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August 21, 2009

An Expansion on Palliative Care
Posted by Jim Macdonald at 03:44 PM * 213 comments

I’m promoting this from PNH’s Sidelights: The utter venality of the chattering-class “yes, but” stance (a blog post by Kevin Drum at Mother Jones which I recommend you all read, for it has many intelligent things to say). The story includes this two-paragraph quote from Charles Krauthammer:

So why get Medicare to pay the doctor to do the counseling? Because we know that if this white-coated authority whose chosen vocation is curing and healing is the one opening your mind to hospice and palliative care, we’ve nudged you ever so slightly toward letting go.

It’s not an outrage. It’s surely not a death panel. But it is subtle pressure applied by society through your doctor. And when you include it in a health-care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it’s intended to gently point the patient in a certain direction, toward the corner of the sickroom where stands a ghostly figure, scythe in hand, offering release.

I’m going to comment on this based on my perspective as a health-care professional who has seen more than one person die (in many ways, from relatively good, to bad, to horrible), and as a man who sat at his mother’s bedside for a month as she lay dying with cancer: Whether Charles Krauthammer likes it or not, we are all going to die. That “ghostly figure, scythe in hand,” is waiting at the end of every path.

And on that day, I promise you, you, or your nearest and dearest and best beloved, are going to wish to God that you had taken the time to make some plans and communicate those plans to others.

Here’s another point that Charles Krauthammer may not have thought of: In health care, if insurance doesn’t pay for it, it doesn’t happen. So denying insurance payments for a discussion now is saying, “You’re going to have to make health care decisions in a rush, in emotional and physical distress, and possibly you won’t get what you wanted because you can’t communicate at all.”

Comments on An Expansion on Palliative Care:
#1 ::: Wellescent Health Forums ::: (view all by) ::: August 21, 2009, 04:26 PM:

I too am very disappointed with these suggestions that health reform will cause doctors to act in a role to council patients to "let go" just to save costs or the life of someone else.

The act of helping people to plan early for their demise is the best way to ensure that their wishes are respected when the end comes and to ensure that they have some control in a situation where they might not otherwise. Given that the counseling activities were a non-partisan issue before Palin started into the "death panel" hyperbole, this sort of discussion seems to be a very transparent attempt at political manipulation.

#2 ::: Lori Coulson ::: (view all by) ::: August 21, 2009, 04:40 PM:

What puzzles me about this situation, is that everyone I've ever talked to about "end of life" issues usually states that they "want to die at home."

As I understand it, these discussions would help people to fulfill that wish. Do doctors charge a fee for this, I mean above and beyond what they'd charge for a normal health check appointment?

I confess, I currently have only a vague idea of the options available to me should I have a terminal illness. However, my family members do know that should circumstances warrant, I would rather they pulled the plug -- being bound to a bed with innumerable tubes and machines minding the body's various functions while the brain is not functioning is not living, IMVHO.

I see this as just another case of necessary information, like letting your family know where your important documents are when you do dance off with the Reaper.

#3 ::: Linkmeister ::: (view all by) ::: August 21, 2009, 04:42 PM:

For a guy who spends his days in a wheelchair, Krauthammer is curiously obtuse about death.

#4 ::: Madeline Ashby ::: (view all by) ::: August 21, 2009, 04:50 PM:

By Krauthammer's logic, my Canadian government has no reason to reimburse obstetricians for providing pre-natal counseling regarding folic acid requirements or dietary restrictions. Because really, if universal healthcare is about bringing costs down, why not just nip the problem in the bud? Babies don't pay taxes. In fact, they're a tax deduction! And in this economy, we just can't have that! Golly, my government must just be totally confused about how this universal healthcare thing really works -- I mean, they act like they're actually concerned with the health of the mother and her child, and not just bringing down the bottom line! I'd better phone my MP!

#5 ::: Summer Storms ::: (view all by) ::: August 21, 2009, 04:52 PM:

Lori, the current situation (as I understand it) is that if a Medicare recipient brings up the discussion of end-of-life wishes during an appointment where he or she is being seen for an actual medical condition, the fee for that appointment is covered... but if a Medicare recipient makes a doctor's appointment specifically to discuss end-of-life care options, without said discussion taking place as a tack-on to a care appointment, Medicare does NOT cover the cost, and the patient has to pay the full amount for the appointment.

The item which Palin and the rest of the Ridiculous Rightwing Nutbar Squad chose to interpret as "Death Panels" is nothing more than a change in policy to have the above type of voluntary (in that they are initiated by the PATIENT) consultations be covered by Medicare, once per every five year period, the same as any other doctor's appointment.

Covered, rather than the patient bearing the cost.

Seems like an eminently reasonable idea to me, which is probably why Palin & Co. can't stand it.

#6 ::: Bruce Cohen (Speaker To Managers) ::: (view all by) ::: August 21, 2009, 04:55 PM:

As you can imagine, statements like Krauthammer's have been quite common in the media here in Oregon ever since assisted suicide was put on the ballot. It's easy to refute these sorts of claims, because the number of people who have actually made use of the law to kill themselves has been very low: 401 total over the first 11 years of the Death With Dignity Act (through 2008) cite. Moreover, up to March of 2007, by which time 341 people had died under the act, 541 people had gone through the process far enough to obtain the prescription used; clearly even after going that far (the entire process typically takes months) many people felt sufficiently un-pressured that they don't go forward.

Incidentally, one of the positive benefits of the act has been to force doctors and local medical groups to re-evaluate their palliative care policies. Many applicants stated that they were unsatisfied with the pain amelioration standards of their doctors and clinics; the re-evaluations were done in the hope of removing that reason for assisted suicide. I believe the same outcome on a national scale would be a good thing, because the standards of palliative care nationwide are probably worse than Oregon's was.

#7 ::: Stefan Jones ::: (view all by) ::: August 21, 2009, 05:10 PM:

I'm really surprised at the Right's riding this car of the crazy train for so long.

I would have thought that they'd have moved onto something else by now, like criticizing colonoscopies, breast cancer screening, or vaccination.

#8 ::: Summer Storms ::: (view all by) ::: August 21, 2009, 05:14 PM:

Stefan @ 7: Ah, but the Kool-Aid cocktail service has been superb, and they've yet to figure out that a disguised cattle car is still a cattle car.

#9 ::: Summer Storms ::: (view all by) ::: August 21, 2009, 05:15 PM:

(oops, hit "Submit" too soon):

And, of course, like every cattle car, completely full of BS.

#10 ::: Fragano Ledgister ::: (view all by) ::: August 21, 2009, 05:29 PM:

I have just gone through the process of watching someone near and dear go to her death. In a hospice. With palliative care. In accordance with her express wish that she receive only palliative care in the last fortnight of her life.

Krauthammer is the stopped clock of the right. Correct on average twice a year. This is not one of those times.

#11 ::: eric ::: (view all by) ::: August 21, 2009, 05:57 PM:

Dear Charles:

Do you really want to argue with a 97 year old granny who's had a good life and now has a DNR order? Not really a good idea.

#12 ::: C. Wingate ::: (view all by) ::: August 21, 2009, 06:03 PM:

I don't know that I really agree with Krauthammer's position. But what I do know is that I don't need Mother Jones to interpret it for me, especially since they blow right on by the first several paragraphs that don't gibe so well with their thesis. I don't have to read MJ to know where they stand on these issues, and I could guess ahead of time that they need to discredit those among the opposition that at least give the appearance of being sane. They need to do this because of their "to the barricades" style of discourse, which has the effect on me of discounting them unless I can verify for myself what they're saying. Their analysis of Krauthammer's column is entirely tactical, which to me says that they may not be able to argue against him honestly.

As I said, I don't know that I agree with Krauthammer. I do think that the point he makes about the possible meaninglessness of making up such statements far in advance do have some merit. Some merit. I think his statement about what a living will is good for is incorrect (think "Terry Schiavo"). That's not the real point of the MJ article; the point of that article is to paint him as being a more respectable-sounding version of the "death board" folk.

That's what bothers me here. It's one thing to say, "look, you really ought to have a living will because you need to make some provision for these sorts of situation." The MJ article isn't even faintly interested in that. Their claim that Krauthammer intends to say that "allowing Medicare to reimburse doctors for advance care counseling might be the first tiny step toward turning them into junior Dr. Mengeles after all" is an exaggeration. All they want to do is cut him out of the discussion, because they are afraid that because he isn't foaming at the mouth, someone might listen to him.

#13 ::: julia ::: (view all by) ::: August 21, 2009, 06:09 PM:

OK, I'm a cynical beast, and anyone who knows me knows that.

But that said, my read on this is that Terri Schiavo worked out dismally for the wingnut branch of the Republicans, but they're still convinced it's a winning issue. The guy who organized the effort by the then-ruling party and their putative leader, Bill "my surgical skill acts as a faith-based encephalograph" Frist, to turn around the midterm elections by nailing Ms Schiavo to the cross moved on to be the the point man on defeating (or at least tarring) Sonia Sotomayor (spotlight quote: "Hispanic polls, Hispanic surveys, indicate that Hispanics think just like everyone else. We’re not like African-Americans.") Granted, he failed at that too, but at least he still gets the good assignments, which means they're happy with how his campaign played with his base.

I suspect that the end of life issue is another where capital gains tax cuts are the end game in trying to make americans picture some soulless government apparatchik slaughtering grandma.

But then, like I said, I'm cynical.

#14 ::: Josh Jasper ::: (view all by) ::: August 21, 2009, 06:12 PM:

I watched the nitwit who created the "Death Panel" fear on John Stewart. While he's smart, he didn't address her main lie, which was that encouraging doctors to counsel elderly patients on end life care is in no way sinister. It's a good idea. And her fearmongering that a living will couldn't be overridden by someone who was able to say "y'know, I'd rather not die" was nauseating.

If you've got the stomach, you can watch here.

#15 ::: Jim Macdonald ::: (view all by) ::: August 21, 2009, 06:21 PM:

And her fearmongering that a living will couldn't be overridden by someone who was able to say "y'know, I'd rather not die" was nauseating.

We have a little saying: "No matter what the machine says, if the patient looks at you and says 'Please don't shock me,' defibrillation is contraindicated."

#16 ::: KeithS ::: (view all by) ::: August 21, 2009, 06:22 PM:

C. Wingate @ 12:

Isn't the whole point of that article to point out that sane-sounding people are saying stuff that's not true? People who are obviously crazy are easy to spot. People who sound reasonable who say unreasonable things need to be called out, otherwise you wind up with people saying things like, "I don't know that I agree with Krauthammer," but they still think his ideas may have some legitimacy.

Krauthammer says: "So why get Medicare to pay the doctor to do the counseling? Because we know that if this white-coated authority whose chosen vocation is curing and healing is the one opening your mind to hospice and palliative care, we've nudged you ever so slightly toward letting go." If you have any interpretation of that other than that he's saying that letting doctors talk to patients about end-of-life issues will lead to a slippery slope of government-driven suicides, please enlighten me.

#17 ::: abi ::: (view all by) ::: August 21, 2009, 06:40 PM:

Looking for this article on the work of a palliative care physician, I found myself at this other article on much the same topic. Key quote, for me, from a discussion with Dr Holly Prigerson, an authority in the area of palliative care:

While the timing and appropriateness of these discussions should be considered in each individual case, talking about end-of-life care “doesn’t inhibit or prohibit patient choices. Instead patients will be more likely to make better informed decisions and to get the kind of care they want. And physicians will have an idea of their patients’ preferences, regardless of what those preferences are.”
#18 ::: Josh Jasper ::: (view all by) ::: August 21, 2009, 07:01 PM:

Damn, Abi, the first article brought me to tears. I never, ever, want to go through what that poor woman at the end of the article went through, or put an family member through that.

There's a deep wrongness to spending one's last days doped up to prevent one from screaming. Pratchett has it right. That is *not* an endgame I will accept.

#19 ::: Serge ::: (view all by) ::: August 21, 2009, 07:35 PM:

KeithS @ 16... Isn't the whole point of that article to point out that sane-sounding people are saying stuff that's not true?

You mean, like what the Republican Party and its henchpeople fed the country for the first 8 years of this century?

#20 ::: Serge ::: (view all by) ::: August 21, 2009, 07:40 PM:

I'm not sure what the situation is like in Canada, but, when I got that call from my sister in February 1993, I knew something bad had happened. My father had died, and his body had been brought back 15 minutes later, his body and nothing else. The family had to make a decision and nobody interfered. Because that's what my dad would have wanted, the doctors pulled the plug.

#21 ::: Serge ::: (view all by) ::: August 21, 2009, 07:48 PM:

I asked about Canada because that's where I come from and the experience of my father's death leads me to believe that DNR isn't an issue up there and I wanted to confirm. Of course, that was 16 years ago and things may have changed.

#22 ::: edward oleander ::: (view all by) ::: August 21, 2009, 07:51 PM:

There were people in the Bush White House who sounded sane?

#23 ::: Ginger ::: (view all by) ::: August 21, 2009, 08:28 PM:

Like Fragano, we've recently watched a member of our family decline and die, in our case from dementia, in hospice. Not only did the family discuss end-of-life care, but we all knew exactly what she wanted done at her funeral and burial. Death is not something to be feared; we fight to delay it as long as possible, but it is inevitable.

#24 ::: Terry Karney ::: (view all by) ::: August 21, 2009, 08:34 PM:

C. Wingate: I read the Krauthammer piece, and you know what..., he's playing the Deather card. His argument is the doctor counselling you to make one (which isn't what the law says; what it says is you can schedule an appointment, once every five years, and the gov't will pay for it; even if that's all you wanted to talk about), is a gentle push in the direction of filing a DNR Order on yourself.

He's giving cover to the Palin's and the other, "Death Panel" whackjobs.

Josh: I watched the whole interview, and yeah, I saw what she did there. She never actually answered the questions. She did a nice job of being affable, and playing o to the camera (in the form of the crowd) and I think, all in all, she won the round. The people who are inclined to buy into her schtick will be persuded, and those who are on the fence will be confused (the bit about, "is that section all you read," was perfect. She establised her bona fides as an expert, while not actually showing any proof she'd read the bill).

Her fumbling with the pages (when there was only one small section of the bill she was going to need) was also good. Proof that she was planning the whole thing is implied by her having, very conveniently, a letter from a San Francisco paper (written by a physician in Los Angeles, which makes me wonder at it), right on top, but not a tab to the part of the bill she cares so much about.

#25 ::: Terry Karney ::: (view all by) ::: August 21, 2009, 08:42 PM:

This brings to mind the question of what do I do?

The person whom I was entrusting that set of questions to, is no longer someone I can burden with it. It's not fair to her.

And the other people whom I might care to have involved are spread out, none of them closer than 400 miles from me.

Which, since I had a wreck last week (the bike is totalled, I'm fine. Really, much less damage than the simple physics trick which cut my knee open three weeks ago). Details, for them as care, guy in the lane to my left started to merge into me, I was checking him when, for no apparent reason, the car in front of the car in front of me stopped. I had to put the bike down.

Tucked it under her bumper, my front tire under her front tire. Helmet scraped, jacket scraped, boot scraped, me a little scraped (elbow, hip, knee, minor abrasions all).

But, if I'd not dropped the bike (or been keeping less following distance), and I'd eaten her bumper, I might be in a bad way.

As Jim says, the Grim Reaper's waiting for all of us. Not taking him into account is a foolish sort of magical thinking. I have no problem with the idea of taking the time to discuss the things medicine knows how to do, and trying to decide which circumstances I want which of them used.

#26 ::: Serge ::: (view all by) ::: August 21, 2009, 09:00 PM:

edward oleander @ 22... Well, by sane, I meant not-looking-insane-and-foaming-at-the-mouth. They obviously had problems.

#27 ::: Serge ::: (view all by) ::: August 21, 2009, 09:03 PM:

Terry Karney @ 25... Glad to hear things weren't worse.

#28 ::: Jim Macdonald ::: (view all by) ::: August 21, 2009, 09:56 PM:

Krauthammer says:

" have to be a fool or a knave to deny that it’s intended to gently point the patient in a certain direction...."

I am neither a fool, nor a knave, yet I do deny it.

I deny it for many reasons, one of them being that it would require doctors (who, as Krauthammer admits, have chosen curing and healing as their vocation) to suddenly and without motive act out of character, all for the sake of money that they, themselves, will never see. That is frankly unbelievable.

#29 ::: Josh Jasper ::: (view all by) ::: August 21, 2009, 10:01 PM:

Terry @ 24 - It was her "laugh" that was the final straw in convincing me that she was actually some sort of humanform hell spawn. And thanks for saying to C. Wingate what I wanted to say, but was too tired to articulate.

I'm tired of people trying to present a "fair and balanced" reason to hold up a public health care option and looking for rationality among the dissenters. Either they don't like it because it involves taxes paying for someone poor getting health care, or not. Can we *please* stop trying to pretend that Republicans and blue dogs have any other agenda? It's all too much to deal with. I'm tired. I can't take confronting the lies anymore. They just keep piling up. It's like sweeping back the tide.

Anyhow, I'm glad to hear the bike accident recovery is going well.

#30 ::: P J Evans ::: (view all by) ::: August 21, 2009, 10:26 PM:

You could be hit by a car tomorrow, and wind up brain dead. How is that made more likely by talking to a doctor today about a living will and advance directives?

Krauthammer is a fool. Or maybe a knave.

#31 ::: Lizzy L ::: (view all by) ::: August 21, 2009, 10:31 PM:

Terry, glad you're okay.

I can't speak comfortably about this, it hurts, and makes me unspeakably angry at the same time. It's hard for me to believe that these people are using people's fear of death as a political tactic to turn them against reforming the health insurance/care system of this country. I do believe it, though, because it's right in front of me.

