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Washington Post's Charles Lane on Section 1233, Advance Care Planning Consultation:

Columnist Charles Lane - full disclosure, an old friend and a journalist who I have admired going all the way back to his Central America days in the 1980s - has a striking piece in today's Washington Post, "Undue Influence: the House Bill Skews End-of-Life Counsel."

About a third of American adults have some form of living wills, advance care directives, and so on, but, notes the column:

When seniors who don't have them arrive in a hospital terminally ill and incapacitated, families and medical workers wrestle with uncertainty — while life-prolonging machinery runs, often at Medicare's expense. This has consequences for families and for the federal budget.

Enter Section 1233 of the health-care bill drafted in the Democratic-led House, which would pay doctors to give Medicare patients end-of-life counseling every five years — or sooner if the patient gets a terminal diagnosis.

On the far right, this is being portrayed as a plan to force everyone over 65 to sign his or her own death warrant. That's rubbish. Federal law already bars Medicare from paying for services "the purpose of which is to cause, or assist in causing," suicide, euthanasia or mercy killing. Nothing in Section 1233 would change that.

The actual text of section 1233 can be found here via Thomas, the Library of Congress data base (if the link doesn't get you to section 1233, search the data base using H.R. 3200, then go to section 1233). But as the column goes on to point out, the bill creates an undue conflict of interest for doctors. It is not just, as Lane says, that Section 1233 "addresses compassionate goals in disconcerting proximity to fiscal ones." (Mickey Kaus has made this same point.) The column raises a much more specific concern and conflict of interest for doctors:

Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren't quite "purely voluntary," as Rep. Sander M. Levin (D-Mich.) asserts. To me, "purely voluntary" means "not unless the patient requests one." Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that's an incentive to insist.

Patients may refuse without penalty, but many will bow to white-coated authority. Once they're in the meeting, the bill does permit "formulation" of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would "place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign," I don't think he's being realistic.

What's more, Section 1233 dictates, at some length, the content of the consultation. The doctor "shall" discuss "advanced care planning, including key questions and considerations, important steps, and suggested people to talk to"; "an explanation of . . . living wills and durable powers of attorney, and their uses" (even though these are legal, not medical, instruments); and "a list of national and State-specific resources to assist consumers and their families." The doctor "shall" explain that Medicare pays for hospice care (hint, hint).

Admittedly, this script is vague and possibly unenforceable. What are "key questions"? Who belongs on "a list" of helpful "resources"? The Roman Catholic Church? Jack Kevorkian?

Ideally, the delicate decisions about how to manage life's end would be made in a setting that is neutral in both appearance and fact. Yes, it's good to have a doctor's perspective. But Section 1233 goes beyond facilitating doctor input to preferring it. Indeed, the measure would have an interested party — the government — recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations. You don't have to be a right-wing wacko to question that approach.

In a separate post, I want to consider something that the column mentions in passing - that, according to the section's backers, it is merely "trying to facilitate choice — even if patients opt for expensive life-prolonging care." I'll try to find a moment to post on what I see as the relationship between that and the current love affair (I share the love, in part, to be sure) with behavioral economics.

In one sense, in other words, section 1233 can be understood as a Nudgy move to reset the default rules. The question then becomes, is it merely trying to set the default rules for addressing a topic that people would rather skip addressing - end of life issues, living will issues, health care directives - or is it a nudge for getting people, including ones now terminally ill, to shift their social default settings on whether or not to consume expensive resources, while putting it in the context of seemingly making your own decision about it? They are, clearly, two quite different propositions - and both of them amenable to the Nudginess setting of default rules analysis and, depending on how one sees it, either "facilitation" or "manipulation."

This question is implied by Chuck Lane's column, because he is pointing to a conflict of interest on the part of the provider of this advice, on which the distinction in part turns. But it also goes a long way further than the Post column, to a discussion of Nudge-the-book and the ways in which it can be either a means of facilitating the choices that people would rationally make but can't quite step up to the plate to make, or else a means of manipulating human psychology toward public policy ends that someone else has decided are the rational ends, whether people would agree to them or not. The principles of Nudge seem disconcertingly applicable to either agenda.

I'm a big fan of it as a facilitation process. I even buy the idea that there is a form of justified "libertarian paternalism" that is not merely an oxymoron or simple paternalism. But the one, libertarian paternalism and the facilitation of the choices that people will make for themselves and consider themselves rational for doing so, slides really, really easily into the other, paternalism, and manipulating choices. All it really takes is an apparatus of public policy and disconnected group of technocrats willing to decide the things the way that presumably All Rational People Would Decide If Only They Were [fill in the blank with your favorite technocrat - e.g., Ken Anderson]. (I'll try to get back to this, but probably not soon.)

kietharch (mail):
The "conflict of interest" Mr. Lane mulls will always be with us. If my wife has a life-threatening illness and the cost of promising treatment equals our net worth then she and I have a choice to make. If it is the US taxpayer whose net worth is at issue then I think it is understandable that someone (who would, I hope, feel a "conflict of interest") should talk this choice over with the patient.
It's easy to demonize this sort of conversation but it should be happening now and probably does.
8.8.2009 1:44pm
JunkYardLawDog (mail):
There is more than just section 1233 of the bill that makes people rationally concerned about the government moving (ultimately) into the euthanasia business. Combine the nudges in 1233 with the stated promises out of the mouth of Obama and others that the goal is to cut 500 Billion out of current medical care to seniors. That they intend to begin to have doctors tell older patients they don't need or can't get that hip replacement or life saving surgery because they are too old or don't contribute enough to favored liberal causes in their life's work. Combine it also with the health bill providing funding for statistical research to be used as a basis for denying care to older people, etc.

Sure the bill doesn't explicitly say that they intend to start the killing factories for the elderly right away, but the bill in all of its contexts certainly seems to be laying the groundwork for a more subtle kind of killing factory to be started up in the not too distant future.

Says the "Dog"
8.8.2009 1:59pm
Raoul (mail):
I think we need to initial psychiatric meetings with all this nonsense spewing around- a doctor initiating conversations on end-of-life issues is a problem? I am in utter disbelief. No doubt about it, we have too much time in our hands. Go away.
8.8.2009 2:01pm
Oren:
Thinking in analogy to the ALCU rights card (PDF), perhaps concerned citizens could give seniors a card they could hand doctors that would unequivocally end the conversation.

That way, their desire for maximal-resuscitation (or whatever) is documented and ends up protecting those seniors that want that sort of treatment.
8.8.2009 2:03pm
Hans Bader:
It should be noted that Charles Lane is quite liberal, and thus would not depict provisions of the liberal health-care overhaul bill backed by the Administration unfavorably unless there were genuine cause for concern.

In the Washington Post, he once depicted the Supreme Court term that ended in 2003 as being pro-civil liberties, even though he admitted that 7 out of 8 free speech claims lost, because the Supreme Court upheld affirmative action and other liberal causes.

I mention this to preempt any liberal commenters dismissing Lane's observations based on the false assumption that he is not a liberal like them.
8.8.2009 2:05pm
road2serfdom:
"I mention this to preempt any liberal commenters dismissing Lane's observations based on the false assumption that he is not a liberal like them."

They will be here later. Right now they are busy reporting Charles Lane to the authority.
8.8.2009 2:26pm
Richard Johnston (mail):
If one presumes the doctor initiating the consult is the patient's regular primary care physician, and therefore one who treats the patient on an ongoing basis, then the incentives posited here would seem to militate against a nudge by the conflicted physician toward an early end-of-life. They don't get paid for treating dead people, but can get paid a lot for treating slowly-dying-and-requiring-constant-care people. That sounds callous and I do not presume callousness or bad faith on the typical physician's part (Obama's musings about tonsillectomies for profit notwithstanding)but if I understand the point that is the incentive being posited here.

