Rivlin's Rebuke and Why It Matters

So, can someone ask Alice Rivlin to respond to Paul Ryan not as a policy wonk, but as a politican would? You know, something to the effect that she is shocked and dismayed that Ryan is dragging her name around claiming bipartisanship for his health care plans when she completely and totally opposes what he is doing with them? Can she get herself quoted by news outlets other than Politico and Ezra Klein, so that the average voter who pays some general attention to this stuff through the main news media channels and the news blurbs in his e-mail account can see headlines like "Democrat Who Worked with Ryan Repudiates His Plan"? Because if that doesn't happen, Ryan can just keep lying that he has bipartisan support for his plan and no one in the news media will call him on it.

It's true that the delivery of health care is inefficient; and it's also true that ACA has many provisions designed to make it more efficient. But the reality is that, no matter how much more efficient it may become, controlling costs will require more. And there are two ways to accomplish it: the Ryan way, which is to put a government cap on medical insurance and medical care for seniors, and the freedom of choice way, which is for seniors, in consultation with their physicians, their families, and their clergy, to make the best choice for medical care. Treating seniors as the mature adults that they are would be the first step to controlling health care costs.

Rivlin, for all of her honesty, intelligence and effort in trying to work on a plan to address the issues of Medicare, has fallen victim to the classic Right's slight-of-hand trick of calling for 'bipartisanship' and then disingenuously using said Democrat's name to drag it through the mud as the Right claim victory by using 'bipartisanship' as a form of whitewashing their regressive and anti-progressive policies back into the Gilded Age of Robber Barons.

Now she realizes that the only way to pursuade folks that her name isn't attached to the Ryan-Rivlin plan is to claim her name isn't THAT Rivlin but another Rivlin who tried to do right by the world and has had her name, position and policy stances stolen from her and twisted into some cadaverous hunk of rotting flesh we call the Ryan Solution.

I would second rayward that treating people making decisions about their health care as adults is a big step in the right direction, but I would add that a big part of making adult decisions is making cost vs benefit choices. If most or all of the cost of your decisions is covered "magically" by the government or subsidized insurance, that won't happen.

Here's how an adult consideration would go, in my mind. As we age in retirement, an INCREASING fraction of health care costs, beyond basic life support and palliative care, would come out of seniors' own pockets. I would do this proportionally - by percent of assets, not by absolute dollars - so to make it clear that choosing, say, an organ transplant at 70, is going to take some of your assets - which means, if you have children, taking money out of their potential inheritance, and if you don't taking the risk of surviving but being increasingly impoverished.

We need to focus our social spending on the future - on the health and education of people with potential to contribute into the future, and on the infrastructure to make enable them to do so. It is not wrong, in my opinion, for an older person to have to choose between not getting exceptional care that will likely extend their life minimally, or paying for it themselves or out of their family's resources.

I have watched my Amish neighbors deal with this. Grandpa or Grandma gets old, frail, and ends up with cancer or pneumonia, or whatever, and guess what? They do NOT break the family farm to extend Grandpa or Grandma another 9 months, they make the person comfortable, prepare their graceful, tearful, heartfelt goodbyes, and return to the business of raising and succoring their children. Their society is not poorer for it, but rather, I would say, richer. Death comes not as some horrible, unfair and unanticipated end, but as part of the normal course of things. Part of what we do in life is leave it, and expecting those left behind to go bankrupt so that we can do that a little later than we otherwise would, is damaging to all parties in involved.

Well spoken, Iowa. Very well spoken.

Amish death panels -- does the former 1/2 governor of Alaska know about this?

Dan

Iowa, you seem well-intentioned enough, but, speaking as a physician, let me assure you that your idea of somehow gradually introducing market incentives into personal medical choices is pure fantasy. You want seniors to have to pay for everything beyond "basic life support" out of pocket, but really for all old people and people of any age suffering from chronic diseases, ALL medical care is "basic life support." Certainly the expensive stuff such as ICU care, major surgery, and life-long drug treatment for conditions such as diabetes, hypertension, coronary artery disease and congestive heart failure are life-extending treatments. No patient ever says, "Oh, if you knocked three grand off the price of that heart surgery I'd take it, but at the current price I'll give it a pass."

Really, what you're advocating is a form of treatment rationing. Not only that, it's a spectacularly inefficient form of treatment rationing. Of all the players, patients are the least well-positioned to formulate rational cost/benefit analyses; they lack the requisite knowledge and training to accurately assess the true value (or lack thereof) of treatments being offered them and because it's they who are staring death in the eye, they quite systematically and dramatically overvalue treatments that offer limited benefit or, what is much the same thing, a limited likelihood of significant benefit.

Don't get me wrong, I'm all for treatment rationing. The only way to cut health care costs is to offer less treatment, and any system that manages to deny treatment to patients who would receive it under the present systemis a form of rationing. I just think that the idea that patients should be made the decision-makers in such rationing schemes is ridiculous.

