Wednesday, August 12, 2009

Public option talk. part 2

Supporters of the Obama health plan are livid that Sarah Palin posted a statement suggesting that the plan would result in a "death panel" which might decide whether a baby with Down's Syndrome would receive health care. She is, in consequence, "evil" and a "monster."

This is going to be a three part post and we'll get to whether Palin's concern is as far fetched as her critics think it is. But, as Wesley Smith puts it, she'd be a more effective critic "if she didn’t write like a college-student blogger." So, I'll concede that it is hyperbolic and demagogic statement. No one has yet proposed a "death panel" to decide who will get care. As It sort of reminds me of Barack Obama saying that John McCain was willing to fight the war in Iraq for another 100 years of war. Maybe McCain was too commited to Iraq for Obama's taste, but that statement was false. It was hyerbolic and demagogic. Bad Sarah. Bad Barack. But then you can hardly blame a lion for eating a gazelle. This is what politicians do.

Still, isn't the issue of rationing care for the elderly or infirm on the table? And didn't the President put it there?

Obama has raised the issue of health care for persons in the later years of their lives. He wonders whether someone in the position of his grandmother (then 86 and diagnosed with cancer) should get a hip replacement (although he said that he would have paid for hers). He noted that the chronically ill and those at the end of their lives potentially constitute 80% of the cost of health care. He told a woman that perhaps her very elderly mother (99 at the time she needed it; 105 at the time of the question)should take pain killers rather then receive a pacemaker. (This turns out to be lousy medical advice; but you get the picture).

Despite saying yesterday that he believed that no one but "you and your doctor" should make health care decisions. He doesn't mean that. On another occasion, he suggested that the government do exactly that, suggesting that "[i]f there's a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that's going to make you well?"

The reason, presumably, would be that your doctor doesn't agree that the blue pill works just as well as the red one. The "honest broker" needs to set her straight on that. In a related context, he has said that "[t]here's always going to be an asymmetry of information between patient and provider ... [a]nd part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options." The way in which the government "acts as an honest broker" is not by endorsing one treatment over another (a pointless exercise), but by deciding which one it will pay for. No red pills for you. For people without the price of a hip replacement burning a hole through their pocket, this means making a medical decision other than that preferred by the patient and her doctor.

The current form of ObamaCare contains a provision requiring doctors to be reimbursed for end of life counseling. It does not, as some have wrongly said, make such counseling mandatory. But advocates for the disabled are concerned that it may have the effect of pushing patients into declining care. Obama, seeking to deflect criticism, said that the provision came from Republican Senator Johnny Isaakson. Isaakson says that's wrong. He says that he wants people to get assistance with living wills but he wants the initiative to be that of the patient and not the doctor. Whoever wins this little shoving match, the point is that the provision can reasonably read as an effort to encourage palliative care and DNR orders. That may be a good thing, but it brings us back to the issue of limiting care for the elderly or infirm.

It is the President who has engaged Rahm Emmanuel's brother, bioethicist and physician Exekiel, to advise him on health care reform. Dr. Emmanuel has advocated a more communitarian form of health care decisionmaking, suggesting that “Doctors take the Hippocratic Oath too seriously, as an imperative to do everything for the patient regardless of the cost or effects on others” he has said that we ought to discriminate against old people in the provision of health care. He advocates the notion of "life-years" as a guide to health care decisionmaking. This is more or less what they do in socialized systems like the UK. He has at least suggested the notion of discrimination based on the age of the patient and seems to advocate (at least in theory) the notion of "life-years" as a guide to health care decisionmaking. He has suggested that care ought not be guaranteed for "services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed." Might that be people like Trig Palin? More later.

This doesn't mean that Dr. Emmanuel is a gentler version of Dr. Kevorkian. Salon breathlessly reports that he is not even for voluntary euthanasia or physician assisted suicide.. That hardly makes him a convervative, but he does seem to be a bright and serious man who deserves to be heard. So I'm not about to call him "Dr. Death." But here is another item suggesting government ("communtarian")involvement in making those decisions that the President says it should stay out of. It raises, again, the question of rationing care for the elderly or infirm.

In fact the push for a public option in and of itself raises the notion of rationing. All public health care systems ration.

Now, private systems do too. What are the differences? That's the next post.


Dad29 said...

First off, Gingrich makes the point that Obey's "CER"--authorized as part of Porkulus, is de facto the 'death panel' of Gov. Palin.

And OF COURSE that's not what it it called.

Moving toward the point, however, you state: The current form of ObamaCare contains a provision requiring doctors to be reimbursed for end of life counseling. It does not, as some have wrongly said, make such counseling mandatory.

Umnnnhhhh.....Rick, this is called An Incentive. The MD's will have An Incentive to bring up end-of-life discussions.

Just as Doyle had An Incentive to make seatbelt use a primary offense instead of a secondary offense.

Gehr Ste'he?

Dad29 said...

For more on "CER" see this:

Laid out in lavender.

Anonymous said...

Thankfully Sarah Palin's opinion resonates with about, ummmnnhh, 20 percent of the reactionary crowd. When are Republicans going to hold an intervention and get this woman to cease and desist?

Dad29 said...

Thankfully, about 20% of the population pays attention to the details and the direction.

IIRC, a minority of the Colonists were paying attention to King George's details and directions.

Dad29 said...

Sarah Palin's opinion resonates with about, ummmnnhh, 20 percent of the reactionary crowd.

Including the Senate, which dropped the provision this afternoon.