Recall the provision in question authorizes payment for such consults no more often then every five years (or on the occasion of a terminal diagnosis). That does not seem to me, at least, to create a very powerful incentive for using this as a cash cow.

BTW -- my 87-year-old mother was recently seen in a Kaiser emergency room, for what turned out to be a benign fainting incident. But while she was there the ER doc very hamhandedly suggested she may want to consider a do not resuscitate directive "in case something goes wrong." Again I do not extrapolate from that one anecdote, but the point remains that many of the ills feared from HR 3200 are already with us courtesy of the private insurance industry.
8.8.2009 2:27pm
sputnik (mail):
end-of-life / advanced care planning consultation, legislation amended and included by Republican Senator Johhny Isakson, R-GA:

******************************​***********

Current HCR Proposals of Interest to the End-of-Life Care Community

The following proposals have been voted upon and agreed to during the legislative action on health care reform. Please note that the process is still in early stages and this does not represent what will be in the final package.

In the House Proposal, HR 3200, "America's Affordable Health Choices Act of 2009":

1. Hospice Annual Market Basket increase reduced by Productivity Factor Adjustment beginning in fiscal year 2010 (Sec 1103)

2. Extension of Moratorium on BNAF Rate Cuts (Sec 1113 -- in Chairman's Mark)

Extends the moratorium on the removal of the hospice budget neutrality adjustment factor through fiscal year 2010.

3. Advance Care Planning Consultations (Sec 1233)

Provides coverage for consultation between enrollees and practitioners to discuss orders for life-sustaining treatment. Consultations would be provided every 5 years, or more frequently if the enrollee is diagnosed with an advanced illness.

It also instructs CMS to modify the "Medicare &You" handbook to incorporate information on end-of-life planning resources and to incorporate measures on advance care planning into the physician's quality reporting initiative. Read the legislative analysis of this provision.

4. Programs to Increase Awareness of Advance Care Planning Issues (Agreed to -- Baldwin/Burgess Amdt)

Establishes a grants program to maintain an information phone line and clearinghouse for state-specific advance directive materials, and an additional grants program to fund an advance care planning educational campaign. Grants cannot be made to any government or non-government organization that promotes suicide, assisted suicide, or the active hastening of death.

In the HELP Committee Proposal, "Affordable Health Care Choices Act":

1. Allows for utilization of CLASS Independent Benefit Plan for advance care planning (Agreed to -- Isakson Amdt)

Within the establishment for a national voluntary insurance program for purchasing Community Living Assistance Services and Support (CLASS) available to individuals with functional limitations, program funds can be used for advance care planning.
8.8.2009 2:29pm
Fallacist:
I agree that physicians would have a monetary incentive to conduct such consultations, but I don't see that their incentive would be to push people into refusing procedures or going into hospices. Quite the contrary, wouldn't the physician's financial interest be in prolonging the patient's life as long as possible through expensive treatments? The section of the bill would be much more worrisome if it were a bean-counting Medicare bureaucrat doing the counseling rather than a physician. If the section was intended to save money, it might actually backfire by making many patients' wishes for heroic treatment explicit.
8.8.2009 2:31pm
DiverDan (mail):
I just want to know one thing -- If I get diagnosed as terminal, will Medicare pay for my last trip to Cozumel, where I can enjoy a last few days in the sun, and my last dive, to 250 feet or more down Santa Rosa Wall, where I can get so narced (that's Nitrogen Narcosis, for those unfamiliar with the term - Nitrogen at high partial pressures absobed into the blood has a narcotic effect and induces euphoria) that I won't care that I'm drowning? If I gotta go (and I do, sooner or later), I'd sure as hell rather go that way than lying on my back in pain in some dreary hospital, or worse, a Medicare Hospice.
8.8.2009 2:46pm
Badness (mail):
More and more, I find myself drawn to the conclusion that this political theater is being manufactured overplayed by political commentators of all stripes.

Loud protests: nothing new. Generally an annoyance, regardless of who is protesting what.

Loud protests in august: Yay, we can blather about something more interesting than where Clinton Bush Obama will spend summer vacation.
8.8.2009 2:54pm
Dan M.:
Doctors will be getting squeezed on reimbursements for end of life care plus they will be getting kickbacks from the government to encourage people for forgo care. I think we all know where this will lead. At the very least people will need to be prepared to accept the decision of the rationing board.
8.8.2009 3:04pm
corneille1640 (mail) (www):

Doctors will be getting squeezed on reimbursements for end of life care plus they will be getting kickbacks from the government to encourage people for forgo care. I think we all know where this will lead. At the very least people will need to be prepared to accept the decision of the rationing board.

I'm not sure this provision will definitely lead to where you say it will. Still, the provision strikes me as rather inauspicious.

Just because you're paranoid doesn't mean they're not all out to get you.
8.8.2009 3:09pm
byomtov (mail):
On the far right, this is being portrayed as a plan to force everyone over 65 to sign his or her own death warrant. That's rubbish.

This is the main, overwhelming, point. When some conservative commentators start admitting this, and calling those who claim otherwise what they are - rabble-rousing liars - we can discuss these sorts of subtleties.

No criticism from anyone who disagrees with that point can be considered as being made in good faith.
8.8.2009 3:15pm
Curious Passerby (mail):
I think we need end of life care for this bill. Blame the recession, the mobs in the streets, whatever, and tell Obama and Co. that we've got to pull the plug and move on.
8.8.2009 3:30pm
Brian K (mail):
Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren't quite "purely voluntary," as Rep. Sander M. Levin (D-Mich.) asserts. To me, "purely voluntary" means "not unless the patient requests one." Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that's an incentive to insist.

So in other words, doctors will get paid for performing the standard of care. as i was trained, when you give someone bad news you 1) explain all of the treatment options to them (this includes the option of doing nothing) and 2) ask them what they want and plan to do. the second part is termed end of life care for people with terminal illnesses or who are not expected to live longer than 5-10 years or so. and yes, this often is initiated by the doctor.

so basically all this provision does is make sure physicians get paid for often long and emotionally difficult discussion they should be and are having already.

Patients may refuse without penalty, but many will bow to white-coated authority. Once they're in the meeting, the bill does permit "formulation" of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would "place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign," I don't think he's being realistic.

i think this guy is being overly biased and inflammatory. end of life care can refer to anything between "i want everything done to help me" to "do not resuscitate/do not intubate". referring to end of life care documents as a "plug pulling order" is a cue that this person is not arguing in good faith.
8.8.2009 3:39pm
Brian K (mail):
Doctors will be getting squeezed on reimbursements for end of life care plus they will be getting kickbacks from the government to encourage people for forgo care.

do you have any proof of these "kickbacks"?

i think you should put your tin foil hat back on...
8.8.2009 3:43pm
Dan M.:
Of course people over 65 aren't going to have to sign their own death warrants. They're just going to be encourage to forgo treatments. The less people that actually decide to go forward to only get denied by the rationing board, the better. But hey, the less that actually brush off the advice of the doctor, the better odds for those that actually do try to get care.
8.8.2009 3:45pm
Brian K (mail):
I want to echo the statements made by others above that the incentive does not lead to physicians pressuring patients to forgo care.

physicians are either paid on a per patient basis or on a per procedure basis. both result in loses to the doctor if the patient dies.

the only way this would make sense is if everything conservatives have been saying about incentives and the free market is wrong.
8.8.2009 3:47pm
Brian K (mail):
dan,

so in other words, you have no proof and it's just fanciful thinking on your part? gotcha.
8.8.2009 3:48pm
Oren:

But while she was there the ER doc very hamhandedly suggested she may want to consider a do not resuscitate directive "in case something goes wrong."

Think of it in the other light -- if she absolutely never wants to be taken off life support, filling out a living will ensures that her children don't chose for her.


But hey, the less that actually brush off the advice of the doctor, the better odds for those that actually do try to get care.