To Iowa Beauty, most of us in the US are not Amish farmers still living in the 18th Century. We are 21st Century citizens of the most powerful and potentially the most productive nation in the history of civilization.

I see how so many of my Fairfield County, CT (and by extension Westchester County and Upper East Side NYC) neighbors handle their lives -- with ostentatious displays of wealth, wealth largely from banking and hedge fund activities along with inheritance and services (such as law) to the bankers, hedge fund operators, and heirs. (Very little of the big money today comes from actually producing useful things.) With some reasonable tax increases, which would not lower my neighbors' standards of living one bit, plus some efficiencies added to the medical system and reductions in the government subsidized profits of insurers and pharma manufacturers, we can favor life over death for even those with ultimately terminable cancer and pneumonia.

One of the wonderful things about our current system, even with all of its problems, is that it favors life over death. In a country as rich as ours, forcing someone to weigh getting a transplant against passing on something to heirs is -- to use an apt phrase -- sick.

AaronW, I think you and Iowa are in agreement on the whole rationing thing, and the rationale for it; Iowa just took a more humanistic approach to the position, whereas you've taken a more rationalized approach.

To GSpinks: Re - "AaronW, I think you and Iowa are in agreement on the whole rationing thing, and the rationale for it; Iowa just took a more humanistic approach to the position, whereas you've taken a more rationalized approach."

Their agreement about rationing means that they both want to limit access to health care, which in our wealthy nation is neither economically necessary (quite the contrary) nor ethically defensible.

AaronW, by the way, as an MD will probably never have to face the prospect of rationed health care, nor as I said above will my wealthy hedge fund and banker neighbors, for whom even a $1 million medical bill is only a drop in the bucket.

Let's improve, in a reasonable way, the efficiencies of health care and, among other things, focus on preventive medicine, reducing the wasteful use of emergenccy rooms, and adequate follow up (which almost never happens -- I have never had an MD or nurse call to ask me how I am doing after treatment).

A better start would be to catalog the differences between the French system and ours in terms of the nature and extent of treatment, the outcomes, and the prices. We have valuable precedents we could look at in detail. In our American hubris, we refuse to do so simply insisting, despite evidence to the contrary, that this is the best system in the world.

One thing is certain. Doctors in France do not make millions. Yet, they are not short of doctors there. We would save a fortune just by controlling physician prices and utilization and providing to the most qualified a free medical education, right through specialization, for the number of doctors we need. Set drug and device profits based on standard costs, use computerized protocols to decide what is optimal care, and I will bet we are 90% of the way there. Of course, then medical care would no longer be a "free enterprise" which is anathema to the market purists even though market-based medical care is killing us.

"Really, what you're advocating is a form of treatment rationing. Not only that, it's a spectacularly inefficient form of treatment rationing. Of all the players, patients are the least well-positioned to formulate rational cost/benefit analyses; they lack the requisite knowledge and training to accurately assess the true value (or lack thereof) of treatments being offered them and because it's they who are staring death in the eye, they quite systematically and dramatically overvalue treatments that offer limited benefit or, what is much the same thing, a limited likelihood of significant benefit."

Yes, I am advocating rationing treatment for people at the long end of life. I do not in any sense advocate rationing palliative care, or treatment that clearly improves quality of life. I know, of course, that these are incredibly hard choices, and none of them can be made perfectly.

I am not a medical professional, but members of my family are, and I have worked closely with the medical establishment both professionally and as a patient and relative of patients. if your position is that physicians are the ones in a position to make this type of choice, I couldn't disagree more. Physicians could be and should be the source of unbiased information about likely outcomes and costs, but it should not be their role to determine whether that cost/benefit tradeoff is positive or not. That belongs to the family affected, and the payer. What I see, instead, is physicians who do not, or cannot, give people reasonable estimates of the life and quality of life extending value of a treatment, and medical establishment that absolutely will not (because of our fee for service model) provide cost estimates.

A personal example: an elderly relative who for the last ten years of her life (she died at 100), was in an out of hospitals for for various treatments, minor surgery, and repeated pneumonia. She enjoyed, as nearly as I can tell, not a single moment of the last 8 years of her life. The inevitable course - of successive decline after each hospitalization and lack of true recovery - was clear after the first two years. She was ready to die, and knew she could not really recover, and her children were (with one exception) ready to let her do so. No one in the medical establishment could even bring themselves to say that not treating the repeated pneumonia was an option, so she died by inches, ending up blind, deaf and stupid - a shell of a once proud women who, had the system helped her to a human and responsible choice, would have gratefully and gracefully died at 92. Finally her son simply refused permission to transfer her to hospital for yet another episode of pneumonia - which her physician continued to insist was necessary and correct, and she died.

I saw multiple similar cases at a major hospital where I was doing consulting work, and where a family member was on the medical staff. Sometime the family was at fault, sometime the physicians, but never was the required information about likely outcomes and costs made clear.

I have enormous respect for physicians, and I do not blame them personally for a system that does not work in end of life decisions. But the system is broken, and it is in no small part due to the the way currently pay or don't pay for treatments.

