fines and penalties. Still, the company argued publicly that OxyContin has “done far more good than harm,” and it sought to place responsibility for the bad acts on “certain of its supervisors and employees.”

Privately, the complaint suggests, the Sacklers were concerned about alienating two executives, then-CEO Michael Friedman and then-legal counsel Howard Udell. Friedman and Udell each pleaded guilty in 2007 in U.S. District Court in Abingdon, Virginia, to a misdemeanor charge of misbranding OxyContin, as did a former executive. The board signed off on the three executives’ decisions to plead guilty. No member of the Sackler family pleaded guilty.

Purdue paid $5 million to Udell in November 2008, and up to $1 million in November 2009, the complaint states. In February 2008, the company paid $3 million to Friedman. The complaint doesn’t mention any payments to the former executive.

“The Sacklers spent millions to keep the loyalty of people who knew the truth,” the complaint alleges.

Udell died in 2013. A person answering a phone number listed to Friedman declined comment.

The plea deals did little to hinder OxyContin sales or the Sacklers’ hands-on management. At the direction of the board, Purdue repeatedly increased its sales force, which pushed doctors to prescribe higher opioid doses.

In 2008, the same year that Purdue paid Udell and Friedman, Richard Sackler advised other family members that it was important to select a new chief executive who was loyal to the family. “People who will shift their loyalties rapidly under stress and temptation can become a liability from the owners’ viewpoint,” he allegedly wrote. A defendant in the Massachusetts lawsuit, Richard Sackler served in a number of different positions at the company before being named president in 1999 and then co-chairman of the board in 2003.

The company did install five new, non-family board members in the wake of the federal investigation. But in hundreds of board votes, the new directors never opposed the family, according to the complaint. Although Purdue does not operate outside the U.S., board meetings took place at a castle in Ireland as well as in Bermuda, London, Portugal and Switzerland.

When sales results disappointed, Sackler family members didn’t hesitate to intervene. In late 2010, Purdue told the family that sales of the highest dose and most profitable opioids were lower than expected, according to the complaint. That meant an expected quarter-end payout to the family of $320 million was at risk of being reduced to $260 million and would have to be made in two installments in December instead of one in November.

That news prompted a sharp email question from Mortimer D.A. Sackler, whose late father, also named Mortimer, was a Purdue co-founder. “Why are you BOTH reducing the amount of the distribution and delaying it and splitting it in two?” he asked. “Just a few weeks ago you agreed to distribute the full 320 [million dollars] in November.” The complaint doesn’t say how much was ultimately paid.

From 2009 until at least 2014, McKinsey helped Purdue shape its message for selling OxyContin and overcoming concerns about addiction and overdoses, according to redacted passages. The consultant told Purdue in a slide presentation that it could increase prescriptions by convincing doctors that opioids provide “freedom” and “peace of mind” and give patients “the best possible chance to live a full and active life.”

Purdue staff, according to the complaint, told the Sacklers that McKinsey would study “patient pushback” to encourage hesitant doctors to prescribe opioids. In a meeting with Purdue executives, McKinsey planned how to “counter the emotional messages from mothers with teenagers that overdosed in [sic] OxyContin" by recruiting pain patients to talk about the need for the drugs.

In a 2013 report, McKinsey recommended directing sales representatives to focus on the most prolific opioid prescribers because that group writes “25 times as many OxyContin scripts” as less prolific prescribers. Because prescription rates rose in tandem with visits from sales reps to doctors, McKinsey recommended increasing each salesperson’s quota from 1,400 visits a year to closer to 1,700. McKinsey estimated that targeting the most frequent prescribers could boost OxyContin sales by hundreds of millions of dollars. The quotas rose, as did total visits, the complaint states. Purdue said it planned to decrease visits relating to opioid products, and any increase was due to promoting a laxative.

McKinsey also recommended Purdue fight back against efforts by a major pharmacy chain, the U.S. Drug Enforcement Agency and the U.S. Department of Justice to stop illegal opioid prescribing, the complaint states. These new rules were cutting into sales of the highest doses, which were also the most profitable, it says. The complaint doesn’t say if Purdue followed McKinsey’s recommendation. Purdue said the recommendations “actually relate to ensuring continued access to pain medicines for appropriate patients.”

A McKinsey spokesman declined comment.