God forgive them -- I can't.

#32 ::: Russell Coker ::: (view all by) ::: August 21, 2009, 11:14 PM:

If Medicare was to pay for visiting the doctor for the sole purpose of discussing end of life issues, how many visits might that involve?

My health is really good, but I seem to visit a doctor at least twice a year.

Merging a once per 5 years discussion with one of the other 10+ medical visits in that time period doesn't seem difficult or unlikely.

People who are actually in bad health will probably see a doctor at least once a month and will have plenty of opportunities to discuss such things.

Currently anyone could visit a doctor complaining about a headache (or something else trivial) and then talk about a living will to avoid any costs. Most doctors would be happy to work with this, the care of the patient is much more important than an accurate description of the visit for billing purposes.

I can't understand why anyone would bother about this on either side.

#33 ::: janetl ::: (view all by) ::: August 21, 2009, 11:21 PM:

My pet peeve is hearing people talk about an Advance Directive or Living Will as if it were synonymous with "Do Not Resuscitate". Oregon has a simple form to fill out, where you answer questions about what you'd like done under various circumstances. You can fill in keep me going no matter what!, or say to not do much, and everything in between. You also designate the person to make decisions for you, and a backup if they're not available.

I wish my father had filled out something like that. He had formally given my oldest brother authority to make medical decisions for him, but he hadn't left any description of his preferences. When he had a massive stroke, making decisions was a big burden for my brother, and us. I have a will, and an Advance Directive, as a kindness to my relatives.

#34 ::: Dan S. ::: (view all by) ::: August 21, 2009, 11:49 PM:

"So why get Medicare to pay the doctor to do the counseling? Because we know that if this white-coated authority whose chosen vocation is curing and healing is the one opening your mind to hospice and palliative care, we’ve nudged you ever so slightly toward letting go."

Ok, so from what I understand of that part of the bill (section 1233)[big pdf], , it really is talking about advance planning for end-of-life care in general - palliative care & hospice are certainly mentioned, but as part of "the continuum of end-of-life services and supports available." Regarding "‘order[s] regarding life sustaining treatment", it's specifically stated that "The level of treatment ... may range from an indication for full treatment to an indication to limit some or all or specified interventions." And as mentioned by Jim @28, financial incentives for the doctors aren't there - if anything, they could run the other way, towards more expensive interventions!

So if they're no evidence that drs would be stubbornly pushing hospice/palliative care, but rather providing patients with (voluntary) counseling on the full range of care&planning options, what's Krauthammer's problem? Assuming it's not merely partisan - well, look at it this way: (one of) the main problem(s) w/ Krauthammer's piece is that it trades on his (bizarre & inexplicable) status as a reasonable & respected commenter to bestow legitimacy to something fundamentally illegitimate - deather hysteria. Similarly, given that a sensible restatement of "... if this white-coated authority whose chosen vocation is curing and healing is the one opening your mind to hospice and palliative care" is simply 'if the dr. provides you with information about the full range of advance planning and care options', it would seem the issue is using doctors' status to grant legitimacy to something he finds fundamentally illegitimate - hospice and palliative care*. Honestly, he basically says says as much right there - the problem is doctors talking about that (and therefore patients might decide it is a legitimate option).

* And of course, that's his decision to make - for himself.

#35 ::: Stefan Jones ::: (view all by) ::: August 21, 2009, 11:50 PM:

Of course it's wrong to fantasize about pushing Charles Krauthammer in front of a bus, but . . .

#36 ::: Stefan Jones ::: (view all by) ::: August 21, 2009, 11:52 PM:

Of course it's wrong to fantasize about a bullet bouncing off the skull of a moose and blowing off Sarah Palin's nose, but . . .

#37 ::: Tom Whitmore ::: (view all by) ::: August 21, 2009, 11:57 PM:

Having been a hospice volunteer, and having watched both my parents die -- I can't believe the people who are opposed to this. And McCaughey's inability to find the "pull quotes" for what she says the bill contains (and listening to Maher say "That's not what I read") is train-wreck sickening.

Jim, I told your saying to a friend who works freelance with a defibrillator company, and she laughed.

#38 ::: Terry Karney ::: (view all by) ::: August 22, 2009, 12:12 AM:

Thom: As an aside, it was Stewart, not Maher.

Dan S: The incentive (as I understand it) is derived from a perversion of the reading of the bill.

1: Medicare has added some incentives for quality of care.

2: The reporting structure allows a doctor to include end of life discussions.

3: When so doing, a doctor has to cover all bases, to include various palliative, and DNR functions.

4: How well a doctor adheres to such directives is a measured object.

What is being bruited about is the use of the word, "adhered" Mcaughey would have you believe the doctor is required to force the patient to adhere to the directive if said doctor is to avoid a small hit on the rating.

That's the "death" argument. If you say, now, "I don't want 'x'" and later change your mind, the doctor will have an incentive to try to force you to refuse 'x'.

Which is a filthy lie.

#39 ::: Dan S. ::: (view all by) ::: August 22, 2009, 12:17 AM:

Link Between Religious Coping And Aggressive Treatment In Terminally Ill Cancer Patients

"ScienceDaily (Mar. 23, 2009) — In a new study of terminally ill cancer patients, researchers... found that those who draw on religion to cope with their illness are more likely to receive intensive, life-prolonging medical care as death approaches –– treatment that often entails a lower quality of life in patients' final days. Previous research has shown that more religious patients often prefer aggressive end-of-life (EOL) treatment. ...The study's findings suggest that physicians tend to comply with religious patients' wishes for more aggressive care...
The researchers also found that religious copers in the study were less likely to have completed advance medical directives, such as a living will or do-not-resuscitate order...The effects of religious coping ...remained significant even after adjusting for differences in advance care planning.

#40 ::: Dan S. ::: (view all by) ::: August 22, 2009, 12:21 AM:

Terry @38 - that makes sense. Well . . it doesn't, it's insane - but you know what I mean.

#41 ::: Avram ::: (view all by) ::: August 22, 2009, 12:36 AM:

What's funny (in a sad way) about C Wingate's comment @12 is that he dismisses Kevin Drum and Mother Jones Magazine "because of their 'to the barricades' style of discourse", while giving a free ride to Charles Krauthammer, a man who, during the 2003 build-up to the Iraq War, screamed at his own rabbi, in shul, during Yom Kippur services, because the rabbi had spoken positively of peace.

Wingate, the reason Drum reads Krauthammer tactically is because Krauthammer writes tactically. To ignore that fact is to fail to understand the political environment in which we are soaking.

#42 ::: C. Wingate ::: (view all by) ::: August 22, 2009, 01:28 AM:

re 16: No, it is not, because they don't even bother to address the "truth" of what Krauthammer said. All they seem to care about is that his opinions might get in the way of their goal, so it is necessary to discredit him, and refuting him is apparently more work or something like that than actually addressing his points.

The thing is that slippery slope arguments don't work on me. It is possible for me to consider the possibility that there is some degree of a conflict of interest and decide to live with it anyway because there's no better alternative. Thus, when I read Krauthammer's article, particularly the larger context of it, I don't have the kind of strong reaction that a lot of other people have. It invites a certain hesitancy at most. Which leads to....

re 24: Um, when I read the MJ article, and your response, it seems to me that they and you are the ones in the card-playing business. Card playing, after all, is tactical. It is useful to paint Krauthammer as a nutcase in disguise.

But what I'm also seeing is that as a case of political dialogue the incident as a whole seems to me to say that nobody thinks it worth the trouble to try to get me to sign on to any side-- at least, if I go with the interpretation that Krauthammer is being disingenuous. The death panel thing is so stupid that it cannot possibly be expected to sway any but the paranoid idiot undecided, and I have to suspect that paranoid idiots are already in the anti-plan camp. The corollary to that, though, is that one doesn't get any points (from me,at any rate) for refuting a claim so bogus as to not need refutation. The sense I get as to both sides is that conflict ("argument" is too high a word) over this sort of issue is about reinforcing the fervor of the committed. When I look at the MJ article, I am not really its audience; its advice is to activists. And its advice isn't really about the Krauthammer article per se, but about any, well, non-stupid doubt about the plan of the moment; his column is merely an example.

Finally, at 41: Avram, I've been hearing Krauthammer for decades, at least since his days back on Agronsky & Co.. When you say I'm giving him a "free pass", you seem to be implying that he's someone I agree with, when, as it happens, he has never been someone I've agreed with much. I think he does raise some points worth thinking about in the column in question, but he doesn't convince me in the end. But I don't have to appeal to any malign motives to get to that conclusion. I gave him the benefit of the doubt in that regard, and he still "lost". There's no benefit to be given to the MJ article because it is quite up front about its emphasis on the tactical.

And even if I don't give him the benefit of the doubt, even if he is writing tactically, that merely means that he and MJ are damned. Yeah, you are agreeing with me: political discourse these days is basically dishonest, corrupted either by partisanship, money, or ideology. In this case the problem appears to be the last.

#43 ::: Avram ::: (view all by) ::: August 22, 2009, 02:08 AM:

C Wingate @42, Drum can't address "the 'truth'" of what Krauthammer says, because there is no truth there. His entire argument is based on hypotheticals and imagination. The one relevant factual claim that he makes -- "there are no 'death panels' in the Democratic health-care bills, and to say that there are is to debase the debate" -- is made early, in the second paragraph, and then undermined with his hypotheticals.

Which is tactical on his part. That essay is designed to spread fear, uncertainty, and doubt about the health care plan. Krauthammer's early admission about the non-existence of death panels is a signal to the reader that Krauthammer isn't one of those screaming nutcases. The entire rest of the essay then repackages the "death panels" claim in less hysterical clothing.

Drum's been reading political writing long enough to recognize this tactic when he sees it. We know it's a tactic because, just a few years ago, the very same conservatives who are now implying that Obama wants to kill your grandma were supporting advance directives and end-of-life care. Back before she became a vice-presidential candidate, Sarah Palin proclaimed a "Healthcare Decisions Day" in Alaska, when Alaskans would be encouraged to discuss end-of-life care with their physicians. Just last month Newt Gingrich wrote an editorial for the Washington Post praising "community-wide advance care planning". Then the orders came from GOP central command, and the two of them clicked their heels, spun 180 degrees, and announced that Oceania had always been at war with living wills.

What you're doing is complaining about Drum being honest and perceptive, while granting Krauthammer the benefit of the doubt because he's being deceptive and wily.

#45 ::: Jim Macdonald ::: (view all by) ::: August 22, 2009, 06:44 AM:

It is useful to paint Krauthammer as a nutcase in disguise.

No, he's not a nutcase. Nutcases genuinely believe what they're saying (however insane it might be).

He's a knave. Or a fool.

But not a nutcase.

#46 ::: Serge ::: (view all by) ::: August 22, 2009, 08:33 AM:

Jim @ 47... He's a knave. Or a fool. But not a nutcase.

In a knutshell.

#47 ::: Ann L ::: (view all by) ::: August 22, 2009, 10:49 AM:

Among the things about this business that make me uncharacteristically spitting mad is the implication that those of use who have been in this situation--who have had dying parents or children or siblings or partners unable for whatever reason to make their own choices, those of us who have had to hear the doctor say that there isn't really anything else to do and these are the options, and have decided to terminate treatment--we are, in fact, murderers. Even when we have documents in hand, even when (as my mom did, thank all the gods) our loved one was frequently very explicit about just what she did and didn't want.

I will not under any circumstances wish anyone might find themselves in that situation. But I wish people who haven't could find even the tiniest bit of compassion for those of us who have.

#48 ::: Serge ::: (view all by) ::: August 22, 2009, 11:04 AM:

When there's a gap between movies, Turner Classic Movies will run old featurettes, documentaries, that kind of stuff. They just showed one from not long after 1945, about a nurse who goes around Alaska providing medical care to people who can't afford it. I especially the part where, during a meeting at a local church, she says that sometimes what we can't achieve individually can be achieved by the group. She probably is a fan of death panels.

#49 ::: Bruce Cohen (Speaker To Managers) ::: (view all by) ::: August 22, 2009, 01:11 PM:

Terry Karney @ 25:

Glad you got out of that without damage to you. Bike accidents are scarey: there's a lot more going on that you don't have any control over than if you're in a car (because it's more likely the other drivers don't even see you on a bike, let alone do the right thing when something unexpected happens).

You're absolutely right; it's drastically inconsiderate to leave end of life decisions for someone else to make at the last minute. If the health care bill includes a provision to encourage people to make those decisions ahead of time, I'm all for it.

#50 ::: Don Fitch ::: (view all by) ::: August 22, 2009, 01:23 PM:

Feeling a bit pessimistic, I can't help wondering just why so many people --l mostly conservatives, I guess -- are opposed to the idea of an end-of-life consultation.

Frankly, the "slippery slope" (towards doctors promoting or advising pulling the plug) doesn't hold up. As I understand it, the last few weeks of struggling care tend to be the most expensive, and hence the most profitable to the doctors & hospital -- more profitable than letting the patient die and admitting a new one.

Jim is, I think, a bit optimistic when he implies that all doctors have chosen curing and healing as their vocation. It seems to me that a significant number of them, nowadays, have chosen the vocation of making a lot of money. If so, the biases in these counselling sessions seem likely to cancel out, or come close enough to this as to make no nevermind.

I suspect that the actual and basic objection, from many conservaties, is to the government spending (or mandating spending) money to benefit citizens*. That really ought to be a different discussion.

* Their objection could, of course, be to having facts presented to them, and being forced to make some kind of decision based upon them.

#51 ::: KeithS ::: (view all by) ::: August 22, 2009, 01:27 PM:

Don Fitch @ 52:

I really don't think they are opposed to end-of-life consultation—in fact, at least a few were for it until just recently. What they are opposed to is overturning, even slightly, the existing system, and whipping up a fear of death is as good a way of doing that as anything.

#52 ::: janetl ::: (view all by) ::: August 22, 2009, 01:33 PM:

I have never, ever heard someone complain of their doctor pushing hospice, or a DNR. I have heard many stories of doctors not informing patients of the option of hospice care. A cynic would say that the physicians want the money from expensive care at the end of life. I bet it's more a combination of a commitment to win, and discomfort with having a potentially emotional conversation like that. I've had great doctors who treat me like a whole person, and listen to me, but I've also seen doctors who rush in and out of the room like an assembly-line worker applying a wrench to the next car on the line.

#53 ::: anaea ::: (view all by) ::: August 22, 2009, 02:39 PM:

Russell Coker at #34

You could do that, but it's fraud. You have to have a patient decide, "I want to have this conversation, I think I'll lie about a headache to do that." Then you have to have a doctor to decide to complete the documentation necessary to justify the visit when that wasn't what was going on in the visit at all. Some people aren't devious enough to come up with the fraud in the first place. Some doctors aren't willing to risk the consequences of the fraud by perpetuating it. They don't get to just say, "Treated grandpa for headache, that'll be $50 please." They'd have to do charting to support the visit for the alleged headache, then submit it.

And more importantly, any system that requires you to perpetuate a fraud in order to get things you really ought to have anyway is a bad system and needs to be fixed.

#54 ::: Bemusedoutsider ::: (view all by) ::: August 22, 2009, 02:40 PM:

An Expansion on Pallative Care
Posted by Jim Macdonald at 03:44 PM * 54 comments

The story includes this two-paragraph quote from Charles Krauthammer:
So why get Medicare to pay the doctor to do the counseling?


Among other reasons, because this doctor is the person who will follow (or not follow) the directive when you are in the ER/ICU and unable to communicate.

It needs to be done and filed in the 'family physician' or 'personal physician' facility, with all the blanks filled in just right. Maybe some staff person in the facility could do it (and maybe some will). But if the doctor does it himself, then he will have more trust in the document and be more likely to follow it.

Especially if he remembers the counseling session and what all you said that does not fit on the page. He will have his own judgment as to whether you were serious, informed, not depressed....

#55 ::: James D. Macdonald ::: (view all by) ::: August 22, 2009, 03:07 PM:

Since the objection has been raised that MJ only looked at two paragraphs from Krauthammer, let me bring in a third:

My own living will, which I have always considered more a literary than a legal document, basically says: "I've had some good innings, thank you. If I have anything so much as a hangnail, pull the plug." I've never taken it terribly seriously because unless I'm comatose or demented, they're going to ask me at the time whether or not I want to be resuscitated if I go into cardiac arrest. The paper I signed years ago will mean nothing.

Let me explain something to Mr. Krauthammer: At the moment he goes into cardiac arrest he will be comatose. No one will be able to ask him anything, nor will he be able to reply.

He forgets that "comatose or demented" are really common. He could be in either state at the moment the ambulance delivers him to the ED. I'm glad he's got a living will, because if he didn't ... I could tell him horror stories.

#56 ::: j h woodyatt ::: (view all by) ::: August 22, 2009, 03:40 PM:

It's also worth noting that Kevin Drum was never particularly leftist, neither when he was writing his own blog at Calpundit, nor when he was writing with Hilzoy at Washington Monthly. He didn't move at all leftward when he went to Mother Jones. I can certainly see how trying to discredit his center-right credentials by equating them with the Mother Jones editorial stance is a tempting play, but for anyone who's been reading both of them for very long, it's pretty silly.

Kevin Drum is far to the right of rest of the Mother Jones editorial staff. He's currently pissing all over his generally more lefty readers by telling them to give up on the public option to get a weaker health insurance "reform" package past the Blue-Dog/Crazy coalition in the Senate. He's never taken the advocates of single-payer at all seriously. Complaining about his lefty affiliations is pretty rich, if you ask me.

#57 ::: Neil in Chicago ::: (view all by) ::: August 22, 2009, 03:41 PM:

You're rebutting Charles Krauthammer? Why bother??