"To Iowa Beauty, most of us in the US are not Amish farmers still living in the 18th Century. We are 21st Century citizens of the most powerful and potentially the most productive nation in the history of civilization."

The Amish live in the 21st century, in the same country you do. They just choose to live differently. We could learn from some of those choices, in my opinion.

"we can favor life over death for even those with ultimately terminable cancer and pneumonia."

I favor life over death. I don't want to kill any person. But we all die, and I don't favor a system that thinks every life extension is worthwhile. Not all are. If anyone can show me how folks like the Amish are emotionally or spiritually poorer for their choices, argue away. I haven't seen it.

I use the Amish as an example deliberately. No people on earth could be further the idea that a person's value is determined by their wealth, or from "granny death panels" or eugenics. No people I have ever met value family life more strongly.

With respect to Iowa Beauty - nuts.

Just nuts.

You do not have the right to say this or that person is worth less because he or she is over a certain age.

Furthermore: where is all this magic money, supposedly owned by seniors, coming from?

Do you realize how truly poor most of us are? especially in regard to our so-called health care system which is actually more closely resembling a network of high-priced professional vultures.

This is especially so since the devaluation not only of people's homes, portfolios etc but also - of our time.

Our time and educations and creativity are also not considered valuable. Labor isn't considered valuable. The arts - forgetaboutit. Yet these are things - wisdom, artistic skill, even creativity - that improve with time and with age are they not?

As for labor in general, I'm not just speaking of old people either but of all of us. How many people are working on wages that won't sustain a single person let alone a household? Yet - we see attacks on unions! Union members are called "thugs!"

Nevertheless, here we have "the Amish" who'd bury folks prematurely, it seems to me, and I don't find anything edifying about this.

And, we have people like Paul Ryan who just want to employ more paper-shufflers, ie insurance industry administrators, who don't actually produce anything - they make a living from shuffing the same money around and charging a fee for it.

WORK THIS IS NOT. Work = making something, do something, contributing something creative, passing along knowledge to the future, building things, fixing things, planting forests, caring for animals, caring for our planet and for each other.

Meanwhile, charging more and more for passing money around is not a solution it is a problem.

And artificially limiting life because of some arbitrary time line that declares one "less valuable" because you're over 70 and/or because a person might not be lucky financially - what on earth is right about that? That is jungle law not human law.

I'm only 61 and believe that my life will be quite short simply because I'm poor. Yet, I'm an artist, a dancer, I teach art and dance, and think I have something to offer the world ESPECIALLY to the young - and this goes double for the many other talented, accomplished senior citizens of America. Do they not continue to grow with age? Did Picasso stop being creative because he was over 70?

My dad, a painter, did his best work in his seventies and was productive up until recently; now he's 87. Should we just set him out on the prairie? He has dementia after all - maybe it's time for him to go and stop sucking up our so-called inheritance right?

FTS.

"Forward thinking" your ideas, Ryan's ideas, and ideas that would place an economic value on life itself, or which glorify NON-CREATIVITY, are not. There is nothing good about killing off wisdom and experience - nothing.

These ideas are reactionary and foolish. We do the youth of the world no favors by killing off people who have worked all their lives to learn something and have the ability to transmit it to younger generations and who are creativity, who have ability, who can work and make a contribution even if that contribution is merely telling stories.

My dad's WWII stories, which he only started telling after he stopped painting, ie when he was over 84, are priceless and they are valuable and I'm glad to have heard them and I wrote them down. If he were dead, he couldn't have told those stories could he.

Damn I am beginning to hate our so-called "civilization." We are becoming barbarians.

"And artificially limiting life because of some arbitrary time line that declares one "less valuable" because you're over 70 and/or because a person might not be lucky financially - what on earth is right about that? That is jungle law not human law."

Sophia...I'd like to comment regarding your last passionate post. The complexities of dealing with an aging adult are not easy. Least of which when it is your parent. My grandmother passed away a week after she turned 90. She had had many ups and downs the last 15 years with broken hips, hernias, pneumonia, etc. Each time she went into the hospital it seems my mother and her siblings were hold bedside vigils because they thought it was the "it's time" moment for their mom to pass. She didn't, she would recover and each time she would recover. When she decided to sign a 'do not resuscitate', my aunt and uncle when apeshit arguing with my mother because they wanted anything and everything possible available to keep their mom alive - regardless of her wishes. My grandmother finally had to have the doctor sit down with the whole family and explain what she had decided to do. So when she finally went into the hospital for the last time, the staff asked if she wanted artificial support, she said no and they simply made her comfortable enough and "well" enough to get her into hospice until she passed.

My point is that the arguments being made about ways to quantitatively evaluate effective treatments that extend life should also make sense to the person getting it. Having a hear transplant at 90 doesn't make sense if that same heart can go to another person who has a greater chance of surviving, recovering and having more than a few extra years of added life because the kids "can't let go." Automatically assuming one's life is improved with endless medical treatment just so we can say they're alive isn't really quality of life but quantity of life instead.

