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Health Care Reform: Is Euthanasia in the Offing?
For folks confused, or delighted, or driven to inchoate rage, by the bubbling controversy over whether Section 1233 of the proposed health care reform bill will mean strong-arming senior citizens into offing themselves, this Charles Lane piece from the Washington Post gives what strikes me as a pretty reasonable take on the matter.
He states with a setup of the controversy for those to whom the numerals 1233 don't yet summon visions of a sci-fi dystopia of the ill elderly turned to Soylent Green for the greater good of lessening health care costs:
Section 1233 of the health-care bill drafted in the Democratic-led House...would pay doctors to give Medicare patients end-of-life counseling every five years -- or sooner if the patient gets a terminal diagnosis.
On the far right, this is being portrayed as a plan to force everyone over 65 to sign his or her own death warrant. That's rubbish....Still, I was not reassured to read in an Aug. 1 Post article that "Democratic strategists" are "hesitant to give extra attention to the issue by refuting the inaccuracies, but they worry that it will further agitate already-skeptical seniors."
If Section 1233 is innocuous, why would "strategists" want to tip-toe around the subject?
Perhaps because, at least as I read it, Section 1233 is not totally innocuous.....Section 1233, however, addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they're just trying to facilitate choice -- even if patients opt for expensive life-prolonging care. I think they protest too much: If it's all about obviating suffering, emotional or physical, what's it doing in a measure to "bend the curve" on health-care costs?
Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren't quite "purely voluntary," as Rep. Sander M. Levin (D-Mich.) asserts. To me, "purely voluntary" means "not unless the patient requests one." Section 1233, however, lets doctors initiate the chat and gives them an incentive -- money -- to do so. Indeed, that's an incentive to insist.
...Once they're in the meeting, the bill does permit "formulation" of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would "place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign," I don't think he's being realistic.
What's more, Section 1233 dictates, at some length, the content of the consultation. The doctor "shall" discuss "advanced care planning, including key questions and considerations, important steps, and suggested people to talk to"; "an explanation of . . . living wills and durable powers of attorney, and their uses" (even though these are legal, not medical, instruments); and "a list of national and State-specific resources to assist consumers and their families." The doctor "shall" explain that Medicare pays for hospice care (hint, hint).
....the measure would have an interested party -- the government -- recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations. You don't have to be a right-wing wacko to question that approach.
It helps to remember in thinking about how any portion of this bill, if it were to pass, would be interpreted that job one for "health care reform" is keeping health care costs down. Rationing, whether thorough prices, waiting, or state dictates, is always a fact of life in a universe lacking utter plenitude of all resources.
Is it intellectually defensible to say that if a law does not explicitly demand or require something, then one is crazy to suggest that it eventually might do so in practice? If you don't believe laws often have results not obvious from their letter, then you aren't paying much attention to how government actually works. See Katherine Mangu-Ward on the Consumer Product Safety Improvement Act in Reason magazine's June issue, and me from back in April on the proposed Food Safety Modernization Act for examples.
|8.10.09 @ 3:25PM|#
I am four-fucking-square against this public "option" crap, but
my HMO makes me sign to acknowledge that I have a living will on
file with them every time I see a doctor. I don't see this a big
deal.
But if it will stop socialized medicine, I'm fine with scaring the
Lawrence Welk out of old people about it.
|8.10.09 @ 3:34PM|#
Sugerfree,
Your living will can say anything you like. Having one doesn't have
to mean pull the plug. It can say "keep me alive for as long as
humanly possible". So them making you have one is not quite what is
going on here. Here the government wants to make you take
"counseling". That is more than just "please tell us what you
want". That is a bunch of bureaucrats in a room telling you that
you really need to give them the power to deny you care if you
should ever be incompetant.
|8.10.09 @ 3:34PM|#
OK, "refuses treatment until I," which I am comfortable referring to as "makes."
hmm|8.10.09 @ 3:34PM|#
I'm all for killing off the old people. Lets start with DC as a test region and see how it goes.
|8.10.09 @ 3:37PM|#
End of life costs have to be addressed, by both the public and
private sector. Where's the logic in sparing no expense to keep a
comatose 80-year alive as long as possible?
Let the insurance companies or Medicare decide what will be spent
in these borderline cases. We have to start putting more stress on
palliative care for hopeless cases.
|8.10.09 @ 3:37PM|#
John,
Just going by the quoted passage, I don't see anything that
mandates the patient sign a DNR.
The Angry Optimist|8.10.09 @ 3:38PM|#
I was wondering about that, too, John - what if you made a living will that said "Pull out all the stops to keep me alive"?
|8.10.09 @ 3:39PM|#
That is only one piece of the concern. The concern mostly is
economic reality combined with the written beliefs of advisors
Obama has brought in on this bill about how to manage costs.
Medicare was a forced government insurance company, and much as it
should never have been created, older people paid in what were
billed as premiums through employment tax over their working lives
for it. It's looming insolvency is well known. This plan cuts
medicare benefits to a 'cost effective' standard and takes 500
billion from the medicare fund to fund the rest of the plan. Part,
but not all of that, will be paid back over the years.
More beneficiaries, including with preexiting conditions, under a
fund that was insufficient to begin with. If you read the
literature they are absolutely counting on cutting procedures
someone's doctor may recommend, but which they don't consider cost
effective. Rahm Emmanuel's brother who was brought in as a
consultant on the bill has written numerous articles about
rationing care by age and disability.
It is when you add the end of life counseling to the idea that at
80 you might not be able to get a hip replacement that would
otherwise make life worth living that people get concerned.
Even the Washington Post has called for the administration to be
straight with people on this point, because their obvious ducking
of it only raises concern in those who will be impacted.
The Angry Optimist|8.10.09 @ 3:40PM|#
Where's the logic in sparing no expense to keep a comatose 80-year alive as long as possible?