#58 ::: KeithS ::: (view all by) ::: August 22, 2009, 03:55 PM:

Neil in Chicago @ 59:

Which brings us back to the whole point of the original post: we shouldn't bother to waste our time rebutting him because he's arguing in bad faith and giving weight to loony arguments. Unfortunately, a lot of people seem to think that this is a debate class where both sides are arguing in good faith and there's a moderator keeping score. As long as people think that, then pointing out that he's more dangerous than the loonies because he keeps their ideas on the table is seen as an unwillingness to engage with his arguments, and therefore the people who say that must have a weaker position.

By artificially distancing himself from the deathers' craziness while lending credance to some of their claims, he uses the expectation that reasonable-sounding people are actually reasonable to keep crazy ideas in circulation. If this were an actual debate class, he'd get a poor grade (I hope), but he's not playing to the moderators, he's playing to the audience.

#59 ::: Ursula L ::: (view all by) ::: August 22, 2009, 04:02 PM:

If Medicare was to pay for visiting the doctor for the sole purpose of discussing end of life issues, how many visits might that involve?

My health is really good, but I seem to visit a doctor at least twice a year.

Merging a once per 5 years discussion with one of the other 10+ medical visits in that time period doesn't seem difficult or unlikely.

People who are actually in bad health will probably see a doctor at least once a month and will have plenty of opportunities to discuss such things.

For this type of discussion to be meaningful, you need to have the time to do it right. Talk about end-of-life issues from a variety of perspectives, ask questions and get them answered, discuss different ways in which people can die and different issues one can face when dying. (Pain, loss of intellect, physical disablity, dependancy, expense, etc.) Also to discuss who is available to make end-of-life decisions on behalf of the patient (friends, family) and who they might want to specifically exclude (e.g., if one's closest relative is mentally ill.)

These days, the typical doctor's visit is quite short. Maybe a quarter hour, often less. That's not enough time to discuss these issues in a way that is appropriate.

Rushing is probably more likely to leave a patient feeling as if they are pushed towards a doctor's preferred end-of-life philosophy. When you see a doctor for 10 minutes for an infection, you don't have time to discuss every possible antibiotic, its history, and all its possible effects. But for end-of-life decisions, you do want the time for in-depth discussion.

Ideally, I'd think that these sorts of discussions should happen over something like a weekend seminar. Take the time to have lectures about different issues, group discussion where questions are answered, private discussions with one's loved ones, and then privately fill out the appropriate forms. Work through something like "The Five Wishes section by section.

#60 ::: The Raven ::: (view all by) ::: August 22, 2009, 04:31 PM:

It's not a debate, it's an outshout. And Krauthammer usually wins because he has a megaphone and we have a kilophone.

Washington Post, crashed, burned, smoking, and spewing poison.

#61 ::: Wesley ::: (view all by) ::: August 22, 2009, 04:42 PM:

Serge, #50: When there's a gap between movies, Turner Classic Movies will run old featurettes, documentaries, that kind of stuff. They just showed one from not long after 1945, about a nurse who goes around Alaska providing medical care to people who can't afford it.

Cartoonist Kevin Huizenga's blog recently featured another vintage endorsement of government health care, this one with a celebrity spokesman.

Here's Milton Caniff, hardly a flaming liberal, talking up free health care in an old Steve Canyon strip. (A lot of this strip is cold war propaganda. It's interesting that Caniff promotes America by citing the kind of things modern conservatives scorn as "socialism.")

And then there's the Warner Brothers short "So Much for So Little."

#62 ::: Don Fitch ::: (view all by) ::: August 22, 2009, 05:37 PM:

KeithS @ 53:

Probably some/many conservatives are afraid of any alteration of the current system, yes. I think maybe more of them just want to make sure the Democrats don't accomplish _anything_ the voters would consider good.

And, ultimately, just about everyone, now, is talking/arguing about improving Health/Medical Insurance.

What the American People really need, in my opinion, is improved Health/Medical _Care_ -- which is a very different topic, albeit with some overlap -- and that appears to be off the table or sucessfully (from the Conservative view) derailed.

As others have said, "It's over. They won."

#63 ::: P J Evans ::: (view all by) ::: August 22, 2009, 05:38 PM:

he has a megaphone and we have a kilophone


#64 ::: Serge ::: (view all by) ::: August 22, 2009, 05:50 PM:

Wesley @ 62... It's interesting that Caniff promotes America by citing the kind of things modern conservatives scorn as "socialism.")

Funny, isn't it?

Regarding your first link, it's no wonder that celebrity endorsed public heath care. He's a stinkin' illegal alien!

#65 ::: Caroline ::: (view all by) ::: August 22, 2009, 06:21 PM:


My grandfather (a conservative Republican!) chose to go with hospice when he was told he had a brain tumor and a month to live. It's my understanding that Medicare helped pay for hospice care, for the nurses and volunteers and home equipment that helped him live out his last days peacefully at home, as he wanted to.

My grandmother (a moderate/liberal Republican) now wants to make sure she has her end-of-life wishes made clear. She knows she may not have a month of advance warning while she's still competent to state her decision.

Medicare should pay for her to have that conversation with her doctor. It's just that simple. It's completely ridiculous to say that Medicare covering that appointment means she'll be pushed to make a decision she didn't want to make.

God rest my grandfather's soul, he'd be arguing with me about health care reform if he were alive today, but I don't think he'd buy this particular argument for a minute.

#66 ::: Stefan Jones ::: (view all by) ::: August 22, 2009, 06:22 PM:

#63: Yes. If there's something Americans are more resentful of than taxes it's Being Told What to Do by tree-hugger health-nazi do-gooder food police.

One of the scared bumpkins at a town hall shouted something like "They want to tax us for being obese!"

#67 ::: Stefan Jones ::: (view all by) ::: August 22, 2009, 06:29 PM:

#66: I wouldn't be surprised if MOST Republicans and conservatives know damn well that living wills and advance directives and hospice care are good things.

That's including the oh-so-concerned politicians and pundits. (Except maybe Sarah Palin, who is quite the genuine thick-skulled loony.)

But they have a president to disgrace and a congress to re-win, so they're being hypocrites in public and deploying the Armies of DUH!ness. Their numbers (ALL minus MOST) are sufficient to gum things up and ruin it for everybody.

#68 ::: Caroline ::: (view all by) ::: August 22, 2009, 06:35 PM:

Furthermore, this post reminds me to get the ball rolling on a living will and health care power of attorney.

For North Carolinians, here is the Department of the Secretary of State Advance Health Care Directive Registry website. Forms and instructions are there.

Also, see's guide to planning ahead.

#69 ::: Marilee ::: (view all by) ::: August 22, 2009, 06:44 PM:

Terry, #25, I have an appointment this month with my psychiatrist to help me figure out whom I can trust locally. Maybe learn how to trust people more.

I've already told my nephrologist that if I get to the point where I need dialysis, I'm not having it. She says we'll talk about it then.

#70 ::: Caroline ::: (view all by) ::: August 22, 2009, 06:52 PM:

Stefan Jones @ 68 -- I'm more inclined to think that the Republicans who are ranting in public about this stuff just aren't thinking about end-of-life issues realistically. Maybe they never went through it with a family member; maybe they're not old or sick themselves, and think they never will be. For whatever reason, they seem to think that planning for it means they'll die -- and if they don't plan for it, they'll never die.

The lie works because it touches on real fear for some people. Certainly, I think the pundits are pushing it just because they want Obama to fail. But I think a lot of people swallowing that lie really are just in denial, and think that a living will lets in the possibility of death when it wasn't there before.

My grandfather might even have bought this line before he got sick, I don't know. But I think anyone who's seen the reality of death doesn't buy it. Those who haven't seen (and refuse to imagine) the reality that death comes to everyone -- even people you love, even people like you -- can buy it.

#71 ::: Spiny Norman ::: (view all by) ::: August 22, 2009, 07:03 PM:

I see no reason to be dainty about this. Charles Krauthammer is a motherfucker.

#72 ::: Lee ::: (view all by) ::: August 22, 2009, 07:13 PM:

Caroline, #71: I am also convinced that there's a strong religious link involved. Being able to choose NOT to have heroic measures taken to squeeze out every last possible drop of life is seen as a form of suicide, and Suicide Is A Sin.

#73 ::: Scott ::: (view all by) ::: August 22, 2009, 07:48 PM:

Lee @73
I'm not confident that it's a way of avoiding the sin of suicide. More likely, to me, is the over-reliance on anecdotes of full and unexpected recovery. The belief that doctors aren't competent to judge a probability of regained consciousness (or whatever else was lost) despite the fact that they're paying lots of money to those same doctors to extend the patient's life.

They hear a story like my oldest brother...

He had a stroke at a young age, and my parents were told he'd never feed himself, much less have the mental capacity of an adult.
Of course, he's approaching 40, and just finished school. AGAIN. (his 2nd master's degree, following his Ph.D) So, maybe he is mentally retarded, right at the age of post-graduate education! But I kind of doubt it had anything to do with the stroke.
And they decide that when a doctor says "It's grim," that the doctor in question just doesn't know what he's talking about.

#74 ::: Bruce Cohen (Speaker To Managers) ::: (view all by) ::: August 22, 2009, 07:55 PM:

Lee @ 73:
Being able to choose NOT to have heroic measures taken to squeeze out every last possible drop of life is seen as a form of suicide, and Suicide Is A Sin.

But it's OK to have someone else make the decision for you, since that's not suicide (which sort of makes it murder, no?). To my way of thinking this is entirely backwards; it's my life to end (or not), so it should be my decision. But even if I didn't feel that way, I'd still insist that the religious argument is fine for them as believes it; they don't, however have the right to jam their beliefs down my throat.

But then, isn't that what the whole right-wing onslaught on health care is about: jamming what the corporations or the right-wing elite* want down everyone else's throat?

* Yeah, let 'em eat their own epithets!

#75 ::: Jim Macdonald ::: (view all by) ::: August 22, 2009, 07:58 PM:

#63: As others have said, "It's over. They won."

It is not over, nor have "they" won.

#76 ::: Rob Rusick ::: (view all by) ::: August 22, 2009, 09:16 PM:

Lee @73: I had seen reports this week that the religious were more inclined to seek treatments to extend their lives* (one would think they'd be less inclined; what should they fear of death?) Perhaps, as you say, they consider it suicide not to put up the most stringent fight. On the other hand, if God is calling you home, isn't it presumptuous to dig in your heels resisting?

* Not the original article I read, but one I found google-searching for it.

#77 ::: Scott ::: (view all by) ::: August 22, 2009, 09:22 PM:

Rob Rusick @77

That was a big part of the Christian Science sect. But it's certainly not a mainstream religious belief (that modern medicine is thwarting God's will for how and when people die).

The simplest counter-point is "God helps those who help themselves." Not that I have the SLIGHTEST idea where that expression came from, and am TOTALLY aware of its "God doesn't actually do anything undercurrent," it still expresses a popular attitude among religious people. (That you should do whatever YOU can to make your life better, and not SIMPLY expect God to hand you a good (or in this case, long) life).

#78 ::: Don Fitch ::: (view all by) ::: August 22, 2009, 09:29 PM:

Jim @ 76:

Oh, not the war (IMHO) -- I should've made that clear -- but this battle sure seems to me to have passed its turning-point, what with the deflection to concentration on Insurance. (Sure, I might be feeling excessively pessimistic at the moment, and the Administration and Congressional Majority might start playing hardball. I hope so, of course, but.....) I don't think we'll get much improvement -- maybe just enough to make future changes even more difficult.

Fortunately, this isn't by any means the decisive battle in the war /o/f/ /g/o/o/d/ /v/s/./ /e/v/i/l/ for much greater social enlightenment.

Mind you, I'm going to be really difficult to get along with if even a little of my tax money starts getting paid to Health Insurance company executives & stockholders.

(I'm perfectly okay with the idea of that money -- and even higher taxes -- going to pay for a decent level of health care for people who otherwise couldn't afford it, but spectacularly not okay with the idea of having any of it go into the pockets of people who haven't actually done anything to provide medical care. And the latter is what would happen if we don't get a good, government-operated, Public Option Plan.)

#79 ::: Avram ::: (view all by) ::: August 22, 2009, 10:23 PM:

Rob @77, I wonder how many are worried about Judgment.

#80 ::: P J Evans ::: (view all by) ::: August 22, 2009, 10:24 PM:

I know a woman who bought a cemetery plot for herself years ago. Her husband won't even talk about buying one, never mind anything beyond that, including a will or an advance directive. (He's had at least two siblings and a adult - middle-aged - child die already; you'd think it would have gotten through to him that he needs to face reality.)

I'd like the guy with the scythe and the lantern to waltz me out, please.

#81 ::: TexAnne ::: (view all by) ::: August 22, 2009, 10:41 PM:

PJ, 81: Me too, but only if he TALKS LIKE THIS.

#82 ::: Julia Jones ::: (view all by) ::: August 23, 2009, 06:02 AM:

Avram @80: that was my thought too. I have one or two elderly relatives whom I think are in that situation, courtesy of youthful indoctrination with the idea that they cannot possibly measure up to God's standards.

#83 ::: Lila ::: (view all by) ::: August 23, 2009, 08:03 AM:

Ann L @ 49, my family has been in such a situation (documents in hand, relative lucid and able to speak for herself in firmly rejecting various treatment options) and a member of the staff of the institution in which she died still obliquely accused us of murder.

Nobody--NOBODY--in a situation like that, needs the situation made harder for them. My heart goes out to everyone facing end-of-life decisions in the current toxic environment.

#84 ::: Mark ::: (view all by) ::: August 23, 2009, 08:05 AM:

TexAnne: Personally I'd prefer that perky goth chick with the funky little Egyptian doodle under her eye. But hey, that's just me.

#85 ::: Ginger ::: (view all by) ::: August 23, 2009, 10:01 AM:

There was a good article in the Washington Post just recently, which talked about a religious community (aka convent) and how the elderly nuns were dealing with end-of-life issues. The article indicated that religious people were less afraid of death. Perhaps this is because nuns might not fear being "sinners", or it might be related to their Catholicism, versus the literalist Protestants. I am trying to find the article so I can link to it.

#86 ::: paul ::: (view all by) ::: August 23, 2009, 10:12 AM:

The report about self-reported religious people asking for more care suggests to me that the term "religious" really needs to be split into more descriptive subterms. But also that families including religious members may have more intrafamilial conflicts of the type that make "pulling the plug" difficult. (I still remember my father, when his long-senile mother was diagnosed with pneumonia at the nursing home, saying "One wouldn't want to think that one hadn't done everything possible.")

Meanwhile I think Krauthammer's reference to his own living will is pretty clearly designed to spread the FUD just a little further. The impression I got from it was "Sure, it says DNR, but I don't actually want a DNR order, and anyone who knows me knows I wouldn't want a DNR order. But ZOMG if those evil Obama people get their way someone would take the legally-binding document I signed seriously, as if I'd meant it."

#87 ::: janetl ::: (view all by) ::: August 23, 2009, 12:24 PM:

Paul @ 87: The report about self-reported religious people asking for more care suggests to me that the term "religious" really needs to be split into more descriptive subterms.

I often think of religious labels as being more about what tribe you belong to, than what beliefs guide your life. Catholics and Protestants in Northern Ireland haven't been angry with each other about disparate views of the celibacy of the clergy. It's about who your community is, and how the communities have interacted in the past.

For someone to actually live their life, hour by hour, by all the precepts of the Christian New Testament is to renounce most property and any self-interest. The few people who do that are called saints. When people describe themselves as religious, it virtually never means that. (Warning! I'm about to go off the rails into total stereotype land.) Being part of the tribe that identifies as religious tends to go along with a world view that includes going to a "regular" doctor and not a naturopath, trusting medical technology rather than challenging and adapting it. Note that I'm talking in terms of demographics and correlations here, not about individuals. I wouldn't be at all surprised to see that more intensive medical treatment at end of live shows up in red states, and more at-home hospice, palliative care show up in blue states. I wouldn't think of it as being about religious belief specifically.

I would like to mention that two relatives who are firm Republicans and live in the southeast (red state land), both asked me about Oregon's Death with Dignity law. I thought they were going to castigate it, but they thought it sounded like a great idea.

#88 ::: Jim Macdonald ::: (view all by) ::: August 23, 2009, 12:59 PM:

Lori @ #2 What puzzles me about this situation, is that everyone I've ever talked to about "end of life" issues usually states that they "want to die at home."

Not that dying at home is always a great thing. (Some people manage it, then a month later an out-of-state relative, wondering why Granny isn't answering her phone, calls the local cops to do a health-and-safety check. But that isn't the worst...)

#89 ::: The Raven ::: (view all by) ::: August 23, 2009, 03:04 PM:

Mark, #85: of course, it could say, "SQUEAK."

#90 ::: Pendrift ::: (view all by) ::: August 23, 2009, 03:44 PM:

Ginger @86: Could it be this article? (NY Times, though, but it's the first one that came to mind.)

#91 ::: inge ::: (view all by) ::: August 23, 2009, 05:21 PM:

What I find incomprehensible is, every person I ever talked with about the topic, or who mentioned it in a pub when talking about recently dead grandparents, or when a discussion drifted to end-of-life matters after a funeral -- every one, every single one, without exception, has put "ending one's life as a slowly rotting vegetable while wired to machines that make your body go through the motions, while bankrupting your family in the process" somewhere around "die in a fire" on their list of Do Not Want.

Out of what woodwork has crawled a whole propaganda department worth of people who consider that a good way to go?

(In a discussion on LJ it was suggested that they expect that their children will murder them, given the opportunity. Which creates a whole other set of questions.)

Caroline: For whatever reason, they seem to think that planning for it means they'll die -- and if they don't plan for it, they'll never die.

