Life at All Costs: Part Three, The Politics
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Life at All Costs: Part Three, The Politics

The political hyperbole surrounding the health care debate has shut off a frank discussion of how to approach end-of-life care

Representative Earl Blumenauer doesn’t remember the exact moment last summer when the death panel frenzy began. A thin, professorial-looking Democratic Congressman from Portland, Oregon, Blumenauer had authored a bipartisan provision in the House health reform bill that provided funding for end-of-life counseling to Medicare patients. Then the Republicans, led by Sarah Palin and others, seized on the provision as a foil to attack the bill by insisting the Democrats   wanted to kill old people to save money.

And so the “death panel” sound bite was launched like a sidewinder missile into the health care debate, with demagogues on one side accusing the other side   of wanting to kill granny.

"I didn’t mean to kill Grandma. I didn’t even mean to create death panels."
-- Earl Blumenauer

Truth and Consequences

“This was an outrageous distortion of the truth,” says Blumenauer, who wears bow ties and was first elected to Congress in 1996. “Even Sarah Palin supported the idea of end-of-life planning when she was governor of Alaska.”

Regrettably, this dust-up has obscured the real issue that needs to be discussed. As painful as it is, Americans need to address what to do about a tech-driven health care system that is able to keep dying people alive for additional weeks or months, often with a diminished quality of life, and at an extraordinary cost. Is this something we want? This conversation is particularly urgent as America’s senior population rises from about 13 percent of the population today to 20 percent by 2030, according to government projections

Until now, the U.S. has been able to pay its medical bills, despite the share our Gross Domestic Product spent on health care since   the 1970s doubling. But left unchecked, costs are likely to get significantly worse with a triple whammy of 78 million aging baby boomers entering their “medical years,” people living longer, and the ever-quickening pace of pricey technological advances.

Medicare costs are projected to nearly double during this decade, from $432 billion in 2007 to $830 billion in 2117. About a quarter of that spending will be devoted to caring for people in the final year of their lives. That will mean that just seven years from now, the government will be spending $208 billion annually on end-of-life care.

The Big Squeeze

Many lawmakers, administration officials and policy experts agree that tough political decisions need to be made soon to slow or reverse this growth trend. Maintaining the status quo will mean spending a full one-third of our GDP on health care in 2040, with the last year of life accounting for 2 percent of GDP by 2040. That’s a $500 billion price tag for dying just three decades from now.

Maybe, after a vigorous national debate, we will decide that this is fine — that this is how we want to spend our money. But there will be trade-offs as health care displaces education, transportation, housing, infrastructure, the environment and the military as national spending priorities.

The alternative to lavishing ever more resources on health care is to do something that does not come easily to the richest country in history: As individuals and as a society we have to learn to say no. Better yet, we need to do exactly what Earl Blumenauer   — and Governor Sarah Palin — proposed: informing seniors and the terminally ill and their families about end-of-life options so that those people who do not want expensive high-tech care can opt out in advance.

Bring this up in the wake of the summer of 2008, however, and you risk being called a Nazi. That’s essentially what Fox’s  Glenn Beck said after Palin’s death panels comments — that the Nazis advocated the elimination of the infirm to save money for the healthy. Other attacks on “Obamacare,” including some from Democrats, raise the possibility of rationing and health care being doled out by government bureaucrats.

 

But of course Americans already ration scarce resources. Most of us make tough choices about what we can afford in our personal budgets. In health care, insurers ration through denial of care, and Medicare rations through requiring copayments of 25 percent for drugs. For some cancer drugs, this can amount to thousands of dollars. Studies show that even among Americans with insurance, 43 percent have self-rationed care by limiting treatments to save money. The Urban Institute reported that 22,000 Americans died in 2006 because they were unable to get access to life-saving treatments due to lack of insurance.

New York Times columnist David Leonhardt has pointed out that waste in health care is another form of rationing. “[W]hen middle-class families complain about being stretched thin, they’re really complaining about rationing,” writes Leonhardt. “Our expensive, inefficient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition.”

No one disagrees with eliminating waste, although several stakeholders who profit from the current system oppose tinkering too much with the status quo. For instance, the American Medical Association   and other physician groups have successfully resisted efforts to reduce or eliminate fee-for-service. Trial lawyers have successfully blocked the inclusion of tort reform in the current health care reform process. And the American Hospital Association has spent millions making sure that their fees don’t get the ax.  Not coincidently, lobbyists for trial lawyers provide substantial funding for Democrats in Congress.

Another Leviathan opposed to changing the current system is the private health insurance industry and its lobbyists. They are bit players in end-of-life care given Medicare’s role as major payer. Yet their opposition to any plan that reduces the billions of dollars spent on administrative costs diverts resources away from actual medical care.

Critics also blame politically powerful patient advocacy groups for pushing up the cost of dying by insisting on new technologies, drugs and treatments. Rebecca Kirsch, Associate Director for Policy at the American Cancer Society, agrees that this has been a problem. She insists, however, that this message is shifting. “We are not death denying,” she says. “We got a little sloppy with our message with race to the cure and all of that. There are often not cures. It’s about quality of life, that’s the message we’re marketing now.”

Yet even the term “quality of life” has taken on a negative political overtone for some people. “I see ‘quality of life’ as code for the government deciding who is worthy of living and dying,” says conservative commentator Wesley J. Smith. “How do you decide what quality of life is? Who determines this? The government?”

Earl Blumenauer believes that the incendiary summer of 2008 may end up having a positive impact by focusing attention on how we die. “I think we are ready to talk about this,” he says. “You’ve got a convergence of forces … We’re moving away from high tech and urgent care and interventional methods … People are starting to realize that they have more choices.” He notes that the counseling provision that caused all of the death panel nonsense is still in the House version of the health reform bill — though a similar provision was pulled from the Senate version. It’s anyone’s guess if it will end up in whatever bill finally emerges from the current effort of the president and Democrats in Congress.

“We need to get rid of the politics,” says Cynda Hylton Rushton, a bioethicist and nurse at Johns Hopkins, “to stop using dying as a battleground. It’s harmful for our country, and for each of us. We need a discussion with dignity. We need to acknowledge that resources aren’t limitless, and we have to decide where to place the emphasis.”

I’m old enough to have seen the feminist movement, civil rights, and environmentalism,” says bioethicist Daniel Callahan. “Health care may be the next one.”

But is the United States really ready to have a grown-up discussion about dying?

Click here for part four of this five part series. Click here for part two (previous)  Click here for part one (previous). Click here for part  five of this five-part series.

See the whole David Ewing Duncan - Life at all Costs Series

David Ewing Duncan’ s most recent book is "Experimental Man: What one man’s body reveals about his future, your health, and our toxic world."

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