I don't go around examining your grocery bill and asking you where
the "logic" is in this purchase or that, so spare me your
judgment.
We have to start putting more stress on palliative care for hopeless cases.
"We" ain't gotta do shit, white boy.
|8.10.09 @ 3:40PM|#
The U.S. is the ONLY western industrialized nation without a workable national health system, period. Why are so many Americans simultaneoulsy scared to death of government and too high and mighty to take note of how other countries make access to health care a top priority and a practical process? Only a moron would want to keep the U.S. system the way it is -- broken.
|8.10.09 @ 3:41PM|#
"John,
Just going by the quoted passage, I don't see anything that
mandates the patient sign a DNR."
There is not. The fear is that these counseling sessions will turn
into bureaucrats bullying people into signing such things. Yes, you
don't have to by law. Yes, if the system worked perfectly, these
sessions would be run by wonderful helpful wise government
employees who try their best to help people make the right choice
for them. Or, they could be run by blood sucking incompetant
assholes looking to cut costs by getting people to sign DNR.
Considering the history of our government and governments in
general, I don't think it is hysterical to think that the second
option might happen.
24AheadDotCom|8.10.09 @ 3:41PM|#
Reason makes a good point about thing sometimes working
differently in practice, and the linked article makes good points
as well.
And, all that would be great if not for the fact that the
Dems are going to do what they want to do no matter what Reason
thinks.
Now, the smart way to solve that problem isn't to encourage people
to go to meetings and act like baboons. It's to encourage people to
confront politicians on
videotape.
And, by that I don't mean the Reason/Instapundit/Freedomworks way
of chanting like ACORN, or asking stupid things like, "did you read
the bill?"
I mean the smart way: "you said this, but all these studies show
you're wrong. Can you direct us to one study backing your claims?
If you can't answer now, someone else will follow-up at your next
meeting".
Or: "there's certainly the possibility that [bad thing] could
happen, right? So, what's in there to prevent [bad thing] from
happening?"
|8.10.09 @ 3:41PM|#
The fact that this provision has been hugely controversial, but
I have not heard anyone who supports the bill proposing to take it
out, makes me worried.
In principle, of course, the government should not be dictating, in
any way, shape or form, a single syllable of any conversation
between any doctor and any patient. Period.
And, it tells me worlds about the high level of ignorance of the
people designing our Brave New Healthcare System that they didn't
know that end-of-life issues are radioactive as hell with
patients.
Mad Max|8.10.09 @ 3:41PM|#
'the measure would have an interested party -- the government --
recruit doctors to sell the elderly on living wills, hospice care
and their associated providers, professions and organizations. You
don't have to be a right-wing wacko to question that
approach.'
Yes, but it seems that the opposition to this clause - although it
includes conscientious liberals and moderates like Lane - has been
largely galvanized by the right-wing wackos, and that the support
for this clause seems galvanized by the wackos on the other
side.
|8.10.09 @ 3:42PM|#
"The U.S. is the ONLY western industrialized nation without a
workable national health system,"
Our system is not workable. That is why we have 78 year lifespans,
87% of the people happy with their healthcare, and are the medical
innovator to the world. Nope, nothing workable about that.
If you are going to come on here, at least try something besides
boilerplate copied from KOS.
|8.10.09 @ 3:42PM|#
Angry Optimist;
The taxpayers or the insurance payers aren't footing your grocery
bill, (in case you haven't noticed).
hmm|8.10.09 @ 3:44PM|#
You keep my sorry ass alive as long as science can.
The U.S. is the ONLY western industrialized nation without a
workable national health system, period.
That was last months talking point. They have moved on.
Only a moron would want to keep the U.S. system the way it is
-- broken.
No one here wants to keep it the same. Most would rather not make
it worse.
The Angry Optimist|8.10.09 @ 3:44PM|#
The U.S. is the ONLY western industrialized nation without a workable national health system, period.
Argumentum ad populum. In other words, so what?
Why are so many Americans simultaneoulsy scared to death of government and too high and mighty to take note of how other countries make access to health care a top priority and a practical process?
Demonstrated lie. The quickest way to show you are serious about
something working is to privatize it. The fact that we spend this
much on health care shows where our priorities are, Steve.
Only a moron would want to keep the U.S. system the way it is -- broken.
Ad hominem.
you are a big fat FAIL at logical argumentation.
|8.10.09 @ 3:46PM|#
I don't think it is hysterical to think that the second
option might happen.
I don't either, but that doesn't mean we have to sound crazy on the
subject. Hint rather than jump out behind the bushes. Old people
aren't stupid, they know everyone wants them to just die
already.
The Angry Optimist|8.10.09 @ 3:46PM|#
The taxpayers or the insurance payers aren't footing your grocery bill, (in case you haven't noticed).
Let the taxpayers deal with Medicare, then.
Let a private company manage end-of-life care how it wants.
What cracks me up is that you have otherwise "live and let live"
liberals actively agitated about what somebody else spends
on end-of-life care, and suddenly wanting to throw around all kinds
of authoritarian diktats because they don't like how other people
spend their own money. Fuck that noise, yo.
Free Quark|8.10.09 @ 3:53PM|#
Insurance companies are in their rights to determine what is
cost effective. If someone wants more care, they should be free to
pay for it out of their own pockets.
It would be non-libertarian to force one party to pay for services
for another party.
|8.10.09 @ 3:56PM|#
There is not. The fear is that these counseling sessions
will turn into bureaucrats bullying people into signing such
things. Yes, you don't have to by law. Yes, if the system worked
perfectly, these sessions would be run by wonderful helpful wise
government employees who try their best to help people make the
right choice for them. Or, they could be run by blood sucking
incompetant assholes looking to cut costs by getting people to sign
DNR.
Except these sessions aren't being run by bureaucrats, they're done
by doctors. People that have an incentive to not piss off their
patients. Not just for return business or referrals, but also
because the likelihood of being sued for malpractice goes up the
less your patients like you.