That is extremely common behaviour, though. I've observed it mostly with students who went amazing length not to study for an exam, because acknowledging the reality of the exam mean acknowledging that they would likely fail it.

#92 ::: Lizzy L ::: (view all by) ::: August 23, 2009, 05:24 PM:

My father would not discuss end of life care, even when it was clear that he was dying. By the mercy of God, he died at home, in bed, swiftly. His last six months might have been more comfortable had he been under the care of hospice, but no one would have been comfortable raising the issue with him.

My mother was clear well before the time came that she wanted no extreme measures. We had that conversation with her doctor. Nevertheless, when the doctor finally ordered hospice care, six months before she died, she was rude to the nurses and uncooperative. (They took it in stride, bless them.) She also died at home, in a process that quite frankly was not made any easier for her or for me by hospice care. They were not there when she died. However, I am grateful for what they did do, and also that we had a medical POA and a DNR all taken care of well in advance, so that she got to die at home, with no IVs or feeding or anything that would have kept her longer. (She was one tough woman -- she lingered 10 days with no food or water, not that we wouldn't have given it to her, but she could no longer swallow.)

I don't know if Stefan Jones or Caroline is right, but I'm not inclined to give the professionals -- the pundits, the politicians -- the benefit of the doubt. Not hardly, in fact.

#93 ::: Craig R. ::: (view all by) ::: August 23, 2009, 05:48 PM:

Ginger --

I think the difference in how different people (sometimes even in the same congregation) face the prospect of death may be more a matter of how they view what is the guide that has them hold to a "fill-in-the-sect guideline": Is it that they follow the precept and live that life because It Is The Right Thing To Do or they live that life because If They Don't They Will Pay For It Later.

One of the curiosities, from my seat, firmly in the mainstream Christian section, is that those who fear what will happen sometimes feel more free to be sh*ts because they feel they can also count on playing the He/She/Whatever Will Forgive card, whereas the Do The Right Thing people may be more apt to think -- "this is not a Right Thing, I should Not Do This." Taking the responsibility of being correct on themselves.

I think that's as clear as I can articulate what I see as the difference.

#94 ::: Don Fitch ::: (view all by) ::: August 23, 2009, 06:25 PM:

Inge @ 92:

Unless you protest strongly, I intend to quote your first two paragraphs (deleting "in a pub", perhaps) whenever it seems appropriate in future discussions I might have on this topic. Its elegance would be impossible for me to top when describing my identical experience, and this is a topic that deserves the best presentation possible

#95 ::: paul ::: (view all by) ::: August 23, 2009, 06:40 PM:

@Lizzie in 93. It seems likely that surviving spouses' ideas about how to die are strongly colored by the style of the first spouse's death. (My mother watched my father die by inches, mind first, and when she fell ill denied and ignored her symptoms so assiduously that it was less than a month from the time she was diagnosed with stomach cancer until she died.)

We don't have a lot of modern role models for how to do a good job dying of disease or old age. I'd like to go like a poet I knew, who when his cancer recurred spent a few grand putting a picture window in the bedroom. (Which of course you can only do if your health care is paid for and you're not worried about losing the house...)

#96 ::: inge ::: (view all by) ::: August 23, 2009, 07:15 PM:

Don Fitch @ 95: Unless you protest strongly, I intend to quote your first two paragraphs (deleting "in a pub", perhaps) whenever it seems appropriate in future discussions I might have on this topic.

I'm fine with it -- flattered, actually. (I included the "in a pub" line only because it was such a weird moment...)

#97 ::: Lee ::: (view all by) ::: August 23, 2009, 07:15 PM:

inge, #92: Another place where that behavior is extremely common centers around sexual activity, especially in the populations where "abstinence only" is a strong meme. Being on the Pill, or having a condom in your pocket, means you were thinking about it in advance (and hence cannot plausibly claim that you were swept away by the passion of the moment), and that makes it ever so much worse.

Craig, #94: What you're describing is the difference between internal and external morality, and something I've been aware of for a very long time. I think this also ties into the notion expressed in #92, that the deathers are afraid their children will murder them if given the opportunity. When all you have is external morality, that fear makes much more sense, because it's hard to conceive of someone else having internal morality.

#98 ::: Alex ::: (view all by) ::: August 23, 2009, 07:19 PM:

But ZOMG if those evil Obama people get their way someone would take the legally-binding document I signed seriously, as if I'd meant it.

Krauthammer, and a lot of people like him, are heavily invested in the notion that their statements should not be taken to reflect their mental state, which implies legal responsibility.

#99 ::: inge ::: (view all by) ::: August 23, 2009, 07:35 PM:

Lee @ 98 -- The fundamental error in "don't carry condoms" is IMO the assumption that sex is a bad thing, which is a different class of error from "if you don't think about it, you won't die". Unless I missed something, even those who blame people for not being asexual rarely blame them for not being immortal.

#100 ::: Craig R. ::: (view all by) ::: August 23, 2009, 08:49 PM:

Lee -- #98 --
Oh, I've been aware of the difference for a long time -- I think the aspect of those who will be more fearful of death is that they are fearful in the knowledge that they haven't dotted each "i" and crossed each "t" (and, being human, they are right)and now they wonder if they should be counting on that "forgiveness" card after all.

And, of course, if your guidance relies on fear of retribution, you begin to wonder if you have instilled the proper amount/type of fear in your offspring.

To me, that kind of "external morality" is a form of nihilism that can eat at a soul, because it relies on the external supreme being, but, without faith, that supreme being's existence is open to doubt, and the person with that mindset is always holding the losing hand in Pascal's Wager and forced into an involuntary state of existentialism.

And yes, I know all too many people who deny that any altruism exists (all good works must have an ulterior motive) and that all society must, be definition, fall apart unless *their* worldview is maintained, and any deviance punished as severely as possible.

Which is the mindset that hold that patently absurd and demeaning constructs like "don't ask, don't tell" and the very title of the "Defense of Marriage Act" are so all-important.

It is, also, to my opinion, part of the basis for the perpetuation of cruelty and pain across generations under the reasoning "I went through that pain to get where I am, why should *they* get to accomplish the same level of success without the pain?"

(and now I probably sound like a college sophomore after about three beers, full of profound insights)

#101 ::: CHip ::: (view all by) ::: August 23, 2009, 10:09 PM:

Wingate@42: The death panel thing is so stupid that it cannot possibly be expected to sway any but the paranoid idiot undecided.

How can you say that, looking at the things people in this country believe? Or do you count a large fraction of the country as "paranoid idiot undecided"?

Texanne@82: I'd settle for c&lc if he had Christopher Lee's voice, as in the animations.

#102 ::: Don Fitch ::: (view all by) ::: August 23, 2009, 10:25 PM:

And now we're getting a big flurry of protests -- from the U. S. President, major law-enforcement officials, and senior military officers -- about the release of a Terrorist from a Scottish prison so he can go home to die of cancer.

It's difficult to figure out how much of this is due to horrified reaction against a penal/legal system that is inadequately centered on Revenge, and how much it has to do with revulsion against the NHS Death Panel that obviously engineered this so that the /c/i/v/i/l/i/z/e/d/ socialist health-care system won't have to bear the considerable costs of Megrahi's end-of-life care.

(With a little work, it's probably possible to think of even more interesting convolutions and conspiracies in this context, but I'm saving most of my energy to work in the vegetable garden tomorrow.)

#103 ::: Paula Helm Murray ::: (view all by) ::: August 23, 2009, 11:08 PM:

I was afraid to call my mom since this whole thing hit the fan. I finally did on our 31st anniversary just to remind her. We talked about a lot of stuff and about three times she said, 'well, if you or Jim got really sick, they HAVE to take care of you!" And every time I repeated, "yes, and then they would take our house and any other assets to pay for it. And leave us homeless."

She listens to the bloviating gasbag all day and I expected more crap from her.


#104 ::: Lisa Padol ::: (view all by) ::: August 24, 2009, 12:18 AM:

I am currently furious at my father. I am also quite sorry that he is extremely sick, to the point where his being in MICU is good news.

I learned from one social worker at the hospital that he did actually fill out a health proxy. I know what's in it, because she told me, but she was out when I went to the hospital last, and no one else had time or inclination to look for it so I could copy or photograph it.

My brother would very much like to be able to use my father's money to pay my father's bills, but, as my father didn't set anything up that the bank knows of (probably -- there's one guy who'll be back next week who'll know if special arrangements were made that Dad never informed us about), we will need to get Surrogate Court to grant my brother a temporary guardianship. I'll be calling to ask how we do that tomorrow. My father either did not set up any kind of Power of Attorney in case something happened to him, or he did not let anyone know if he did.

I'll also be calling the nursing home where my mother is, as my father set things up so that no one could visit my mother (who has dementia and is on a ventilator machine) without his presence or at least a call from him, neither of which is going to happen right now. The social worker at the nursing home was sympathetic, but this is a team decision, and her boss was out on Friday.

The law firm my father dealt with did not prepare a will for my father. This probably means that either the will is lost or it is in a safety deposit box. If the latter, my father was unaware of it, believing the law firm he used years ago lost the will. The hypothetical will in the hypothetical safety deposit box would be years out of date -- e.g., made before my mother got dementia. If my father does have a more recent will, he has not told anyone about it.

I had raised the matter of all of these documents back in 2006, when my father spent weeks in the hospital, and then weeks in rehab. I probably raised it before hand. My father either would not talk with me about these matters on the grounds that he was too overwhelmed or would not talk with me about them, saying it was all laid out and not to worry.

Should worse come to worst, I have no idea if he or Mom ever made arrangements for graveyard plots.

I do hope that he pulls through with all of his faculties at least as good as before he went in. Well before, given how much was wrong with him. I truly do. But, I am furious that he did not feel the need to set things up when it was in his power to do so, and I am furious that he waited somewhere between 24 hours and 2 weeks to go to the hospital. (24 hours I can attest to -- he was planning to go into the hospital, but refused to let my brother take him there or call an ambulance Monday evening, and so did not get there until Tuesday, and waited at least 9 hours for a room. Two weeks is what his aide said, but I'm not sure if she's correct or if she's conflating my father's arm being in a sling a week earlier, which may well have been a sign of him needing to be in the hospital, but may also have been something that genuinely seemed to be responding to ibuprofen, as my father and brother thought.)

#105 ::: janetl ::: (view all by) ::: August 24, 2009, 12:22 AM:

Lisa Padol @ 145: Best wishes for your father's recovery, and for good luck sorting out the paperwork mess. It might be more manageable on Monday.

#106 ::: Mez ::: (view all by) ::: August 24, 2009, 01:24 AM:

… and I'm so afraid we'll be making some kind of decision like this about my friend (please let it not be, please no, please).

Eight or nine days now since the cerebral haemmorrhage (on right, don't know details). Aneurism evacuated, tube now on left to relieve pressure by draining fluid. He's some spontaneous breathing & body movements, but no eye reaction yet. They're balancing morphia and hypertension. We talk and touch and massage him, but I just don't know what the odds are.

He's a similar age to Soren and so much potential still for him to achieve more excellent things. And I'm just re-starting chemo, so desperately hoping I'll be well enough to spend the hours with him I am now.

So asking for some good vibrations thisaway, if you have ones to spare. I'll be in and out, depending on sleep and other obligations.

Just seen Lisa's comment: I hope some of that works out better than you fear.

#107 ::: Jeffrey Smith ::: (view all by) ::: August 24, 2009, 01:34 AM:

My grandmother (to whom I was next of kin) thought she had everything taken care of. She filled out -- at least partially -- a living will form she had found in a magazine, but after she showed me it to me with a few lines filled in, I never saw it again.

And she always had told me that her funeral arrangements had been taken care of with the funeral home, so she didn't have to discuss them with me, though she did mention that she wanted to be cremated. I believed her, because she and the funeral director were old friends. But when she died, the old director's granddaughter couldn't find any file on her. She even was able to call her aged grandfather, who didn't remember them ever doing any paperwork.

I trusted, but I didn't verify. (Fortunately, none of this really mattered, the way things turned out.)

#108 ::: paxed ::: (view all by) ::: August 24, 2009, 02:05 AM:

Tiny nitpick: the post topic says "pallative"

#109 ::: Serge ::: (view all by) ::: August 24, 2009, 09:08 AM:

Lisa Padol... Mez... Good thoughts flowing your respective ways.

#110 ::: Tim in Albion ::: (view all by) ::: August 24, 2009, 12:22 PM:

Krauthammer unfortunately reflects the nearly ubiquitous tendency of Americans to think as if death were something avoidable. Look at the language we use: we speak of "saving lives" by medical intervention. What's really happening in most cases is death delayed; in the best cases, life is prolonged, but in far too many instances it's the painful transition from life to death that is prolonged by medicine.

I ranted about similar issues in my LJ.

#111 ::: Jenny Islander ::: (view all by) ::: August 24, 2009, 01:16 PM:

We aren't all like that. I used to work for a financial planner who said right up front that he made absolutely no money by advising people to get a living will (and he didn't; he knew the name of the cheapest lawyer in town, but got nothing for referrals). He also handed out "Non-Will Living Wills" to all of his clients. I can't remember the exact wording, but it was something like:

In case I become incapacitated, I do not want anybody to know how far I want my doctors to take heroic measures. Instead, I direct my loved ones to gather outside my hospital room and argue about it.

If both of us become incapacitated, we do not want our minor children to go to a guardian of our choosing. Instead, we wish them to be placed in a foster home until a judge can decide where they ought to go.

If I should pass away, I do not want my children to know ahead of time who is supposed to get which of the family keepsakes. I want a lawyer to get most of the profit from the estate while the family deals with this deeply emotional issue on top of disposing of my remains.

And so on. It opened a lot of eyes, I think.

#112 ::: Lisa Padol ::: (view all by) ::: August 24, 2009, 01:53 PM:

#106, 110: Thanks.

I know I'm preaching to the choir, but -- here's another part of why, in an emergency, you will be in a less than ideal state of mind to make decisions about the fates of your loved ones.

Human beings can get used to anything.

Peter Beagle said that at Balticon, explaining that it was one of the strongest elements of horror.

Hospitals are amazingly illustrative of this. When I arrived at the Moses division of Montefiore on Friday, I followed a path lit by eerie blue lights, feeling like I'd wandered into somewhere surreal. I did eventually find the elevator, and that took me to the seventh floor, where my father was.

There was a nurse's station there -- a large desk unit with enough space behind it for smaller desks and for a lot of people. There was a small office in that area as well. There were a couple of hallways with patients' rooms.

Every so often, there were loud beeps of varying pitch and urgency.

Every minute or two, a man's voice could be heard, screaming for help. Every minute or two.

We all ignored this, the same way one might ignore a co-worker's music on the radio, back before everyone had walkmans or ipods and headphones.

It is understandable that someone working in a hospital would tune this out fast. I mean, otherwise, how could one work there?

Is it as understandable that I tuned it out almost at once? Maybe it is. I've been in hospitals and nursing homes before.

I remember television and movies showing hospitals as relatively nice places, all things considered. I mean, sure, there was drama and angst, but the physical environment, especially a patient's room, didn't look that bad. Is this still how hospitals are shown?

Even at the best of times, I find hospitals creepy. And, sometimes, the odors get to me. But, today, that wasn't a problem.

Today, all of the conversations I had with hospital personnel took place standing, wherever we happened to be. Not in an office. Not in the nice waiting room -- and the waiting room was nice enough, and away from most of the noise.

I talked to one doctor on a phone in the hallway of the hospital, carefully taking notes as we spoke.

I talked to the physicians' assistant right by that phone, where she found me.

One isn't supposed to crowd the desk, of course. But, I talked to the social-worker-covering-for-the-usual-social-worker there, and then to the attending physician and a geriatrics physician, and then to the kidney doctor, in succession, at the front desk. That's where I was when other people, doing their best to be helpful, said, "Oh -- you wanted to talk to him / her. Oh, Dr. So-and-So, this is Mr. Padol's daughter."

Now, try making rational decisions or making long term plans or issuing if-an-emergency-occurs instructions for doctors there.

You're standing at the chaotic hub of the hospital floor, with people being as helpful as they can -- really and truly -- while they are also dealing with the usual countless crises and being short staffed. It's an uncomfortable space.

If you indicate that you are done, and the person with whom you are talking leaves, you might not get him or her to come back for one final question any time soon.

And, every minute or two, there's this guy in some room somewhere, screaming for help which he may or may not desperately need, which may or may not be possible to give him -- but which isn't coming any time soon. And every human being in earshot, including you, is ignoring this. You aren't even wondering why no one is helping the poor guy.

After all, he's not the one guy in the hospital you've come to see.

You're used to it by now -- the screaming, the beeping, the feeling like you're in the middle of Grand Central Station at rush hour. Human beings can get used to anything. Anything.

But, that doesn't mean it doesn't affect us.

#113 ::: albatross ::: (view all by) ::: August 24, 2009, 02:21 PM:

I think our difficulty thinking and talking openly about death and dying is behind a lot of our problems with medical care. We apparently spend a lot of money on futile care at the end of life[1][2]. We dope our parents into insensibility rather than offer them the treatment any veterinarian would offer for a dog with their condition. We get legal judgments that basically expect doctors to cure death, or to avoid unavoidable stuff. Most people don't sign up to donate their organs. A lot of this, I think, comes down to just having a hell of a hard time openly acknowledging that we've all got an appointment with that dude with the hood and the scythe, or perhaps that cute Goth chick.