Isn't that exactly the point? That not every person wants to prolong his death?
8.8.2009 3:57pm
RPT (mail):
It should be noted that Hans Bader is a Republican judicial activist/corporate lobbyist who believes that everything that has occurred since January 20, 2009 is heinous.
8.8.2009 4:04pm
Dan M.:
Brian

Doctors will be getting extra money to introduce end of life care options in the course of a doctor's visit that they'll already be getting paid for. So they're getting extra money to encourage people to behave in such a way that saves the insurance companies money.

Encouraging people with "low productivity" to forgo care = profit for government. Sharing that profit with doctors = kickbacks.

You know, when the doctor is actually giving people advice about how to stay healthy, that makes sense. It wouldn't seem corrupt to me for an insurance company to provide financial incentives to specifically give dietary advice, which saves the insurance company future health care costs and benefits the health of the patient and keeps their premiums low. But when the advice is intended to reduce the demand for life-saving treatment by simply encouraging people to forgo said treatment, I don't know what else you can call it.
8.8.2009 4:08pm
NowMDJD (mail):
Where I come from (I'm a gynecologic oncologist) it's considered good medical practice to discuss end-of-life choices, living wills, and health care proxy (durable power of attorney in some states) with patients. This is best done when a terminal event is not imminent, so that decisions can be made rationally. It's best if a trusted friend or relative is part of the discussion.

As for incentives, doctors' monetary incentives usually are to prolong care, as has already been noted. But hospitals may be payed on a per-case basis, and may have an incentive to see the patient die sooner, depending on the type of insurance and the terms of its contract with the hospital.

I can't say whether or not the goal of the bill's sponsors is to create a general policy of euthanasia for the medically expensive elderly. (I strongly recommend Children of Men, by P.D. James, a novel as good as the movie was bad, which (among other things) this issue is explored.) In the contemporary US, the opposite phenomenon is a greater concern-- people being maintained alive who suffer greatly thereby (or who are irreversibly comatose) but whose medical care is determined by the psychological needs of the family or by reluctance of doctors-- for whatever reason-- to withhold treatment that preserves life in people who don't want their lives preserved. .
8.8.2009 4:10pm
Brian K (mail):
Doctors will be getting extra money to introduce end of life care options in the course of a doctor's visit that they'll already be getting paid for. So they're getting extra money to encourage people to behave in such a way that saves the insurance companies money.
1) you are making the erroneous and rather silly assumption that end of life care automatically entails forgoing care. this fact alone shows that you just repeating without thinking.
2) doctors are paid per visit not based on the length of time they actually spend with the patient but based on the length of time the insurance company thinks the doctor should have spent with the patient. i've seen end of life discussion that have easily lasted for an hour or more in addition to all the other stuff that happened during that patient encounter. how much did the doctor get paid for? 15 minutes. they are at most getting paid for part of it, if any at all. please bring yourself back into reality before making comments.

Encouraging people with "low productivity" to forgo care = profit for government. Sharing that profit with doctors = kickback
you still haven't shown any proof of "kickbacks". why is that? oh, it's because you don't have any.
8.8.2009 4:25pm
24AheadDotCom (mail) (www):
If anyone wants to resolve these issues, instead of going to public meetings and ranting, use this plan to go ask those named in the article questions.

Of course, that has to be done in the right way. The standard way from Obama's supposed opponents would be to just ask them to respond to the article, or to rant, or other things like that. Something better would point out contradictions, things that could wrong, etc. and would be structured in a way that would anticipate any stock response.

And, ask those opposed to the bill why they're not encouraging people to do things like that.
8.8.2009 4:46pm
Oren:

But when the advice is intended to reduce the demand for life-saving treatment by simply encouraging people to forgo said treatment, I don't know what else you can call it.

Did it ever occur to you that many people, myself emphatically included, want (nay, demand) the cessation of life-saving treatment under certain conditions?

Encouraging people to think about their death and make a rational decision about what level of care they want sounds like a winner no matter how you slice it.
8.8.2009 4:49pm
Dan M.:
End of life care entails forgoing life-saving treatment or caring for people for which there is no life-saving treatment. What am I missing?

Why are you talking about how much they get paid for general doctor visits? They're going to be getting EXTRA money to discuss end of life care.

Doctors are going to get squeezed into encouraging hospice care and other alternatives to life-saving treatment because the rationing boards are going to say no and the reimbursements for continued care are going to be low and the government will give them sweeteners to push it.

How are doctors going to lose money by losing a patient when doctors will be in short supply and one less patient simply opens up the schedule?
8.8.2009 4:52pm
Dan M.:

Did it ever occur to you that many people, myself emphatically included, want (nay, demand) the cessation of life-saving treatment under certain conditions?


So you think the government mandates are only going to involve discussion of when to pull the plug?
8.8.2009 4:56pm
nicehonesty:
No criticism from anyone who disagrees with that point can be considered as being made in good faith.


It should be noted that Hans Bader is a Republican judicial activist/corporate lobbyist who believes that everything that has occurred since January 20, 2009 is heinous.


I think these two comments pretty well encapsulate why fewer and fewer people are willing to waste any of their time trying to discuss issues with Democrats.
8.8.2009 5:03pm
Bill Harshaw (mail) (www):
I wonder how many of the commenters have their appropriate end of life documents prepared and in order? Or, like most of us, are they succumbing to the fantasy we'll live forever as a able-bodied sentient person?

After we require all the Dems in Congress to read the bill before they vote on national health vote, I for one would require every Rep who wants to vote to produce his living will, durable power of attorney, etc. etc.
8.8.2009 5:04pm
Mac (mail):

Fallacist:
I agree that physicians would have a monetary incentive to conduct such consultations, but I don't see that their incentive would be to push people into refusing procedures or going into hospices


As I understand Obama, the "Reform" would change payment/reimbursement to physicians from one of Pay for each procedure to one that pays the physician for the outcome. The physician would have a strong financial incentive to urge and encourage a DNR as he won't be paid for all the care he provides otherwise. At least, this is my take on a Bill that no one in Government, clearly including Obama, seems to have read or understand.

Also, I have never seen a Doc do the counseling themselves. That is normally handled by a social worker or nurse or other staff. I won't say it has never been known to happen, but Living Wills and DNR counseling is left to other folks who understand it, as a rule, a whole lot better than any Doc. Doctors are really not comfortable in discussing this and have very little practice with it. They are way too busy, among other things, to spend the time on a non-medical matter like this.

It is a very bad idea for the Government to be involved in this in any way. Too much of a conflict of interest.
8.8.2009 5:07pm
Richard Allen (mail):
Perhaps the best analogy as to the kind of pressure that might be felt by the elderly is to be found in the body of law concerning school prayer.
8.8.2009 5:12pm
Mac (mail):

After we require all the Dems in Congress to read the bill before they vote on national health vote, I for one would require every Rep who wants to vote to produce his living will, durable power of attorney, etc. etc.



Amen! Starting with Ted Kennedy.

Then we require every member of Congress to sign an irrevocable commitment to only use the "public option" for themselves and any dependents forever and for all of the Democrat special interest groups like the unions who, among others, are curiously exempted from this wonderful Bill.
8.8.2009 5:12pm
Ak:

In the contemporary US, the opposite phenomenon is a greater concern-- people being maintained alive who suffer greatly thereby (or who are irreversibly comatose) but whose medical care is determined by the psychological needs of the family or by reluctance of doctors-- for whatever reason-- to withhold treatment that preserves life in people who don't want their lives preserved



This is absolutely correct. I'm a card carrying Republican (or at least I was), but anyone who is arguing what Anderson is arguing on this subject has no experience with how people die in modern America. Period.