FWIW, my living will would probably say something like, "Pump me so
full of morphine it would stop an elephant's heart" I have no
desire to be Terri Schaivoed.
The Angry Optimist|8.10.09 @ 4:00PM|#
Insurance companies are in their rights to determine what is cost effective.
THAT depends on what is in the contract, conrad.
Free Quark|8.10.09 @ 4:01PM|#
Mo;
I agree with your morphine comment. One of the disadvantages of
modern medical technology is that you can be kept alive longer that
you'd want to be.
As a society, we all need to get more comfortable with documenting
what we want done near the end of life when we can't speak for
ourselves.
Mad Max|8.10.09 @ 4:01PM|#
'Except these sessions aren't being run by bureaucrats, they're
done by doctors. People that have an incentive to not piss off
their patients. Not just for return business or referrals, but also
because the likelihood of being sued for malpractice goes up the
less your patients like you.'
The problem here is that, after the patient dies, it's his or her
relatives who are the ones from whom you need to fear a lawsuit.
What if these relatives were the very people who wanted you to tell
Grandma about her 'end-of-life options,' so that Grandma would stop
being so stubborn and just let you pull the plug already?
The Angry Optimist|8.10.09 @ 4:05PM|#
Except these sessions aren't being run by bureaucrats, they're done by doctors. People that have an incentive to not piss off their patients. Not just for return business or referrals, but also because the likelihood of being sued for malpractice goes up the less your patients like you.
If it's as benign as you seem to think, then why incentivize this
at all?
I think Charles Lane's concerns are wholly legitimate.
|8.10.09 @ 4:06PM|#
I don't want you people to do a lot of talking. Not in my house. Don't go there. Hoop there it is. Swish!
JB|8.10.09 @ 4:10PM|#
Here is some free counseling for Democrat fetusues: abort
yourselves.
That or leave and go to one of your socialist paradises that you
incessantly squawk about.
robc|8.10.09 @ 4:10PM|#
The U.S. is the ONLY western industrialized nation without a
workable national health system
Dont know about you, but it works for me. And for most
Americans.
|8.10.09 @ 4:17PM|#
The euthanasia talk has hit a nerve of the Democrats. I can't count the number of talking heads that have come out trying to douse the concern. Anyway, since medicare already covers almost all of the end of life cases, the government is already capable of mandating the discussions without clause 1233. It is really guys like me with a retarded kid who deserves to live as long as we can afford to keep her going that needs to worry about this. Kill off the old people, fine, but don't tell me my girl will have to face the death panel.
|8.10.09 @ 4:21PM|#
I remember when this whole health care thing started, one of the
big reasons was blah blah blah U.S. has lower life expectancy than
like 45 other nations.
Ignoring the fact that we keep newborns alive that would otherwise
be still born, can you imagine what killing off seniors and
children like James Ard's is going to do to that?
Of course, I guess all still borns will make up for it.
|8.10.09 @ 4:22PM|#
The part that disturbs me about this section is that it
fundamentally interferes with the principle of the Doctor - Patient
relationship. As it stands now, patients are provided with
information regarding their wishes should they be incapacitated and
need "extradorinary care".
This is a highly personal subject and is governed by a person's
moral and ethical belief system. It should not be interfered with
by Governmnet, friends or family; none of those entities may have
the best interest of the patient in mind.
If a person decides to confer with their Doctor regarding the
prognosis of thier condition; keeping in consideration their
beliefs, then that should be covered from a time payment
perspective. However, it should clearly be initiated by the
Patient, not by a Government provided Medical Professional.
As such, when I read this section of the Bill, it must be removed
or completley reworded to make the "counseling" initiated by the
Patient and clearly voluntary on their part.
|8.10.09 @ 4:24PM|#
Rationing, whether thorough prices, waiting, or state
dictates, is always a fact of life in a universe lacking utter
plenitude of all resources.
This is an abuse of language. So-called "price rationing" is not
rationing in the usual sense of the word. If a life-saving
procedure costs more than you initially want to spend, you have
several options: try to get donations, take out a loan, or cut back
on spending in other areas of your life.
If a bureaucrat in a national health care system says no, your only
option is what color tuxedo you'll wear in your coffin. Not even
remotely the same.
|8.10.09 @ 4:25PM|#
James,
You are exactly right. My sister is mentally disabled and I find
doctors to be the worst about not considering her care to be worth
it. I don't find Mo's assurance that the sessions will be done with
doctors in anyway reassuring.
hmm|8.10.09 @ 4:25PM|#
After the July McCaughey article in the NY post it got a little harder to not think age was going to be a point of discrimination.
comatose 80-year-old|8.10.09 @ 4:30PM|#
"Where's the logic in sparing no expense to keep a comatose
80-year alive as long as possible?"
If you could feel what I'm dreaming!
|8.10.09 @ 4:31PM|#
What cracks me up is that you have otherwise "live and let
live" liberals actively agitated about what somebody else spends on
end-of-life care, and suddenly wanting to throw around all kinds of
authoritarian diktats because they don't like how other people
spend their own money.
This isn't restricted to health care. Liberals are totally OK with
your personal choices as long as they don't involve money. Once you
start making or spending money, or God forbid employing someone,
you need to just bend over and think of England.
|8.10.09 @ 4:32PM|#
For the umpteenth time: When the time comes, man-up and die. Why is that so hard to grasp???
Free Quark|8.10.09 @ 4:34PM|#
Big B;
U.S. has lower life expectancy than like 45 other nations.
Ignoring the fact that we keep newborns alive that would otherwise
be still born
And a much higher homicide rate as well
|8.10.09 @ 4:37PM|#
For the umpteenth time: When the time comes, man-up and die.
Why is that so hard to grasp???
I'll decide, to the extent I can, when that time comes, thank you
very much.
