Thursday, August 27, 2009

What is a "death panel"?

[This is the third post in my series on “death panels”. The first post is here and contains definitions important to understanding the later posts. All posts in this series are categorized under “Death Panels”.]

What is a "death panel"? According to Sarah Palin:

The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care.

Is anything like that likely to happen? No. This is not a literal description of a likely outcome. Rather it is a very clever symbolic representation* of something that is a likely outcome: the government making decisions to limit the amount of health care it will pay for in certain situations. No particular person is ever going to stand in front of a panel somewhere and ask to be allowed to live - or even ask to be allowed to receive treatment. Instead a government agency is going to provide a ruling on which treatments will be provided (or not provided) under what circumstances. If there is an appeals process it’s going to consist of your doctor filling out forms.

Think even the idea of something like that happening is nonsense? Let’s consider some quotes. Here are two conservatives, one liberal, and one (probably) independent talking about this issue:

Here’s conservative TigerHawk sort of agreeing with Obama:

Barack Obama is right. It is profoundly wasteful to perform hip-replacement surgery on somebody who is probably going to die in a matter of weeks or even months, and as a conservative I am against profoundly wasteful things. The question is, what should we do about it? [snip]

The solution, the only real way out of the end-of-life cost trap, is to privatize health insurance for senior citizens, give them vouchers that subsidize their health care to some baseline, and let them negotiate the end-of-life deal they prefer (and can afford) when they would have become eligible for Medicare.

What services will the government subsidize and what services will they not? Will that subsidization vary based on the senior’s age: heart transplants and hip replacements for the young-old; hip replacements only for the middle-old; nothing but palliative care for the old-old? In other words, who defines the baseline? Seems like a job for super-panel.

Here’s conservative Ross Douthat explaining we need to tell Grandma “No”:

For liberals trying to find the money to make health insurance universal, these inefficiencies make Medicare an obvious place to wring out savings. But you can’t blame the elderly if “savings” sound a lot like “cuts.” When the president talks about shearing waste from Medicare, and empowering an independent panel to reduce the program’s long-term costs — well, he isn’t envisioning a world where seniors get worse care, but he’s certainly envisioning a world in which they receive less of it. [snip]

In this future, somebody will need to stand for the principle that Medicare can’t pay every bill and bless every procedure. Somebody will need to defend the younger generation’s promise (and its pocketbooks). Somebody will need to say “no” to retirees.

That’s supposed to be the Republicans’ job. They should stick to doing it.

Less care but not worse care. That would seem to envision a situation in which the government determines what is and is not necessary. How? Via “an independent panel” according to Douthat who is simply citing liberal Barack Obama:

THE PRESIDENT: I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

INTERVIEWER: And it’s going to be hard for people who don’t have the option of paying for it.

THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

INTERVIEWER: So how do you — how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

Obama gets points here - big points. Unlike TigerHawk and Douthat, he provides an actual example of the kinds of decisions he is talking about. Even more impressive, he doesn’t hand-wave by making his example one that almost everyone would agree clearly represents waste or unnecessary care - like, say, a heart transplant for a 95-year-old with end-stage pancreatic cancer. Rather Obama’s example accurately represents the type of murky water we wade into when we consider the issue of health care and costs.

That said, the President of the United States who is - at least in theory - the driving force behind Obamacare is explicitly saying that we need a “group” to give guidance on what the government should and should not pay for in just such heart-wrenching situations. Sounds panel-ish to me.

And finally here’s (probably) independent Ed Koch in the midst of talking about falling out of love with Barack Obama:

In order to keep costs from rising, most people acknowledge the need for some kind of limitations on spending. Rationing of public monies makes sense, e.g., should public monies be used to give a kidney or heart transplant to a 90-year-old patient, when it is necessary to reduce the costs of Medicaid and Medicare to keep them solvent? Both programs are totally government funded and operated. I would say no.

Koch also gets big points. He is straightforward enough to use the word “rationing” and he talks about solvency rather than waste and unnecessary care. He is also honest enough to bring up Medicaid which - while it does fund some care for senior citizens - also funds care for junior citizens. On the other hand, Koch takes the hand-wavy route when he legitimizes his argument with the relatively easy example of transplants for 90-year-olds. (Which is not always actually that easy; there are some darn healthy 90-year-olds out there and while I almost certainly wouldn’t think giving them a new heart is a great idea I might be persuaded about that kidney.)

