Throw Granny from the Train: The Washington Post Gives a Boost to Age-Based Health Care Rationing

Two pieces on the front page of the Washington Post’s Sunday “Outlook” section go a long way toward illustrating what’s wrong with the  terms of current debates around health care costs and health care for the elderly. The juxtaposition of these two commentaries, which appeared side-by-side under a photo of a sunset and the heading “The Dying of the Light,” sends an insidious message about the need for “rationing” treatment to the very old and very sick: To keep health care costs from bankrupting our society, it suggests, we may have no choice but to pull the plug on the geezers.

The Post feature is only the latest of a growing volume of commentary on so-called age-based health care rationing. Even beyond any core ethical questions, the problem with these discussions is what they too often fail to mention: the role of private profits in creating, or at least seriously exacerbating, the supposedly intractable problem of health care costs. Like everything else in the public debate over health care policy, the “dying of the light” has become subject to the lying of the right, where corporate interests trump even questions of life and death.

There’s nothing inherently objectionabale about one of the two pieces, written by doctor at a Minneapolis hospital who cares for “patients struggling through the winter of their lives.” Craig Brown writes:

Today, thanks to myriad medications and interventions that have been created to improve our health and prolong our lives, dying has become a difficult and often excruciatingly slow process.

The author questions the prevailing practice of using extreme measures to prolong the lives of the “threadworn elderly,” when “what’s waiting for them at the end of this illness is just another illness, and another struggle.” Mercy, he says, demands that we change our attitude and our approach toward death. I’ve got no argument with this, which is why I support end-of-life choice for the chronically and terminally ill.

Craig Brown is careful to say that “nothing in my medical training qualifies me to judge what kind of life is satisfying or worth living.” He also states clearly that his position “isn’t about euthanasia. It’s not about spiraling health care costs. It’s about the gift of life–and death. It is about living life and death with dignity, and letting go.”

The same is not true of Post health and science reporter David Brown (also a physician), who wrote the companion piece. He points out that health care costs are growing faster than the economy, due largely to advances in medical care. “Each year, there’s more that can be done and more that’s judged worth doing”–and it’s all terribly expensive. At the same time, life expectancies are lengthening and the population is aging. As a result, he says:

We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish. Whether we can somehow avoid the collision is perhaps the most important domestic issue of this century. From now on, health care costs will be up there with globalization, terrorism and climate change as a force shaping our world.

While David Brown doesn’t blame this all on old people, per se, he does point to the growth in Medicare’s costs, and warns that “unless something changes, in about 75 years, Medicare alone will cost as much as the sum of all our federal income taxes.” And while he says he has no solution to offer that will “rescue us from the Malthusian Spectre of health care spending,” the implicit solution is clear–if not from the article itself, then from its placement alongside Craig Brown’s piece on the tormented lives of the chronically ill elderly. The obvious way to slow our progress toward economic and social destruction is for old folks to stop having all those expensive interventions and just give up the ghost. And if the geezers won’t make the decision to do this voluntarily–well, then, society might have to make it for them.

In blog for the American Prospect, Dean Baker of the Center for Economic and Policy Research lays out why the underlying terms of this debate are fatally flawed. Criticizing David Brown’s Post piece for “telling readers that there is nothing we can do about health care costs,” Baker writes:

Remarkably, this lengthy column never once notes the fact that the United States pays more than twice as much per person for health care than the average of the other wealthy countries, all of whom enjoy longer life expectancies.

This is a hard to overlook piece of evidence suggesting that the United States could do a great deal to lower its health care costs. Among other things, we have a hugely wasteful insurance system (noted in the column), pay close to twice as much for prescription drugs as people in other wealthy countries, and pay our medical specialists close to twice as much as they earn in other wealthy countries.

Overpaying for drug and doctors not only directly wastes money by causing us to pay more for the same services. The huge rents created by these over-payments leads drug companies and specialists to find ways to promote excessive use of their products and services. The result is really bad and really expensive medicine.