My friend's dad took a bad fall, and for about a month the docs
said he'd never be anything more than a vegetable. They hinted
pretty heavily at just ending it. Amazingly, today he pretty fully
functional. Doesn't remember everybody's name and has some trouble
speaking now, but otherwise functional. You really want those
people in charge of your decisions?
Free - good point
Typical liberal response|8.10.09 @ 4:37PM|#
You are completely heartless. So only the rich should be able to have the benefit of a living will? Conservatives are always trampling on poor old folks, haven't they suffered enough?
|8.10.09 @ 4:38PM|#
"The taxpayers or the insurance payers aren't footing your
grocery bill, (in case you haven't noticed)."
Nor my healthcare.
|8.10.09 @ 4:38PM|#
So if somefolks want to live on government cheese and bulgar, that's their fucking choice, not mine.
hmm|8.10.09 @ 4:42PM|#
So if somefolks want to live on government cheese and
bulgar, that's their fucking choice, not mine.
Government cheese makes the best grilled cheese sandwiches ever. I
am dead serious about that. We used to trade, if you want to call
it that, chickens and eggs and veggies from the garden with a few
families that got government cheese and butter.
|8.10.09 @ 4:48PM|#
"EAP - by all means, you first."
Fine by me and my sister (executrix) knows this.
Look, I have had both parents die after years-long battles with
cancer (ovarian and esophageal) and IMHO, heroic efforts are just
another useless transfer of wealth. What good is it to live an
extra 18 months if the bulk of that time is going to be spent in
hospitals throwing up black vomit?
But hey, it's America, so be my guest.
Chicago|8.10.09 @ 4:48PM|#
When the time comes, man-up and die. Why is that so hard to
grasp???
Does anyone really know what time it is?
|8.10.09 @ 4:52PM|#
Liberals are totally OK with your personal choices as long
as they don't involve money.
Liberals are OK with you as long as you're a fellow traveler, or as
long as they think you're one. Fall outside that narrow envelope
and you're "one of them."
For a group of people that likes to crow about "choice," they sure
have gotten pretty good at limiting that to only the few select
options that they say you have.
|8.10.09 @ 4:52PM|#
"Government cheese makes the best grilled cheese sandwiches
ever"
I grew up on government cheese and bulgar (we passed on the
powdered eggs). To be honest, I don't recall making grilled cheese
sandwiches, but we must have.
Rich|8.10.09 @ 4:52PM|#
How about just punting the euthanasia decision to the Secretary of the Treasury? He's got pretty much everything else.
Art-P.O.G.|8.10.09 @ 4:56PM|#
Does anyone really know what time it is?
Time-travellers and the like.
|8.10.09 @ 4:59PM|#
Except these sessions aren't being run by bureaucrats,
they're done by doctors.
I'm thinking you've never dealt with the Centers for Medicare
Services. Here's how this will play out:
(1) Doctors will be required to track and report to CMS when they
have had these conversations. When that number gets high
enough:
(2) Doctors will be required to track and report to CMS how many
patients actually have advance care planning. After awhile:
(3) Doctors will be required to track and report to CMS how many
patients have advance care plans that call for something other than
"balls to the wall" care.
(4) Hospitals will be required to track and report to CMS how many
patients have livings wills and whatnot. Hospitals will also be
required to track and report to CMS how many patients opt for
"palliative" care (that is, no extraordinary life support).
Did I mention that CMS will have financial incentives for reaching
nice high numbers for all of these? And financial penalties for
those who don't? And audits for "outliers"?
This is exactly how CMS does business right now. They just haven't
added advance care planning to their list of things to
micromanage.
Mike Laursen|8.10.09 @ 5:00PM|#
...Once they're in the meeting, the bill does permit
"formulation" of a plug-pulling order right then and
there.
Well, only if the patient gives the wrong answer to the first
question: "What party do you belong to?"
|8.10.09 @ 5:01PM|#
All say, "How hard it is to die" - a strange complaint to come
from the mouths of people who have had to live.
- Mark Twain
|8.10.09 @ 5:03PM|#
And my doctor, financially incentivized to lead me to a quick
rather than long-winded death, is going to be just fine and OK with
me saying "I don't care what the hell I have failing/dying/eating
away at me, keep me alive."
I don't think so.
|8.10.09 @ 5:08PM|#
TAO,
I have no clue. Probably the same reason NutraSweet's HMO makes
him, cost savings. My guess is that if someone else is footing the
bill, the family of the comatose is significantly more likely to
want to keep a loved one alive than that person. My ex rectum guess
is that the save me to kill me ratio is 2:1 while the "keep pop pop
alive" to "let's end pop pop's suffering" is closer to 9:1 (the
more kids, the higher the ratio because of increased chance of
conflict over the decision). The living will eliminated the gap and
could end up leading to the win win situation of costing less and
giving more people what they want. Kinda creepy that it's
government mandated (and not a personal fan of Obamacare), but I
wouldn't really care too much if they made it part of Medicare.
|8.10.09 @ 5:09PM|#
This is why global warming is such an important issue. We
need icebergs to set the elderly adrift on.
In all seriousness, I'd shitcan medicare entirely and medicaid for
anyone over the age of majority.
Life's a bitch and then you die.
|8.10.09 @ 5:11PM|#
What I want to know is how can anyone read this section and
*not* be creeped the fuck out that the gummint has an interest in
how long you manage live, despite their best efforts
otherwise?
Every 5 years? What? Are you cranked up becasue I'm still working
that Cialis scrip? I'm not dead yet. In fact, I'm feeling much
better. I'd like to go for a walk. Fuck off.
If you aren't creeped out by 1233, then you are officially
too-far-gone-bat-shit partisan insane and should be put out onto
the nearest ice flow.