In virtually every other country in the world people go along, reasonably healthy in peaks and valleys until their time comes and they shuffle off the mortal coil in a (hopefully) brief and painless period. Here death is a multi-year event involving lots of invasive testing, perhaps a tube in the stomach for feeding, dozens of medications while being warehoused in a nursing home and eventually progressing to a stay in the ICU on pressors and a ventilator, devoid of any awareness with the limiting factor being the ability to convince the family that when breathing, eating, drinking and heart function are all being performed by machines indefinitely, perhaps the person isn't actually alive in any real sense anymore.

Most old folks have enough sense to not want this, the key is getting them to say so before their children who feel guilty about not visiting for the past 5 years have the chance to demand "everything be done!". So yes, I support this idea.
8.8.2009 5:14pm
Michelle Dulak Thomson (mail):
Richard Allen,

Perhaps the best analogy as to the kind of pressure that might be felt by the elderly is to be found in the body of law concerning school prayer.

Yes, exactly. (And I admire very much your reticence here.)
8.8.2009 5:37pm
Bob from Ohio (mail):

I'm a card carrying Republican (or at least I was)


Why do people include this type of comment? Its very common right before elections where the person is voting for the liberal because the conservative is evil/wrong/foolish etc. and the person has "seen the light".

I assume its not true and ignore the comment/post/statement as a result.
8.8.2009 5:39pm
Mac (mail):

In virtually every other country in the world people go along, reasonably healthy in peaks and valleys until their time comes and they shuffle off the mortal coil in a (hopefully) brief and painless period. Here death is a multi-year event involving lots of invasive testing, perhaps a tube in the stomach for feeding, dozens of medications while being warehoused in a nursing home and eventually progressing to a stay in the ICU on pressors and a ventilator, devoid of any awareness with the limiting factor being the ability to convince the family that when breathing, eating, drinking and heart function are all being performed by machines indefinitely, perhaps the person isn't actually alive in any real sense anymore.


Ak,

You are not entirely wrong, the devil is though that it is darned hard to tell just exactly when the end has come. I have known a lot of people who went into hospice and had to eventually come out of hospice because they didn't die. Ditto, people who seemed hopeless who recovered and went on to live productive lives for quite a few years longer.

Who knows when it's "the end"? It is not at all as cut and dried as you may think it is.

Also, the question must be asked, how are we going to somehow avoid doing what every other country with socialized medicine does, which is to evaluate the disease and the age of the patient and approve or deny treatment based on that? Posters here say that won't happen. Well, it has happened everywhere else. It quickly becomes rationed care.

We don't have enough doctors now. If nothing changes, the doctor and nurse and other allied health care shortages are just going to get worse. You add more people to the system now and the shortages are exacerbated immediately. When it is "free" people will utilize the system a whole lot more.

As for the concerns of the "elderly', although 65 doesn't seem so elderly anymore, Obama has already said he is cutting Medicare and Medicaid to pay for this public option. If a Republican said he was going to do this, the screaming would be so loud you would go deaf from the decibel level. So, he is cutting health care for the elderly and the poor to pay for this.

I think anyone who is "elderly" is quite justified in being concerned about this due to comments Obama and others around him have made regarding it not being discrimination to deny health services to someone who is 65 to give it to someone who is 25 because, I think this is how the quote went, "all people were 25 once". Yeah, that's a little scary, I think..
8.8.2009 5:44pm
Mac (mail):

(I strongly recommend Children of Men, by P.D. James, a novel as good as the movie was bad, which (among other things) this issue is exploredNow




MDJD,

Interesting. I thought that this was the worst novel she ever wrote and one of the worst I ever read. I will note that she has not gone back "there" again, but has returned to the subject matter and genre she for which she is so noted and loved.

Just adding my thoughts here. I am glad you were able to enjoy it.
8.8.2009 5:57pm
jukeboxgrad (mail):
Lane said this:

Indeed, the measure would have an interested party -- the government -- recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations.


Really? Where does the bill say the government will "recruit doctors?" It doesn't. It just says that end-of-life counseling is defined as a reimbursable medical service.

And where does the bill say that end-of-life counseling is defined as an effort "to sell the elderly on living wills, hospice care and their associated providers, professions and organizations?" It doesn't. As factcheck has pointed out, "consultations like this are treatment-neutral." And this is reflected in the language of the bill, which calls for a continuum of options to be discussed, and not only "living wills, hospice care and their associated providers, professions and organizations." So Lane is making various claims that are not supported by the actual language in the actual bill.

And Lane said this:

I have a living will and a durable power of attorney for health care. I'm glad I do. I drew them up based on publicly available medical information, in consultation with my family and a lawyer. No authority figure got paid by federal bean-counters to influence me. I have a hunch I'm not the only one who would rather do it that way.


Lane didn't need the services of an "authority figure … paid by federal bean-counters" because he could afford to hire his own "authority figure" ("a lawyer"). People "who would rather do it that way" will remain free to do so, if they can afford it. What's so sinister about making this same counseling available to people who currently can't afford it on their own?

And what's with the paternalistic attitude that worries about people being subjected to undue "influence" by an "authority figure?" I think Americans can be trusted to hear counseling from an "authority figure" and then make up their own minds. Suddenly lots of conservatives seem to have adopted the belief that Americans are ignorant puppets who need to be protected from undue "influence" by an "authority figure." How ironic. After all, knowledge is a dangerous thing, and we're better off if we have less information about our options.

ka:

if the link doesn't get you to section 1233, search the data base using H.R. 3200


You provided a temporary thomas link, so it expired and doesn't work anymore. A regular thomas link to the bill is here. Also available in pdf.
8.8.2009 6:07pm
Dan M.:
Well, is it discrimination to deny driver's licenses to 10 year olds because they are presumed to eventually turn 16? It's a tough question with regard to health care; I just don't think it's the role of government.
8.8.2009 6:11pm
Michelle Dulak Thomson (mail):
Ak,

It's trivially easy to reduce spending on end-of-life care: You just don't try to heal anyone who looks like s/he's in serious danger of dying. Amazingly, the fraction of healthcare spending devoted to "the last six months of life" will plummet.

(So, of course, would the US's notoriously mediocre infant mortality stats.)

I am not trying to say that Obama or anyone on his healthcare team is actually advocating this; on the other hand, people who think it's a neat idea to have a candid little talk with the old and the sick, with suggestions that they think about do-not-recusitate orders and so on, do creep me out just a bit.
8.8.2009 6:11pm
Brian K (mail):
dan,

your posts are based on so many unfounded assumptions i don't know where to begin...

a good beginning would be for you to provide proof of your statements. and, no, saying "the voices told me it is that way" only means you need to go back on your meds.

Why are you talking about how much they get paid for general doctor visits? They're going to be getting EXTRA money to discuss end of life care.

they will be getting paid for a service that they now don't get paid for. i have no idea how conservatives can be against paying for something that doctor's were previously forced to do but not paid for.

before this charade of debate continues, provide proof that your claims are even remotely based on reality.
8.8.2009 6:14pm
Oren:

End of life care entails forgoing life-saving treatment or caring for people for which there is no life-saving treatment. What am I missing?

What you are missing is the fundamental part where each individual's end-of-life care will be determined by his own preferences.

This requires that we get those preference written down in a durable fashion before your brain turns to mush (an unfortunate but inevitable side effect of being thinking meat).
8.8.2009 6:26pm
Oren:
MDK, withholding EOL care is limited to those that have affirmatively consented to the regimen of treatment while still competent to do so. That would no doubt exclude infants.


on the other hand, people who think it's a neat idea to have a candid little talk with the old and the sick, with suggestions that they think about do-not-recusitate orders and so on, do creep me out just a bit.

(1) Part of the point of the program is to do this before the person is sick so they can approach the question rationally.

(2) What's wrong with thinking about whether you want a DNR? I mean, surely just considering the issue (even without deciding) is preferable to never even having had it cross your mind.

