Tag Archives: age-based health care rationing

Meet the Real Death Panels: The Truth About Age-Based Health Care Rationing

The latest issue of Mother Jones includes an article by me about the controversy over age-based health care rationing, which got transformed by the right into government “death panels.” Unfortunately, liberals have fallen into a different trap, because they refuse to take on the real enemies of affordable health care for all: the insurance companies, drug manufacturers, and other profiteers of our private health care system.

As a result, old people are being asked if we would be willing to give up some expensive, life-sustaining treatment so that our grandchildren can have health care. This is a bogus question, and a bogus “choice.” The real question, as I say in the article, is whether we should give up the treatment “so some WellPoint executive can take another expensive vacation, so Pfizer can book $3 billion in annual profits instead of $2 billion, or so private hospitals can make another campaign contribution to some gutless politician.”

It’s a long article, and I’m including just the opening here, with a link at the end to continue reading at the Mother Jones web site. Or you can read the whole thing at MotherJones.com by clicking here. And if you’re one of those geezers who still likes reading print and turning pages, the July/August issue is on newsstands now.

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From Mother Jones, July/August 2010

There’s a certain age at which you cease to regard your own death as a distant hypothetical and start to view it as a coming event. For me, it was 67—the age at which my father died. For many Americans, I suspect it’s 70—the age that puts you within striking distance of our average national life expectancy of 78.1 years. Even if you still feel pretty spry, you suddenly find that your roster of doctor’s appointments has expanded, along with your collection of daily medications. You grow accustomed to hearing that yet another person you once knew has dropped off the twig. And you feel more and more like a walking ghost yourself, invisible to the younger people who push past you on the subway escalator. Like it or not, death becomes something you think about, often on a daily basis.

Actually, you don’t think about death, per se, as much as you do about dying—about when and where and especially how you’re going to die. Will you have to deal with a long illness? With pain, immobility, or dementia? Will you be able to get the care you need, and will you have enough money to pay for it? Most of all, will you lose control over what life you have left, as well as over the circumstances of your death?

These are precisely the preoccupations that the right so cynically exploited in the debate over health care reform, with that ominous talk of Washington bean counters deciding who lives and dies. It was all nonsense, of course—the worst kind of political scare tactic. But at the same time, supporters of health care reform seemed to me too quick to dismiss old people’s fears as just so much paranoid foolishness. There are reasons why the death-panel myth found fertile ground—and those reasons go beyond the gullibility of half-senile old farts.

While politicians of all stripes shun the idea of health care rationing as the political third rail that it is, most of them accept a premise that leads, one way or another, to that end. Here’s what I mean: Nearly every other industrialized country recognizes health care as a human right, whose costs and benefits are shared among all citizens. But in the United States, the leaders of both political parties along with most of the “experts” persist in treating health care as a commodity that is purchased, in one way or another, by those who can afford it. Conservatives embrace this notion as the perfect expression of the all-powerful market; though they make a great show of recoiling from the term, in practice they are endorsing rationing on the basis of wealth. Liberals, including supporters of President Obama’s health care reform, advocate subsidies, regulation, and other modest measures to give the less fortunate a little more buying power. But as long as health care is viewed as a product to be bought and sold, even the most well-intentioned reformers will someday soon have to come to grips with health care rationing, if not by wealth then by some other criteria.

In a country that already spends more than 16 percent of each GDP dollar on health care (PDF), it’s easy to see why so many people believe there’s simply not enough of it to go around. But keep in mind that the rest of the industrialized world manages to spend between 20 and 90 percent less per capita and still rank higher than the US in overall health care performance. In 2004, a team of researchers including Princeton’s Uwe Reinhardt, one of the nation’s best known experts on health economics, found that while the US spends 134 percent more than the median of the world’s most developed nations, we get less for our money—fewer physician visits and hospital days per capita, for example—than our counterparts in countries like Germany, Canada, and Australia. (We do, however, have more MRI machines and more cesarean sections.)

Where does the money go instead? By some estimates, administration and insurance profits alone eat up at least 30 percent of our total health care bill (and most of that is in the private sector—Medicare’s overhead is around 2 percent). In other words, we don’t have too little to go around—we overpay for what we get, and we don’t allocate our spending where it does us the most good. “In most [medical] resources we have a surplus,” says Dr. David Himmelstein, cofounder of Physicians for a National Health Program. “People get large amounts of care that don’t do them any good and might cause them harm [while] others don’t get the necessary amount.”

Looking at the numbers, it’s pretty safe to say that with an efficient health care system, we could spend a little less than we do now and provide all Americans with the most spectacular care the world has ever known. But in the absence of any serious challenge to the health-care-as-commodity system, we are doomed to a battlefield scenario where Americans must fight to secure their share of a “scarce” resource in a life-and-death struggle that pits the rich against the poor, the insured against the uninsured—and increasingly, the old against the young.