In September 2014, Purdue embarked on a secret project to join an industry that was booming thanks in part to OxyContin abuse: addiction treatment medication. Code-named Project Tango, it involved Purdue executives and staff as well as Dr. Kathe Sackler, a daughter of the company co-founder Mortimer Sackler and a defendant in the Massachusetts lawsuit. She participated in phone calls and told staff that the project required their “immediate attention,” according to the complaint.

Internally, Purdue touted the growth of an industry that its aggressive marketing had done so much to foster.

“It is an attractive market,” the team working on the project wrote in a presentation. “Large unmet need for vulnerable, underserved and stigmatized patient population suffering from substance abuse, dependence and addiction.”

While OxyContin sales were declining, the internal team at Purdue touted the fact that the addiction treatment marketplace was expanding.

“Opioid addiction (other than heroin) has grown by ~20%” annually from 2000 to 2010, the company noted. Although Richard Sackler had blamed OxyContin abuse in an email on “reckless criminals,” the Purdue staff exploring the new business opportunity described in far more sympathetic terms the patients whom it now planned to treat.

“This can happen to any-one – from a 50 year old woman with chronic lower back pain to a 18 year old boy with a sports injury, from the very wealthy to the very poor,” it said.

Company documents recommended becoming an “end-to-end pain provider.” Initially, Purdue intended to sell one such medication, Suboxone, which is commonly retailed as a film that melts in the mouth. When Kathe Sackler asked staff members to look into reports that children might be swallowing the film, they reassured her. They responded, according to the complaint, that youngsters were overdosing on pills, but not the films, “which is a positive for Tango.”

In 2015, Purdue turned its attention to another potential product, the overdose reversing agent known as Narcan, calling it a “strategic fit.” Purdue executives discussed how its sales force could promote Narcan to the same doctors who prescribed the most opioids. Purdue said in the statement Wednesday that it decided against acquiring the rights to sell Suboxone and Narcan.

While those initiatives appear to have stalled or ended, Richard Sackler received a patent last year for a drug to treat addiction, according to the complaint. The patent application states that opioids are addictive and refers to people who suffer from substance use disorders as “junkies.”

Besides being a defendant in the Massachusetts case, Richard Sackler was deposed in a lawsuit against Purdue in Kentucky, which the company settled. It’s believed to be the only time a member of the family has been questioned under oath about OxyContin and its addictive properties. The Kentucky Court of Appeals has ordered the release of his deposition, in response to a motion by STAT, but Purdue is asking the state Supreme Court to review the ruling. Hundreds of other lawsuits filed by states, cities, counties and tribes against Purdue have been consolidated in a pending case in federal court in Ohio.

The Massachusetts complaint cites multiple incidents of Purdue allegedly sitting on information, sometimes for years, about doctors it had reason to believe were inappropriately prescribing OxyContin. In 2012, a Purdue employee appealed to the company’s head of sales to alert health insurers to data the company collected about doctors suspected of abusing or illegally prescribing OxyContin. The list of doctors was code-named Project Zero.

“At a basic level, it just seems like the right and ethical thing to do,” the employee wrote. “Doing so could help those companies identify those physicians that may be of a concern, not just with respect to our products, but also other” pain medications. “As a result, if it reduces abuse and diversion of opioids then it seems like something we should be doing.”

The idea was rejected and the employee left the company a month later, according to the complaint.

Update, Jan. 31, 2019: The day after this article was published, a judge rejected Purdue's request for a further stay, and the entire complaint was made public.

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The Drug Treatment Racket: Union Workers Feel Trapped as Their Benefits Are Drained

Targeted by an addiction treatment center, union workers feel trapped as their benefits are drained

They'd been promised a "spa for teachers," but were brought to a rundown, low-slung building on an unremarkable stretch of road miles from the beach. ... cards, and driver's licenses. One after another, New Jersey public school teachers arrived at the Recovery Institute of South Florida after asking their union to find them addiction or mental health ...

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This Strung-Out Dope Pusher Peddled Pills for Big Pharma

Sales executive for opioid maker was addicted to the drug he promoted

As a district sales manager for Insys Therapeutics, Jeffrey Pearlman led a team that aggressively pushed doctors to widely prescribe the company's highly addictive opioid painkiller Subsys. He even threatened to stop paying a nurse speaking fees if she didn't help boost sales of the drug, emails show. All the while, Pearlman held a secret: He…

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