Sunday, August 30, 2009

On death panels.

I've been reflecting on why this lie, among all those that have been told about what improving health care financing models in this country means, stuck with the public psyche so powerfully.

I think the popular notion is that one of the ways that those looking to improve access to health care in this country will pay for it is by denying care based on age, as a proxy for social worthiness. There will exist some panel that decides that an aged person's care is just too expensive, that some sick people are of such an advanced age that they are really just costing us money. We'll then decide that it is time for this person to die, so we'll push their gurney down to the far end of the hall and wait for something to start smelling bad instead of starting another round of chemotherapy.

How black does someone's heart have to be to believe that is possible? How misanthropic must one be to think that legislators would even craft such an idea? How little faith does one have to have in humanity to believe that you could find people to do this even if it did become law? It really is tragic that we have people who are capable of believing such things, but we do. My heart goes out to them, they exist in their own personal version of hell instead of looking at the world around them.

What was in the bill was a provision that pays people for helping patients anticipate decisions at the end of life, and it makes the provision of this kind of care-planning a potential quality measure. In my business, that's about as controversial as praising someone for keeping their desk organized. Of course we should do this, and experts should be paid for their service. There are a number of complicated decisions to be made. People should have the opportunity to consider them with a sound mind and body, and they should be given that opportunity widely and robustly because people get paid to do this. Right now this kind of excellent health-care is essentially subsidized by a concerned provider. If it gets done, it gets done for free.

That's right, right now, this kind of excellent care is provided to people, but it is done for free. There's no way to pay for a conference between an end-of-life expert and a well person about their choices concerning end-of-life decisions. There's no code for it in the Medicare rules.

We socially engineer health-care in this country by what Medicare pays for. Don't even start to believe that your private plan is in any way different. Medicare sets the rules, everyone else just adopts them as a starting place from which to further deny people care. If Medicare doesn't pay for it, no one pays for it. The best health insurance in this country is Medicare. It's rules are the most thoughtful and fair, it's benefits are the most generous, and it's overhead is less than one third of private equivalents (because those other two-thirds are not going in executive and shareholder pockets).

That's government-run health care for you--cheap, fair and generous.

I think this whole national psychosis about "death panels" belies a deeper concern. People know that we don't have the money to keep the promises of the government, particularly after eight years of the profligate larceny during the Bush administration. Remember back before the bust, when financial concerns were taking huge salaries and obscene bonuses year after year after year? Where do you think they got the money from? They got it from this ponzi scheme of financial instruments that came crashing down a year ago. That TARP money and all the related taxpayer pay-outs ultimately ended up filling the gaping voids left in the system by the larcenous cash-out by the people running the financial industry. And they got their taxes cut while they did it.

At some level, people know this. They know that there will come a day when these roosters are home to roost. Someone is going to have to be hurt, so they're hunkering down, putting up as much resistance as possible, so it won't be them, or if it ends up being them, they can delay it as long as possible.

It is this desperation, this coming apocalypse mentality, that drives the opposition to improving our badly-broken system of health care financing. People don't want a health care system that is fair because, in fairness, you can't get all the care you can demand. There are people sicker than you who need the resources. That's the boogey-man in the distance, not death panels.

We have death panels now, by the way, they are called Ethical Review Boards and I sit on one. It exists almost entirely because a decision has to be made and the patient didn't have a chance to make the decision before becoming too ill to participate in it. Usually a balance has to be made between the benefits and burden of some treatment, i.e., do we keep causing this person to suffer pain and discomfort in pursuit of delaying death?

Most ironically, if the controversial provisions of this bill were enacted and practiced as intended, we'd have drastically fewer cases to review. There are usually two unknowns to consider: first, will their treatment do any good? Second, what would they have wanted? We actually have pretty good guesses for the former. We could have definite, unambiguous answers for the latter in a lot more cases. Then, those patients would have made these life-or-death choices for themselves, rather than having someone like I make it for them.

And the people fear-mongering with death panels are the same ones screaming "choice" as a slogan. We're not in a good place here, a lot of people are going to have to die prematurely before we collectively will be able to mature enough as a society to face our decisions here. This isn't going to be pretty.