And for those that are creeped out by DNRs themselves (as opposed to merely considering or conversing about them), you can take the opportunity to file a living will/ medical power of attorney that specifies that you want to be kept alive at all costs. Win/Win.
8.8.2009 6:32pm
Dan M.:
They are getting paid for the patient's visit, and then getting an extra sweetener to bring up topics that the government thinks will save them money, with the government mandating everything they have to talk about. How hard is that to understand? The only assumption that I am making is that health care reform has the purpose of covering everyone while reducing costs. All else follows from that premise. How does paying extra for something that they weren't pay for before reduce costs while expanding coverage if it doesn't ultimately reduce the amount of care provided?
8.8.2009 6:33pm
jukeboxgrad (mail):
people who think it's a neat idea to have a candid little talk with the old and the sick, with suggestions that they think about do-not-recusitate orders and so on, do creep me out just a bit.


People who think it's a neat idea to sweep these issues under the rug until it's too late for the sick person to participate creep me out just a bit. Likewise for people who think adults can't be trusted to make wise decisions for themselves, and are instead going to simply succumb to someone else's "suggestions."
8.8.2009 6:33pm
Oren:

You are not entirely wrong, the devil is though that it is darned hard to tell just exactly when the end has come.

Which is why the person, while still of sound mind and body, should enumerate clearly the criteria by which to decide exactly when his end has come.
8.8.2009 6:34pm
byomtov (mail):
I think these two comments pretty well encapsulate why fewer and fewer people are willing to waste any of their time trying to discuss issues with Democrats.

If making up a lot of nonsense and then repeating it loudly is your idea of discussion then I'm just as glad you have that attitude.
8.8.2009 6:36pm
Oren:

They are getting paid for the patient's visit, and then getting an extra sweetener to bring up topics that the government thinks will save them money

Maybe you still don't get it. The "topic" is really a question, to wit, "what sort of EOL care do you want?". "Everything you got" is an accepted answer.


How does paying extra for something that they weren't pay for before reduce costs while expanding coverage if it doesn't ultimately reduce the amount of care provided?

Because some people (like myself) have a genuine preference for minimal EOL care but (unlike myself) do not have that formalized in a legal document.

In those cases, we are actually providing care against the will of the patient if only they could speak to let us know. Eliminating that care (that the patient doesn't even want) will save money.

This isn't really all that hard to understand -- we want people to make an informed decision and give their consent in advance. It's just as bad to keep someone alive when they would have wanted to die than to withhold care from someone that would have wanted to live.
8.8.2009 6:38pm
Mac (mail):

What you are missing is the fundamental part where each individual's end-of-life care will be determined by his own preferences



Oren,

Have you always had such absolute faith in the US Government and their good intentions and promises?

Imminent Domain comes to mind. As well as the drug laws that allow the Government to seize the property of an individual even if they, clearly in all innocence and without their knowledge, aid or assist someone who is carrying drugs. I am reminded of the guy who had a private plane charter service who got his plane taken away because the guy to whom he provided, for a fee. a ride, was a drug dealer and, I believe, had drugs on him.

If it can be abused, and the Government has a motive to abuse, I can't put my faith and trust in them. Too many examples where they have abused citizens or tried to do so.
8.8.2009 6:41pm
David Hardy (mail) (www):
I recently have had some experience with a similar federal mandate. Every time I went to a hospital, I was asked if I had a living will (i.e., provision for who would make the non-treatment decisions if I wound up incapacitated to make them).

It was so predictable that I decided to have some fun. A week or so ago I went in for a CATScan. The receptionist asked if I had a living will. I gave her a suspicious look and asked, "Is there something about this test that you haven't told me?" She got a bit flustered.

I am told by a friend that the drafters of the reg forgot to exclude psychiatrist hospitalizations. So if a horribly depressed person is brought in after a suicide attempt, they must be asked if they have a living will, and if the answer is no, told how such a document would, in the event they wind up in a brain dead vegetative state during their treatment, allow someone to turn off their life support

Many think this is a poor beginning to treatment of extreme depression.
8.8.2009 6:43pm
Michelle Dulak Thomson (mail):
Oren,

MDK, withholding EOL care is limited to those that have affirmatively consented to the regimen of treatment while still competent to do so. That would no doubt exclude infants.

There doesn't appear to be a "MDK" on this thread, so I'm not sure whether this is meant for me or not. I would just say that positive euthanasia in the Netherlands is supposed to be only at the patient's consent also; and yet everyone seems to agree that disabled infants are routinely euthanized.

jukeboxgrad,

People who think it's a neat idea to sweep these issues under the rug until it's too late for the sick person to participate creep me out just a bit. Likewise for people who think adults can't be trusted to make wise decisions for themselves, and are instead going to simply succumb to someone else's "suggestions."

I see. Adults can be trusted to "make wise decisions for themselves"; nonetheless, we really ought to, um, encourage them to make them, because otherwise the wise deciders might not think to do it?
8.8.2009 6:48pm
Mac (mail):

Which is why the person, while still of sound mind and body, should enumerate clearly the criteria by which to decide exactly when his end has come.



Oren,

Somebody has to decide what to do and what DNR covers. This is not in the Bill. Even if the person has signed a DNR it may easily be interpreted to include things that neither the patient or the person assisting them ever contemplated.

Examples, even though clearly not included in a DNR, I have personally had to argue with a DON to do the Heimlich on a patient who was choking on his dinner. She thought that DNR means not even when choking. She was wrong, but see how easily it can be misinterpreted? I have seen health care people try to deny someone antibiotics because they have a DNR even though antibiotics are not an extreme life continuing measure. (I am excluding Hospice, in this example.) I have other examples, but I think you get my point.

Since so much in this Bill is "to be written and clarified later, who knows what they will decide are extreme measures? Things are always a lot simpler when you don't know much about them. Just consider people's ignorance of the law.

I have seen the DNR abused enough times, that I won't ever sign one myself. I have talked with my family about what I want and will trust them to carry out my wishes. But, I am not signing a bland check to be "offed". I am even less likely to give the Government a blank check to "off" me so they can save money.

Also, when one is faced with death, life often becomes a lot more important. We don't even know, really, if they will let you change your mind. You have to have a lot of faith in your Government to do what you want them to do. I don't have it.
8.8.2009 6:56pm
Dan M.:

What you are missing is the fundamental part where each individual's end-of-life care will be determined by his own preferences.


Well, it will be decided by the individual after prodding from the doctor during the discussion and then it will be carried out if the rationing board approves. The only way to limit rationing is to limit demand for life-saving care.


Maybe you still don't get it. The "topic" is really a question, to wit, "what sort of EOL care do you want?". "Everything you got" is an accepted answer.


Surely he doesn't need extra money from a doctor visit just to ask a simple question. We both know it'll be a lot more complicated than that when the government's paying and the government's mandating everything that must be covered. "Everything you got" is NOT an accepted answer. The doctor will not be compensated if you do not sit through the entire lecture about the options available which the government mandates that he discuss to receive compensation.

In those cases, we are actually providing care against the will of the patient if only they could speak to let us know. Eliminating that care (that the patient doesn't even want) will save money.

This isn't really all that hard to understand -- we want people to make an informed decision and give their consent in advance. It's just as bad to keep someone alive when they would have wanted to die than to withhold care from someone that would have wanted to live.


No, the government wants them to forgo potentially life-saving treatment so that we can save tax dollars. They only want them to make an 'informed decision' because the government has the incentive to inform in such a way that your informed decision is most likely the decision that they wanted you to make.

Then maybe we'll have the government mandating that pregnant women will be given testing for birth defects and then the doctor will be given a sweetener to give her "all the information" and we just assume that she'll make the "right decision" that will save the government money.
8.8.2009 6:57pm
santa monica (mail) (www):
In a way, this whole debate just astonishes me, since the one thing that is clear is that these EOL conversations would be done at the wishes of the patient.

In other words; more options for the patients. In other words; government *not* getting between you and your doctor. You want to confront end of life issues, but can't afford it? Now you'll be able to do it. Don't want to have that conversation? No problem--just don't avail yourself.

