Death and Budgets

[shagdrum]

Death and Budgets
By DAVID BROOKS

I hope you had the chance to read and reread Dudley Clendinen’s splendid essay, “The Good Short Life,” in The Times’s Sunday Review section. Clendinen is dying of amyotrophic lateral sclerosis, or A.L.S. If he uses all the available medical technology, it will leave him, in a few years’ time, “a conscious but motionless, mute, withered, incontinent mummy of my former self.”

Instead of choosing that long, dehumanizing, expensive course, Clendinen has decided to face death as one of life’s “most absorbing thrills and challenges.” He concludes: “When the music stops — when I can’t tie my bow tie, tell a funny story, walk my dog, talk with Whitney, kiss someone special, or tap out lines like this — I’ll know that Life is over. It’s time to be gone.”

Clendinen’s article is worth reading for the way he defines what life is. Life is not just breathing and existing as a self-enclosed skin bag. It’s doing the activities with others you were put on earth to do.

But it’s also valuable as a backdrop to the current budget mess. This fiscal crisis is about many things, but one of them is our inability to face death — our willingness to spend our nation into bankruptcy to extend life for a few more sickly months.

The fiscal crisis is driven largely by health care costs. We have the illusion that in spending so much on health care we are radically improving the quality of our lives. We have the illusion that through advances in medical research we are in the process of eradicating deadly diseases. We have the barely suppressed hope that someday all this spending and innovation will produce something close to immortality.

But that’s not actually what we are buying. As Daniel Callahan and Sherwin B. Nuland point out in an essay in The New Republic called “The Quagmire,” our health care spending and innovation are not leading us toward a limitless extension of a good life.

Callahan, a co-founder of the Hastings Center, the bioethics research institution, and Nuland, a retired clinical professor of surgery at Yale, point out that more than a generation after Richard Nixon declared the “War on Cancer” in 1971, we remain far from a cure. Despite recent gains, there is no cure on the horizon for heart disease or stroke. A panel at the National Institutes of Health recently concluded that little progress had been made toward finding ways to delay Alzheimer’s disease.

Years ago, people hoped that science could delay the onset of morbidity. We would live longer, healthier lives and then die quickly. This is not happening. Most of us will still suffer from chronic diseases for years near the end of life, and then die slowly.

S. Jay Olshansky, one of the leading experts on aging, argues that life expectancy is now leveling off. “We have arrived at a moment,” Callahan and Nuland conclude, “where we are making little headway in defeating various kinds of diseases. Instead, our main achievements today consist of devising ways to marginally extend the lives of the very sick.”

Others disagree with this pessimistic view of medical progress. But that phrase, “marginally extend the lives of the very sick,” should ring in the ears. Many of our budget problems spring from our quest to do that.

The fiscal implications are all around. A large share of our health care spending is devoted to ill patients in the last phases of life. This sort of spending is growing fast. Americans spent $91 billion caring for Alzheimer’s patients in 2005. By 2015, according to Callahan and Nuland, the cost of Alzheimer’s will rise to $189 billion and by 2050 it is projected to rise to $1 trillion annually — double what Medicare costs right now.

Obviously, we are never going to cut off Alzheimer’s patients and leave them out on a hillside. We are never coercively going to give up on the old and ailing. But it is hard to see us reducing health care inflation seriously unless people and their families are willing to do what Clendinen is doing — confront death and their obligations to the living.

There are many ways to think about the finitude of life. For years, Callahan has been writing about the social solidarity model — in which death is accepted as a normal part of the human condition and caring is emphasized as much as curing.

In the online version of this column let me provide links to three other essays, which offer other perspectives on why we should accept the finitude of life and the naturalness of death. They are: “Born Toward Dying,” by Richard John Neuhaus, “L’Chaim and Its Limits: Why Not Immortality?” by Leon Kass and “Thinking About Aging,” by Gilbert Meilaender.

My only point today is that we think the budget mess is a squabble between partisans in Washington. But in large measure it’s about our inability to face death and our willingness as a nation to spend whatever it takes to push it just slightly over the horizon.

 

[shagdrum]

David Brooks: The scary and sloppy case for rationing

David Brooks: The scary and sloppy case for rationing

By Jennifer Rubin

David Brooks of the New York Times likes to fancy himself as a truth-seeker, bringing social and hard sciences to the masses. But in his Friday column on health care and death, he makes some shocking and inaccurate assertions. Given his coziness with the Obama administration one has to wonder if he is test-driving some Obama administration rationalizations for rationing.

