Terry Schiavo type cases are expensive but what really drives health care spending and costs is not the person who will be a vegetable for a decade or more. Those cases are actually quite rare. What drives health care costs are chronic conditions like heart disease, diabetes and cancer. Conditions where euthansia via rationing are simply not going to achieve much savings. The primary reason I doubt you’ll see death panels is simply because they don’t make much sense financially but they do make a great story for politicians like Sarah Palin or some pro-lifers who fancy themselves fighting against an onslaught of cartoon Nazis. On the contrary, it’s almost kind of amazing how casually real life ‘death panels’ were so accepted decades ago that they weren’t even debated while today they are unthinkable (again refer to the allocation of dialysis by ‘God committes’ in hospitals, the casual use of children in medical experiments like the first polio vaccine, basically the concept of informed consent in just about all medical research until relatively recently)

Any good or serviced is rationed by one’s willingness and/or ability to either qualify or pay for the good or service.

The more payors there are, the more diffuse the decision making power and the more access there is to the good or service. The fewer providers of the good or service, the higher the price and the less available the good or service.

He who pays gets to decide.

Econ 101.

Health insurance (which I sell) is indeed a method of rationing as well as sharing risk. It’s very existence drives up costs and restricts care while broadening the number of people who have access to at least some level of care. The higher the costs go, the more restrictions are placed upon the care. To get everybody something means no one gets everything. The more we have a ‘right’ to care (whatever that means) the less will be available.

Rationally, people are willing to give up some decision making power and access to make care overall less of a catastrophic financial burden when something major occurs. Irrational folks just want and expect other folks to pay for whatever they need. Some irrational folks don’t want anyone to have any assistance. If people are willing and able to totally self-insure, they have total authority over what kind of care to seek, where to have it delivered and can usually find what they want–even if it is illegal. The less willing and able people are to self-insure, the less actual choice they will have. Few people I have met are rational about their health or the care they receive or the cost of it.

Those who propose a single-payor plan for healthcare know the facts. The care will be more costly and less available. It would not be so bad if they didn’t routinely lie about what they know demogoguing the issues to get votes and power.

They also have an entire ideological and social agenda which goes along with the camel’s nose that is oppressive and tryannical.

Those who propose a ‘free market’ approach also know that such a thing is a phantasmagoria of their own vain imaginings (the idea of social responsibility for others; HMO’s; PPO’s; TPA’s; government mandates; sinful passions**; inequalities of knowledge and power make any ‘free’ market impossible). They also routinely lie about what they know. They too have an ideological and social agenda which they want to foster that has nothing to do with anyone being cared for, but everything to do with who controls the care and who makes the money. While less obviously tryannical, the final outcome is not much different.

The real question is not about rationing. The question is who will make the decisions; what criteria will be used; how will the criteria be applied; and what level of honesty and transparency will be allowed and what the cost will be socially and economically

Most of the ‘solutions’ which I have personally studied in Obamacare are looking for a problem, at least in my state. Our state insurance commissioner admits to that in her public meetings regarding the transition to government run care. She also says that the states have no idea what they are supposed to do or how to do it, but they are spending a lot of taxpayor time and money trying to do it anyway in the hopes of keeping the process as local as possible. They are just following orders.

Despite all of the difficulties, inequties, lies, fraud, abuse and stupidity–the more decisions are made closer to where the care is actually delivered, the better off we will be. The more cost and quality decisions are made by parties far removed from the people and the circumstance, the less well off we will be.

IMO, all of the angst so liberally on display is simply a smoke screen for refusing to examine our own hearts and minds–an excuse for facing ourselves and living by Godly standards in our own lives. “God will provide” is a Biblical truth that we all too easily forget. We too readily acquiese to the chiliastic vision of all types of political ideolgies and idealogs who deny God. “God is with us! Understand all ye nations and submit yourselves, for God is with us!”

**Sinful passions include the costs of care for morbidly obese; chronic substance abusers (includes alcohol & tobacco); a promiscuous culture that routinely impoverishes women and children while spreading disease in the name of personal freedom; kills babies; glorifies legal substance abuse as treatment; promotes the false idea of a perfect outcome as attainable; the canniblization our young and our use of the bodies of others to keep ourselves alive in ways that are Frankensteinian.

The slogan is indeed used over broadly, including by euthanasia proponents.

George: I thought it was the political hit of the year. But she at first aimed it at the wrong place. She later corrected herself and pointed at the potential for explicit rationing.

–Leo Peter

Let’s call this ‘death panel rationing’ where decisions about who gets medical care are based on value judgements of the individual person. Hence one person might be a respected college professor while another might be a drifter with no history of solid employment but the machine is given to the professor not because his health status is different from the drifter but because his perceived ‘value’ to society is considered more worthy.