Now, the reason this comes up in health care reform, IMO, is that everyone who's paying attention knows that we have to find a way to control costs. Sooner or later, that must come down to providing less care, or excluding some care. This has to be done on financial grounds--we don't have the money to spend $10M trying to buy you another two or three months of life, we're just not that wealthy. And saying this openly is really hard, because nobody likes the idea that he might be the guy whose experimental chemotherapy isn't covered, or that some bean counter (whether working for Medicare or Kaiser) is going to decide that two or three months of your expected lifespan isn't worth the cost.

This opens the door to the FUD and the fearmongering. There really is a hard issue at the core, and people really do seem to be scared about it. And this is an issue that we have historically not been able to be very rational about. ("If it saves one child....")

[1] There was an interesting exchange on the Happy Hospitalist's blog a while back, on whether it made sense for a woman in her 90s to get chemotherapy for breast cancer; the doctors and other medical folks in the discussion very clearly didn't agree.

[2] According to this article, found by Google search, about a quarter of all medical costs happen in the last year of your life. This fraction is apparently stable across the last 20+ years, so it doesn't explain medical inflation by itself. (That is, we don't see end-of-life care ballooning over time.) During this time, use of hospice also went way up; I have no idea how that changed the costs.

#114 ::: Ursula L ::: (view all by) ::: August 24, 2009, 02:31 PM:

Now, the reason this comes up in health care reform, IMO, is that everyone who's paying attention knows that we have to find a way to control costs. Sooner or later, that must come down to providing less care, or excluding some care. This has to be done on financial grounds--we don't have the money to spend $10M trying to buy you another two or three months of life, we're just not that wealthy. And saying this openly is really hard, because nobody likes the idea that he might be the guy whose experimental chemotherapy isn't covered, or that some bean counter (whether working for Medicare or Kaiser) is going to decide that two or three months of your expected lifespan isn't worth the cost.

Of course, if you want to cut costs, the most humane way would be to cut all the costs that come with supporting dozens of different insurance companies and hundreds or thousands of different plans. The multiple billing systems, the complications of doctor's offices ensuring that the right form is filled out for each patient and sent to the appropriate company, the duplication of bureaucracy in each different company, the diversion of "health care" funds to things like profit margins, advertising, and dividends.

And it's gotten to the point where it is easier to imagine solutions that let people die then to imagine solutions that kill off corporations.

#115 ::: abi ::: (view all by) ::: August 24, 2009, 02:38 PM:

albatross @114:

An excellent comment.

I suspect that a large part of our fear of death is that we encounter it much more seldom. In an earlier time, I would probably have buried at least one child (simple fact of blood typing). I would also have lost my mother at the age of 11 (ectopic pregnancy) and one of my childhood friends at 10 (leukemia*).

And yet, here I am, nearly 40, with only one experience of death (colleague and friend, breast cancer) apart from the usual losses of grandparents.

It's easier, in this day and age, to deny death. I've never been in the room with the cute Goth girl or the guy who talks LIKE THIS. I come to them a stranger. This is good fortune in many ways, but it has its cost.

* I remember her saying, a couple of years later, "Thank God for Kaiser Permanente. My parents would never have been able to afford my medical bills." A 12 year old kid, in 1982, already knew her parents' health insurance provider and how much it mattered to her life. This has been coming on for a long time.

#116 ::: albatross ::: (view all by) ::: August 24, 2009, 02:45 PM:

Ursala #115:

Right, but remember that most of the administrative overhead w.r.t. insurance companies (and the resulting administrative overhead at doctors' offices) is designed to decrease costs. Getting rid of all that will decrease the amount spent on shuffling paper around, but that doesn't mean that it will decrease the total amount spent! (Medicare's lower rate of cost growth suggests that it might slow the rate of increase a bit, but that's not clear to me.)

Get rid of that administrative complexity, and you end up with something much more like car insurance. It's not prohibitive for body shops to deal with dozens of insurance providers, because they're not in an endless arms race to control costs/get reimbursed.

Neither profit margin nor advertising explain the cost inflation in health care. If they did, it would be obvious. IMO, somewhere, somehow, there are one or more feedback loops going on, probably most importantly between payers' decisions of what to reimburse and provider's decisions of what to recommend/do for patients.

#117 ::: David Dyer-Bennet ::: (view all by) ::: August 24, 2009, 03:05 PM:

Abi@116: Kaiser Permanente is an actual provider, not just an insurer, aren't they? A kid that was being treated for leukemia would be expected to know the provider that was handling the treatment. (This by no means completely defuses your point; just knowing that the medical bills would be disastrous if not covered is a lot to know.)

#118 ::: abi ::: (view all by) ::: August 24, 2009, 03:14 PM:

David @118:
You're probably right. I was 12, too; it struck me hugely that she knew the name (which is why I still remember it). I was more vague on the distinction between the insurer and the provider; I don't know if she was too.

#119 ::: OG ::: (view all by) ::: August 24, 2009, 05:21 PM:

Terry @38

What is being bruited about is the use of the word, "adhered" Mcaughey would have you believe the doctor is required to force the patient to adhere to the directive if said doctor is to avoid a small hit on the rating.

That made me angry to the point of incoherency. That provision gives the next of kin some weapon, however small, to make sure the living will is followed.

My mother assumed that the last trip to the hospital, like the ones before, would end with Dad coming home. So she agreed to the installation of a feeding tube. A few days after the tube was installed, he had a cascade of microstrokes that left him unable to swallow or talk. A few weeks later, he was moved to a nursing home.

Once there, his regular doctor was shoved out of the loop, and he was assigned to a staff doctor. Mom had come to accept that he would not be coming home and tried to get the tube removed. The new doctor refused, even with Dad's living will in front of him, and managed to thoroughly scare her about how it would increase his suffering. She called me, and I flew in to handle it.

Which I did, implacable, serene, and well-armed with copious research about his various ailments. And armed with the one thing that finally ended it when he switched from medical horror stories to arguments designed to guilt me into backing down.

"Doctor," I said, "my parents are Christians. They do not fear death. Rather, they see it as a rest and reward for a life well lived."

I have never been able to shake the feeling that money was at the root of his opposition.

I did allow them to continue to give him fluids, mostly because I felt that Mom needed the time. I've never regretted that decision. While he never regained the ability to swallow, he did eventually recover enough to talk, and he got to say goodbye.

Scott @78

The simplest counter-point is "God helps those who help themselves." Not that I have the SLIGHTEST idea where that expression came from, and am TOTALLY aware of its "God doesn't actually do anything undercurrent," it still expresses a popular attitude among religious people.

Ben Franklin writing as Poor Richard is probably the best known source (to Americans), but I don't think it originated with him.

#120 ::: Terry Karney ::: (view all by) ::: August 24, 2009, 05:39 PM:

abi: I don't know if my acquaintance with the guy in the cowl makes me better off than you are, or not.

(warning, stories are grim, and a trifle gruesome)

Before I joined the army, I was in journalism; in college I was a security guard; for hospitals (as you may imagine, a lot of the work was done in/around the ER).

Part of the job at those hospitals was moving the corpses to the morgue; where they waited for the funeral homes to remove them. One got a trifle inured, and a grim sense of humor.

In the Army (and the Navy, and the Corps, and for people who deal with pilots, the Air Force), staying in for more than a single tour is an almost certain guarantee of having friend, or at least passing acquaintances, die in a training accident.

There were three at Ft. Leonard Wood in the summer I went to Basic (one recruit, two West Point Cadets; heat)

Then I got to go to a war zone. Focus changes. I was shipped to Germany with a breathing corpse. He'd dropped of heatstroke, no way he was going to pull through. They were sending him to where his family could be there when he "died".

I was in the second wave of the invasion. Things hadn't been cleaned up much as we drove along. For different reasons to Jim's, Death and I are well acquainted.

I'm more resigned to it, in some ways (there are times there is nothing one can do), and I resent it a lot more than I did when it was something which only happened to "old people".

I think, actually, the very familiarity I have with Death is what makes me so angry about the things being done about healthcare. We can't beat Death, but we sure as hell can make him work a lot harder. We are choosing not to, and a lot of people are dying too soon, and needlessly.

albatross: If something between 10-20 percent of the cost of a physicians practice is dealing with insurers, there is some benefit to culling it. More to the point, the real-world examples (in lot of variations, from France, to Germany, to Canada, to Britian, to the Netherlands, Belgium, Puerto Rico, etc.) all show a vastly lesser sum being spent on medical costs, with a better outcome in treatment effects.

#121 ::: Jacque ::: (view all by) ::: August 24, 2009, 05:52 PM:

abi @116: I suspect that a large part of our fear of death is that we encounter it much more seldom.

I have to note a debt of gratitude to my guinea pigs on this score, if only in microcosm.

After one has watched loved ones die (unexpectedly or long anticipated, slowly or quickly, naturally or assisted) forty or fifty times, it clarifies one's thinking considerably.

I find that I don't feel the grip of panic I hear in the voices of others in discussion of the subject.

#122 ::: Cheryl ::: (view all by) ::: August 24, 2009, 06:44 PM:

I try, sometimes, to talk to my mother about end-of-life issues, both hers and mine. As Canadians, we have health care, but there are still the decisions to be made.

She adamantly refuses to discuss it. She closes her eyes, turns her head away, and waves her hand at me. "I can't talk about that," she says. It drives me nuts.

We were hit by an honest-to-Ghu train. That's how my father was killed, in that accident. That's why my mother spent a year learning how to walk again, after her surgeries to put her leg back together.

The only reason that we survivors were not well and truly buggered was our family. My paternal grandparents paid the rent and took care of funeral arrangements, and a succession of aunties and my maternal grandmother took care of my sister and me. After my mum was released from the hospital, my grandmother lived with us until mum could take care of us again.

My father had never changed his life insurance over from his mother being the beneficiary after he married; my grandmother simply signed it over to my mum, but she wasn't legally required to do so. My father had no will, which meant that his siblings had first dibs on his property; they signed it over to my mum, but they didn't have to. The only reason we had/have anything at all is because our family rescued us. I makes me crazy that my mother refuses to make any plans, even knowing first-hand that out-of-the-wild-blue shit just happens. I just don't understand the resistance to it. It isn't religious, that's for sure.

#123 ::: Terry Karney ::: (view all by) ::: August 24, 2009, 06:56 PM:

Jacque: I completely forgot the mice, rats, cats, dogs, snakes, fish and guinea pigs, which have all died in my care.

The one's which horrify me at the thought of losing (even at the remove they are now) is the horses. It's almost impossible to fathom the loss of them, and Leus is getting into late middle age (21-22).

That will be devastating.

#124 ::: Lee ::: (view all by) ::: August 24, 2009, 07:00 PM:

abi, #116: Datapoint -- by the time I was 10 years out of high school, I'd had 5 contemporaries die. One was hit in the head by a fastball, one died of Hodgkin's Disease, one fell asleep at the wheel and went off a cliff, one fell out of a tree and broke his neck, and the last was the sort of thing senior citizens fear; his roommate was gone for the weekend, and he fell and cracked his skull on the kitchen counter. Not all of us are as fortunate as you have been.

albatross, #117: When I broke my wrist, several of the health-CARE providers with whom I wound up dealing offered me a 50% discount because I was paying cash and they didn't have to deal with health-INSURANCE paperwork. I'm quite sure that they didn't lose any money by doing so, which suggests that you are severely underestimating the amount of waste generated by said paperwork.

Right now, we don't HAVE a health-care system in this country. We have a health-insurance and medical-profits system. It's time to change that.

#125 ::: Ginger ::: (view all by) ::: August 24, 2009, 07:36 PM:

As a veterinarian, I can understand the desire to fight death for as long as possible. However, for us, "as long as possible" is always balanced by "quality of life"; in other words, when the disadvantages of life outweigh the advantages, it's time to give in and let the Opponent win. I know that all of my battles with my Opponent will ultimately result in my loss; that's one reason why each "win" is so precious and so exhilarating. There is nothing like knowing you've saved a life, with your brain and your hands.

Then, when the Opponent wins, it's a crushing blow. In most cases, euthanasia still allows us some measure of control, some weight of relief, as a gift to our patients when we end the battle and hasten the inexorable slide to the Door.

It doesn't stop me from being depressed when I lose; it just helps me keep on trying, with the next one, and the next.

#126 ::: Terry Karney ::: (view all by) ::: August 24, 2009, 07:52 PM:

Lee: The discount was profitable because they have to give a huge discount to the insurance companies.

The insurers demand it, it's a sort of extortion to force people to buy insurance, actually. When I had my kidney stone the bill was about 8,000. We were told that, should we pay in full, in less than 30 days, we would be given a fifty-percent discount.

When I made enquiries about how they could do that, and still make money (expecting it to be something on the order of, "it gets money in the door, and not offering it means people just refuse to pay/go bankrupt") the answer, from folks in the business was the costs are artificially high, for the uninsured.

Because if they don't bill the uninsured at those hellacious rates ($50 labor to do an IV push of fentanyl, $225 for a bag of plain saline, plus $50 labor to swap it in, $250 to insert a venous catheter) the insurance company will say, "Hey, we were promised a discount," and either sue for breach of contract, stop providing coverage at that hospital, or both.

It's a nasty thing for those who can't afford the rates (or, like me, are excluded from coverage, even if we could afford the rates).

#127 ::: Connie H. ::: (view all by) ::: August 24, 2009, 07:58 PM:

I can only strongly hope that Krauthammer gets something very painful that keeps him conscious but totally unresponsive so that he can linger as long as possible while medical personnel and his family argue over what procedures he would have OK'd.

I won't go so far as to hope it leaves his estate destitute, but that would also serve him right.

#128 ::: P J Evans ::: (view all by) ::: August 24, 2009, 08:49 PM:

I think the legal term for what the insurance companies are doing there is extortion. 'Nice little hospital you have here ....'

#129 ::: Rikibeth ::: (view all by) ::: August 24, 2009, 09:02 PM:

I've been in the room with the cute Goth chick. No, actually, I was the one sitting in the waiting room calling funeral homes for price quotes while the almost-bereaved wife and sister sat in the room waiting for the cute Goth chick to reach that stop on her route.

It wasn't a pretty story. My friend had suffered a series of strokes. Things had looked grim, then there was progress, she'd made it out of the ICU and into a rehab facility... and then one morning they found her unresponsive. Back into the ICU, and a new round of waiting: is there any chance she can recover from THIS one? It took a heart-wrenching time to reach the conclusion that she couldn't, that there wasn't anything left of her in there to recover.

I can't criticize the end-of-life palliative care she got. The ICU nurses were great. And she had her wife calling the shots, and I'm certain her decisions didn't go against what my friend would have wished.

What gets me is that better access to health care might have kept my friend from being IN this situation. She was diabetic, and on disability, and financially strapped, and was skimping on testing to save money on test strips. She was GUESSTIMATING her insulin dosages and whipsawing her sugar with it. She may have been skimping on her blood pressure medication too. Even in the days when she'd had good coverage, she wasn't always great about looking after herself (when she helped run conventions, people were aware that they needed to assign one staff member just to make sure she ate), but the lack of affordable treatment just exacerbated that, and probably exacerbated it right into the stroke, a year and a month ago.

She died last November.

She was 41.

#130 ::: James D. Macdonald ::: (view all by) ::: August 24, 2009, 09:57 PM:

Connie #128: That's a terrible curse, and I hope nothing of the kind ever happens to anyone. And still, that is absolutely not the worst that I've seen, far less the worst I can imagine.

Mr. Krauthammer waves away as rare and inconsequential situations which are both common and devastating. He is Faustus saying to Mephisto, "Come, I think hell's a fable."

#131 ::: Serge ::: (view all by) ::: August 24, 2009, 11:33 PM:

"...give me your hand... You see. No shock. No engulfment. No tearing asunder. What you feared would come like an explosion is like a whisper. What you thought was the end is the beginning."
- Robert Redford as Death in the Twilight Zone's episode Nothing in the Dark

#132 ::: janetl ::: (view all by) ::: August 25, 2009, 01:57 AM:

Rikibeth @ 130: That's so damn heart-breaking.

#133 ::: Bill ::: (view all by) ::: August 25, 2009, 02:21 AM:

Any time I find myself possibly agreeing with Krauthammer I know that either I'm badly misinterpreting his writing or else that if I read a couple of more sentences things will be back to normal - usually it means he's just setting up a straw man to kick over later. It's still quite annoying to have to do that with somebody like Krauthammer who's basically intelligent and serious, unlike, say Ann Coulter who's being as offensive as possible for entertainment value or [fill in many different politicians and pundits here] who are clueless.

Terry, if you want to keep the guy with the scythe away a bit longer, get rid of the [part-of-speech-name-I'm-forgetting deleted] motorcycle! I've lost too many friends to the [] things in the last couple of years, and had another friend get seriously injured a couple of times. (He decided doing judo rolls for a quarter mile would be less painful than just skidding, so he lived through the first one; another time he rode back from Colorado with his splinted broken leg propped up on the bike.)

When my father was dying, he chose to do hospice care after a couple years of chemo had done anything useful they were going to. It wasn't like aggressive medical care had anything to offer anyway, and even the chemo had been the slow-stuff-down type because it wasn't something curable. It covered some home nursing care and better painkillers.

My wife's real clear about her preferences on aggressive medical treatment - in spite of our religious beliefs, if I let the doctors pull the plug on here, she'll find a way to come haunt me...

#134 ::: inge ::: (view all by) ::: August 25, 2009, 06:58 AM:

albatross: Sooner or later, that must come down to providing less care, or excluding some care.

After the waste and profiteering has been eliminated, one hopes.

Also, the tendency goes towards saving on "quality of life" stuff, before saving on dramatic end-of-life measures. E.g. you can still get your teeth drawn for free, but if you do not want to spend the rest of your live (estimated to be thirty or fourty or sixty years) with missing teeth and all the problems that causes, you better cough up a few hundred or thousand Euros for replacement.