We're now at a point in the political debate where the ACA proposed funding for these kinds of decisions, that were summarily decried as 'death panels' and now we see the GOP literally throwing the sick and poor to the dogs. As long as you don't become eligible for Medicare by 2022 you're still covered by the current system. Count yourself lucky.

I, on the other hand, will face having to figure out and plan for what my health care future may hold without ANY guarantee of a modicum of a safety net like Medicare (if the GOP get their way.) How does one plan for their future health care needs when I can't even predict where I'll be in 5-10 years! "Even the best laid plans of mice and men go astray." Yet the Ryans of the world and his Ilk would like us to believe, and most especially the aging boomers, that yep...the retirees can still have it all while we give the shaft to the youth.

I think it's a travesty and a crime that we are now at a point where the Right are literally legislating into place class and age warfare. http://www.fastcodesign.com/1663567/infographic-of-the-day-the-gops-war-...

It shouldn't be so. But until we realize that we collectively have to face down the skullduggery that is the GOP of late we are in for dark days ahead.

Pete et al, limitation of access to treatment happens every day all around the world including the USA. It is an inevitable part of medicine. Not all patients derive equal benefit from given treatments, however the process of determining who will benefit from treatment and who will not is a crude science and such decisions are often subject to debate and disagreement. The question is where do you draw the line? If a treatment costs $100K and gives 90% of those who receive it 10 years of additional life, by the standards of most everyone in the developed world it gives good value for money. But what if it cures only 10% of those who receive treatment and the other 90% derive no benefit at all? In the USA our system for making these judgments consistently skews in favor of spending more money for less benefit which goes a long way to explain why we spend at least twice as much per capita on health care as anybody else and have no improvement in outcomes.

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Sophia writes, "You do not have the right to say this or that person is worth less because he or she is over a certain age.".
From neonatal to geriatric care and at all stops in between a culture balances the costs and value of health care. And those costs include pain and suffering along with financial considerations. It is folly to claim people do not choices regarding worth, it is part most medical options.
But it is probably taboo to question postponing death at any age in the United States. Rich or poor, young or old we place an irrational price on not dying and that cost often excludes pain, suffering and dignity. Does a person have the right not to live or is not dying worth more...at any age?

Of course there are limits. I don't think it's smart medicine or even kind to spend millions of dollars to keep a person alive for an additional six weeks - but then - who are any of us to judge? I just lost a dear dear friend - she had liver cancer. Another has acute leukemia. The former was 87 and the additional months she lived, no doubt expensive months - were incredibly precious to us.

My friend with acute leukemia is 62. She will die soon regardless but without EXPENSIVE care would have died a year ago. Nevertheless, I am sure that she and the people who love her are grateful for the time she's had.

Who are any of you to judge?

More importantly - there is a real ageist thing going on here lately - on TNR specifically - it's giving me the creeps.

The suggestion that older people have huge amounts of money is absurd. We don't. Had the Baby Boomers NOT run into serial recessions, layoffs, insane inflation and the deflation in value of our labor - all of which factors have made all workers more poor vis a vis the ruling elites, we'd be pretty well fixed by now. But that isn't what happened. We did run into this - plus "globalization," ie the export of American jobs which only enriched the wealthy and screwed the rest of us.

And seniors older than the Boomers often struggle between paying for food, rent, and/or medical care - so who are these mythological creatures who can afford to pay for transplants out of their own pockets????

Moreover - I reiterate: the idea that because people are older they don't have a right to live is wrong. It's the inverse of the equally stupid idea that fetuses are humans and are more important than living people especially than their mothers.

Also, not all of us HAVE children so this idea that we should "live for the future of our children" is a little absurd. In fact it's pretty abstract.

I think people should have information and the ability to make rational choices, as President Obama suggested. I do not think we should have insurance driven death panels and I think the Paul Ryan budget is barbarous.

I do think that means testing is a reasonable idea when it comes to Medicare. If people are rich, by all means let them pay more! Better yet - get a decent tax policy! Bring back our jobs so we have a tax base! Re-establish the dignity of labor, fight for unions and working people - don't just roll over and buy into the Republican idea of "productivity" because it's the path of least resistance.

And - if people are poor, they shouldn't be left to die simply because they are poor. People shouldn't be left to die simply because they are, in your opinion, "too old."

This is wrong by any standard of decent human behavior.

And, I don't think there's a one-size-fits-all standard. Judging whether a person is worthy of saving simply because they're poor and/or over 70 is cruel. It's reminiscent of Nazism in fact.

"I don't think it's smart medicine or even kind to spend millions of dollars to keep a person alive for an additional six weeks - but then - who are any of us to judge?"