I agree that this is very ethically dangerous territory but there are times and places where it may be acceptable. For example, on a sinking ship ‘women and children first’ used to be the motto. In such a case you are making decisions based on ‘social worth’ (i.e. the 5 yr old kid is deemed more important to save than the 40 yr old man). Another place where it may be acceptable is where there’s an absolute finite limit on the available resource. Hence organ transplant committees will apply some ‘social worth’ criteria. The 20 yr old non-drinker may get the liver before the 50 yr old drunk. Although here you may object that this isn’t really a ‘death panel’ type of rationing. The twenty yr old may be reasonably expected to live 50 more years with the new liver while the 50 yr old may not make another ten. You could say in terms of life years you’re simply sending the liver where it will produce the most bang for the buck (or liver in this case).

The only other example of ‘death panel’ rationing I can think of was proposed by some Republicans in Texas (I think) who proposed abolishing Medicaid. They were quoted as saying they were willing to help people who ‘really needed it’ but if you had someone who ‘smoked and drank’ the state shoudn’t pay for their care. There is pure ‘death panel’ rationing being proposed…..granny doesn’t get care because she liked her smokes and scotch in her younger days. But that was just a minority proposal which didn’t go anywhere.

This is the 2nd type of rationing; where hurdles are placed in front of care based on cost. My wife just experienced this. She was given a prescription. When she filled it the pharmacist told her the doctor had to go through ‘pre-authorization’ from the insurance company. The insurance company told the doctor she has to use one of the $10 generics first to see if it works before they would pay for the $100 drug. Now I don’t really have much of an issue with this for a few reasons:

1. The drug is still available to us, if we opt to pay for it ourselves for $100 a month.
2. While it’s annoying, I’m being forced to act in a way that expands the supply of health care to all. If the $10 generic works, that’s $90 freed up that can go for some medication or treatment where no cheap $10 generic yet exists. It also rewards the drug company $90 less for making a ‘me too drug’ as opposed to making a drug for which no generics exist (in other words a breakthrough drug for something that no drugs currently exist).

If you’re a purist, though, this is still rationing. The premium drug she was originally prescribed is better in some ways than the existing generics. If its cost was only $10 then the decision could just be a contest based on the pure medical facts of the drugs. But since its cost is $100 one asks is it ten times as good as the generic or just, say, 1.5 times as good? If its the latter I’ll try the generic first to see if I can get away with it.

I would say that this is an example where you have to allow market rationing but its not even that, there simply is rationing due to the fact that resources are scarce. Not every hospital has the latest trama care, not every doctor can train for ten years under the world’s best surgeon. Even socialists accept that resources must be allocated if they are not infinite. Trying to insist otherwise is worse than immature, it’s creating real ‘death panels’. If every hospital must have the latest technology there will be fewer hospitals. If a simple procedure requires only the world’s greatest surgeon when an average one will do almost as good a job, then the world’s greatest surgeon isn’t available for a complicated procedure.

Now in terms of your criticism of ‘end of life counseling’, I’m seeing less about actual death panels and more about potential conflicts of interest.

First if a doctor is paid to consult with a patient he is legally and morally obligated to do his best to give impartial and honest advice. If he steers people towards DNRs simply because some patients become less profitable for him to treat he opens himself up to very nasty malpractice suits as well as professional sanctions.

Second there’s nothing wrong with compensation based on a flat ‘per head’ treated. The other method of compensation based on just reimbursing for every visit, every procedure, every test provides a bad incentive to overuse all of those. That’s bad not only because it limits care for others but it’s also often bad for the patient. For example, part of the bill lets Medicare refuse to reimburse hospitals for patients who get readmitted within a certain time period of being discharged. What was happening before was that hospitals were getting paid for surgery, discharging patients too soon to free up the beds, then some patients return with infections and other problems which becomes a new billing opportunity for the hospital. Technically the patient is getting ‘more health care’ but he would have been better off spending another two days or so in recovery and avoiding infection all together.

Third, if the compensation system does create a bad incentive to ‘off’ expensive patients doctors and hospitals will find ways to steer this outcome quietly, undercover. Actual formal counseling with the threat of professional sanction on the doctor (either thru malpractice suit or complaint to the medical board) would give the patient the opportunity to say clearly what it is that they would want. If they say ‘keep me going no matter what’ then yes maybe at some future point that could get overridden in the courts or by doctors but better to have that roadblock there in place, in writing than to have nothing at all and rely upon nurses and doctors deciding to let a patient go because they ‘think’ he would want it that way.

A shorter way of saying this is that just about any system can be corrupted towards something we don’t want. No bill is going to guarantee that would never happen, only vigilengce can do that. So unless a bill explicitly does something we wouldn’t want, I find the ‘it may allow this’ argument to be very weak as a reason to not do it.

In any case, it is letting the camel’s nose under the tent wall.

Regardless, “death panels” has become part of Obamacare’s legacy and has entered the political lexicon. If for no other reason than that, it can obfuscate the work of those who believe in uber-rationing up to and including euthanasia. (Make no mistake, they believe in pro-active killing and not just passive DNR directives.)

What are we to do? In the words of the Psalms:
‘Seek God and your soul shall live’.