Brooks is enamored of Dudley Clendinen’s “splendid” essay, as he describes, “The Good Short Life.” Brooks thrills to this definition of a life worth living:

Instead of choosing that long, dehumanizing, expensive course, Clendinen has decided to face death as one of life’s “most absorbing thrills and challenges.” He concludes: “When the music stops — when I can’t tie my bow tie, tell a funny story, walk my dog, talk with Whitney, kiss someone special, or tap out lines like this — I’ll know that Life is over. It’s time to be gone.”​

Well that “dehumanizing, expensive course” allows millions of Americans who would have died in past years to “kiss someone special.” But is someone confined to a wheelchair (no dog walking) or who needs help dressing not living a life of value? Clendinen, and in turn Brooks, begin down a slippery slope as they decide that, really, is it worth it to keep grandpa around for years if he can’t tie his tie?

Brooks then embarks on a flight of misinformation to suggest we’re wasting much of that money. He finds other useful sources:

As Daniel Callahan and Sherwin B. Nuland point out in an essay in The New Republic called “The Quagmire,” our health care spending and innovation are not leading us toward a limitless extension of a good life.

Callahan, a co-founder of the Hastings Center, the bioethics research institution, and Nuland, a retired clinical professor of surgery at Yale, point out that more than a generation after Richard Nixon declared the “War on Cancer” in 1971, we remain far from a cure. Despite recent gains, there is no cure on the horizon for heart disease or stroke. A panel at the National Institutes of Health recently concluded that little progress had been made toward finding ways to delay Alzheimer’s disease.​

Much of this is flat-out wrong or misleading. We may not have “cured” all cancers (Brooks is misinformed if he thinks “cancer” is one disease). But survival rates for many types of cancer have soared, especially for breast, prostate and lung cancer. Five-year survival rates for the range of cancers went from 50.1 percent to 65.9 percent in 2000. Peter Pitts of the Center in the Public Interest told me in a phone interview that for many cancers ”early detection and aggressive treatment” can now extend life or result in effective “cures,” that is long-term remission.

A recent report from the Center for Disease and Prevention control explained:

As a result of advances in early detection and treatment, cancer has become a curable disease for some and a chronic illness for others; persons living with a history of cancer are now described as cancer survivors rather than cancer victims . From 1971 to 2001, the number of cancer survivors in the United States increased from 3.0 million to 9.8 million. . . . [T]the number of cancer survivors increased from 9.8 million in 2001 to 11.7 million in 2007. Breast, prostate, and colorectal cancers were the most common types of cancer among survivors, accounting for 51% of diagnoses. As of January 1, 2007, an estimated 64.8% of cancer survivors had lived 5 years after their diagnosis of cancer, and 59.5% of survivors were aged 65 years. Because many cancer survivors live long after diagnosis and the U.S. population is aging, the number of persons living with a history of cancer is expected to continue to increase.​

In other words, in just six years the number of cancer survivors increased nearly 20 percent. Interestingly, women and seniors have benefited the most. “Women are more likely to be survivors because cancers among women (e.g., breast or cervical cancer) usually occur at a younger age and can be detected early and treated successfully; in addition, women have a longer life expectancy than men. Among men, a substantial number of cancer survivors had prostate cancer, which is diagnosed more commonly among older men. The large proportion of cancer survivors aged 65 years reflects the increase in cancer risk with age and the fact that more persons with diagnoses of cancer are surviving 5 years.” Put differently, millions more Americans are alive because of progress in cancer research and treatment. I don’t know how one would put a price on the value of lives saved, the contributions those survivors continued to make to society and the children they gave birth to and raised.

Brooks likewise bizarrely claims that there is no “cure” for a heart attack. He surely picked the worse example possible. A heart attack used to be a death sentence or a recipe for permanent convalescence. Now with the advent of beta-blockers, new medical technology and surgical innovations survival rates have risen dramatically. (Researchers, for example, found “rates [of in-hospital mortality] decreased among all patients from 1994 to 2006, falling more markedly in women than men. The steepest drop, 52.9%, occurred among women younger than 55. The mortality rate for men in the same age group decreased by 33.3%.)

Alzheimer’s hasn’t been cured, but drugs to slow the rate of deterioration provide building blocks needed for continued progress. For diabetes the results are stunning. (“People diagnosed with diabetes between 1965 and 1980 lived approximately 15 years longer than those diagnosed between 1950 and 1964 (53.4 years vs. 68.8 years).

Brooks, Pitts says, makes a fundamental error by setting up “cures” as the metric for assessing medical progress. “It is well-established that innovation in health care comes in incremental steps,” he explains. With increasingly personalized treatment made possible by genetic research the type and timing of drugs can be designed for optimal results. If we don’t spend money to make progress that might, for example, slow the rate of Alzheimer’s we’re not going to invest millions in one fell swoop to locate the “cure.” Pitts says, “If you don’t reward innovation,” by funding the painstaking process of step-by-step research we will cease making progress toward long term survival rates and cures, a result that is not morally or politically acceptable in this country. He observes, “The average American male’s life expectancy has increased by a decade over the last 50 years, largely to due pharmaceuticals. We innovated our way to that.”