Going by a set of anecdata, it seems like a sizable number of people would prefer better teeth now and morphine at end of life to gaps now and "heroic measures" later, but whether it's bean counting or lobbyist groups, that's not what we're getting.

#135 ::: Lori Coulson ::: (view all by) ::: August 25, 2009, 09:40 AM:

Jim Macdonald @89: Yes, we've had several of those make the news here in the last few months.

That was not what I had in mind...I'm thankful we live in a friendly neighborhood, one that would notice if they hadn't seen someone in the last 24 hours.

#136 ::: Joel Polowin ::: (view all by) ::: August 25, 2009, 10:45 AM:

Jim Macdonald @ 89, Lori Coulson @ 136: Eric Bogle's "A Reason for it All".

#137 ::: Jacque ::: (view all by) ::: August 25, 2009, 12:25 PM:

Terry Karney @124: Well, the good news is that if Leus is getting good veterinary care, you might have as much as ten more years with h(im?). Friend of mine's horses both passed away in their early thirties. (Somehow, I predict that doesn't make it any easier when the time comes, though.)

But, yeah. Every time one of my guineas goes (or, worse, is going), I sob my eyes out and swear up, down, and sideways that I'm done, that's all, I'll never get any new ones. That lasts for about a week, and then one of the others does something unbearably cute, and here we go again....

#138 ::: Jacque ::: (view all by) ::: August 25, 2009, 12:42 PM:

Bill @134: Terry, if you want to keep the guy with the scythe away a bit longer, get rid of the [gerund] motorcycle!

I second the request. Terry, I've never met you in person (I think), but I'd like to. Devout environmentalist that I am, and gas mileage notwithstanding, I'd much rather meet you upright and chatting than reconstituted from a greasy spot on the road.

#139 ::: Lee ::: (view all by) ::: August 25, 2009, 01:40 PM:

Serge, #132: "Death is just another doorway, one we all must pass through." - Gandalf in ROTK

Terry, I concur with Bill and Jacque. This is two incidents in the last couple of weeks, neither of which was of your causing. This suggests that you're living in an area where riding a motorcycle is more than normally dangerous, and that a beater would be a safer option for you.

#140 ::: Lee ::: (view all by) ::: August 25, 2009, 02:07 PM:

Joel, #137: The premise behind that song is one of the things that's currently tearing this country apart. People are so terrified of the idea that there might NOT be a Unified Master Plan for their lives that they can't stand being exposed to anything which might call their interpretations into question. Worse, they insist that THEIR Unified Master Plan must also be MINE, and take my resistance to the notion as a threat.

#141 ::: Zack ::: (view all by) ::: August 25, 2009, 03:27 PM:

I should be interested to hear what people here think of this proposal: A friend of mine likes it a lot; I have serious reservations but think it might be better than the status quo or small patches thereto.

#142 ::: OG ::: (view all by) ::: August 25, 2009, 04:08 PM:

Zack @142:

There's one very bad assumption he's making in that article:

Imagine my father’s hospital had to present the bill for his “care” not to a government bureaucracy, but to my grieving mother. Do you really believe that the hospital—forced to face the victim of its poor-quality service, forced to collect the bill from the real customer—wouldn’t have figured out how to make its doctors wash their hands?

Not for a minute do I believe that who the invoicing machinery in a hospital gives the bill to will make a lick of difference. The only power a consumer has is to take their business elsewhere, and that's not so easy to do with health care.

#143 ::: Terry Karney ::: (view all by) ::: August 25, 2009, 05:00 PM:

Bill, Jacque, Lee, et al:

The two accidents were very different in type. The first was my fault. A combination of new bike (a large percentage of bike accidents, esp. for experienced riders who have them, are on bikes new to the rider; this is one reason "lending" a bike to someone isn't something to be done lightly, even if they are good riders, but I digress), and lack of practice.

I flinched at the unexpected appearance of two lanes of left turn. I didn't notice there were two lanes. I overreacted. After that it was simple physics, the wheel was cut to far. From that point on it was inevitable.

The second wreck could have happened in a car. Had it happened in a car the result would not have been any better for me. Had I been in the other lane, I 'd have been able to move to the left (into the bicycle lane) and so avoided the problem. Was it my fault? No. Could I have made better choices? So it seems.

If I get another bike, I know the risks (just as I do when I ride a bicycle, a horse, go rock climbing, etc.). I appreciate your concern, but I choose to take them, or not.

Some of it is, perhaps, the greater sense of fatalism I have now (combat zones will do some of that for you, and some of it is from all the rest I described). To reach for a cliché, I could be hit by a bus tomorrow. I've been hit (on my bicycle) by two cars. I've been in four, or five, automobile accidents, as a passenger (and one as a driver; rear ended). Nothing is certain.

If/when I get another bike I'll be as careful as I can, wear all the gear, and take my chances; just as I do when I drive.

I don't want to die, but in the meanwhile I will live.

#144 ::: Jim Macdonald ::: (view all by) ::: August 25, 2009, 05:55 PM:

Sooner or later, that must come down to providing less care, or excluding some care.

We exclude some care every day. If you have chicken pox no one gets upset if I don't splint your leg.

#145 ::: Epacris ::: (view all by) ::: August 25, 2009, 07:08 PM:

OG @143, from Zack @142, Surely I've seen instances in news precisely of hospitals presenting bills to the victim or their survivors – a small minority of the actual instances; ones which got publicity.

"The only power a consumer has is to take their business elsewhere, and that's not so easy to do with health care."
But if the "real customer" is a "government bureaucracy" which holds them to standards of care, cleanliness, good outcomes, &c, with inspections & statistics, not just hewing to budget they do have that power. Where the "real customer" is insurance company bureaucracy, they're interested in low costs.

Yes, system can be gamed, corrupted, politicized. Nobody's perfect. But if footing is good, it can be dragged back to that periodically. If foundation is profit, not service, it's continually pushing against care & safety.

#146 ::: Bruce Cohen (Speaker To Managers) ::: (view all by) ::: August 25, 2009, 07:28 PM:

Jim Macdonald @145:
We exclude some care every day.>

Indeed, and often because of rationing. The number of organs for transplant is limited*, and so there are institutions which control the access to new organs by establishing waiting lists and setting priorities for patients. In this situation, we have no choice but to ration, because there is a fixed number of available organs; personally, I prefer this mechanism than simply letting the market control the allocation of organs.

On a darker note, we also ration the availability of medical treatment geographically. There is a critical shortage of individual doctors in many rural areas, and, because rural health care isn't as profitable as in the cities, many small rural hospitals have been closing in the last few years. So by default, the US has decided that rural populations are a lower priority for health care and rationed it for them.

Not choosing is also a choice. Not rationing means that you will not control the way rationing works.

* Far too limited. My Oregon driver's license declares me an organ donor, but I know there are states that don't do that. Why?

#147 ::: Linkmeister ::: (view all by) ::: August 25, 2009, 07:40 PM:

Bruce Cohen (STM) @ #147, "We ration health care by geography.

And price. "I'd rather eat/pay the rent than buy BP meds, if those are my choices."

#148 ::: Terry Karney ::: (view all by) ::: August 25, 2009, 07:49 PM:

I don't accept the author's contention that gov't can't control costs. The VA (in this arena) gives the lie to that, as does Medicare. Looking at other countries, the same seems to apply. Costs are contained, care isn't adversely affected.

As to his "solution". I can't afford it. A $50,000 deductible? No fucking way. I'd be dead/bankrupt if something like that were the way of it.

I hate to think about the ways in which the mandatory HSAs he's advocating will be gamed (and I wonder how he/the Right will feel about that Singaporean style of micromanagement). Who will have control of all that money in savings? Where will it be invested? Is it just supposed to sit, like dollar bills in a coffe-can?

What will be the rate for the, "gap-coverage credit" he postulates? Again, who controls the collection? I know there is no way, should I get $40,000 worth of sick that I can find credit to pay for it. So I'd die.

He tosses about the, 1.7 million in "hidden costs/payments" over an average lifetime's work. Well that's swell, for someone who gets a job at a company, and sticks with it. What about the self employed, or the person who is presently at a company which doesn't spend all that much on health care? Where is that money coming from?

It's a weird sort of privatisation of taxation. Some banker somewhere is going to make money off of storing money I am later going to spend on healthcare. Better to make it a bigger pot (like say, the NHS) and have it not being a looming sword, hanging on a string above everyone.

Who, I wonder will do the actuarial tables? Will the young man pay more than the middle-aged one? A married man less than a single one? It will be no simpler, and the system gaming will be more destructive. Futher it leaves an opening for the present system to metastasize into the new one I'll bet there will be companies looking to offer, "insurance" to cover those gaps. What do you want to bet they suddenly find reasons to deny the payments when someone actually gets hurt?

About the handwashing, and the "having to face the patient," the hospital had no problem asking me to kick in $500 before they would start giving me relief for my kidney stone. I was in agony; so much so that the moment I was seen by the intake nurse I was correctly diagnosed.

They had no problem then handing me another $7,500 worth of bills for the next three and half hours of care (most of which was just me taking up a bed).

So I don't see them having any problem washing their hands, much as Pilate did.

#149 ::: P J Evans ::: (view all by) ::: August 25, 2009, 09:10 PM:

I looked at that article last week, and decided that anyone who thinks that a $50,000 deductible is any kind of solution is clearly not living in the same world as 90% (at least) of the US population.

#150 ::: albatross ::: (view all by) ::: August 25, 2009, 09:26 PM:

Have healthcare costs risen faster than inflation in other countries? My impression is that this is uniquely a US problem, but I really don't know. It seems pretty much impossible that the rise in costs is explained in any simple way, such as by waste/fraud, profit (or profiteering, which ISTM is just profit made by people doing stuff you don't like), malpractice costs and associated defensive medicine, etc, just because of the size of the year-after-year cost inflation--waste, fraud, profit, or malpractice judgements would have to have ballooned almost without bound, over decades of that cost inflation.

Terry: Medicare also has constantly rising costs, though apparently its costs are rising more slowly than the private insurance companies' costs[1]. Those constantly rising costs are what makes the Medicare budget shortfall so much scarier than the Social Security budget shortfall[2]. I've heard both very good and very bad things about the VA system, but have no personal experience with it, so I don't know how it works as an alternative.

One thing that's always interesting, to me, is that the US government runs at least five working medical care paying/providing systems: Medicare, Medicaid, Federal employee insurance, the military health system (doesn't each branch have it's own?), and the VA. This makes it a bit weird to hear people talking about how getting the government into healthcare will wreck it.

[1] It's interesting to ask why this is, given that the private companies spend so much resources trying to avoid overpaying. The stuff I've read says that Medicare pays more reliably and sooner, but less generously. And that both Medicare and private insurance offers all kinds of weird incentives and screwy rules for reimbursement.

[2] And I know the difference between these budget crises because of people and discussions here.

#151 ::: Linkmeister ::: (view all by) ::: August 25, 2009, 09:30 PM:

albatross, as I understand it from a brief look the other day, the Fed employee system is actually a basket of about 15 private provider plans from which all employees can choose the one that fits their circumstances best. Then it's like any other employer-paid plan; the employee pays a small share of the overall premium.

Any Fed employee, feel free to correct my impression.

#152 ::: Ginger ::: (view all by) ::: August 25, 2009, 09:42 PM:

Bruce Cohen @147: Actually, the Public Health Service has been trying for years to get enough doctors into rural and other under-served areas. It's hard to compete against the higher paying jobs when medical school graduates have crushing levels of debt. Making med school low-tuition or even free would go a long ways towards freeing people to choose specialities they love, rather than ones which pay lots of money.

#153 ::: Terry Karney ::: (view all by) ::: August 25, 2009, 09:56 PM:

albatross: Medicare isn't the system to compare with, because it's, functionally, the same system, with some price controls; and a much more efficient enforcement action against fraud (though it's large enough that there are lots who slip through the net.

The VA, however, is a single payer, socialised, system (with some private model accretions; notably a means test, to decide if you are covered in whole, or merely in part. It also suffers from not having a secure revenue stream; and being a political tool in the hands of both parties (though as a user, the Dems seem to be more consistent in funding it).

The cost growth in the VA are below that of Medicare. The services have the same care model, but each has it's own medical personell. In my experience, the different cultures of the different services means the style of care is a little different from branch to branch (I've been treated by all three; the Marine Corps uses naval personell). The Air Force is much friendlier, and an Army dentist was the nastiest medical providor I've ever had; I should have known when he put in earplugs).

It's when you get to dependents that it gets pear-shaped. It used to be dependents got the same treatment as service members (it was part of the contract to keep people in). Then under (IIRC) Reagan, we got, "TriCare" which was sort of like Kaiser.

At this point a lot of people started to complain that dependent care went downhill, and I'm not surprised, because the care was outsourced; in effect we, the people, stopped providing the care, and started outsourcing it.

The explanation was it would make more care available, because dependents wouldn't be treated after service members (which only happened when the situation wasn't life threatening. Urgent = head of the line. It still does. If your kid/spouse has acute appendecitis, they go to the nearest military hospital, and boom, they are on the table).

Because of the profit model, and the fee for service problem, we have a cycle where doctors don't actually get raises for increasing skills, seniority, etc. They make more money only by seeing more patients, or ordering more treatments.

Which means the least justification can be used to add more to the bill. Which means another person (or two, or three) has to be added to the staff; to keep the paperwork straight/dun those who get denied.

Ginger: Making it a single payer system would do a lot to fix that too, becaus the pay for a big-city doctor wouldn't be so dichotomous to a small town doctor. Add the two ideas and we'd be in really good shape.

#154 ::: Joel Polowin ::: (view all by) ::: August 25, 2009, 10:07 PM:

Ginger @ 153: IIRC, at least a couple of Canadian provinces offer a deal to prospective medical students: all basic med school expenses covered in exchange for a commitment to spend some number of years in practise in rural communities, as assigned by the province's health-care organization.

#155 ::: Tehanu ::: (view all by) ::: August 25, 2009, 10:15 PM:

It is useful to paint Krauthammer as a nutcase in disguise.

There's no disguise. He's a nutcase, period. And a tool.

#156 ::: pat greene ::: (view all by) ::: August 26, 2009, 02:26 AM:

I'm married to a Federal Employee, and have coverage through a him. Employees are allowed to pick from several plans (less than fifteen -- I seem to recall about six or seven, but I may be mistaken, or that may just be those available in my part of NorCal). We go with Blue Cross (*spit*) only because it's about the only plan our providers all will take.

The Fed employee plans have a couple of important restrictions: plans have to cover all pre-existing conditions, and the company cannot drop you if you get sick. As someone with health conditions that make me uninsurable, I greatly appreciate this. As my jobs have all been without benefits, I have no idea if that is the norm for other employer plans, but I get the strong impression it is not.

#157 ::: Linkmeister ::: (view all by) ::: August 26, 2009, 02:44 AM:

pat greene @ #157, here's the Hawai'i plan list. That's how I got to fifteen.

#158 ::: Jenny Islander ::: (view all by) ::: August 26, 2009, 02:56 AM:

$50,000 deductible? I don't know anybody who has $50,000 in liquid assets. I don't know anybody who could possibly build $50,000 in liquid assets in less than 10 or 15 years. What are they supposed to do if they get sick during that time frame? Or have any other catastrophic expense, like damage to their homes that insurance won't cover? Just start over and pray that they don't get sick (again) during the NEXT 10 to 15 years? (While paying off the second mortgage, credit card balance, or however they scraped up the $50,000 they had not yet built up in savings?) And are people who are paying off education loans by working crappy jobs supposed to simultaneously build up $50,000 in savings?

#159 ::: John Mark Ockerbloom ::: (view all by) ::: August 26, 2009, 08:05 AM:

Well, as of yesterday, I'm an uncle once again. We're quite happy about that.

Why am I bringing it up here instead of the open thread? Well, the dad is self-employed, and, not having an HMO, did what some conservative commentators recommend, and negotiated a deal in advance with the hospital for delivery. The payments wouldn't be easy, but they'd be manageable.

They didn't, as far as I know, include the cost of an emergency C-section and neonatal intensive care. Nor were the parents in any position to negotiate over *those*, at the moment the attending physician noticed the umbilical cord prolapse, and took off with the mom down the hall to surgery before things went completely pear-shaped.

Mom and baby are doing well now, and will probably be in the hospital till the end of the week. I think they did have some degree of insurance coverage, but having seen some examples of what passes for insurance in many of the "low cost" plans for self-employed (some of which have lifetime caps that could be easily blown through in a single day in the hospital), I have no idea what the ultimate bill will be, or if it will be at all affordable.

For now, though, we're simply relieved that everybody involved seems to be all right in health. But we're also thinking that the Canadian side of our family has it much better.

#160 ::: Michael I ::: (view all by) ::: August 26, 2009, 08:10 AM:

pat green@157

The exact number of plans available will vary depending on locality. Based on a check of a few states on the FEHB website, it looks like there are 10 "fee-for-service" plans (although from a smaller number of providers) that are available in most of the country. Plus a varying number of locality-specific HMO and other plans.

#161 ::: albatross ::: (view all by) ::: August 26, 2009, 08:42 AM:


The point is, there are multiple different models there to choose from, all doing a similar job. Medicare, Medicaid, and the FEHB all have private providers paid for by insurance of some kind. Each has problems, though my impression is that Medicaid is the one of these which does the worst job for its patients, probably because it serves people who are poor and don't have much voice or negotiating power. VA and the military systems have (as I understand it) a complete government-run sort of system--and again, I've heard comments on VA care ranging from "wonderful" to "nightmarish." Somewhere in there is also Medicare Advantage.