One of the most oft-repeated arguments about more govt. involvement in health care is that we will have fewer choices. The fact that this particular provision is being used as "evidence" of unwanted govt. involvement is, frankly, bemusing to me. The irony is so thick I can cut it with a knife.

I actually suspect that the *real* reason this provision is so controversial is what Michelle (5:37) alluded to. Conversations of this type are really creepy and uncomfortable for many people. For those of us who think a provision like this is an extremely good idea, it might help to acknowledge that almost everyone opposing it is not arguing from bad faith. Their concerns are based on some deep-rooted feelings (and ones that these people may not be aware of), and they are impacting their views. My own family's experiences with death have undoubtedly colored my own perceptions of this issue.

One only has to look at the number of people who do not have wills, or (in spite of being in favor of organ donation) do not take the 30 second to fill out the "opt-in" part of their driving license, to see examples of closing our eyes to some of the ugly realities in our lives, and to some of the unpleasant decisions we have to make--or will have to make--for ourselves or our loved ones.
8.8.2009 7:14pm
jukeboxgrad (mail):
mac:

If it can be abused, and the Government has a motive to abuse, I can't put my faith and trust in them.


Now you tell us. I don't remember you singing this tune when Bush told us "the Government" would never, ever wiretap someone who wasn't a terrorist. Or that we would never, ever torture anyone. Or that we would never say we were sure Saddam had WMD unless were sure Saddam had WMD.

I think you're perfectly happy to put lots of "faith and trust" in "the Government," if you happen to like the guy in charge at the moment.

================
michelle:

everyone seems to agree that disabled infants are routinely euthanized [in the Netherlands]


I think you're using certain words quite loosely. Like "everyone" and "routinely." I hope you'll tell us what you mean by "routinely," and I hope you'll show evidence to support your claim.

I see. Adults can be trusted to "make wise decisions for themselves"; nonetheless, we really ought to, um, encourage them to make them, because otherwise the wise deciders might not think to do it?


Nonetheless, we really ought to, um, pay attention to what the bill actually says. The bill doesn't call for anyone to "encourage" anyone to do anything. It simply defines end-of-life counseling as a reimbursable medical service. Period. Which means that if a doctor and a patient agree for this service to be provided, that the expense is reimbursable. Period. And if the patient has no interest in such counseling, then there will be no such counseling, and the world will not come to an end.

You have stretched the word "encourage" beyond recognition. Just like you did with "everyone" and "routinely."
8.8.2009 7:43pm
Michelle Dulak Thomson (mail):
santa monica,

You want to confront end of life issues, but can't afford it?

By all means, set up free living will services and put them in the phone book. That will ensure that anyone who wants such services will have access to them, any time.

What creeps me out, to use my own phrase, is taking the extra step of putting a bug in one's PCP's ear suggesting that now would really be a good time to have that little talk. I find it difficult to believe that the point here is only to increase patients' knowledge of options. It has been the lament of the healthcare reform side for a long time that people are far too well aware of their options (via prescription drug ads, &c.), and would be better off knowing less.

I actually suspect that the *real* reason this provision is so controversial is what Michelle (5:37) alluded to. Conversations of this type are really creepy and uncomfortable for many people.

Well, yes and no. I am not squeamish about thinking of my own death. I am squeamish about setups that are designed to encourage people to forgo healthcare for the sake of their relatives' inheritance or, for that matter, the Greater Economy.

Does anyone imagine this provision is in the bill with the expectation that people thus made aware of their options will ask for more care? Or that the purely voluntary consultation will be genuinely voluntary? If I go to the public library and check out a random book from the shelves, that may be said to be a voluntary act. If my physician were to say "You really ought to read ________" each time I saw her, and moreover pushed a copy into my hands at no charge, I am not sure that we are quite in the same territory.
8.8.2009 7:53pm
Constantin:
Now you tell us. I don't remember you singing this tune when Bush told us "the Government" would never, ever wiretap someone who wasn't a terrorist. Or that we would never, ever torture anyone. Or that we would never say we were sure Saddam had WMD unless were sure Saddam had WMD.

I think you're perfectly happy to put lots of "faith and trust" in "the Government," if you happen to like the guy in charge at the moment.


Barack's still doing the wiretapping, FYI. And doesn't this whole filibuster make you a hypocrite, too? Because I don't see you singing this tune about health care, though I'm quite sure you were during the war, etc. It's almost like you're perfectly happy to put faith in the government because you like the guy in charge right now. That's fine, but let's see what tune you're singing when Mitt Romney or Sarah Palin (gasp) is deciding whether you get that wisdom tooth pulled in a few years.

Keep your laws off my body.
8.8.2009 8:01pm
Ak:

I am not trying to say that Obama or anyone on his healthcare team is actually advocating this; on the other hand, people who think it's a neat idea to have a candid little talk with the old and the sick, with suggestions that they think about do-not-recusitate orders and so on, do creep me out just a bit.


Yes, well, that's most likely because you don't actually see the sausage being made in the factory. Questions about what life sustaining measures people want can be uncomfortable (although they really usually aren't). But I guarantee if you had to run codes on terminal cancer patients where you break their ribs with chest compressions, pump them full of epinephrine and then stick a breathing tube down their throat even though you know they're not going to live another day and wouldn't want it done if they had the choice, you'd view it as the far lesser of two evils. Getting people to express their desires ahead of time is a GOOD THING.

I know some people have started bringing families into the room to watch the code being run. I'm definitely mixed on this because it's potentially traumatizing. But it's certainly telling that I hear just about 100% of them stop full code measures after they see it's not at all like television.
8.8.2009 8:04pm
NowMDJD (mail):


Also, I have never seen a Doc do the counseling themselves. That is normally handled by a social worker or nurse or other staff. I won't say it has never been known to happen, but Living Wills and DNR counseling is left to other folks who understand it, as a rule, a whole lot better than any Doc. Doctors are really not comfortable in discussing this and have very little practice with it. They are way too busy, among other things, to spend the time on a non-medical matter like this.

I talk to my patients in general terms about end-of-life treatment instructions and proxies, informing them, in general terms, what this state requires of me if there are no instructions.
8.8.2009 8:07pm
NowMDJD (mail):

In virtually every other country in the world people go along, reasonably healthy in peaks and valleys until their time comes and they shuffle off the mortal coil in a (hopefully) brief and painless period. Here death is a multi-year event involving lots of invasive testing, perhaps a tube in the stomach for feeding, dozens of medications while being warehoused in a nursing home and eventually progressing to a stay in the ICU on pressors and a ventilator, devoid of any awareness with the limiting factor being the ability to convince the family that when breathing, eating, drinking and heart function are all being performed by machines indefinitely, perhaps the person isn't actually alive in any real sense anymore.

This is a caricature of what happens in the US, and a gross idealization of what hapens overseas.
8.8.2009 8:11pm
Johnny Canuck (mail):
Didn't this proposal re paying doctors for end-of-life/ advanced care planning consultation, originate with Republican Senator Isakson, R-GA?

If so, is it Republicans who want to prematurely kill off the elderly?

Obama finds current system deficient in that US life expectancy lower than some other countries? If oldies are killed off, won't this hurt the metric?
8.8.2009 8:29pm
Mac (mail):

Now you tell us. I don't remember you singing this tune when Bush told us "the Government" would never, ever wiretap someone who wasn't a terrorist



jbg,

And, you didn't believe it.. Now, that Obama is continuing to do the same thing, silence from you. Also, we were talking National Security and had just had 3,000 citizens killed. You didn't trust the Government then, but now, as Constantin pointed out, you trust them implicitly.


The ACLU. for all of its trying, to the best of my knowledge, never came up with even one person who had their rights violated by the Patriot Act. I am sure that if I am wrong, I am in the right place to be corrected.