Moreover, Brooks ignores diseases such as AIDS, once a death sentence, that is now, albeit by use of expensive drugs, a manageable, chronic disease. Should we not have spent the money? Pitt, noting the dramatic improvements in drugs to treat mental illness, explains that millions of people in the past were never treated at all. “Now people with depression are functioning beautifully.”

Brooks says, “Most of us will still suffer from chronic diseases for years near the end of life, and then die slowly.” True, but the alternative is more dead people.

Brooks in the end doesn’t have the nerve to reach the logical conclusion of his arguments. He declares, “Obviously, we are never going to cut off Alzheimer’s patients and leave them out on a hillside. We are never coercively going to give up on the old and ailing. ” Well, then what is the point of his column? If he can’t stomach these outcomes why shouldn’t we continue to spend substantial sums to improve and elongate life?

Perhaps the point is to rationalize reductions in health-care dollars spent on the elderly, which by gosh is precisely what the Obama administration is trying to pull off with its Independent Advisory Patient Board. Limiting care, conscience free! After all, do all these old people really enjoy living to 90?

By all means we should have the debate over public and private resources. Let’s come up with market solutions that increase competition and reduce cost. Let’s minimize out unnecessary, external costs (e.g. malpractice insurance). And for the record, I am in favor of living wills and allowing those with terminal illnesses to refuse care. But let’s not kid ourselves.

Anyone, for example, who has had an elderly parent, a friend with cancer, or an experience with mental illness knows the difference our health-care system, warts and all, has made in the lives of millions and millions of Americans. Who of us would choose to receive only the medical care available 20 years ago? And, from where I sit, I’m not ready to throw in the towel on my loved ones (or anyone else’s) because they can’t walk the dog.

 

[Calabrio]

There's articles cover a lot of things, but the first thing I thought of reading Brooks' piece was the role of the family in the cost of long term care. Because society and families feel that the government is obligated to provide care for the elderly because of both a mistaken understanding of the role of government, and the expectations and promises made while the parents were paying into a "system" decades ago, and because the subsequent generations continue to pay, generations no longer necessarily feel responsible for the care of their parents. Someone else will do it and someone else has been paid to do it.

So, because of this, that Alzheimer patient, instead of living with their child and grandchildren to look after them, instead lives at a home. Instead of just hiring a health aid to assist once or twice a day, they are provided 24hr a day care in a dedicated facility at the expensive of the tax payer.

It's off the topic but an important sociological issue. The connection between generations is crucial for a society. That line from past, through the present, into the future, is very powerful and it affects how we live, the culture and norms passed on, and the stability of a society. And I think you can see it being weakened as gov't is expanded to take up the space between generations.

 

[foxpaws]

Part of the reason we have SS and Medicare was because families weren't taking care of 'their own'. So, although now we may depend more on government to take care of our elderly - the disassociation of families started long before government stepped in with entitlements.

I suppose we could do what the Chinese do - there the government requires families to take of their elderly, otherwise it penalizes.

So, shag - is there - or should there be a 'between' the two extremes presented? Should we (the government - with our tax dollars) spend literally millions of dollars on a terminally ill patient - or should the government do what insurance companies do currently - place limits on lifetime/illness coverages (the private insurers, once limits are met, hand the problem over to the government - the private insurers cut off the patient - and then they get placed on medicaid.)

Capitalism has created a solution to the problem - limits to the amount that is paid out - so shouldn't government emulate the private sector - which is a successful model in this case? Insurance companies are fairly successful - pay out dividends, create profits, a positive bottom line, all because of a good model - cut off benefits at a certain point. If medicaid/medicare were run by the insurance companies that is what they would do.

 

[shagdrum]

Part of the reason we have SS and Medicare was because families weren't taking care of 'their own'.

Kinda like the "crisis" in the 1960's of poverty or premarital sex/STD's/teenage pregnancy that was the rhetorical catalyst for the intrusive government programs but which A) did not actually exist, and B) saw no positive (and arguably negative) consequences as a result of those programs?
__________________________________________________________________________________________________________________________________________________________________

All the lazy assumptions, false choices and rhetorical smoke and mirrors aside, I posted Mr. Brooks' column for a reason.

While I do disagree with a lot of his conclusions, he can still be insightful and have some strong premises and, from them, some very valid points.

Whether intentional or not, Brooks' article lays out a choice of who is to decide on what care is necessary at the end of life. There are cost issues and basic issues of human dignity involved. Who is in the best position to weigh those factors and make the appropriate decisions; the individuals (and their families) or far-removed "expert" bureaucrats in Washington?