Studies comparing health care in the United States and other industrialized countries–including those conducted by the World Health Organization, Congressional Research Service, Kaiser Family Foundation, and Commonwealth Fund–consistently find dramatically higher spending in the U.S. (both per capita and as a percentage of GDP), and poorer performance on a host of important health measures, from life expectancy to infant mortality to medical errors. All of these other countries, of course, have public single-payer health care systems, while we have medicine for profit.

I’m as public spirited as the next person, and I have a Gen-X son. So I’d like to think I’d be willing to give up some expensive, life-prolonging medical treatment if the future of humanity depended upon it. But I’m certainly not going to do it so that some pharmaceutical company executive can take another vacation in Bora-Bora, or so that an elected official can get another big campaign contribution from the insurance industry.

So here’s my advice to anyone who suggests that American geezers should do the right thing and accept age-based health care rationing: Institute a single-payer system, cut our national health care costs in half–and then get back to me.

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7 responses to “Throw Granny from the Train: The Washington Post Gives a Boost to Age-Based Health Care Rationing

  1. Pingback: How Much Is a Year of Your Life Worth? « Unsilent Generation

  2. Marilyn Howells

    Something new and very, very scary !! I wonder if anyone has ever hear of this or had it happen to them. My employment related insurance that covers actives and retirees, now is proposing that we have to provide End of Care Directives (Advance Directive) or pay higher premiums than those that do provide this, WHEN MANY WOULD ONLY WANT THIS FORM IN THE HANDS OF THEIR FAMILY OR THE PERSON WHO THEY DESIGNATE AS MEDICAL POWER OF ATTORNEY. This should and may be unconstitutional. While I don’t disagree with someone’s right to have and End of Care Directive, I’m outraged that the insurance company wants to financially coerce us into providing the paper to them or some third party registry. What are the chances one of the forms will get enacted before the family even gets there if you are in an accident? What are the chances one John Smith’s forms will be mixed up with another John Smith’s form? Or some of the middle pages will get switched with someone else’s middle pages. After all none of us have ever be mixed up with someone else, received a bill or piece of mail that is wrong etc. Of course there will be mix ups. However, if you die because of it, you won’t be around to straighten it out. Then what will happen over the years. will the insurance companies dictate the wording on these directives, raise your premium even more if you don’t sign one, withhold services if you don’t sign, or drop your insurance if you don’t sign.Or maybe eventually, they won’t pay for certain services if you don’t sign one. But if they know you have a directive or even the content, will services you might want be withheld, or withheld prematurely. Eventually, will this lead to insurance companies to put pressure on you physicians and family, or on your family through the pressure the insurance company puts on the physicians. Will the insurance company or some supposed mediator or adviser presume to interpret the living will? They already withhold antibiotics on the very sick sometimes. What if you have a slow cancer, like prostate and are only in for tests and could like for years on lupron, and choke on you dinner steak? Will you not be resuscitated because technically you are terminal. How can we trust insurance companies in this. End of Care / Do Not Resuscitate Directives are very serious and every word is open to interpretation. It should NOT be the insurance company where CEO’s make up to 124 million based on company profits, who interpret these living wills, or their flunkies or any third party entities they choose. These should only be interpreted by the family in conjunction with your physicians. Once the precedent is set the even one insurance company require proof of a living will and it affects your payment, then how long until others follow suit???? Obviously, if this gets started other insurance companies will jump on the band wagon, and a lot of people will be mislead into signing dangerous broilerplate directives, that don’t protect them adequately and are wide open to interpretation, and could be misused, and more poorly worded than you would think. If we don’t stop the insurance companies now, it will be to late later. As far as I know neither Medicare, Medicaid, VA, Federal Employees Insurance, nor any private insurance of anyone I’ve asked requires this or ties it to premiums. The whole idea makes one think of 1984 (by James Orwell), Make Room, Make Room (by Harry Harrison, think Soylent Greeen the movie), or Logan’s Run. Anyone doing an Advance Directive would want to be real careful into whose hands they put it and when. I doubt