For years, any push to improve the nation’s finances—balance the budget, pay for the bailout, or help stimulate the economy—has been accompanied by rumblings about the greedy geezers who resist entitlement “reforms” (read: cuts) with their unconscionable demands for basic health care and a hedge against destitution. So, too, today: Already, President Obama’s newly convened deficit commission looks to be blaming the nation’s fiscal woes not on tax cuts, wars, or bank bailouts, but on the burden of Social Security and Medicare. (The commission’s co-chair, former Republican senator Alan Simpson, has declared, “This country is gonna go to the bow-wows unless we deal with entitlements.”)

Old people’s anxiety in the face of such hostile attitudes has provided fertile ground for Republican disinformation and fearmongering. But so has the vacuum left by Democratic reformers. Too often, in their zeal to prove themselves tough on “waste,” they’ve allowed connections to be drawn between two things that, to my mind, should never be spoken of in the same breath: death and cost.

Click here to the rest at MotherJones.com.

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Time for Hell’s Grannies to Ride Again

This is not a good time to be old in America. In addition to dealing with the usual burdens of aging–our aches and pains, and our worries about senility and death–we now have to contend with a backlash against the supposedly greedy geezers who insist upon clinging to life in definance of the public good.

On one side, we have pundits like David Brooks babbling on about old people stealing the nation’s wealth, and billionaire geezer-basher Pete Peterson bankrolling a campaign for an “entitlement commission” to cut Medicare and Social Security. Why should we expect a government handout just because we’ve worked and paid taxes all our lives? (Never mind that Wall Street has already decimated our retirement savings and home values.)

On the other side we have the champions of age-based health care rationing, led by “ethicists” like Daniel Callaghan, trying to convince us to go gently into that good night, while our corrupt system of medicine for profit goes on unrestrained. How would you like to be denied a kidney transplant or even a new hip, on the grounds of enlightened “cost-benefit analysis,” while the drug and insurance companies continue to rake in their profits?

It’s no wonder elders around the world are taking matters into their own hands. The only thing that’s surprising about the German geezer gang described in yesterday’s post is that it doesn’t happen more often. You hear about other incidents every now and then: an oldsters’ crime wave in Japan, or an octogenarian bank robber with an oxygen tank in San Diego. Maybe soon we’ll be seeing more elderly sapper gangs in action.

In the meantime, a reader dropped me a line last night with a reminder that there is indeed a precedent for all this, deftly portrayed by Monty Python. Seems to me that it might be time for Hell’s Grannies to ride again.

How Much Is a Year of Your Life Worth?

If they know what’s good for them, older folks will be especially attentive to one undercurrent in our present health care debates: an increasingly widespread view that the allocation of medical treatments—and indeed, the worthiness of human life—should be subject to a cost-benefit analysis.

Obama’s stimulus plan, for example, includes substantial funding for what’s called “comparative effectiveness research,” to test various treatments for the same illnesses and report their findings to the president and Congress, which will presumably use it in their policymaking decisions. As the New York Times reports, “Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.”

On one level, this is only sensible. And thusfar, the main opponents of comparative effectiveness research seem to be conservatives, who fear any kind of government intervention into the current–and highly unequal–private system of health care dispensation. But what worries me about this approach is how the data it acquires might be used—or misused. 

On its Economix blog, the Times has been running a series of posts by Princeton economics professor Uwe E. Reinhardt, the latest of which discusses the concept of “QALYs”–“quality adjusted life-years”—which could be used to help determine how the government spends its health care dollars. 

QALYs are a metric widely used now in cost-effectiveness research. They are meant to adjust for the fact that not all years added to people’s lives are equal. A medical intervention yielding a given number of additional life-years in perfect health makes a greater contribution to human well-being than an intervention that yields the same number of life-years in less-than-perfect health. QALYs are used to adjust for that difference in a patient’s quality of life. 

Who, I wonder, is going to determine the quality of our life-years—especially as we get older? I’m 72, and I know it’s been a long time since I had a year in “perfect health.” It seems to me a very short leap from calculating QALYs to instituting age-based health care rationing, an increasingly popular proposition under which the elderly are told they should sacrifice some of their “less than perfect” life-years for the good of all by forgoing costly medical treatments.

As I’ve written before, arguments for age-based health care rationing are in turn based upon the idea that if we don’t do something like this, health care costs—and especially Medicare—will soon bankrupt what’s left of the American economy. But this idea rests upon a major fallacy:  that there’s nothing else we can do to lower costs other than withhold care from the greedy geezers who want a new hip or a heart bypass when they haven’t got long to live, anyway.

In fact, there are plenty of other things we can do to cut costs—for a start, kicking the insurance companies out of the mix, reining in the drug companies, and instituting a single-payer system, which could lower our national health care  bill by as much as 40 percent while providing improved care to Americans of all ages. This fact is supported by numerous studies comparing health care in the United States and other industrialized countries, conducted by the World Health Organization, Congressional Research Service, Kaiser Family Foundation, and Commonwealth Fund, among others. 

So I’ll say it again: As a public-spirited old person, I might be willing to give up some costly, life-sustaining treatment if the future of humanity depended upon it. But I’m not going to sacrifice a single life-minute to preserve our system of medicine for profit.

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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