In the long run, there really is no middle ground between those two positions; either those decisions are left at the individual level or, due to the reality of scarce resources, moral hazard and bureaucratic inefficiency, it will inevitably end up solely in the hands of "experts" in Washington.

Question: "Outside the medical criteria for prolonging the life of someone who is elderly, is there any consideration that can be given for a certain spirit, a certain joy of living, or quality of life; or is it just a medical cut off at a certain age?"

President Obama: "Yeah, we're not gonna solve every difficult problem in terms of end of life care. A lot of that is going to have to be we as a culture and a society making better decisions within our own families and for ourselves. But what we can do is make sure that at least some of the waste that exists in the system that is not making anybody's mom better that is loading up on additional tests or additional drugs that the evidence shows is not going to improve care, that at least we can let doctors know and your mom know that, you know what, maybe this isn't gonna help. Maybe you're better off not taking the surgery, but taking the painkiller."​

 

[fossten]

Part of the reason we have SS and Medicare was because families weren't taking care of 'their own'. So, although now we may depend more on government to take care of our elderly - the disassociation of families started long before government stepped in with entitlements.

I suppose we could do what the Chinese do - there the government requires families to take of their elderly, otherwise it penalizes.

So, shag - is there - or should there be a 'between' the two extremes presented? Should we (the government - with our tax dollars) spend literally millions of dollars on a terminally ill patient - or should the government do what insurance companies do currently - place limits on lifetime/illness coverages (the private insurers, once limits are met, hand the problem over to the government - the private insurers cut off the patient - and then they get placed on medicaid.)

Capitalism has created a solution to the problem - limits to the amount that is paid out - so shouldn't government emulate the private sector - which is a successful model in this case? Insurance companies are fairly successful - pay out dividends, create profits, a positive bottom line, all because of a good model - cut off benefits at a certain point. If medicaid/medicare were run by the insurance companies that is what they would do.

Insurance companies don't deny care, they simply deny coverage.

Government would deny care, even to those who could afford it.

 

[shagdrum]

Capitalism has created a solution to the problem...

Actually, "capitalism", in any real sense, has been absent the health care industry (especially in the area of health care insurers) for generations.

If you substitute "corporatism" for "capitalism" I would generally agree with that statement.

 

[foxpaws]

Insurance companies don't deny care, they simply deny coverage.

Government would deny care, even to those who could afford it.

If you depend on your insurance, and have paid forever into a plan - and you hit the limits what happens? If I max out my policy - they deny care at that point. They tell you to go onto medicaid - I have seen it happen foss. They do deny care on their dime - and they move your care to the government's dime.

And why do you think you won't be able to pay cash for care? I haven't seen anything that would indicate that you wouldn't be able to go to the Mayo Clinic, put down your 5 million in cash - and get the very best care money can buy. Even in countries with true socialized medicine, like Norway -there are private hospitals where cash speaks very loudly. Our private hospitals, and access to them aren't going away, if you have the money to afford them.

 

[foxpaws]

Kinda like the "crisis" in the 1960's of poverty or premarital sex/STD's/teenage pregnancy that was the rhetorical catalyst for the intrusive government programs but which A) did not actually exist, and B) saw no positive (and arguably negative) consequences as a result of those programs?

No shag - there was a real crisis with seniors living in poverty before SS - it wasn't fabricated, and the results of SS have been very positive. It is basically a good program - whose biggest problem was Johnson and his 'borrowing' from it, and second biggest problem was not being realistic about how long we are living - the age requirement should have been 70 years ago - and should be inching higher every year.

Whether intentional or not, Brooks' article lays out a choice of who is to decide on what care is necessary at the end of life. There are cost issues and basic issues of human dignity involved. Who is in the best position to weigh those factors and make the appropriate decisions; the individuals (and their families) or far-removed "expert" bureaucrats in Washington?

Families don't decide now - if private insurance is involved - the insurers decide what hospital you go to - if you get surgery - what doctors are on you plan. If you want doctor 'b' because he is the best in town - but your insurance doesn't cover him - well, you will have to find a way to pay for him out of pocket. Often that isn't a real world choice - not many can afford a $150,000 doctor's fee on top of everything else.

There is this false idea that we have had some sort of choice in the past - we haven't. We have been a series of calculations at an actuarial firm, they figure out what is best for the insurance company at the end of the day. It isn't an appropriate decision, made by caring individuals, it is a decision made by bean counters in Boston.

 

[shagdrum]

If you depend on your insurance, and have paid forever into a plan - and you hit the limits what happens? If I max out my policy - they deny care at that point.

