A Ration

Here's one of the clearest discussions of rationing of health care, the impossibilities, the need, the politics that I've read in a while.

....We want our doctors to go all-out for our loved ones and ourselves. But as voters and consumers, we send a different message. We pick politicians who promise to cut taxes, and we demand low-cost insurance. We're telling government and the health-care industry to hold the line on health-care costs, even if it means sacrificing clinical benefits. And we put doctors in the middle of this contradiction.

In recent weeks, private insurers have revealed plans for double-digit rate hikes. Our medical bills are already close to a fifth of our national income, on track to reach one-third within 25 years. Soaring Medicare and Medicaid costs are the main reason for nightmarish federal deficit projections over the long term. Yet as Republicans and Democrats battle over the federal budget to the point of threatening a government shutdown, serious health-care spending cuts remain unspeakable.

House Budget Committee Chairman Rep. Paul Ryan, R-Wis., recently proposed to cut Medicare and Medicaid by shifting their costs to poor and middle-class Americans who can't afford them. It's an unconscionable approach, but it at least acknowledges the urgency of gaining control over federal health-care spending. Neither President Obama nor congressional Democrats have put forth plausible proposals for doing so.

I'd disagree with the last sentence: the ACA calls for effectiveness research, which might well go a long way toward controlling unreasonable costs. Rs, of course, have convinced teabaggers that it's another form of death panel; as is the case with pretty much everything teabaggRs believe, the exact opposite is true.

Along similar lines, there's this thoughtful suggestion:

Andrew Sullivan has a proposal to lower health-care costs that actually makes some sense. “If everyone aged 40 or over simply made sure we appointed someone to be our power-of-attorney and instructed that person not to prolong our lives by extraordinary measures if we lost consciousness in a long, fatal illness or simply old age,” he writes, “then we’d immediately make a dent in some way on future healthcare costs. A remarkable proportion of healthcare costs go to the very last days or hours of our lives.”

His idea is voluntary. But I’d make a different suggestion. What if, to be eligible for Medicare, you had to give someone power of attorney and sign a living will? You could tell your attorney, and write in your will, that you want every possible measure employed to keep you alive. You could say cost is no object, and neither is pain or quality of life. You could make whatever choice, and offer whatever instructions, you want. You just have to do it. You have to make the decision.

The Palinites wouldn't be able to get past the "to be eligible part," of course. But, in fact, the suggestion reiterates what's always been true: living wills allow you to choose whatever you want.

Thoughtful people -- the President included -- have put thoughtful ideas on the table. Sadly, any thoughtful idea is necessarily fraught with the non-starter that realism no longer has a place in our politics. So we stumble on toward the darkening horizon, preferring to sling slime at those who actually try. No wonder birtherism, secret-Muslimism, have taken hold: when he took office, President Obama actually thought there'd be a place for give and take discussions, serious ones, about serious problems.

What planet was that guy from??? He sure as hell doesn't sound like one of us.

Doing The Right Thing

When I read this, I knew there'd be hell to pay for President Obama. It also impressed the hell out of me. It's political... courage.

WASHINGTON — When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system. But the Obama administration will achieve the same goal by regulation, starting Jan. 1.

Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.

No question the president knew what would be coming. Shit like this. And yet, because it's the right thing, he presses on, politics be damned. That's leadership. That's guts, or some other slightly more southerly anatomical metaphor.

Even readers of The New York Times, evidently, are caught up in the fecal efflux coming from the right (as in "wrong") side of our politics. Here's a recent letter to the editor, among several:

I read your article about “end-of-life planning” and I am completely appalled. I have been a longtime supporter of President Obama, but it appears as if death panels are becoming a reality.

My mom, 93, recently received a diagnosis of colon cancer, and her doctors recommended an operation to remove the tumor. It was successful and she can now expect to live several more years.

Who are we, or any doctor, or any president to judge when the end of life is and when to deny aggressive care?

What a shame. How sad to be so misinformed.

For the length of my career as a physician, and in the recent declines and deaths of my parents, I've come to appreciate the need for health care directives, and, unlike the mouth-breathers of the right wing and the fears of the letter-writer, I came easily (for it's simple, obvious, and completely logical, absent the screamings of the screamers) to understand what they are. And, more importantly, what they are NOT. Once again, the so-called controversy begs the question: are the dissemblers really that stupid, or are they, per usual, grasping at anything they think they can sell to a gullible public in an effort to discredit our president? (My opinion: there's a lot of stupidity seeping sadly from the screamers, but they can't be so dumb as to believe their own words in this matter. It's cynical politics at its very worst.)

That the lady of the letter is so misinformed is not entirely her fault. For one thing, there's confusion -- because our fourth estate is so damned incompetent -- between end of life directives and the concept of effectiveness research. Though very different (and useful) ideas, such intellects as Sarah Palin and Glenn Beck have used the concepts interchangeably in their race to the bottom of the pickle barrel of demagogues. Because they're cynical assholes (to use diagnostic terminology), I doubt it's accidental.

Simply put, end of life directives are a way for people to ensure that their wishes are carried out. Shall I repeat? Ensure that their wishes are carried out. Carried out!!! It's the absolute opposite of a "death panel." It's a directive. By the patient. And it applies only when that patient is unable to express his/her wishes. It's not an unbreakable contract that overrides one's current wishes. Like my dad. In his directive, he'd said he didn't want to be hooked up to a ventilator. When the time came, he chose to be intubated. No one did -- or could have -- told him, sorry, we have your directive here, and it says no.

As long as you're capable of expressing your desire, the directive does not apply, no matter what it says. DOES NOT APPLY. There is no panel, nohow, nowhere, that can decide otherwise. Period.

No. Fricking. Panel.

[What panels there are, by the way, are those instituted by Republican governors, in Republican states.]

The other concept -- effectiveness research -- is more complicated and, because of the very nature of medical research, rightly a subject of controversy and disagreement. But, for one thing, that's not what the president and the NYT article were talking about. For another, who, given a moment's thought, would want to be treated using methods shown to be ineffective? If -- and it's not a tiny "if" -- research could point to the best treatment and away from those that are a waste of time and hope and effort and suffering and money, would that not be something we'd want? Demand??!! Even if the idea came from a black guy?

But the Sarah Palins and Foxobeckians of the world, the teabaggers, are neither capable of such subtle thinking nor interested in what's reasonable or factual. Not to mention what's in the best interest of our country. Never missing an opportunity to lie and to frighten, they spew their dishonesty and people like that poor letterer are deceived. Like my ninety-three year old aunt who just underwent colon resection and chemotherapy for cancer, the writer's mother got the treatment she needed. There's nothing about end-of-life directives that would have changed that -- or even addressed it! -- unless she were in a coma and had previously directed that, under those circumstances, she'd not want aggressive care.

Likewise, effectiveness research might have prevented her from having her back manipulated and taking homeopathic remedies or aromatherapy for her cancer, or, possibly, from receiving Avastin for it; but, until the day arrives that there are data showing surgery doesn't cure colon cancer, she'd receive that, too.

Unless, of course, we ever get around to looking at the books and deciding how much we want to and/or can afford to spend on medical care; and if, when we realize that there's a limit, we're willing to confront whether, given limits on resources, paying for colon surgery for a ninety-three year old carries the same weight as doing so for a forty year old.

But that's another matter entirely. Nor will it ever fit into the minds of teabaggers, who want simultaneously to reduce taxes and bitch about cuts in medical care; who call it "rationing" to refuse to pay for treatments that don't work.