What Koch is avoiding with his example is the fact that someone is going to have to decide on cases that are not quite so easy. This is the same problem TigerHawk and Douthat sidestep with their references to wasteful and unnecessary care. If we turn again to Obama’s grandmother we learn:

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

So should an 85-year-old who will almost certainly be dead within the year get a hip replacement? If those who believe we must restrain spending say no, are they willing to let her spend that last year in pain and misery or to hasten her death by making her bedridden? What if she was expected to live two years? Three years? Three months? What if instead of talking about Obama’s terminally ill grandmother, we’re talking about an otherwise healthy 85-year-old, both of whose parents lived well into their 90s? Should she get a hip replacement? And that’s just the tip of the iceberg. Does the answer change if the patient is 80 instead of 85? What if she’s 75 - or 95 or 105? What if we’re talking about arthroscopic surgery to free a frozen shoulder rather than a hip replacement? Can TigerHawk, Douthat, Obama, and Koch define that magic meeting point of age, health, cost, and expected outcome that separates necessary treatments from unnecessary, that separates the wasteful from the worthwhile in all those cases where reasonable people can reasonably disagree?

Whether we claim we’re going to eliminate wasteful and unnecessary treatment or we just flat out admit we’re rationing care to keep government programs solvent, someone somewhere is going to have to sort out all the not so clear-cut cases. Enter a government panel. And if that government panel decides that no 90-year-old is going to get a kidney transplant then some people whose lives could have been saved will die. If that panel decides that no 85-year-old is going to get a hip replacement then some people who could have had several more happy, productive years are going to get painful, restricted years instead. Understanding that makes me neither ignorant nor insane, neither paranoid nor wingnut. Understanding that makes me reality-based.

Does this mean I now believe the Right is correct when it says the Left wants to pull the plug on grandma?** No. I believe each side in this fight has grasped part of the truth. I also believe neither side has helped us have the vitally important, extremely difficult discussion we should be having about the issue of health care and cost . Furthermore those on the Right - some honestly, some for political advantage - are late to the party and looking in the wrong direction: the issue of government control over health care is a ship that sailed long ago; Medicare and Medicaid are already restricting what care they pay for; and a panel to make the sorts of decisions I discuss doesn’t need Obamacare to pass in order to become a reality. I’ll look at those topics in future posts in this series.


* If you’re one of the people who think Palin is dumb as a whole yard of dirt you will be horrified at my describing anything she says as “clever” - and probably even more horrified at my believing she could possibly understand symbolism. Please feel free to continue to believe that she is simply too stupid to understand the subtleties of bioethics. It won’t materially impact my line of reasoning.

** My husband is getting quite irate over the whole “pull the plug on grandma” discussion. He demands to know why we as a society aren’t equally concerned about pulling the plug on grandpa and is considering seeking some type of legal redress for this sexist dismissal of the value of male progenitors.


Grim said...

Some years ago I read about a lady in Paris who was sixty years old. She had a nice apartment, which in Paris is a bit of a luxury.

The Parisians have a tradition whereby you can sell the right to buy your home, once you have died. Essentially, the contracting party agrees to pay you "rent" on your apartment until you die, in return for having the right to purchase the apartment afterwards (at a fair price).

This is often used by older Parisians, the article said, to provide themselves with an annuity that helps them deal with later-in-life expenses.

This particular lady lived to be over a hundred. The fellow who contracted with her at sixty died, having paid her for forty years at no benefit to himself.

So, when an eighty-five year old is denied hip replacement... well, she will probably die in a few months. Or a decade. Or two. In the meantime, how does she get around?

Anonymous said...

Palin writes:

The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's "death panel" so his bureaucrats can decide... whether they are worthy of health care.

Sigh. Someone needs to buy this woman a clue. Private health care providers have already determined that babies born with down syndrome are not worthy of health care because their chromosonal disorder is deemed "pre-existing." Nice, huh? That's one of the very discriminatory industry tactics Obama and others are trying to change!

Perhaps, if the former Governor had to buy her own health insurance instead of being covered under the government's plan, she may be aware first hand of the rationing that occurs everyday by private insurance companies. Perhaps if she spent more time reading instead of commenting on Facebook, she might be aware just the same.

I find it so, so sad that Palin is choosing to use her "voice" to attack make believe boogey men instead of trying to change the ones that already exist.

WLindsayWheeler said...

The problem here is that "He who owns the gold, writes the rules".