Again, "care" is not the same as "coverage". As long as there is some competition in the market, this is a distinction that cannot be avoided.

there was a real crisis with seniors living in poverty before SS

Based on...your word?

Your example does highlight the inevitable ratcheting effect of government encroaching on liberty. SS was meant to be temporary, and yet we still have it today. When government takes away liberty it rarely if ever gives any of it back.

It is basically a good program - whose biggest problem was Johnson and his 'borrowing' from it,

Again, the ratcheting effect of government intervention.

Johnson may have been the first, but he certainly wasn't the last...

...and second biggest problem was not being realistic about how long we are living - the age requirement should have been 70 years ago - and should be inching higher every year.

Highlighting, yet again, the issue of moral hazard that government entitlements inevitably create. Due to the reigning attitude of the political class that the only solution to government failure is more government, we once again get a ratcheting effect in both encroachment of liberty and in moral hazard.

Moral hazard occurs when a party insulated from risk behaves differently than it would behave if it were fully exposed to the risk.​

Medicare's failure becomes the "crisis" that Obamacare has to fix...

Foxy, you are all but making my points for me here.

Families don't decide now

I feel sorry for your family if that is how it works.

In my own experience, we, as a family, made the final call regarding my Grandmother when she passed away and are calling the shots currently with my Grandfather in his final days.

if private insurance is involved - the insurers decide what hospital you go to

Again, your argument is based on a false premise that ignores the distinction between "coverage" and "care".

Since that premise has been directly questioned, it demands a justification and defense. Without one, any argument rooted in that premise is invalid and gives the appearance of manipulation.

 

[shagdrum]

The reason the distinction between individual choice and bureaucratic dictate is so vital right now is because we are a profound tipping point and there will be no turning back.

Obamacare's "Advisory Boards" aimed at controlling cost will, inevitably become more then merely "advisory". They WILL lead to death panels to control costs.

Even Leftist economist Paul Krugman has admitted as much.

With government created moral hazard of the degree Obamacare will leave us, as well as the driving out of private insurers, government will HAVE to step in to control costs. That is why this "Independent payment 'advisory' council" was put in place. That is why so much of Obamacare is simply a granting of broad, vague, unaccountable legislative authority removed from the political process is given to the HHS secretary in the law.

Who is in the best position to weigh the factors involved with end of life care and make the appropriate decisions; the individuals (and their families) or far-removed "expert" bureaucrats in Washington?

 

[foxpaws]

I feel sorry for your family if that is how it works.

In my own experience, we, as a family, made the final call regarding my Grandmother when she passed away and are calling the shots currently with my Grandfather in his final days.

I assume your grandparents are on medicare - believe me shag - with private insurance it is a whole lot different.

The government program that you so despise is allowing your family to make caring decisions.

Thank you for making my point

 

[foxpaws]

Again, your argument is based on a false premise that ignores the distinction between "coverage" and "care".

Since that premise has been directly questioned, it demands a justification and defense. Without one, any argument rooted in that premise is invalid and gives the appearance of manipulation.

So, shag what happens when the insurance company doesn't cover a procedure - and you paid into for years expecting them to cover your medical costs - you will not get the care you need - correct? You will not be able to afford it

Isn't this just a question of semantics? You won't be getting the care you need because the insurance company has denied you coverage.

Yes, if you were a millionaire - you could buy the care - but since 99% of us aren't - we depend on insurance to provide the care we need.

 

[fossten]

If you depend on your insurance, and have paid forever into a plan - and you hit the limits what happens? If I max out my policy - they deny care at that point. They tell you to go onto medicaid - I have seen it happen foss. They do deny care on their dime - and they move your care to the government's dime.

And why do you think you won't be able to pay cash for care? I haven't seen anything that would indicate that you wouldn't be able to go to the Mayo Clinic, put down your 5 million in cash - and get the very best care money can buy. Even in countries with true socialized medicine, like Norway -there are private hospitals where cash speaks very loudly. Our private hospitals, and access to them aren't going away, if you have the money to afford them.

Insurance companies cannot deny care. They don't control it.

When government controls care, they will deny it.

Your assertions mean nothing.

 

[shagdrum]

I assume your grandparents are on medicare

My grandfather was a family physician in a small town in Kansas from the 1950's through the 1990's (probably one of the last such physicians to make house calls). He saw the political debate for medicare, saw it implemented and saw it profoundly change the healthcare industry and his own business.

I have learned more about the negative consequences of medicare (and over regulation of the healthcare industry in general) from him (and his daughter who went into the same field) then from anything I have read.

Medicare, as it is currently set up, is an unsustainable Ponzi scheme.

Lord Keynes famously said, "in the long run we're all dead". Well, when it comes to Medicare and SS, we have reached the long run.

You won't be getting the care you need because the insurance company has denied you coverage.