Zeb|8.10.09 @ 5:11PM|#
I'm with EAP: when your time comes, just hurry up and fucking die. Of course it is your choice (and should remain so), but long drawn out illnesses/deaths suck a lot for everyone else involved.
|8.10.09 @ 5:14PM|#
My guess is that if someone else is footing the bill, the
family of the comatose is significantly more likely to want to keep
a loved one alive than that person.
My completely unscientific/anecdotal experience is that people are
much more likely to spare any expense to prolong life when they
weren't picking up the bill anyway.
I have actually seen family members ask "How much is that going to
cost?" and then, only after being told it wouldn't cost them
anything, demand that anything and everything be done.
Zeb|8.10.09 @ 5:15PM|#
Life's a bitch and then Obamacare forces you to
die.
Sorry to ruin a good snark, but I am pretty sure people were dieing
even before Obama was elected president.
mark|8.10.09 @ 5:15PM|#
My main observation of the current administration is that it has
not even attempted to feign detachment from politics. Earmarks
everywhere, zero transparency, torture, indefinite detention,
signing statements, jobs "saved or created", threading the needle,
compromising with EVERYONE (especially lobbyists) except
Republicans and Dennis Kucinich, and now newspeak about
"disinformation" and "fishy" conversations with your friends. Pass
a stimulus bill with no Republican support and then act surprised
(and thuggish) when they attack it. Bail out automakers/Goldman
Sachs and pretend to care about minuscule bonuses (as compared to
the bailout money). Stimulate, stimulate, stimulate; who cares
about production or job creation or really anything meaningful to
the economy. Increase this or that, appropriate, talk about, and
complain. Politics as usual, which wouldn't be so disheartening if
it was not coming from a President elected on a platform to end
politics as usual.
So when they try to take over the health care market and save cost
controls for later, why is anyone surprised? This administration
has pursued the path of least resistance from day one.
When the inevitable giant tax hike comes, on Nov. 7th 2012, they
will pretend that the revenue shortfall was "unexpected". When the
inevitable rationing comes, because tax revenues will never be high
enough, who will have enough sense to see the error of their ways,
and reverse the course? Nobody, that's who. There will be another
scapegoat to be laid on the altar of politics, because if there is
one thing there will never be a shortage of in Washington, it's
scapegoats.
|8.10.09 @ 5:22PM|#
I'll state here that I have no intention of dying a slow and
painful death. I could give two shits about the money. I have no
desire to live like that.
I don't know how I'll kick, but it will be spectacular, if I have
anything to say about it, something along the lines of Jeremy
Clarkson's "fighting a tiger with a knife in an abandoned nuclear
power plant."
|8.10.09 @ 5:25PM|#
End of life costs have to be addressed, by both the public
and private sector. Where's the logic in sparing no expense to keep
a comatose 80-year alive as long as possible?
Let the insurance companies or Medicare decide what will be spent
in these borderline cases. We have to start putting more stress on
palliative care for hopeless cases.
I prefer keeping these decisions up to the individual and their
families. I realize it's painful to say "okay I could live another
six month, but then my family would be bankrupt and my grandkids
wouldn't be able to go to college", but I'd MUCH rather have that
decision made by me or my family than a panel of government
officials who want to save teh state some money.
This is precisely WHY we MUST return to a fee-for-service,
catestrophic insurance model. You pay out of pocket for routine
healthcare, and get insurance for serious illnesses. This gives you
some control over where and when to end your life, by the direct
effect of how much you are willing to pay for doctors fees and
insurance, and it does so without bankrupting your family, your
neighbors, or the entire country in the process.
Duncan|8.10.09 @ 5:27PM|#
Experience? How many of you have had to make these decisions for a relative? Seriously, have you ever seen a DNR or a living will? The patient chooses which treatment options they'd reject and which they'd support to continue their lives. It's a big, easy to understand check-list that helps to guide the family in making their decisions. In many cases there is enough room for interpretation that family members still make key decisions but the DNR does provide real guidance as to the patients wishes and desires.
Duncan|8.10.09 @ 5:29PM|#
Hazel Meade--end of life is exactly when catastrophic insurance
kicks in to cover the expenses b/c dying is often expensive. How
does your idea change the situation?
The DNR provides the doctor and family with guidance as to the
wishes of the patient.
Duncan|8.10.09 @ 5:32PM|#
A DNR is truly libertarian in that the patient, even while incapacitated, gets to decide/influence how they are treated.
|8.10.09 @ 5:41PM|#
Hazel Meade--end of life is exactly when catastrophic
insurance kicks in to cover the expenses b/c dying is often
expensive. How does your idea change the situation?
The DNR provides the doctor and family with guidance as to the
wishes of the patient.
DNR's are fine. The point is that when the government is paying for
your health care, you create incentives for the government to
pressure you to end your life. Ditto insurance companies under the
"insurance pays for everything" and employer-based paradigms. You
take away the connection between what you pay for insurance and
what the insurance company pays to keep you alive, and you create
incentives for the insurance company to pull the plug.
With insurance that covers only catastrophes, you create a direct
link between the end-of-life care you receive and your willingness
to pay.
Yes, some people will not be able to afford to pay as much as
others, but this is better than bankrupting the whole country to
give EVERYONE premium care.
CatoTheElder|8.10.09 @ 6:00PM|#
I searched Sec 1233 and did not find the word "voluntary".
However, when considering the use of this word by politicians, one
must realize it means something different that what most people
expect.
The Washington definition of "voluntary" is entirely different from
the ordinary usage of the word. The closest synonym of the
Washington usage of "voluntary" is the ordinary usage of the word
"mandatory".
For example, Chief Justice Earl Warren wrote, in Flora v. United
States that, "Our system of taxation is based upon voluntary
assessment and payment, not upon distraint."
At www.youtube.com/watch?v=R7mRSI8yWwg one of DC's premiere
intellects explains this usage of the word "voluntary" to the
delight of all.