Who are we to judge? We are the members of the society that has to pay for this stuff. We HAVE to get better at making these hard decisions. American's burn through the majority of their lifetime medical expenditures in the last six months of their lives. Now, the problem you run into is knowing propspectively when that last six months has begun. Especially at the beginning of that time, it can be pretty hard to tell whether a patient has one week, six months or five years left to live. However, the assessment can be made a lot more accurately than it is done in the USA. I've worked as a hospital-based doc in both the USA and Australia, and while Australia is far from as draconian in this regard as some places (such as the UK), here they're a lot better about it than in the US. ICU doctors here in Oz will say to patients' families, "No, we will not mechanically ventilate your 85 year old father who has respiratory failure due to chronic heart failure and pneumonia. To do so would be futile." In the States doctors hem and haw and say to families, "Your dad is probably not going to make it no matter what we do, and maybe it would be best just to keep him confortable, but if you really want us to we can intubate him and admit him to ICU and, who knows, he might surprise us and pull through." What family would say no to ICU in such circumstances and have to live with the thought that they didn't give dad every chance?

Look, somebody has to make these judgements, and patients and patients' families are in no position to do so. To continue with the example of the 85 year old with acute respiratory failure on a background of chronic heart failure, the fact is that fewer than 25% of patients like that are going to make it out of the hospital alive no matter what you do, and of those who do survive the acute episode, most will be dead within a year and essentially all will be dead within 3 years. If you tube those patients and admit them to ICU, the mean time to death or recovery is probably about 4 days. ICU care costs several thousand dollars a day, so if you treat those patients, you're going to spend maybe $20,000--a VERY conservative estimate--on each one. But since you're getting only 1 in 4 through to hospital discharge, that's $80,000 just to get one 85-year-old out the door, and since maybe 1 in 10 of your initial cohort survives the year, you're spending $200,000 to buy an 85 year old one additional year of life. And remember, this is an 85 year old with chronic heart failure, so though he survives, he's likely to have a pretty cruddy time of it. Is it worth it to society to spend that $200,000? Is it even worth it to the patient? So do you still ask who are you to decide? Well, I don't know who you are, but SOMEBODY has to decide. And you can't act like the decision to go ahead and spend that $200K is inconsequential. That's $200K that doesn't get spent on teachers or high-speed rail or on prevention of infant death from diarrheal disease in the developing world.

AaronW, I hope that when I'm 85 you're not my doctor.

It is simply arrogant, unacceptably arrogant, to claim that patients and their families can't make informed decisions -- with professional support -- about questions of life and death. In fact, they are the ones who should be making those decisions. Come off your pedestal, man. Yes, you have a MD degree, but you are a human like the rest of us.

What you are in fact advocating are death panels, purely and simply. Palin may have been wrong to say that they are part of Obamacare, but you clearly think they should be.

The $20,000 for an ICU to possibly save a life is a pittance compared to the literally billions that could be saved with various reforms to the medical system, including among other things lower profits for insurance companies and pharma manufacturers, lower payments to high priced specialists (I just saw the amounts my insurance company paid to have a suspicious mole removed!), better coordination of practices, programs to reduce chronic use of emergency rooms by the uninsured, increased preventive care and support for primary care physicians, and yes, higher taxes on the truly rich whose ostentation I see every single day. When those and similar possibilities are exhausted, I for one -- and I think most of the country if they had enough information -- would be open to considering your solution, but not a moment earlier.

Before we systematically pull the plug on grandma and grandpa, lets see if there are alternative ways to save a buck.

Yes, I am advocating death panels. That is, I am advocating that groups of physicians--it is a good idea if more than one doc contributes to such decisions--who are actively treating individual patients make a realistic assessment of those patients' likelihood of benefitting from further treatment and stop treatment when that likelihood is unacceptably small.

And cost isn't the only consideration here. There's also the valueless extension of suffering to think about. You imagine that you wouldn't want me to be your doctor when you're 85 and the old man's friend, pneumococcal pneumonia strikes, but think seriously about the alternatives: you can be looked after by me and receive some oxygen by facemask and penicillin on the off chance it will help and a hit of morphine when you feel like you're drowning in your own secretions and you can take a drink of water when your mouth gets dry and die relatively peacefully surrounded by your family, or you can see another doc and die with tubes coming out of every orifice, a central venous cathether piercing your chest and an arterial line in your grown, choking uncontrollably on your ET tube every time they lighten your sedation, seperated from your family because visitation to the ICU is limited all for a longshot bet that you'll live to experience few more months--maybe 0.75% of your total time on earth--as a cardiac cripple.

It is not arrogance for me to suggest that when faced with a choice between requesting treatment and no treatment for a loved-one, even when the likelihood of successful treatment is small, most people are not capable of making an objective decision; it's a simple fact. When it's you who is being required to make a decision whether or not to "pull the plug" on your spouse or parent, even if there's a 95% chance that your loved-one will die no matter which way you decide, the full weight of guilt for not giving him or her that 5% chance falls upon you. Most people aren't prepared to accept that responsibility and so time and time again they opt for invasive, undignified, dehumanizing treatment even when such treatment has very little likelihood of providing any benefit at all. In my experience here in Australia where in such cases doctors don't place that burden of choice on family members, the response with which I am most commonly greeted is gratitude. To be sure, if family members object to withdrawal of care, we rarely deny treatment and do so then only after multiple practitioners have reviewed the case and agree that treatment is futile, but such cases are rare and for the most part people seem relieved to be granted the space to confront on their own terms an eventuality, ie death, that sooner or later comes to us all.