if they can legally force you to make on, or if you have one force you to hand it over to get care. some feel that this should only be trusted to a group of several relatives to decide when to hand it over. Many feel it’s best to have it give someone medical power of attorney to interpret your wishes, so some bean counter won’t. You certainly want your relatives to have time to find and consult with specialist and physicians of your and their choosing.After all no one ever went to several doctors over several months or years until they finally got the right diagnosis or treatment. Anyway this gives new meaning to the phrase BURY IN HASTE, REPENT AT LEISURE. They may be planning to have us store our End of Care/Advance Care Directive at a Central Repository. One national one out in California does not require Social Security Numbers, but they are optional as someone people object to giving it out. After someone sends them their living will, they are sent a special identification card with an assigned number that a physician can use to call the company and have the Advance Directive Faxed or emailed. But if the person doesn’t have the card, the hospital can order it by name and SSN, or if the person didn’t give the repository their SSN, the hospital can get it by just giving the patient’s name and birth date. How long until one John Smith is mixed with another. How many people in this country have the same name name as someone else, and maybe even are about the same age. Google your name and also run it on yahoo people search,, and don’t forget to use alternate spellings (especially of your first name), and nick names. Think you won’t be affected because your insurance company doesn’t require this? Think again. You never filed an End of Care Directive with a repository. You’re in an accident and are taken unconscious to a hospital, which calls a few repositories with you name and birth date, and a match is found, faxed, and used to withhold care. But it was only the directive of someone with the same name.Too late, R.I.P. Please post on this site if you’ve ever heard of an insurance company requiring you to Provide an End of Care Directive or pay a higher premium if you don’t. Also if you know of any web sites about the dangers of misuse of Advance Directives/Living Wills, or problems with interpretation of these documents, and tips on wording them please post those site. Below I’m listing a couple of sites found in a quick search with some 2006 Federal law, and concerns about wording of this type of document, or misuse. While one might not support every word at sites they provide a lot of helpful information, concerns, and example.
    For tips on writing living Wills and Advance directives, and pros and cons of language.
    http://www.internationaltaskforce.org/rpt2006_2.htm#212
    Before You Sign On The Dotted Line
    http://mysite.verizon.net/cureltd/id24.html
    Federal law about Advance Directives that prohibits requiring one as a condition of treatment. See Advance Directives, 42 CFR 489.102 (a) (3) (2006).
    http://law.justia.com/us/cfr/title42/42-3.0.1.5.27.8.206.2.html
    You might want to read or skim it all, but it reads in part:
    489.102 Requirements for providers (a) Hospitals, critical access hospitals, skilled nursing facilities, nursing facilities, home health agencies, providers of home health care (and for Medicaid purposes, providers of personal care services), hospices, and religious nonmedical health care institutions must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical care, or patient care in the case of a patient in a religious nonmedical health care institution, by or through the provider and are required to: . . . (3) Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive

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  6. Are DNR’s being misused? Is it dangerous for an elderly person not to have a DNR that spells out the conditions upon which the elderly person does not want to be resucitated.
    If it is possible for physicians who are treating the elderly for cancer to initiate unauthorized DNR’s in office and hospital charts that cut and reduce the costs of treating the elderly cancer patient, doesn’t it follow that the DNRs will be misused to deny the elderly the same interventions that younger patients enjoy?
    When an elderly person with cancer dies –who is being treated for the cancer — it appears that certain procedures that might permit the elderly person to continue to fight the cancer are denied under physician- initiated DNR’s because of the savings realized from ending all treatment.
    Who would question whether a DNR in an elderly patient’s chart is a product of the informed consent of the elderly person? When the elderly person is dead, the matter is moot, isn’t it?

  7. Just went through all this DNR with my father in ICU after a simple knee surgery. He is 86. My Father wanted it more than we did. All he could think about was his family being burdened by taking care of him.

    Mark

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