Our Federal overlords have their ways of persuading taxpayers to
volunteer their tax assessments and payments. If you don't file and
pay, they take what they want and put the shirker in jail.
And if a geezer doesn't attend his "Advance Care Planning
Consultation" and execute "an actionable medical order relating to
treatment for that individual that -- ... (iii) is uniquely
identifiable and standardized within a given locality, region, or
State", our Federal overlords have their ways of making that geezer
wish he were dead. (quoted from Sec 1233, page 430)
jester|8.10.09 @ 6:08PM|#
From "Narrative of the US Exploring Expedition" by Charles
Wilkes, USN (Vol. III, pp 94-95) on 'Customs of the Feejee
Group':
"It is among the most usual occurrences, that a father or a mother
will notify their children that it is time for them to die, or that
a son shall give notice to his parents that they are becoming a
burdento him. In either case, the relatives and friends are
collected, and informed of the fact. A consultation is then held,
which generally results in the conclusion, that the request is to
be complied with, in which case they fix upon a day for the
purpose, unless it should be done by the party whose fate is under
deliberation...The aged person is then asked, whether he will
prefer to be strangled before his burial or buried alive."
Even Fijian cannibals from the 1840s can inform our system.
CatoTheElder|8.10.09 @ 6:15PM|#
"Where's the logic in sparing no expense to keep a comatose
80-year alive as long as possible?"
Maybe this contentious question would be better expressed as,
"Where's the logic in coercing unrelated third-parties without
binding contractural obligations to foot the bill for keeping a
comatose 80-year-old alive for as long as possible?"
Because virtually of the expense is borne neither by the
80-year-old nor his relatives but by unrelated taxpayers.
|8.10.09 @ 6:17PM|#
Healthcare pedant alert:
A "DNR" is a do-not-resuscitate order written by a physician, with
(I sincerely hope) the informed consent of the
patient/family.
A "living will" is a statement of what the patient's desires are,
which is only relevant if the patient cannot communicate those
desires.
|8.10.09 @ 6:19PM|#
You take away the connection between what you pay for
insurance and what the insurance company pays to keep you alive,
and you create incentives for the insurance company to pull the
plug.
Insurance companies have zero authority to pull the plug, and very,
very limited ways to incentivize doctors to "encourage"
"aggressive" end-of-life planning.
The federal government? That's another story.
|8.10.09 @ 6:22PM|#
Daddy won't be going to any death counselor. Back when he could think he was very clear on his views of living past his usefulness. Other than a couple of lumpectomies, he hasn't taken a medicare penny in four years. Fortunately he worked hard enough to land in a place that goes to great lengths to keep the checks coming without expecting medicine to keep him kicking forever.
The Angry Optimist|8.10.09 @ 6:38PM|#
I am hearing a lot of internetz tuff gais telling people to just
"die" already.
I imagine they would be the first ones wetting their pants if death
actually showed up.
|8.10.09 @ 7:00PM|#
Insurance companies have zero authority to pull the plug,
and very, very limited ways to incentivize doctors to "encourage"
"aggressive" end-of-life planning.
Well, they can certainly say "we're not going to pay for this", at
least with the CURRENT hackneyed system. That's precisely the
complaint most people have with it. Instead of having insurance
that's there when a real emergency happens, you get these people
who are paid by your employer that charge you a $10 co-pay for a
routine doctors visit and then cut you off when you get a serious
illness.
If you paid directly for REAL insurance, with it stipulated in the
contract exactly what would be covered (and explicitly include
"whatever it takes to keep me alive") THEN the insurance company
would be contractually obligated to spend whatever it takes.
But unfortunately, that's not the insurance most people have.
|8.10.09 @ 7:07PM|#
Point being that there ARE real problems with the current insurance system. IMO, the link between employment and insurance (rather than the individual paying directly) creates all sorts of perverse incentives for the insurance companies to get out of covering you. After all, YOU aren't paying them, your employer is - and your employer wants to spend as little as possible on your health care.
Neu Mejican|8.10.09 @ 7:18PM|#
Section 1233 requires/ provides incentives for doctors to share
information with patients.
It also attempts to set up mechanisms for patients to communicate
their end-of-life wishes.
Scary.
I hate it when the government mandates the dissemination of
information and forces systems to take the wishes of the individual
into account.
Neu Mejican|8.10.09 @ 7:21PM|#
FWIW,
Hazel has identified the real issue, imho.
I think the current proposals main flaws relate to any
strengthening of the link between employment and health care.
Sure, businesses should be free to offer health care benefits to
entice workers. But it shouldn't be the default assumption that
your employer is responsible for your health care.
Neu Mejican|8.10.09 @ 7:23PM|#
The Angry Optimist | August 10, 2009, 6:38pm | #
I am hearing a lot of internetz tuff gais telling people to just
"die" already.
I imagine they would be the first ones wetting their pants if death
actually showed up.
You'll be the first to go.
You'll be the first to go.
You'll be the first to go.
UNLESS YOU THINK.
Neu Mejican|8.10.09 @ 7:32PM|#
Another question.
Given that the doctor/hospital is going to get paid for whatever
life-saving procedures are given, why would people think that they
would be encouraging people to choose "no thanks"?
I believe the point behind 1233 is to counter the existing
incentive that the seller has to sell the buyer something, even if
they don't really need it.
No?
|8.10.09 @ 7:34PM|#
EAP
"I grew up on government cheese and bulgar (we passed on the
powdered eggs)."
see, that's what's the matter w/ handouts. people just shit on
em.
Neu Mejican|8.10.09 @ 7:36PM|#
Car dealer: "We can add in an additional warranty package and
"undercoat."
Car buyer: "No thanks, I don't think I need that."
Car Dealer: "Well, okay, but if something goes wrong, you'll have
to pay out of pocket. And I know I wouldn't want to drive around in
a car without "undercoat."
Car Buyer: "Really? Is it important?"