And the truth is, death panels already exist. How do you think it is decided who gets a bown marrow transplant and who doesn't? If you have non-Hodgkins lymphoma and you relapse after first-line chemotherapy, your only hope for survival is a BMT. But no one over 70 gets a BMT. Is that because BMT doesn't work at all for anyone over 70? Of course not; it's because when you add up the numbers, so many elderly lymphoma sufferers die as a result of or in spite of bown marrow transplant therapy that it isn't deemed worth it either in terms dollars or inflicted suffering. (A bone marrow unit is like something out of Dante's Inferno.) If they did decide to transplant oldies would a few defy the odds and achieve longterm remissions? Without doubt. But not enough to make it worth it. So who decided this? Well, it was a group of experts in hematology/oncology, but if you like, you could call it a death panel.

BONE marrow transplant. Jeez, this site really brings out my dyslexia.

Preventative care doesn't save money. It costs money, and it doesn't prevent hospitalization and other more intensive forms of treatment, it only postpones them. Everybody's gotta die sometime.

No, the only way to reduce healthcare expenditures is to reduce the intensity of health care utilization, and the only way to do that is identify situations in which treatments are being offered that give little bang for the buck. But such situations are almost always probabilistic; few treatments offered have ZERO potential benefit. So what you have to do is tell people who have a small but real chance of benefitting from treatment that they can't have that treatment. If you want to call that a "death panel," fine. It's the only way to reduce costs.

You can be my doctor any time aaron. What you describe is what I think of as compassionate care. My medical instructions say that those charged can withhold or require any procedure they see fit, asks them specifically to minimize suffering, and states that the standard they should apply to their decisions is only compassion. And I was sure to thank them for undertaking the responsibility on my behalf in the hope that guilt would play no part.

"You do not have the right to say this or that person is worth less because he or she is over a certain age."

I agree, and I have no desire to make such a determination for anyone other than myself, or people close to me who have entrusted me with those judgments - as my answer to AaronW makes clear. Those decisions belong to the people involved.

Where we clearly disagree is that I think the cost of those decisions needs to be born partly by those deciding, so that they are considered in the decisions. Very expensive treatments that can at best only extend my 90 year old father's life a very few years, and which may not work at all or lead to serious deterioration in his quality of life, are not a good investment for SOCIETY. Society has no obligation to fully and unquestionably fund them, at the expense of other investments. If he and his family wants them anyway, we should bear at least some of the cost. For my part, I want that money spent on my grandchildren's generation's education and health care, on combating global climate change, on research for the future, etc.

Some will say I am making a false trade-off here, but I am not. Health care for the aged does not contribute to the future in any meaningful way, and we are systematically under investing in the future at multiple levels. Health care for the aged DOES contribute, or is a major component of our humanity, of course. But, again, this is why I used the Amish example. The Amish can in no way be dismissed as inhumane, unloving, or uncaring about their elderly. Their approach exudes the kind of family-centered humanity for which they could serve as role models for all of us, but they do it with full cognizance that doing more in the technical sense is too expensive for them. We should be so wise.

Beautifully put, Iowa.

I have never heard it suggested that anyone should be prohibited from paying for a low expected value treatment. The issue is whether society should do so in the face of other significant claims, including the education of the young, retirement income security, and universal health care. I think not. We should not allow marginal extensions of life for a few to consume so much of the opportunity for those with years ahead of them. We all have only so much time. Modest additional longevity for a few should not be at the expense of the well-being of the many. Our health care bill, particularly heroic end of life care, is now so large that we are at that point. Enough.

Very few people would bankrupt their children to grasp at straws, but because the burden on society as a whole is incrememtally modest, the sum of decisions has the same effect. This is a classic market externality. We cannot permit it to continue uncontrolled.

OK Iowa; I can agree with you - that people themselves and their families should make informed decisions. Very few want to wind up as useless, sick, unwanted. We do want to live as long as possible, as well as possible.

What's wrong with that? We have value. We do affect the future in many positive ways even as we age.

AaronW, you are arrogant. Too many physicians get to thinking they are g*d.

You are not.

Great dialogue, people; it's so nice to see the REAL Death Panel debate played out. I believe this is where we start looking at solutions to our dilemma and come up with a way for patients to inform friends, family and health care providers of their wishes prior to becoming incapacitated and in need of costly life-saving procedures with uncertain probabilities for positive outcomes.

Sophia,

Let's be clear. I want only to live as long as I can live well, not as long as I can possibly live. There is a difference. I understand others feel differently. I also understand that one cannot often know when terminal decline sets in, so decisions about when "well" is over and done are fraught. Life is like that, sometimes.