So we get several models:

a. Single-payer run by the government, private providers (Medicare[1], Medicaid).

b. Government paid/sponsored insurance companies, which are private and handle paying the bills to the private providers. (FEHB, I think Medicare Advantage also falls into this category.)

c. Government-run provider--the doctors and nurses are government employees. (VA, and I think the military systems follow this model. Note that these are at opposite ends of the adverse selection spectrum--active duty military tend to be relatively young and healthy, while veterans tend to be much older and less healthy.)

If our only problem were to deal with the uninsured, we could do it using any of these models, right? Simply phasing out the income restrictions on Medicaid would do it, as would letting people buy into the FEHB (Federal employee insurance plans[2]). Alternatively, you could imagine letting people buy into the VA system or some parallel system[3].

But that doesn't deal with the cost problem. And if we don't deal with that, we're just moving the budget crisis that much closer.

[1] Medicare is a big enough chunk of the market to actually work rather like you'd expect a single-payer system to work in a country with a parallel private system, I think.

[2] But those are quite expensive--the full cost becomes clear when you start paying COBRA rates, so they'd have to be subsidized for most people. And the rates would go up, because now they reflect the cost of providing care to people who are healthy enough to work, and their families.

[3] IMO, it's healthy to have many different systems in parallel and choices between them. I'm not convinced which (if any) of Medicare or the FEHB or the VA are the model we should follow, but it would be valuable to find a way to offer people a cost-adjusted choice between them and see what worked out best, year after year. My sense is that this gets pushback from current market participants (especially insurance companies), who don't want the competition.

#162 ::: Velma ::: (view all by) ::: August 26, 2009, 09:59 AM:

Lisa, Mez, Rikibeth -- my thoughts are with you. Mez, remember to stay hydrated and try to get sleep and food; a bunch of the people here can tell you how those simple things helped me, and them.

I am sick to my heart reading these, because my family's been through multiple rounds of people not making any plans (my father died of cancer in 1996 or thenabouts, but he had time to make his wishes known, as did my mother; my older brothers did not). Thinking and planning are good things.

#163 ::: Terry Karney ::: (view all by) ::: August 26, 2009, 10:03 AM:

albatross: Medicare isn't really single payer. It's model is fee for service. Which is the same as the public insurance model. It's distorted. The thing which slows it's cost growth is the lower overhead/lack of profit motive; on the part of medicare.

Looking at the different costs in different areas it's clear the fee for service model is hideously distortive. The article on the border town in Texas with the most expensive healthcare in the nation show how it gets that way. Once it does that, there doesn't seem to be any way to stop it.

From the patient's perspective the expense, in the present systems, isn't a problem, but it's not sustainable. In the private model the expense isn't sustainable either. One way, or another, it kills the goose.

In the process it's killing people, and stunting the nation. We spend a huge amount, and growing, of our GDP on insurance, for a system which is falling apart. More people are without insurance (and so without medical care). Our life expectancy is declining. Our small businesses are declining. Health related bankruptcies are increasing.

The Gov't was not allowed to use it's purchasing power to negotiate for deals on drugs. The "donut hole" was added, on top of that (meaning a large number of Medicare recipients had to get private insurance to cover "the gap"). The Medicare Advantage Providers started cherry picking (and cancelling) the people who paid in.

There are other distortions. Maia's grandparent's pre-paid into a nursing home. When the families moved, they were stuck. The contract was such they couldn't take the money out. When they had to go (because of dementias) it was no longer 10 miles away, but 45.

Medicaid does terribly because the people are poor, have little (i.e. practically no) say in what happens and it's actually 50 different models; but it's also a fee based service model. That (apart from the military/VA model) is really the only model we have systems built on.

That's the problem.

#164 ::: Rikibeth ::: (view all by) ::: August 26, 2009, 10:16 AM:

Velma, I still remember your kindness sending a contribution for the funeral when you were still dealing with the early stages of Scraps' recovery. Not forgotten.

And I second your advice to Mez on staying hydrated and getting sleep and food; seeing to those things for the wife and sister was the main project of the support team during the whole mess. It does help.

#165 ::: Terry Karney ::: (view all by) ::: August 26, 2009, 10:20 AM:

NB: Fee for service being the payment model to the doctors, not the way the insured arrange to get treated.

What we have, for variations, is window dressing on the way the patients arrange to get the services they do get. But the inner workings, are pretty much the same across the board.

#166 ::: OG ::: (view all by) ::: August 26, 2009, 10:37 AM:

Epacris @146:

If foundation is profit, not service, it's continually pushing against care & safety.

And therefore the extra tests that insurance doesn't pay for, the push to prescribe the drugs that are part of the pharmaceutical companies' incentive programs, the pressure for unnecessary surgery.

I've been fighting with doctors over antidepressants for more than a decade. My current doc has largely solved the mystery with a low dose of thyroid medication and vitamin D supplements.

Some of those previous doctors were uninformed, certainly; there has been a lot of new research since I saw them. One was spectacularly lazy, diagnosing me based on a questionnaire I filled out in the waiting room. The most recent, it will be impossible to convince me that kickbacks aren't involved.

#167 ::: Lori Coulson ::: (view all by) ::: August 26, 2009, 11:51 AM:

Gah -- the Medicare Part "D"oughnut hole....

My mother has a small pension (which *just* covers her supplemental insurance) and Social Security check. We've run into the wonderful doughnut hole.

What they don't tell you is they count what the insurance company pays on your prescriptions as well as what you pay towards them, which means you reach the hole that much faster. THEN you have to spend $4000 out of pocket BEFORE your prescriptions are once more covered that year by Medicare. I have yet to meet a person on Medicare who isn't struggling to cover the cost of their meds once they hit the hole. And for many, it comes down to "Do I eat or do I buy my meds?"

I am a Federal employee, and I'd give anything to be able to put my mother on my health insurance as "family." Right now my co-pay on my medications is $20, less if it's generic.

#168 ::: albatross ::: (view all by) ::: August 26, 2009, 01:52 PM:


Fair enough. Medicare is a very big payer that the great majority of doctors and hospitals deal with, but there are other payers, and not all doctors/hospitals deal with them. I think it's the closest we're going to find to what a single-payer system in the US would look like, particularly if we look at fields (say, gerontology) where most of the patients are on Medicare.

If the reason for the cost inflation is the overhead in billing/arguing bills, then HMOs should have priced all other plans out of the market, given their immense cost savings.

If the reason is the profit motive, then nonprofit foundations ought to be able to provide care without the rising costs. Isn't Kaiser partly nonprofit, frex? (Also, why don't all the other for-profit industries suffer the same endless cost inflation?)

At the risk of pointy cross-thread linkages, I suspect the explanation is more complicated than you're allowing for.

#169 ::: Earl Cooley III ::: (view all by) ::: August 26, 2009, 02:37 PM:

I'd like to see a study which counts the number of people killed by the hideous choices forced by the Part D prescription coverage gap, so that the people responsible for it (including heavy lobbying drenched in conflicts of interest by AARP) can be appropriately punished for it.

#170 ::: Terry Karney ::: (view all by) ::: August 26, 2009, 06:10 PM:

albatross: The not for profit models (which vary) have different pressures, and different solutions.

Various problems: Cherry picking. When the pool is limited, everytime someone has an expensive illness, the need to pass it along becomes greater (this also adds to the frustrations, because people aren't seeing value for dollar. They don't get sick, but costs to them go up).

Look at the Mayo Clinic. They have much lower increases in costs.

Hidden pricing. Why is MRI/CT so expensive here, and not in places like Britain/The VA? They buy one, and they use it. They don't suffer, as much, from the need to replace them; though they are subject to the insane costs to maintain them. A lot of the equipment infrastructure costs will go down when that perverse incintive is reduced.

Tests. In the past three weeks I've had two sets of x-rays (one for the knee that needed stitching, and a panel of feet, spine, hips, and hands; for my rheumatologist). I've had a bunch of blood work (standard lipids panels, some genetic testing, again for my rheumatolgist).

I could have been given a lot more. The doctors have no incentive, in the VA to order them. They don't make any more money because they send me to the lab, and they don't need to take another tube to get another couple of panels out of the that quarter hour of the phlebotomists time.

I admit I've simplified the problems. I also think the best solution doesn't care about the present complexities. A single payer, with the perverse incentives which reduce primary care (GP/Internist) numbers, encourage hasty visits, newest/bestest/shiniest/beepiest machines, removed will see a lot of savings from the dimunuition of the hidden multipliers of cost.

I say this because everywhere else in the world this has been the case. I don't think we are so special that it will be different for us. We know the drug companies are gouging us (look at the price differences for the drugs sold here, and in Canada. They come from the same factories, we pay much more than the Canadians do).

It's unsustainable. The real question isn't what do we do, so much as when. We can do a real fix now, before things are so broken we suffer more than we are now, or we can wait, until the whole edifice comes crashing down.

If we do the latter, we add the miseries of the present system, to the miseries of its catastrophic failure. I don't really see it coming apart gracefully.

#171 ::: Bruce Cohen (Speaker To Managers) ::: (view all by) ::: August 26, 2009, 06:18 PM:

Joel Polowin @ 155:
IIRC, at least a couple of Canadian provinces offer a deal to prospective medical students: all basic med school expenses covered in exchange for a commitment to spend some number of years in practise in rural communities, as assigned by the province's health-care organization.

There are places in the US which have similar deals. The last I heard about the one in Oregon, they could not find enough students who were willing to spend those years in a low-income rural practice.

#172 ::: Joel Polowin ::: (view all by) ::: August 26, 2009, 08:50 PM:

Bruce Cohen @ 172: Around here, "low-income" isn't so much of an issue as long as there are enough people in the area who need care, since the rates are fixed by the province. (I don't know how it works in any detail.) The main disincentive is the relative isolation -- most people prefer the amenities of urban life.

#173 ::: Magenta Griffith ::: (view all by) ::: August 26, 2009, 09:10 PM:

There was a TV series some years back about a young New York City doctor in Alaska, "Northern Exposure". He had to work there for so many years to pay off his loans, or they had financed his med school or something like that.

We have several problems, one is that it's too hard and too expensive to get into medical school, and two, we have too few levels of medical personnel. We could do a lot more with PA (physician's assistant) and NP (nurse practitioner). Medicine is too much a guild, even now. And that's also why doctors protect their own, and don't weed out the few bad apples that give them a bad name and are the root of much of the mapractice.

#174 ::: Marilee ::: (view all by) ::: August 26, 2009, 09:45 PM:

Lori, #168, I'm lucky to have Kaiser's Medicare HMO. I get a packet every year just about the drug plan, and it tells me who pays for what. Their contributions do go into to my total until I'm in the donut hole (dropped in two months ago), but they continue to pay for most of generic meds with me just paying the co-pay. At this point, I only have one brand-name and I do pay all of that. I'll have another much more expensive brand-name in the winter, but I refinanced my condo's mortgage Monday and my payments will be about $207 less a month than they are now, so that will handle that.

Terry, #171, I did 2-week (nephrologist), 4-week (rheumatologist), and 8-week (primary & neurologist) labs yesterday (it's nice when they stack up like that), got the results online this morning, and saw the rheumatologist today -- repeat head CT with dye, try PT for "very arthritic" back, and a couple of extra blood tests. She doesn't have to think twice about ordering them because it's Kaiser and they're all in-house, and I paid only the $10 co-pay to see her.

#175 ::: fidelio ::: (view all by) ::: August 27, 2009, 09:53 AM:

Just because, I went and checked the federal pay scales to see what the Commissioner of Social Security and the Commissioner of Medicare make. Social Security is now a cabinet-level post, so the Commissioner pulls a salary at Executive Level 1, which would be $196,700 for 2009. The Administrator of the Center for Medicare and Medicaid Services is an Executive Level 5 post, and makes $143,500. (The table for federal executive level compensation is here; this is the .pdf I used to locate the appropriate salary classes--the page I found my data on is CRS-5.)

Now, there are probably some perks in addition to the salary and the usual benefits you'd expect, like insurance. People who are insider the federal system already might be able to comment on those. However, the US Government's compensation plan does not include housing (remember Jack Welch's deals?), except in a few special cases, such as the President and the Vice-President*. It does not include stock options. It does not, in fact, include a lot of the things that CEOs and COOs in the private sector take for granted as a right when it comes to wresting an acceptable compensation package from their boards of directors. Of course, what the CEO and COO get sets the standard for the CFO, and all the vice-residents who ornament such companies as Aetna, BCBS, and the other health-insurance providers of Our Fair Land. Furthermore, there is no raft of stockowners, expecting a dividend check to appear four times a year. There are no Wall Street analysts, complaining that this year's earnings might not live up to projections and causing the stock price to drop like a rock. SSA and CMS do not have lobbying budgets, either.

Anyone care to go and check the compensation packages for the insurance executives who are so desperate to maintain the status quo? Just remember--the Commissioner of SSA makes right under $200K a year, base, with few of the sorts of add-ons the private sector considers normal. The Administrator of CMS makes under $150K.

*Housing allowances are a possibility--I didn't feel like spending more than few minutes rooting through federal compensation arcana. I'm betting that if they exist they don't compare to what the average CEO would consider acceptable as a pied-á-terre he uses twice a year.

#176 ::: abi ::: (view all by) ::: August 27, 2009, 10:41 AM:

Well, now I've been, briefly, inside the Dutch medical system.

I've been in some pain from my back and left side for a few days now. It feels like a huge, deep bruise, but there's no discoloration on the skin. I wasn't sure what was going on, and that worried me.

So this morning, I got Martin to call the doctor for an appointment. (I could have done it, but I got the shys and knew my Dutch would suffer as a consequence.) My appointment was at 3:30.

I went to the office and sat in the waiting room. There's an admin desk, but it's off to the side; one doesn't check in or anything. The doctor was running about 10 minutes behindhand, so he came out and said my name at about twenty to four.

He shook my hand and we had some chit-chat. I asked if we could speak English, and described the matter. He took me into the examining room and I showed him some of the affected area, and he poked and prodded a little. Apparently, it's just a bruised muscle; he identified which one, checked that I didn't have any range of motion problems, and then told me that it wasn't anything to worry about.

We shook hands, and I left. Never spoke to an admin person, never showed my insurance card, nothing. I gather this sort of visit is free, because of course it's gatekeeping and preventative care as much as it is treatment. (It's also the sort of thing that I might well have put off doing if the threshold were higher. But the next time I have a strange and uncomfortable symptom, it might be important.)

The office is about two minutes' bike ride from my house. I was home by 4:00.

#177 ::: Serge ::: (view all by) ::: August 27, 2009, 10:47 AM:

abi @ 177... The doctor was running about 10 minutes behindhand

That would be considered an extremely short delay here. (Not enough doctors to see all the people who need to be seen.) That being said, I'm glad to hear your problem was not too serious.

#178 ::: Lori Coulson ::: (view all by) ::: August 27, 2009, 11:47 AM:

fidelio @176: To the best of my knowledge, Federal employees whose duty station is in the continental United States do not get a housing allowance.

Compensation for General Schedule employees has what is known as locality pay (for high cost-of-living areas), however those on the Executive pay schedule, like the positions you mentioned above, do not.

I am sure there are perks, I'm guessing that they might have a government car and cushy offices, but that's probably the limit.

#179 ::: Ginger ::: (view all by) ::: August 27, 2009, 12:11 PM:

Cabinet-level government employees certainly do get a car, with driver, and often security as well, although it looks like a minimal detail (one car, albeit a large dark SUV with lights and intimidating men with earpieces).

I had to attend a funeral for my partner's colleague's wife, and one of their sons worked for Elaine Chao. She arrived in a car with attendant SUV.

The rest of us Federal employees on the GS schedule get locality pay, which is an adjustment to the base pay that takes into consideration the rate of local inflation (almost wrote "inflammation"), and varies across the US, based on your official duty station. Other than that, we get Federal health insurance, life insurance, retirement contributions, all Federal holidays off (yeah, all 10 of them, plus Inauguration); because of DOMA, there's no putting the same-sex partner on the insurance. I get a pager and a cell phone, and my name on certain lists*.

Parking is free, and for anyone in the Maryland area, you'll understand why this is a major perk.

That's about it. Unless anyone considers reams of paperwork and meaningless regulations that are strictly enforced, just like in the military, only without the uniforms.

*As in AED-qualified, "mission-critical", and other things which boil down to this: I never get a snow day.

#180 ::: fidelio ::: (view all by) ::: August 27, 2009, 01:28 PM:

Thanks, Lori and Ginger--I do suspect that the cushy offices, while nice, are not going to be the sort of place John Thain would have considered adequate, since I'll bet the trash cans are standard issue and didn't cost $1K, to say nothing of the rest of the stuff.

I checked into executive compensation at Aetna, which includes health-care coverage among its other insurance offerings. Here's the .pdf for the proxy statement for the 2008 shareholders' meeting. At the side, there are direct links to the various sections, including the Executive Compensation section (there's also a section on Directors' Compensation--another expense Medicare and Social Security doesn't have, by the way), which begins on page 48. From the table on page 49 the CEO's base salary, in 2007, was over over $1 million; total compensation, from the column at the far right, was over $23 million. The rest of the crew is listed after the CEO; the least well-paid among them would shake his or her head in dismay over the chump change their federal counterparts were getting. In addition, Aetna, with 436.5 million shares outstanding at the present time, pays a quarterly dividend of 4 cents a share, which works out to dividends paid of $69.84 million annually at the present time. (My source for these figures is here, along with a lot of other interesting details, such as insider trading reports.)
No matter how you slice it, bureaucrats are making decisions about our healthcare; it's just that many of them are employed by for-profit entities managed by people who make more in a year (and who personal advantage rests upon making bigger and better profits every year) than many Americans may see is their lifetimes.