It is plain and simple as that.

The Insurance Industry has the right to make its own rules! Whose money is it? You pay them a pittance and are supposed to pay out hundreds of Thousands of dollars?

Car Insurance is the same way. It has rules.

If you don't like the rules--pay for it yourself---or go without.

Why are Americans so arrogant, that they think somebody elses money is theirs?

Anonymous's comment is a sign of that arrogance of entitlement.

Anonymous said...

Oh, and keep up the good work, Elise. Your balanced approach, and thoughful discussion, is a welcome voice.

Anonymous said...

Yes, Wheeler, insurance companies indeed have the right to make their own rules but I find it highly disingenuous (and reckless) for Ms. Palin to suggest that under Obama's plan her down syndrome son will not be eligible for health care when he ISN'T covered under current private insurance practices!

Why isn't she railing against the private insurance companies existing "death panels?"

What I find so amusing are the politicians (and commenters) who ignore the amount of "rationing" of healthcare that occurs within the private insurance industry. [The worst offenders being those who are among the 40% of the nation who are covered under governemnt's plans.] My private insurance comapny regularly rations my health care coverage by refusing to cover prescriptions it deigns are not covered, and limiting the scope and frequency of procedures recommended by my private doctor. Last December it declined to pay for my semi-annual mammography because my employer's plan no longer covers mammograms twice a year. IOW, "we don't care if you're at high risk for breast cancer, we'd rather your tumor go undetected so that we can pay for your cancer in stage 4 rather than catching it at stage 1)."

Of course, I had the second mammogram, and of course, I paid for it. I understand my role in managing my own health care but please don't distort the need for reform by wrapping the insurance industry in fancy benevolent wrapping paper and pretty altruistic bows. They are in business to make money; if cutting out treatments or prescriptions helps their bottom line, you better bet they'll opt for that at every turn. Google "medical loss ratio" and tell me if you want that to be the underpinning of your health insurance coverage.

By the way, Wheeler, do you have private insurance?

Elise said...

I remember reading about that lady, Grim. I always admired her for outlasting her renter.

You have, of course, nicely illustrated a point I was trying to make: one size does not fit all. I wish I'd thought of that Parisian lady when I was writing.

Elise said...

Anonymous - Whether Trig Palin would be covered under his parents' private insurance policy would depend on what private insurance they had and that would depend to a great extent on how their State regulates insurance companies. From what I know, most family insurance policies cover children born into the family regardless of their health issues. In particular, group insurance policies provided via large employers are good about this.

This is a point I made in my "Crossing state lines" post: how bad private insurance looks to you depends on what state you live in. I'm certainly not going to argue that private insurance is perfect but I'm also not going to accept that it is necessarily worse than public insurance would be. And it makes me realize that many of the problems people believe will be fixed by Obamacare could be fixed equally well by insurance industry regulation. (The issue of what that would do to costs and affordability is a whole other topic.)

As far as I know, the Palins will now have to buy their own health insurance. Her Facebook page is open to comments; ask her how that process is working out or if perhaps she's wealthy enough to not need health insurance.

As for rationing, all systems ration; the only difference is how. I recommend this Megan McArdle piece and the post she links to. I don't think it will change your mind but it might provide something to think about on the other side of the ledger. (I do agree with McArdle's first commenter - competition among insurance companies is not quite as robust as we might hope.)

Anonymous said...

In particular, group insurance policies provided via large employers are good about this.

Yes, that's true, Elise. HIPPA (Health Insurance Portability and Accountability Act, written by Sen. Kennedy) requires that group insurance policies cover employees with pre-existing conditions. However, as you know, not everyone is covered by group insurance including the millions of folks who are self-employed, small business owners, the unemployed and those whose employers do not offer insurance. For them "pre-existing conditions" such as cancer, down syndrome, even pregnancy represent a costly if not insurmountable barrier to health coverage. You may be surprised to learn as I was that in a dozen or so states even women who have been victims of domestic abuse are deemed to have pre-exisiting conditions. It boggles one's sensibilities.

As for the details of the former Governor Palin's insurance coverage, I couldn't care one wit. I trust she'll continued to be covered by the State of Alaska as is the policy for most former state executives. My point is that I would have hoped she would care enough for all the families who have a down syndrome baby who already face discrimination. Ain't the first time nor the last that she'll disappoint.


Elise said...

Mara - I started a response to you and it turned into a post. It's up now and called "The quality of mercy".