I'd agree that this has been a good discussion. One that shows all the complexities that are involved with late-term and end-of-life care. Where to draw the line and when to cross over. My thoughts are that, understandably so, most of, if not a majority, of the aging population in America has not had nor intends to have a conversation with their family or their primary care physician about how they want their end of life to be addressed. Too often that discussion and decisions are not know to the family or ignored sometimes out of the grief, anger, and other emotions one goes through when watching a loved one die.

I've watched a grandfather die a slow death brought on by Alzheimer's knowing full well that a man who was once mentally sharp, slowly decline into the shell of his former self. His last words to my mother were that had he known he'd end up like he did he would have done himself in.

In fact, I think a lot of people, if they had the choice of spending their remaining days on life support or having a humane and painfree as possible way to pass away they would probably take the later if it meant not have to simply extend their life for weeks or months of constant misery and pain. But all too often even the idea of assisted suicide as an option is considered so egregious or immoral that it's off the table.

Oftentimes, we forget the loss of dignity and bruised pride of the person who finds themselves in those terminal illness situations. That they've become a "burden" or can't do anything for themselves anymore, the constant sense of shame for having to ask for help. Often times as family, we emotionally want whatever it takes to keep our loved one around just a little bit longer because I can't say goodbye. Much of that is because we are deathly afraid to make the hard choice of stopping the suffering sooner rather than later. So we find ourselves in the situation we have now. Trying to find ways as a society to address the long term costs of ever increasing medical expenses that will be associated with treating an ever increasing population of aging Americans.

I for one know that neither of my parents want to be stuck on life support or left to slowly die in a nursing home. So my sister and I are faced with trying to understand exactly what they want and how when the time comes. Whether that means pushing my father out to sea in a canoe like he joking said once or what, I'll honor that decision and make it happen to the best of my abilities. One thing I won't do, is keep either parent plugged in for a few more weeks or months and have that be our last memories of them.

Sigh.

Arrogant? What I am advocating is humility in the face of forces over which I/we have no control.

Your insertion of the asterisk in the Creator's name suggests to me that you may be a believer. As a believer--assuming that you are--consider this: when God puts down His hand to call one of his children home, is it more arrogant and god-usurping to rage against that reality bringing to bear every bit of high technology and medical violence--and intensive care is violent, hence the medical slang "flog" for prolonged ICU care--in a mostly vain attempt to postpone the inevitable or instead to accept that there are things we cannot change and attempt to make a person's passage as peaceful as possible?

AaronW,

I think the use of the word arrogant in reference to your position has to do with what we understood to be your assertion that physicians are the right people to make end of life care DECISIONS, rather than providing information and guidance so that patients and loved ones can do so. It was not in reference to any assumption that you wished to prolong life in hopeless situations.

I would simply say this: technical experts in any field are not really the right folks to determine policy actions, at least not on their own, that stem from their expertise. Informed lay people with an interest in the outcomes are equally and often more important to the decision making process. It absolutely is the experts' role to provide clear and insofar as possible accurate information about risks, benefits, and likelihood of specific outcomes. But these can only be turned into decisions with the addition of intentions, morality and often history, which the technical expert does not ant cannot have.

Well, I'll just have to wear the charge of arrogance on those grounds, because I'm not changing my position that patients and their families are in no position to evaluate the choices before them in such circumstances as we have been discussing. It isn't that I think patients are stupid or that they are somehow incapable of grasping the dimensions of the options before them, it's that when the alternative is certain death the human tendency is to overvalue even the slimmest chance of salvation and to underestimate the downsides in terms of money spent and suffering accrued. In individual cases, I submit that doctors are in the best position to make these decisions, though I'm practice they are rarely undertaken by single doctors on their own and typically involve multiple professionals including nurses, social workers and others. I have no problem with this. As for setting blanket policies, such as the UK NHS's blanket denial of hemodialysis to anyone over 60--which, btw, is not something I would advocate--of course representatives of multiple interest groups. I won't back off my original assertion that market factors have little place in such decisions. People with their backs against the wall will pay any amount of money for a chance at survival and their judgements as to which treatments are worth what are necessarily shewed.

I am actually comfortable with patients making the decisions. The real problem is family members making the decisions. If i had a dollar for every case where a family member insited on ultimately futile and costly efforts to preserve a semblance of life in their brain dead and never to awaken relative, well, I'd be able to go a long way toward solving the deficit.

There should be a mechanism for a standardized aand easy to understand advanced directive and this should trump in nearly every case the voices of family members who are NOT in the same position as the patient themselves and are often motivated by a variety of factors that have nothing to do with the wellbeing or wishes of the patient.

You're right, miceelf. Thank you for calling me out on this. More often than not, it's the family members who push for the "full flog." Trouble is, most people don't write advance directives, and even when they do, they're not enforceable.

"It is unfortunately true that real health care savings will require setting a limit to what care is offered, especially at the end of life. It would be ethically cleaner if such decisions affected rich and poor alike. The Republican Medicare plan will result in economic rationing: the elderly rich will receive better, more expensive care than the elderly poor."