Car Dealer: "Very."
|8.10.09 @ 7:46PM|#
"Because virtually of the expense is borne neither by the
80-year-old nor his relatives but by unrelated taxpayers."
which said 80 yr old was forced to pay in advance for on every
dollar he earned with the promise of healthcare in his old
age.
effing leftists trying to fix a problem they created. PERFECT!
makes ya wanna dig up FDR and piss all over him.
Brian Lockwood|8.10.09 @ 7:51PM|#
"Only a moron would want to keep the U.S. system the way it is
-- broken."
See more recent H&R post.
http://www.reason.com/blog/show/135341.html
|8.10.09 @ 7:53PM|#
"Sure, businesses should be free to offer health care benefits
to entice workers. But it shouldn't be the default assumption that
your employer is responsible for your health care."
much better to assume it's the governments responsibility.
Mike Laursen|8.10.09 @ 8:05PM|#
Car Dealer: "Very."
I had a car salesman telling me, "Undercoating is so important that
the State of California requires me to tell you about it." He
points at a sign on the wall that, if one bothered to read it, says
the state demands that he tell me it is not necessary.
The Angry Optimist|8.10.09 @ 8:06PM|#
ransom147 has a point, folks - the sense of entitlement people
have, is directly related to the fact that government pimps
Medicare as an entitlement.
The biggest steps we can take towards rational government policy is
Social Security and Medicare reform. And I will state right-out
that I am willing to forego Social Security and the government can
"keep" my "contributions". Free of charge.
|8.10.09 @ 8:18PM|#
neu mejican:
yes i did. i was just picking at the statement a bit.
yes i do agree w/ Hazel that catastrophic coverage would be a
possible good alternative, but would not limit it to that.
Neu Mejican|8.10.09 @ 8:19PM|#
Hazel,
This is precisely WHY we MUST return to a fee-for-service,
catestrophic insurance model. You pay out of pocket for routine
healthcare, and get insurance for serious illnesses.
It seems a coop model is another good option.
Coops can be set up so that the payment to the system is to "keep
you healthy" rather than "take care of emergencies."
Places an emphasis on preventative care...yadda yadda.
|8.10.09 @ 8:21PM|#
TAO:
if opting out were an option i'd be right beside ya.
sad thing is, government is now a religion.
Neu Mejican|8.10.09 @ 8:22PM|#
TAO,
A nit pick on social security etc...
Your contributions pay for the current retirees.
It is the kids coming up behind you that pay for your
benefits.
The first reform I would make, would be to be up front about what
the money is for...it is to give the generation that raised you
security, with the promise that the generation behind you will do
the same for you.
It is not "personal security" it is "social security" that is aimed
at the health of the society.
Neu Mejican|8.10.09 @ 8:23PM|#
For or against it, it is important to talk about social security for what it is.
|8.10.09 @ 8:27PM|#
NM:
"Places an emphasis on preventative care...yadda yadda."
not disagreeing w/ you. this is fine, as long as it's paired w/
truly free markets (deregulation).
otherwise it's the same argument that gave us HMOs back in
'73.
don't even have to dig ted keneddy up to piss on him, yet.
Neu Mejican|8.10.09 @ 8:31PM|#
ransom,
Of course, of course.
But "truly free" seems like boilerplate to me.
Government can and should provide a stable regulatory framework
that encourages the better ideas.
Coops, on average, beat HMO's and regular old insurance on cost and
outcome, from what I have seen.
The Angry Optimist|8.10.09 @ 8:44PM|#
Neu - you are correct in what Social Security is supposed to do, but you know that the government packages it as "individual retirement accounts". I mean, the deception is complete, what with talks about how people have "paid in" (the only tax I know of that is referenced that way) and bought-and-paid-for "estimate statements" that look and feel like actual retirement account statements, but are a bogus piece of propaganda.
CatoTheElder|8.10.09 @ 8:56PM|#
The Old Age and Survivors program of Social security is a
welfare program. Those who receive Old Age and Survivors checks are
welfare recipients.
Geezers aren't getting their so-called "contributions" back;
they're getting a welfare payment funded by working taxpayers. This
is not my opinion; it's the opinion of the Supreme Court (Fleming
v. Nestor).
|8.10.09 @ 8:57PM|#
Sure, businesses should be free to offer health care
benefits to entice workers. But it shouldn't be the default
assumption that your employer is responsible for your health
care.
Or moreover, if you accept a health insurance benefit, be careful
to read the fine print and know what you are getting. Your employer
doesn't have any incentive to keep you alive past your usefulness
to the company. So why would they pay for catastophic care? It's in
their interest for them to get rid of you as soon as you develop a
serious illness. And that does seem to be the way employer-based
insurance policies have gone - cheap co-pays for "maintainance"
health-care, and then they boot you when you get really sick.
The Angry Optimist|8.10.09 @ 9:00PM|#
Cato - I know that. you know that. But is that how it is presented politically? No.
|8.10.09 @ 9:01PM|#
Given that the doctor/hospital is going to get paid for
whatever life-saving procedures are given, why would people think
that they would be encouraging people to choose "no
thanks"?
Depends on if they are getting paid below cost or not. Which
depends on the government imposed price controls. Lots of stuff in
medicare is already below cost. If they move from fee-for-service
to some other model it also sets up incentives to get rid of
patients.
|8.10.09 @ 9:06PM|#
It seems a coop model is another good option.
Coops can be set up so that the payment to the system is to "keep
you healthy" rather than "take care of emergencies."