This is one of those "lazy assumptions". There is no way to know that with any certainty. It is an assumption of convenience.

When coverage is denied by a carrier, you and your family can look for other options, pool resources, etc. Doctors may be (and if able to, often are) willing to help you in a bind, etc.

There are countless possibilities that are simply not there when government is calling the shots.

Government is monolithic and, when they start dictating medical care in the name of "cost savings", they will inevitably be the only ones left to provide any coverage, at which point health coverage does equal health care.

The fact that you have competition in the health care industry means that, right now, there is a distinction between health coverage and health care.

There certainly needs to be more competition in the health insurance market. The ONLY way to do that is to get government out the health insurance business (or at least minimize their footprint and their influence). What Obamacare sets up will, unquestionable, result in no competition, in the long run.

The reason we are in the position we are at concerning healthcare is because of moral hazard and a lack of strong competition; we have corporatism, not capitalism. That is why costs are rising and costs are the ultimate problem.

 

[shagdrum]

Thank you for making my point

Your "point" misses all the counterpoints that have already been raised.

Extoll the benefits of medicare all you want. It doesn't change the fact that Medicare, as it stands right now, is unsustainable. You might as well extoll the virtues of adolescence; it is just as temporary and just as meaningless to this discussion.

Medicare creates rampant moral hazard and massively distorts the price mechanism in the market leading to huge annual increases in medical costs.

Obama has already put his medicare "independent cost advisory board in place that will inevitably become a death panel. Medicare IS going to change and Obama himself has already set that in motion.

Do we want to allow Washington bureaucrats to medicare to directly dictate health care or do we want to keep the decision making concerning end of life care at the local level?

You have yet to even touch that question...

Whether or not medicare is a benefit right now to anyone is utterly irrelevant to that question; a red herring.

 

[foxpaws]

Your "point" misses all the counterpoints that have already been raised.

Extoll the benefits of medicare all you want. It doesn't change the fact that Medicare, as it stands right now, is unsustainable. You might as well extoll the virtues of adolescence; it is just as temporary and just as meaningless to this discussion.

Yes, as it stands it will run out of money - we never touched on that point - because that wasn't what we were discussing, were we? We were discussing who make decisions - you or the government. However, on the government's plan - medicare - you are finding out how your family is making choices - correct? Take someone who is 45 and who is needing massive care - find out who makes the decisions then. It is not family members - it is a chart and an accounting professional who crunches numbers - and you find out where you lie with regards to the insurance company's bottom line.

Do we want to allow Washington bureaucrats to medicare to directly dictate health care or do we want to keep the decision making concerning end of life care at the local level?

You have yet to even touch that question..

Of course I have - I have used the very programs they have in place right now - medicare. As you have found out your family is making choices - with regards to family members, using a massive government program.

Once again shag - you made my point - your family, your choices, massive government entity.

It isn't a red herring - it is reality - the reality of how government deals with health care. It is our example.

This is one of those "lazy assumptions". There is no way to know that with any certainty. It is an assumption of convenience.

When coverage is denied by a carrier, you and your family can look for other options, pool resources, etc. Doctors may be (and if able to, often are) willing to help you in a bind, etc.

It is not an assumption of convenience - it is an assumption of reality. Costs are so high that options are very limited. Once you use up your insurance limits - you go on medicaid - that is the option Shag. I have watched a family with an extremely sick child - everyone helps - massive fund raisers, hospitals and doctors chip in, the community works to help out the family - and in the end - it isn't enough - they are on medicaid. The costs are astronomical. They even got accepted to St Jude - where all the care is free - but as soon as you go home - the drugs, the medical equipment, the visits with local care givers, the emergency room visits, the daily nurse visits, the costs are almost unthinkable. So, what happens in reality - the government steps in.

Health care can never be a true 'capitalist' entity - because of the way we view it - no one will die outside the hospital doors - those costs need to be figured in. Government will be paying for health care. Elderly care is too massive for insurance companies to consider, there is no profit to be made there. Plus - even if care were at reasonable costs - many of the elderly are on such fixed incomes, a big hospital bill would destroy them financially. So, the only entity large enough to pool resources is the government.

This isn't red herring stuff shag - it is what people deal with daily. Ivory tower ideals don't work in the emergency room. Things do need to be changed - but those programs won't be going away any time soon. You need to deal with the reality, rather than harp on the fantasy.

 

[shagdrum]

Yes, as it stands it will run out of money - we never touched on that point - because that wasn't what we were discussing

either those decisions are left at the individual level or, due to the reality of scarce resources, moral hazard and bureaucratic inefficiency, it will inevitably end up solely in the hands of "experts" in Washington.