$23+ million versus $196K for SSA's Commissioner and the Secretary of Health and Human Serices (CMS's home department) and $143.5K for the Administrator of CMS. Oops, that's not quite right--in 2007 these positions paid $186.6K and $136.2K, and in 2008 $191.3K and $139.6K. You could, in other words, pay about 120 Cabinet Secretaries* for the cost of the CEO of Aetna--and Aetna is only one of the companies in the US that provide health insurance and run HMOs.

You can see right there one reason why private-insurance premiums would cost more than those from a government insurance program, as well as why private entities are compelled to grasp for every single dollar of profit they can find.

*Less cars and drivers, security, and free parking places. Maybe 90 Cabinet Secretaries?

#181 ::: albatross ::: (view all by) ::: August 27, 2009, 07:42 PM:

fidelio: Okay, but what's the relevance of these numbers? Let us imagine that we live in a different world--one in which for-profit[1] insurance companies and hospitals and doctors are running a really well-functioning system, where costs are under control. Let's imagine that this is placed in parallel with something like Medicaid, but with income-adjusted rates to buy into it, and better-run, so that uninsured patients were a very rare problem across the country. In that environment, would we care about the pay of the CEOs of the private insurance companies, or the cardiologists, or the hospital administrators? Would we be concerned about the profit motive adding costs?

Wal-Mart's CEO makes a hell of a lot of money, and they are a very profitable company. So I guess it follows that Wal-Mart's costs are endlessly spiraling up, that people can't afford to buy their necessities there, etc. The same is presumably true of Target.

Similarly, Apple, HP, IBM, Motorola, Dell, they're all profit-driven companies, with well-paid CEOs. That's probably why their product costs more every year, and we never see any cost savings there.

[1] Note that many other countries with much better-functioning health systems have private, for-profit insurance companies, doctors, hospitals, etc. So it's not like the profit motive inherently means bad health care. They're regulated, but so are US insurance companies, doctors, and hospitals--covered by truly enormous amounts of regulations at various levels. Clearly, they're not the right regulations, but we certainly have them.

#182 ::: P J Evans ::: (view all by) ::: August 27, 2009, 09:02 PM:

Walmart, etc, aren't raising their prices 15 to 20% every year, either. If they did, they'd be losing customers in droves.
The health insurance companies claim they have to raise them that much to cover the increase in costs, but they can't, or won't, say how much of that cost increase is because the hospitals and doctors have to raise prices to cover their increased insurance premiums. It's a viciously increasing spiral, and I can't see any way out other than the government taking over health insurance, or at least strongly regulating the insurance companies and their profits (think public utility companies).

(I try to avoid WalMart; I've found that what I get is cheap, not inexpensive. As in, a name-brand set of stainless-steel flatware that had clearly not been through any kind of quality control: three of the four knives were destined for some other brand (being completely non-matching) and one of the forks was mismatched in size even though it was the same pattern. YMMV.)

#183 ::: Lee ::: (view all by) ::: August 27, 2009, 11:47 PM:

The thing that gets me about the whole "what will it cost" argument is that this is not uncharted territory. We have multiple examples of national health-care plans of various types freely available to study. In each and every instance, it proves to be the case that the national plans pay less per capita than we spend currently in America, while at the same time providing better care for more people than we can manage to do.

Is anyone seriously suggesting that we can't do at least as well as Britain, Canada, Australia, France, or Germany? Is America SO unique that we would be the only country in the world able to fuck this up? Because really, if you're fussing about the cost of reform, that's what you're saying.

#184 ::: pat greene ::: (view all by) ::: August 28, 2009, 01:11 AM:

Lori, I do not know if it is still true, but IIRC as of 1993/94, if you were officially stationed at one location (say, Mountain View, CA) and temporarily detailed (for a year, say) to another U.S. location (Washington, D.C., e.g.) you got some sort of per diem. Which was effectively a housing allowance.

#185 ::: Earl Cooley III ::: (view all by) ::: August 28, 2009, 05:32 AM:

What do health care and insurance company executives actually do that adds value to their company's products and services?

#186 ::: Mark ::: (view all by) ::: August 28, 2009, 07:20 AM:

Earl Cooley III @ 186: Anthony Weiner asked that same question on MSNBC's morning show last week. The squirming of the host trying to avoid answering the question provided a bracing shot of schadenfreude.

#187 ::: fidelio ::: (view all by) ::: August 28, 2009, 08:33 AM:

#182--Walmart controls costs by relentlessly tormenting pressuring their suppliers into cutting their costs, even if that means they must close their US plants and operate in mainland China, or other, even cheaper locales. This isn't really a workable option for a lot of healthcare services, even though there is already a move towards people going overseas for cheaper versions of surgical procedures--I've seen at least a couple of pieces on that in the past 18 months, in places like Newsweek.

Wall Streets' insistence on not just profitably in companies (we can agree that's reasonable) but amazing, startling, and nearly-impossible to sustain growth in profits is a factor that can't be ignored. I don't think it's worth ignoring the executive compensation issue, either. Saying this occurs in other industries does not mean that it is, in the long-term, healthy for American business in general or the American economy, however nice it may be for the people who are receiving the compensation.

Speaking as a stock-owner in serveral companies, I know I'd be happier with lower short-term profits if it meant the company I was invested in was being managed with an eye on its long-term health and stability, which is too often not the case these days. I would also like to think that I was getting what I was paying for in the compensation area, and I have trouble believing that anyone can be worth that.

#188 ::: Lori Coulson ::: (view all by) ::: August 28, 2009, 10:44 AM:

pat greene @185: Ok -- I'd forgotten that one. It must be pretty obvious that the agency I work for doesn't have reasons to have employees do that.

And sure enough, when I look up "temporary change of duty station" in the Federal Employees Almanac there is the list of what the Feds pay for in this situation.

#189 ::: albatross ::: (view all by) ::: August 28, 2009, 10:47 AM:

fidelio #188:

I agree that CEO pay is something of a scandal[1]. I've experienced the penny-wise pound-foolish concern about this quarter's numbers to the exclusion of all else, and it is indeed wasteful and at times very damaging[2]. But neither of these explain the unique problems we're having in health care. Otherwise, we'd be talking about the problems we were having in all for-profit sectors of our economy.

[1] The size of the CEO's compensation is also basically never relevant to the rest of the finances of the company. The CEO of Wal-Mart is almost certainly not worth $20M/year, but that's such a tiny drop in the bucket of Wal-Mart's total labor costs that it has no noticeable effect on anything. The CEO pay issue is very much like the issue of earmarks in federal spending--it's a good source of anger and outrage, but an irrelevantly small part of the actual budget.

[2] While the size of CEO pay isn't very important, I think the formula for determining it, as well as formulas for deciding how to pay all sorts of other people in the company, is very important. You'd probably be better off giving the CEO $50M flat salary than giving him $50M worth of stock options that mature in three years, because he will have a huge personal incentive to max out the stock price in three years, regardless of the impact on the stock price in four years.

#190 ::: Steve C. ::: (view all by) ::: August 28, 2009, 11:04 AM:

Down here in Texas, one of the things you can always count on in the relentless expansion of the suburbs is that you will see new hospitals, clinics, labs, imaging facilities following close behind.

That's one of the key things about health care -- it's growing, and it's growing at a faster rate than the rest of economy. And it's providing jobs, a good many of them well-paid jobs. All those hospitals, clinics, labs, etc., are growing because the current business model of health care is pumping in loads of money.

We're in a health care bubble, and one day it's going to pop. No one enjoying the ride right now wants it to end, and they are doing anything to keep it going as long as they can.

Unlike the Internet bubble or housing bubble, consumer demand for health care has room to grow, particularly as the Boomers hit their peak years for health care demand.

But it can't grow forever, and I'd guess that we have about ten years before the bubble collapses. And the results won't be pretty.

#191 ::: Debbie ::: (view all by) ::: August 28, 2009, 02:55 PM:

Lee @184 -- Is anyone seriously suggesting that we can't do at least as well as Britain, Canada, Australia, France, or Germany? Is America SO unique that we would be the only country in the world able to fuck this up?

Maybe part of the problem is that others are in fact fucking it up themselves. People who are trying to start quasi from scratch, as the US is, have an understandable wish to avoid others' mistakes. That is easier said than done.

Take Germany, where I've lived and been insured for over 20 years. We have a system in which you are allowed to choose your doctor and insurance company. There are lots of good things about this system, including very good perinatal care, free meds for children under 18, low co-pays on other meds, and more.[1]

However, the system is in trouble in many ways, and there aren't any easy fixes. During the prosperous '70's and '80's, a lot of bad habits and attitudes were developed, which resulted in a lot of waste and ineffective use of resources for the long term. Faced with increasing numbers of retirees needing health services, and decreasing numbers of people paying into the system (both because of the demographic situation and high unemployment), Germany is considering the question of how much health care can and should be provided to its citizens. I'm afraid both the quality and quantity of service is going to (continue to) go down.

Still, at least there is a (fairly) universal health care system in place. That is a major factor holding me back from returning permanently to the US.

[1]End-of-life palliative care isn't so great. Physicians have many hoops to jump through to provide morphine based drugs for pain management, for example. Living wills exist, but there is no consensus on their validity, so there is little guarantee that one's wishes would be honored.

#192 ::: fidelio ::: (view all by) ::: August 28, 2009, 02:59 PM:

albatross @#190--CEO pay is not the only reason health-care costs via the private sector are so large, and continually growing, and neither is the Wall Street-driven need to constant growth in earnings--but both are factors, as is the expansion Steve C. mentions. However, the need to make a profit and the need for a continually increasing profit are factors that can't be overlooked, and are issues that wouldn't affect a single-payer system--and so the compensation rates of the management are significantly different for the single-payer systems out there--I suspect the head of the Canadian system is paid more along the lines of the head of SSA than the CEO of Aetna. It all adds up, and seeing health care as something where people other than the immediate providers make money off the business must be a distorting factor.

#193 ::: Earl Cooley III ::: (view all by) ::: August 29, 2009, 10:41 AM:

Note that my complaint on health care/insurance industry waste is not just on CEO pay (which gets some of the best bad publicity), but on executive compensation as a class.

#194 ::: fidelio ::: (view all by) ::: August 29, 2009, 12:39 PM:

Good point, Earl. We see more about CEO pay, but the compensation rate at the top levels is in step with that, rather than the CEO compensation level being an extreme outlier.

#195 ::: Mez ::: (view all by) ::: August 29, 2009, 09:01 PM:

Lisa (#113) I've been — conscious or non-, as patient, relative, friend, witness, bereaved; in Emergency, Hospice, Intensive or General wards — in so many similar scenes these last years.
And I trail behind the main Baby Boomer Bulge age. That experience — even nowhere at Bringing Out the Dead levels — must be having some social and mental impact. Still hoping it works out as well as might be for you and your family.

Updating True Tales of Health Insurance #38, and #107, supra: Two weeks on, he's half-opened one, then both, eyes, and shown some more responses. Still has a nasogastric feed tube, lots less IV stuff though. Breathing 'spontaeously', if through tubes into a tracheostomy, means they will soon move him out of Intensive Care so the machines he's not needing can be used by someone in direr need.
So, progress! Small and slow, but some. We push for more.
Thanks for all and any who've wished him well.

#196 ::: Rikibeth ::: (view all by) ::: August 29, 2009, 09:41 PM:

Mez, that's encouraging news about your friend! Here's wishing him more improvement.

#197 ::: Velma ::: (view all by) ::: August 30, 2009, 10:58 AM:

Mez, that's definitely good news!

#198 ::: Marilee ::: (view all by) ::: August 30, 2009, 05:24 PM:

Good news, Mez!

#199 ::: geekosaur ::: (view all by) ::: August 30, 2009, 05:43 PM:

OG @120:
"G-d helps those who help themselves" is a Jewish truism — but the meaning is that G-d won't bother if you won't. ("You are not obliged to finish the task; neither are you free to neglect it." Pirkei Avot 2:21)

#200 ::: Terry Karney ::: (view all by) ::: August 31, 2009, 02:35 AM:

I don't know what 20,000,000 USD (and is that base pay, or perks included) is to the totality of Wal-Marts employee costs, but what is it as a percenteage of gross revenues?

How does it affect the other execs? How does that distort the profit picture? I seem to recall an article saying executive compensation averaged 10 percent of total profits.

#202 ::: Joel Polowin ::: (view all by) ::: August 31, 2009, 09:23 PM:

Marilee @ 202: Well, you know that once they've got the registry set up, they could come and take away your arms.

#203 ::: Lee ::: (view all by) ::: August 31, 2009, 09:48 PM:

I had an idea for another pushback meme, and I'd like to vet it here.

Given that someone who has an ongoing medical condition -- or with a family member who has one -- cannot leave his or her job* if that means losing access to medical care, would it be reasonable to argue that this creates a condition of involuntary servitude? Albatross, I'd especially like your input on this.

* COBRA partially mitigates this, except that (1) it only lasts for 6 months, (2) if you take a job with a company that offers medical coverage, you cannot continue on COBRA even if that company's plan rejects you, and (3) the exact implementation of COBRA varies from state to state.

#204 ::: P J Evans ::: (view all by) ::: August 31, 2009, 10:19 PM:

And Waxman is now asking the insurance companies to provide a lot of information about their small-business coverage, and why so many of those small businesses are having to choose between dropping health insurance plans or dropping employees, when said employees become expensively ill.

#205 ::: Kizor ::: (view all by) ::: September 01, 2009, 02:03 AM:

Scott @ 78:
From what I know, "The gods help those who help themselves" is attributed to Aesop. It's do downright alarming in monotheism, and how it was transferred over, I'll never know. It does sound like something Benjaming Franklin would say.

Also, expletive, this is the first civil health care debate I've ever seen and I live on the wrong contintent to have any insight. You guys keep it up.

#206 ::: Earl Cooley III ::: (view all by) ::: September 01, 2009, 03:24 AM:

Marilee @202, that push poll question sounds like the Republicans are daintily skirting the edge of blood libel against the Democrats. Not a big surprise, though.

#207 ::: albatross ::: (view all by) ::: September 01, 2009, 09:38 AM:

Lee: Not involuntary servitude, exactly, but something uncomfortably like working in a company town miles away from the nearest alternative. Like you're chained to your job. Human nature pretty much guarantees that, when you're chained to your job, you'll often find a boss who understands that fact, and gives you a lot of extra sh-t as a result. What are you gonna do? Leave?

In some sense, I think the housing crisis and financial meltdown made health care reform a much more urgent issue, though I'm not sure that's really driving it as much as political opportunity. We already had a lot of people chained to their jobs because of healthcare, which meant they had a lot less mobility. When that mainly applied to sick, old people, it wasn't so bad--those people usually were going to stay put anyway. But a healthy young couple with a diabetic kid, or where one of the couple has some not-all-that-serious chronic condition, also loses its mobility. Combined with that, falling house prices + home equity loans have chained a lot of people to their homes, because they could only sell their home at a loss. Again, that decreases mobility, which makes the whole economy much less flexible. Even if the perfect job for you is across country, you'd have to lose your healthcare and go bankrupt getting out of your house to get there.

And on the money side, our bailout and stimulus massively ran up the deficit. If you believe there's some limit to how big our deficit can be and still be sustainable, this moves the deadline for dealing with Medicare cost inflation much closer. Fixing part of that is probably really important for the long-term well being of the country.

#208 ::: Lexica ::: (view all by) ::: September 01, 2009, 02:58 PM:

albatross @ 208: Human nature pretty much guarantees that, when you're chained to your job, you'll often find a boss who understands that fact, and gives you a lot of extra sh-t as a result. What are you gonna do? Leave?

Even if somebody doesn't have a crappy boss of that sort, it's still a problem to be locked into one's job. I remember a conversation with my mother once when she said to me, "I'm going to die in this town."

"But Mom," I said, "the doctors said the chemo was successful and the chances are good that you'll be a long-term survivor."

"That doesn't matter; that's not what I'm talking about," she said. "My long-term plan was that once you went off to college, I'd be able to start looking for a job somewhere else — somewhere emphatically not here. Now? Now... I'm going to die in this town."

And she did.

#209 ::: Marilee ::: (view all by) ::: September 01, 2009, 05:50 PM:

Joel, #203, not my arms! I don't walk well already, they can take my legs! But yes, I know what you mean.

#210 ::: Rob Rusick ::: (view all by) ::: September 01, 2009, 09:57 PM:

Joel Polowin : Well, you know that once they've got the registry set up, they could come and take away your arms.

Ha, ha, ha! You can keep your guns ... much good they will do you without fingers!

#211 ::: Steve C. ::: (view all by) ::: September 02, 2009, 11:29 AM:

James Surowiecki has an interesting piece in the New Yorker about the public's attitude towards health care reform.

Status Quo Anxiety


Last year, a Rasmussen poll found that only twenty-nine percent of likely voters rated the U.S. health-care system good or excellent. Yet when Americans were asked the very same question last month, forty-eight per cent rated it that highly. The American health-care system didn’t suddenly improve over the past eleven months. People just feel it’s working better because they’re being asked to contemplate changing it.

#212 ::: Jenavir ::: (view all by) ::: September 11, 2009, 10:50 PM:

So I just had to (well, I say "had to"; really, I'm a glutton for punishment) read Ron Rosenbaum's column on the "death panels" thing, where he claims that Sarah Palin was actually being METAPHORICAL and liberals were too dumb to get it.

Yes, when she said Democrats would decide Trig didn't deserve to live, apparently that's okay because it was all a metaphor.

I wonder if "Iraq has weapons of mass destruction" was metaphorical too? So Bush didn't mislead anyone, it's just that we were too dumb to understand the metaphor?

#213 ::: Joel Polowin ::: (view all by) ::: September 11, 2009, 11:02 PM:

Does Palin even know what a metaphor is, other than to keep cows in?

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