If such a thing can survive in a free market without government
subsidies, go for it. More power to you.
mark|8.10.09 @ 9:14PM|#
who wants to hear my economic plan typed from a cellphone at a
bar?
a) NIT. I'm guessing a 30k individual deductible and 30% flat
income tax should work.
b) drop welfare, medicaid, farm subsidies, equalize all tariffs,
abolish DoEd (including loans), and of course drop EIC and cut
payroll tax in half.
c) no minimum wage. those earning $3/hr will get a 2 or 3 dollar
subsidy so it works out.
d) opt out provisions for SS/Medicare
e) 10 percent corporate tax and zero cap gains tax.
f) end the fed.
whew that was easy. now to go run for congress.
|8.10.09 @ 9:49PM|#
Neu Mejican,
if by "stable regulatory framework that encourages the better
ideas." you mean two or more parties enter into contracts and if
one or more parties reneges on their end, then damages are assessed
and those parties are then encouraged to account for them. then
yes, i wholeheartedly agree!
|8.10.09 @ 9:55PM|#
Hazel:
"If they move from fee-for-service to some other model it also sets
up incentives to get rid of patients."
you are right but going the wrong way. they will move from fee for
service to "capitation" just like medicaid is. what this does (like
public schools) is increase the incentive to take on more patients,
and de-incentivise quality care. doc gets paid by how many patients
are on the rolls, not by how much he sees them or what he does for
them. so it's in his interest to see you as little as possible.
|8.10.09 @ 10:01PM|#
mark,
i like your plan but yer taxes are a little high.
how about 15% flat and start saving revenues so as to push it
further down. also privatize infrastructure of course. abolish med
regs and dr certs. basically all licensing monopoly schemes need to
go. let the markets take care of them. end the need for scrips too.
and i'm not too sure about your wage subsidy...
mark|8.10.09 @ 10:24PM|#
i'm simply following the friedmanite prescription for eliminating destructive welfare policies (which seem to be so popular nowadays): let the IRS handle it. we already do EIC so let's make it work. no more welfare, or welfare-to-work. no more specialized welfare, let people choose. and since minimum wage sucks but nobody wants to kill it, you have to compromise with a subsidy.
|8.10.09 @ 10:31PM|#
mark:
yeah, as i recall friedman was in favor of a "reverse tax" subsidy.
always one of my sticking points w/ him.
what kinda phone you got? hit & run is a pain on my dinky
display pearl.
jester|8.10.09 @ 11:03PM|#
Even a fish joins a school to enhance the probability of his
individual survival. He doesn't join it thinking (for fish do not
think abstractly) that he will perpetuate his species.
Nor do humans join a group to enhance the species. They join to
enhance their own progeny. The smart ones learn the constructs and
proceed by either furthering their very own progeny or their
'adopted' progeny.
The altruistic excuses of pseudo-liberals is that they are acting
contrary to nature to ensure the best for all when in reality it is
a ruse whether they are even conscious of it themselves for
propagated their adopted 'team'.
A libertarian says let them all act selfishly but given free
exchange they'll understand what is best for themselves.
A recent read on Fijian cannibals was a good case in point.
European Christians proselytize the Fijian cannibals. Fijian
cannibals tolerate them and don't eat them because they realize
that their presence brings European ships with goods that they
desire. They probably taste no better or worse that our Fijian
brothers of which there are plenty. So let them live and bring on
the commerce.
Free trade (not Jesus) eventually brings them around and away from
cannibalism.
Fiji eventually supports a rugby team but becomes the vassal of a
military dictatorship. Meanwhile, a person of dubious Fijian
ancestry, dare say we an Indo-Fijian becomes a world-class
golfer.
For $100: Who was...?
perilisk|8.10.09 @ 11:21PM|#
"Point being that there ARE real problems with the current
insurance system. IMO, the link between employment and insurance
(rather than the individual paying directly) creates all sorts of
perverse incentives for the insurance companies to get out of
covering you. After all, YOU aren't paying them, your employer is -
and your employer wants to spend as little as possible on your
health care."
I'm pretty sure that the incentive to avoid paying out claims would
exist regardless of who's actually paying the insurance company.
Sure, they'd lose your business after screwing you over, but once
you get a catastrophically expensive condition, they don't really
-want- your business.
Of course, employer sponsored health care is partially to blame --
since people would be more likely to avoid insurance companies who
didn't pay if they actually had a choice, and would feel more
strongly how much they were getting ripped off if they were
directly paying the full premium. And probably it would have
fostered more competition in the marketplace (provided government
didn't use its regulating power to kill all but the largest
players).
But some of the shadier practices seem borderline fraudulent, and
that suggests room for laws to clarify which practices are abusive
(for instance, finding some "gotcha" that allows them to avoid
paying you shit, then sitting on it and raking in premiums
risk-free; or even just waiting until you get sick to find that
gotcha, which pretty much amounts to the same thing).
|8.10.09 @ 11:41PM|#
Thanks for replying perilisk.
I think what I'm trying to get at is that when the employer is
paying the premiums, the negotiation taking place in the market is
effectively between the insurance company and the employer, not
between the insurance company and you. And the employer has IT'S
interests at heart, not yours. Since they want to pay less and
don't REALLY care what happens to you after you leave their
employment (or become too sick to work), they aren't going to shop
for policies that cover serious illnesses. They'll shop for
policies that are cheap, and maybe have some nice window dressing
(i.e. coverage for trivial stuff like routine doctors visits and
dental care, with low co-pays), to attract workers.
|8.10.09 @ 11:42PM|#
jester:
your sense of humour reminds me of Douglas Adams.
i know jack about sports but i'm gonna guess Tiger.
jester|8.10.09 @ 11:57PM|#
c'mon,
Vijay Singh, one of the greatest golfers and a Fijian rejected
politically (although not really because he has enough money to say
fuck you Fiji) because of his 'race'. I don't follow golf but
peripherally, so you get a...pass...uhm, no. At least read his wiki
article and be absolved.
Neu Mejican|8.11.09 @ 2:40AM|#
Hazel,
If such a thing can survive in a free market without government
subsidies, go for it. More power to you.
Ever hear of Group Health Cooperative out of Seattle? Been in
business since the 50's.
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