Highlighting, yet again, the issue of moral hazard that government entitlements inevitably create. Due to the reigning attitude of the political class that the only solution to government failure is more government, we once again get a ratcheting effect in both encroachment of liberty and in moral hazard.
* * *

Medicare's failure becomes the "crisis" that Obamacare has to fix...

The reason the distinction between individual choice and bureaucratic dictate is so vital right now is because we are a profound tipping point and there will be no turning back.

Obamacare's "Advisory Boards" aimed at controlling cost will, inevitably become more then merely "advisory". They WILL lead to death panels to control costs.

I have been talking about Obamacare's "Advisory Boards" which were created in response to the uncontrolled, rising costs of Medicare. The unsustainable nature of the program and the negative consequences of the program on the costs of medical care in general are all at the HEART of what I have been talking about.

Of course I have - I have used the very programs they have in place right now - medicare. As you have found out your family is making choices - with regards to family members, using a massive government program.

Again, you are not responding to the point I was making. We are having two completely different conversations.

I am talking about current unpleasant realities and the stark choice it leaves us about the future of how healthcare is determined.

You are ignoring those realities and instead focusing on the present, the past and myths about free market influence in the health care industry.

We are not talking about the same thing, but you are framing your statements as a response to what I am saying; implicitly misrepresenting what I am saying.

It is frustrating when people talk past each other because of ignorance. It is insulting when someone intentionally does that to mislead.

How about this; if you want to respond to what I am arguing, I will be happy to respond.

Otherwise, I am not going to waste my time.

 

[shagdrum]

Of course, there are also the issues Cal brought up of social cohesion and cultural transference that are necessary to a civil society but that Medicare handicaps. Another unforeseen and rarely considered consequence of Medicare and other entitlement programs...

 

[Bob Hubbard]

An interesting thread, now, some insight as to what may happen in the future, and perhaps what should happen.
The two are closely tied together, and may well be the only option for the elderly.
Using a sanerio I, and many have had to face in the past;
The situations are similar, but one must concede life, in any form ,will end at some time, be it human or otherwise.
Over the years, we pet owners have been faced with a making a decision to prolong the life of an aging pet who is medically challanged.
Sure, we love them every bit as much as our human counterrparts, and we feel they too are entitled to the best of care, but at what cost?
Then there are others who do not want the pet to suffer with a dibilitating desease,regardless of the cost, so we opt to have the pet put down.
I can tell you here and now, I have loved my pets just as surely, and as strongly as I have ever loved my family members, and putting them down was just as painful as loosing any family member, but in the desire to see the pet's suffering end, I asked the vet to end it's life.
Sure, it was a difficult decision, one filled with with untold sadness, but like all things in life, we that survive DO go on, and we do heal.
Perhaps this scnario should be used when it comes to ending the life of the elderly who for all intense and purpose, will never get better.
It should not be based on finances, or the lack thereof, but soley based on compassion.
I know for sure were I in an incureable condition, and the options were to prolong my suffering, or end my life, I would most certainly opt for the latter.
I think most elderly would.
It bolis down too family not being able to let go.
Death is inevitable, and sooner or later we will all be there, and family will morn as they have for centuries, and heal from the sadness of death as they always have, so why prolong life if it is to be filled with suffering?
There is no better test of life, than to except death.
Sure, I miss my dogs that I have had to put down, and my family members who have passed, and not a day goes by that I don't think of them, but I live today, acutely aware that my time will come.
I only hope that should I suffer in pain, there would be someone there intelligent enought to say "Bob, it's time", and I gracious enought to leave for what could only be, a better place.
Bob.

 

[Bob Hubbard]

So it comes down too, who pays for the care till the end, and who decides when it is the end of someone's life?
Perhaps congress with fight this battle for years to come.
I don't think the government should make the determination of cutting off medical treatment, except in cases where there are no living relatives of the person in question.
Neither do I feel government should be spending countless dolars on trying to prevent the inevitable.
Do I think government shoud intervene to keep a person alive?
Definetely not.
Despite what some may think about life, I have always felt our lives are fully planned out from conception to death, and anything that concerns life, is only a result of that planning.
When it is time for death to take us, be it a family, or government decision, that is the predetermined course that was set out for us in the begining.
We have all been put on this earth to sustain life, and continue generation too generation.
Along the way we are expected to maintain our own existance.
I don't belive the creator had government subsidy in mind for an aging population, when he created us.
We are responsible for our own care, and government should never be put into the position of paying for the welfare of the general population, but because it has, we citizens use that to our advantage.
All of us on medicare are quilty of this, and have shrugged our responsibility to take care of ourselves because medicare has become so available.
Without it, many (including myself) would perish.
That too, if it were the plan for us, would happen, if it were meant to be.
Private insurance needs to be made available to every citizen, and if it is not affordable then those who can't afford it will perish, but that is the way it must be.
Only the fittest will survive, and the lesser shall perish.
This is sad, but it is the painful truth.
We should not expect the government to subsidize us.
Bob.