This is not about National Security. It is about my body. As usual, you never addressed the issue I raised about who decides what is an "extreme" measure.

Anyone can get a DNR signed and a Living Will made out for free. That is a straw man argument.

aK,

I know some people have started bringing families into the room to watch the code being run.

Are you sure about that? Besides the family being in the way (by the time you get the Code team in there, you are crawling over each other) and possibly fainting, codes can be somewhat frenetic and things do not always go according to plan i.e. you can't get the ET tube down or the trach back in, or you can't find a vein or artery and so on. As with sausage, most medical people don't want someone watching, especially someone who does not understand that these things happen and who see them and may be quite inclined to sue.
8.8.2009 8:45pm
Mac (mail):

I talk to my patients in general terms about end-of-life treatment instructions and proxies, informing them, in general terms, what this state requires of me if there are no instructions.


NowMDJD,

I am very glad and impressed that you do. You are not the norm. Also, that doesn't quite count. When you get down to actually explaining the form and what each and every procedure means, it is far more time consuming and far more real to the patient. That signature thing is what makes it legal and holds you responsible for determining that the patient actually understood.

It gets more complicated when you have family present, as one should, as they are part of the process and it is very important that they understand as well and are very comfortable with the patient's decisions.

Also, that they are comfortable that their loved on understood what you were saying enough to make an informed decision. Doctors, generally are not the ones who do that. In this bill, the Doctor would not have extended family or even immediate family present. That also makes this practice subject to abuse and to charges of coercion on the part of the Doctor. But, then again, they can always sue the Dr. since tort reform does not seem to be a part of this package. I am not sure if the taxpayer will pick up the tab for the payout or if the Doctor will have to pay for doing something he was forced to do by the Government.
8.8.2009 8:56pm
PC:
Keep your laws off my body.

Love, Terri Schiavo.

There's nothing like saying no to big government like the president flying back from vacation to sign EOL care legislation.
8.8.2009 10:12pm
Mac (mail):
aK,

Along with my statement above about why families should not be in the room during a code I have thought of two more instances when it would have been a really bad idea.

At a hospital in my former town, the person with the paddles failed to clear the patient (you know, I'm, you're clear, is everybody clear?) and shocked the patient with the result that they had to call a code for two nurses who were out cold with stopped hearts. You can imagine the chaos in the room what with running three codes at once in the same small hospital room.

I can just imagine a distraught family member grabbing onto dear old Dad at the moment he is being shocked and going down with Dad. After all, a lay person would have no idea what being clear means.

Also, respiratory therapists have the option of continuing to bag a patient while he was being shocked as the bag is not a conductor of electricity. I recall an article in Advance Magazine, I believe, reporting a case where the RT kept bagging and the electricity arched through the 100 percent oxygen of the bag and caught the patient's face on fire and burned the heck out of it.

I don't think having families present at codes is going to catch on anytime soon.
8.8.2009 10:30pm
theobromophile (www):
Some of people's squeamishness with government-run health care, especially with respect to euthanasia/hospice/denial of care for "hopeless" cases is that there is no independent body to whom one can appeal. If an insurance company were to be entirely callous about the lives of the elderly (or the terminally ill), families have the option to bring their grievance to the disinterested government, via a lawsuit. No such pressure to do right by patients exists here.

From a social justice perspective, we understand that elderly people may be vulnerable to coercion, feel as if they do not have a good support system around them, and are often depressed (in general, and especially after the death of a spouse). Many will not react to an end-of-life discussion the same way that they would at a younger age; they are more vulnerable to despair and coercion. The school prayer analogy is apt, as are others involving any vulnerable population.

The system need not be designed to coerce the elderly into making end-of-life choices that are not in line with their actual wishes in order to accomplish that goal (inadvertently, or with respect to some doctors and social workers who will not do their jobs properly). Given that death is irreversible, it's not a benign nor remediable error. Even if it doesn't happen a lot, the question ought to be how much elderly coercion we will tolerate.
8.8.2009 11:27pm
Richard Johnston (mail):
If an insurance company were to be entirely callous about the lives of the elderly (or the terminally ill), families have the option to bring their grievance to the disinterested government, via a lawsuit. No such pressure to do right by patients exists here.



Would that it were true. ERISA precludes any meaningful remedy against an insurance company who wrongfully denies care, including when the denial results in death. This describes the situation pretty well (from a wrongful death case against Prudential after it refused to approve a cancer therapy, and the patient died):

"We echo the words of Judge Porfilio of the Tenth Circuit: 'Although moved by the tragic circumstances of this case and the seemingly needless loss of life that resulted, we conclude the law gives us no choice but to affirm.' Cannon, 77 F.3d at 1271. The Basts' state law claims are preempted by ERISA, and ERISA provides no remedy. Unfortunately, without action by Congress, there is nothing we can do to help the Basts and others who may find themselves in this same unfortunate situation."

Bast v. Prudential Ins. Co. of America 150 F.3d 1003, 1011 (C.A.9 (Wash.),1998)

Note this was not because Prudential was not wrong, it was because even if Prudential was wrong there was nothing the court could do -- "ERISA provides no remedy."
8.8.2009 11:40pm
Richard Johnston (mail):
Adding to my previous post above:

Note as well the Basts had insurance, or at least thought they did. It turned out they had an unenforceable piece of paper saying Prudential would cover their care if it felt like it. In my opinion add everyone who gets their insurance through their employment to the ranks of the uninsured, because like they Basts they do not have insurance -- they only think they do.
8.8.2009 11:58pm
Oren:

Have you always had such absolute faith in the US Government and their good intentions and promises?

If you are really this paranoid, you probably shouldn't entrust your care to any doctor or hospital in the first place. After all, they can intentionally make you very sick if it were in their interest to charge your insurance for weeks and weeks of intensive care.
8.9.2009 12:13am
Oren:

There doesn't appear to be a "MDK" on this thread, so I'm not sure whether this is meant for me or not.

I thought it was fairly unique.


I would just say that positive euthanasia in the Netherlands is supposed to be only at the patient's consent also; and yet everyone seems to agree that disabled infants are routinely euthanized.

I have never heard that claim. According to Wikipedia, the law does not include anyone under the age of 12 for any reason whatsoever.


I see. Adults can be trusted to "make wise decisions for themselves"; nonetheless, we really ought to, um, encourage them to make them, because otherwise the wise deciders might not think to do it?

Because otherwise their brain might turn to mush before they've written down their decision. And then someone else has to decide for them, which is decidedly less good than deciding for yourself.
8.9.2009 12:16am
Oren:

Somebody has to decide what to do and what DNR covers. This is not in the Bill. Even if the person has signed a DNR it may easily be interpreted to include things that neither the patient or the person assisting them ever contemplated.

You can write a living will that is as specific as you chose -- DNR for brain trauma but not heart trauma unless ....

If you want to be extra-careful, you can assign medical power of attorney to a trust loved one to be sure that your instructions are carried out accurately.

The point is that if your brain goes to mush without one of these things, someone is still going to have to decide when to pull the plug on you anyway. How could it be a bad thing to give your spouse/sibling/child some extra guidance?


I have seen health care people try to deny someone antibiotics because they have a DNR even though antibiotics are not an extreme life continuing measure. (I am excluding Hospice, in this example.) I have other examples, but I think you get my point.

That sounds to me like all the more reason to invest in (a) training and (b) a more detailed DNR-form that is specific to what sorts of treatments the patient wants.


Since so much in this Bill is "to be written and clarified later, who knows what they will decide are extreme measures? Things are always a lot simpler when you don't know much about them.

Yes, it's hard to do. But doing nothing doesn't make it any easier -- it means more of the same: imprecise DNRs, "intestate" vegetative folks, disputes over who has medical proxy, etc...


I have seen the DNR abused enough times, that I won't ever sign one myself. I have talked with my family about what I want and will trust them to carry out my wishes. But, I am not signing a bland check to be "offed".