This from a physician commenter after Paul Krugman's most recent column. Just to show that I am not alone in my assessment.

(Though I recognize that this will not answer the charge that all medicos are arrogant pricks.)

I think we approach at last common ground here. Perhaps what is needed is a new legal basis for medical decision making, based partly on where I started, and partly on miceelf's comments:

- I would continue to insist that as we become older, we ought to bear part or all of the cost of treatments that go beyond basic upkeep and humanitarian needs for patients near the end of life. I see no problem with forcing people to choose between "flogging" Grandad, and paying for Granddaughters college.

- But lets insist that people designate their end of life care expectations in advance directives and medical power of attorney by age 50 or so, and leave decision making firmly in that latter individual's hands, rather than the entire family, when the patient is no longer competent. For those who fail to make the appropriate arrangements, I'm happy to have physicians determine care (but still at some expense to the family).

I agree AaronW. And I have to admit, I may be a little biased, being the recipient of a lot of stories about end of life decisions from my SO.

But I think that advance directives should be enforceable and widespread. A little investment would make them much more accessible and I think quite popular. Many people were truly horrified by the Schiavo case, and advance directives got a bit more popular then. I think a not insubstantial number of people are horrified about the idea of being kept alive and brain-dead, or for that matter, terminally suffering.

The Lifetime Distribution of Health Care Costs
Berhanu Alemayehu and Kenneth E Warner

Principal Findings
Per capita lifetime expenditure is $316,600, a third higher for females ($361,200) than males ($268,700). Two-fifths of this difference owes to women's longer life expectancy. Nearly one-third of lifetime expenditures is incurred during middle age, and nearly half during the senior years. For survivors to age 85, more than one-third of their lifetime expenditures will accrue in their remaining years.

So, on AVERAGE, old people are going to have to spend over a hundred grand each on health care, some of them much more than that. The need for medical treatment, unlike, say, the need for an automobile, is not distributed uniformly across the population and is simultaneously very difficult to anticipate. Theoretically, you could require everyone to put money into a health care savings account as over the course of a lifetime, many people could probably manage to accumulate something close to the required quarter million, but unless they're allowed to spend those funds on something other than health care, the market incentives go out the window, and if they are allowed to spend those funds on goods other than health care, then people will tend to piss the money away and not have it available for when they get sick and need it. But the bigger problem is that as I've said, health care costs are not uniformly distributed, so if you tell people to spend their own money--whether or not you require them to put money aside for the purpose--you'll have some people who need spend very little and are sitting on a lot of surplus cash and others who are facing such huge medical expenses they have no hope of ever meeting them. This is the whole point of insurance; the risk of future medical expense is more evenly distributed than actual medical expense, so to avoid having a society that forces people into a kind of health-care Russian roulette where through no fault of their own a proportion of the population experiences illness costs they cannot cover and so die for lack of treatment, you put an affordable price on risk and make a market on that. Trouble there is you've divorced the market from actual health care goods. The insurance contract means that within bounds of reason, the insurer HAS to pay for required medical treatment--the requirement being determined by doctors, not by patients. Without such a contract, insurance breaks down.

The upshot is, I don't see any way that you can have a functioning market on medical care--by functioning I mean a market that tends to keep prices low--without having a situation where unlucky people who get very sick and need a lot of time in hospital or who come down with illnesses that are unusually expensive to treat fall by the wayside and die without treatment. So, Iowa, if that's the kind of society you want to live in, then I don't guess I we have anything more to talk about, but if it ISN'T the kind of society you want to live in, then I'd suggest you need to rethink your position on requiring seniors to pay for medical expenses out of pocket.

fixed SUM of money--not some of money

"The upshot is, I don't see any way that you can have a functioning market on medical care--by functioning I mean a market that tends to keep prices low--without having a situation where unlucky people who get very sick and need a lot of time in hospital or who come down with illnesses that are unusually expensive to treat fall by the wayside and die without treatment."

Precisely. The market controls cost and consumption with price, but, by definition, that means many people have to choose not to buy whatever it is. So, if we want the market to manage the prices and consumption of medical care, hence the cost, we have to allow willingness and ability to pay to ration care, like it does for TV sets or restaurant meals. Most of us, when we think about, find that morally unacceptable, and we should in my opinion. We should want people to get the care they need, not the care they can afford.

If the market cannot be used for this purpose because healthcare is not a normal good, there is only one other alternative: government control of prices and utilization, even if delegated in various ways. There is no third way. Nothing else exists. The whole point of single-payer is not that one entity rights the check, but that that entity can control compensation rates and utilization. This is the path chosen by other industrial democracies, very much to their benefit. France spends 11% of a smaller GDP for universal coverage while we spend 17% for no better medical outcome and without universal coverage. Sooner or later, we will learn the lessons. The Republican right wing-nuts are determined that that be as far in the future as possible, because what they believe in above all is plutocracy, and plutocracy needs plutocrats, and plutocrats need the government to arrange matters so that they can be extraordinarily wealthy. The End.