 

[foxpaws]

Again, you are not responding to the point I was making. We are having two completely different conversations.

I am talking about current unpleasant realities and the stark choice it leaves us about the future of how healthcare is determined.

You are ignoring those realities and instead focusing on the present, the past and myths about free market influence in the health care industry.

Shag - just pull back and read this -

"I am talking about current unpleasant realities"

and

"You are ignoring these realities and instead focusing on the present"

I think 'present' and 'current' pretty much mean the same thing.

Otherwise, I am not going to waste my time.

So, finally you have mentioned what you really want to talk about - believe me shag - when trying to discuss things with you it is pretty pin the tail on the donkey - the articles you posted - as Cal stated - 'Those articles cover a lot of things' I was guessing...

But, you have narrowed it down - the idea of advisory boards with regards to government health care - and does it morph into 'death panels' as you stated:

Obamacare's "Advisory Boards" aimed at controlling cost will, inevitably become more then merely "advisory". They WILL lead to death panels to control costs.​

We have government controlled health care right now - costs are a very important concern with both medicare and medicaid - we do not have death panels currently - however we do have advisory panels already in both government health plans. They haven't morphed - why do you think the future ones will? Well, you not only think - but somehow with your magic crystal ball and you have guarantee this will happen (going to take on the stock market next shag?)

That is what always gets you in trouble shag - your speaking in absolutes when it comes to the future - it would be worth discussing this with you if you stated 'They likely will lead' or 'The situation seems to indicate that containing costs will lead to...'

But, lets go with your rock solid declaration 'They WILL' (caps are always nice for indicating your truth shag).

So, lets go back - before health insurance, and before government health care - it appears that is what you would like - correct? Your 'best' future scenario would be a world without the interference of government and no need for health insurance because costs would be driven by a free market. Do you wish to compare that rosy future with the bleak and evil future of private insurance health care augmented by government programs?

Do you have any idea of the choices you had back then shag?

 

[shagdrum]

however we do have advisory panels already in both government health plans.

Can you give me specific examples?

Also, what is the specific function of these "advisory panels" you are talking about?

Before Obamacare, what cost control measures were in Medicare/Medicaid?

Why is there a focus on "comparative effectiveness" in the framework Obamacare sets up?

Why has Peter Orzag, who was Director of the OMB during the Obamacare debate, clearly explained that the Independent Payment Advisory Board is DESIGNED to ration care?

The Independent Payment Advisory Board's proposals will be adopted AUTOMATICALLY, unless the legislative and executive branches act in unison to override those proposals. The bill requires a 67-vote super majority in the Senate to override any proposal as well.

Why would a panel aimed at controlling costs be so well insulated from the accountability of the political process? What is the reason to create such a panel?

‪Robert Reich: What An Honest President Would Say About Health Reform‬‏ - YouTube

 

[shagdrum]

Your 'best' future scenario would be a world without the interference of government and no need for health insurance because costs would be driven by a free market.

How about avoiding false choices involving grossly hyperbolic, exaggerated, snarky, simplistic caricatures of positions you assume I support, ok?

 

[Marcus]

Shag, your position couldn't be more opaque, I suspect even to you. You talk about government rationing, but private companies ration care every single day. If these advisory boards say, "we're not going to cover that", how is that any different from a private company saying, "we're not gonna cover that"?

If I understand what you're trying to assert, you're saying that these advisory boards will go from merely recommending certain procedures over others to actually mandating what care a person gets, regardless of who pays for it. If so, what logic leads you to that conclusion? Your argument has to be better than "government is always screws things up".

And to switch subjects for a minute, I suggest that health care does not lend itself to a "free market" model in any way. Forget the insurance middlemen for now. You have a fixed supply (thanks to the AMA cartel setting quotas to artificially keep the number of doctors down), and a "captive" demand (for lack of a better word).

Unlike lawn or carpet cleaning services, I can't choose to go without healthcare service if I get injured or sick. These factors are not conducive to free markets. The first factor (artificially keeping the number of doctors low) can be alleviated somewhat. The second cannot (captive demand). I can't go into an emergency room and "haggle" over the price of a liver transplant, or take my business to the local hair salon/abdominal surgery shop at the mall instead. No, I am required to pay the fee they have set, even if I can't afford it. The alternative is I DIE. Talk about coercion.

A system where one side can set its own prices by limiting the supply and the demand side has no other choices than to pay that price or die is not "free" and can never be. Free markets only work when both sides can FREELY agree to a price for a given good or service with no coercion. Hence the term.