Perhaps then we can agree on this -- everyone offered a EOL-directive under this plan will have the option to designate a medical proxy (or a list) who must consent to any withheld treatment. IOW, the directive would then be guidance to the medical proxy, who will have power to execute it, as opposed to hospital staff.


Also, when one is faced with death, life often becomes a lot more important. We don't even know, really, if they will let you change your mind.

Isn't that all the more reason to write down your preference when you are still healthy and rational?
8.9.2009 12:30am
Oren:

Well, it will be decided by the individual after prodding from the doctor during the discussion and then it will be carried out if the rationing board approves.

And I'm sure helpful folks like you will give out easy to sign &notarize forms demanding full treatment. If the doctor prods too hard, you hand him the form and walk out the door.


"Everything you got" is NOT an accepted answer.

I beg to differ. One of our family friends (Medicare) did, in fact, have a "do everything" directive. She spent 3 months dying in considerable pain.


No, the government wants them to forgo potentially life-saving treatment so that we can save tax dollars. They only want them to make an 'informed decision' because the government has the incentive to inform in such a way that your informed decision is most likely the decision that they wanted you to make.

It is possible -- just possible -- that occasionally the interests of two parties align. Just think about that for a second.
8.9.2009 12:36am
Brian K (mail):
Oren,

I admire your perseverance in these "debates", especially in regards to some of the posters who are clearly arguing in bad faith.

keep fighting for reason and sanity! i however lack both the time and inclination to continue arguing when my "opponents" clearly aren't even bothering to read my posts.
8.9.2009 12:45am
Constantin:
Love, Terri Schiavo.

There's nothing like saying no to big government like the president flying back from vacation to sign EOL care legislation.


Okay, so someone who was for that and against Obamacare is a shmuck. But so is someone who was against that and for Obamacare. And they're in charge now. George Bush doesn't get a vote.
8.9.2009 12:49am
jukeboxgrad (mail):
michelle:

What creeps me out, to use my own phrase, is taking the extra step of putting a bug in one's PCP's ear suggesting that now would really be a good time to have that little talk


What creeps me out is that you seem to be paying no attention whatsoever to what the bill actually says. It says that the "little talk," if both patient and doctor choose to have it, is considered a reimbursable medical service. How does making the "little talk" reimbursable amount to "taking the extra step of putting a bug in one's PCP's ear suggesting that now would really be a good time to have that little talk?" What "bug?" What "extra step?"

I am squeamish about setups that are designed to encourage people to forgo healthcare for the sake of their relatives' inheritance or, for that matter, the Greater Economy.


How does making the "little talk" reimbursable amount to encouraging "people to forgo healthcare for the sake of their relatives' inheritance or, for that matter, the Greater Economy?"

If you think EOL counseling is a bad idea, then I suggest you avoid having any. But if someone else thinks it's a good idea, what's sinister about the government helping them afford it?

Does anyone imagine this provision is in the bill with the expectation that people thus made aware of their options will ask for more care?


This provision is in the bill with the expectation that people who are more aware of their options are going to make better decisions. This notion is radical only to those who think that ignorance is strength.

If my physician were to say "You really ought to read ________" each time I saw her, and moreover pushed a copy into my hands at no charge, I am not sure that we are quite in the same territory.


If your physician ever "pushed" you to do anything, and you happily submitted to being "pushed," then you are a fool, and you have problems that are outside the scope of this discussion. And your problems should not be used as an excuse to make it harder for other people to make informed decisions.

===============
constantin:

Barack's still doing the wiretapping, FYI


FISA changed, FYI. Which means that certain things that were once illegal are no longer illegal. I'm not against wiretapping. I'm against illegal wiretapping. Is Obama doing illegal wiretapping?

doesn't this whole filibuster make you a hypocrite?


What filibuster?

It's almost like you're perfectly happy to put faith in the government because you like the guy in charge right now.


My support for the bill isn't an indication that I'm "perfectly happy to put faith in the government." It's an indication that I've read enough of the bill to realize that the people opposing it are following their usual practice of making things up. The fact that they have to resort to making things up in order to fight the bill tends to create the impression that the bill is devoid of serious problems. In other words, the GOP has provided a kind of inadvertent endorsement.

===============
mac:

Now, that Obama is continuing to do the same thing


Someone else who doesn't understand the difference between legal wiretapping and illegal wiretapping. See above.

we were talking National Security and had just had 3,000 citizens killed


Figure out how many Americans are dying because they lack health insurance and you'll be looking at a much larger number. And let us know if you really don't understand that "National Security" depends on being economically competitive, which in turn depends on having a healthy workforce.

===============
johnny:

Didn't this proposal re paying doctors for end-of-life/ advanced care planning consultation, originate with Republican Senator Isakson, R-GA?


I don't know if he gets sole credit as an originator, but it's true that for years he's advocated "advance care planning." I guess that means he's part of the 'kill granny' gang, although I think no one has ever tossed that charge at him. IOKIYAR.

And apparently he had a role in the 'kill granny' portion of the reform bills that are being discussed:

The doctor is not forced to bring it up, nor is the patient. In fact, an earlier version from Republican Sen. Johnny Isakson was rejected because it would have required an end-of-life consultation before a patient qualified for Medicare.


If the folks with the swastika signs knew this, they would be marching in front of his office, right?
8.9.2009 12:54am
John Moore (www):
It amazes me that there is not one comment recognizing that when the federal government gets into such detail about such personal matters, the federal government is way too far into our lives!

Good grief, people. Do we really want this level of detail about doctor/patient relationships in legislation, created by a deliberative body with a 20% or so approval rating?

If there was ever an argument for limited government, this and the many, many things like it throughout recent legislation contribute greatly.
8.9.2009 3:24am
Pseuss (mail):
Oren writes:

Isn't that exactly the point? That not every person wants to prolong his death?

No the point is that the govt wants to cut costs by encouraging people to choose early death.

By pretending that this is something humanitarian, officials raise red flags in people's minds.
8.9.2009 6:04am
Sarcastro (www):
It amazes me that there is not one comment recognizing that when the free market gets into such detail about such personal matters, the free market is way too far into our lives!

Good grief, people. Do we really want this level of detail about doctor/patient relationships in bureaucratic policies, created by a corporate body with Lord knows what approval rating?

If there was ever an argument limiting the free market, this and the many, many things like it throughout recent history contribute greatly.
8.9.2009 6:09am
Sarcastro (www):
See, the government is totally all about minimizing costs to maximize profit. Thus, it is logical to assume that they will kill old people and handicapped grandchildren of Republicans.

No actual evidence is needed! I know how government works.

Culture of death!!
8.9.2009 6:12am
Oren:

No the point is that the govt wants to cut costs by encouraging people to choose early death.

And in such cases where that was what the person prefers, the interests align.
8.9.2009 6:13am
Pseuss (mail):
Oren writes:

Have you always had such absolute faith in the US Government and their good intentions and promises?


If you are really this paranoid, you probably shouldn't entrust your care to any doctor or hospital in the first place. After all, they can intentionally make you very sick if it were in their interest to charge your insurance for weeks and weeks of intensive care.



You can change doctors if you don't like them, you can't change to a different all-powerful bureaucrat.

You should know that Oren.
8.9.2009 6:14am
Oren:

By pretending that this is something humanitarian, officials raise red flags in people's minds.

You don't have to pretend it's anything.

Like I said earlier, this is just as much an opportunity for the do-everything crowd to make a binding declaration of their will. Otherwise, their ungrateful liberal spouse/sibling/child will be legally empowered to pull the plug!

We need EOL-directives to save these lives!
8.9.2009 6:16am
Sarcastro (www):
Pseuss is both patronizing and correct! Nowadays, people can choose to disagree with and change doctors, but when the doctor gets paid by the government suddenly you have no choice but to listen and do what they say! Do what the good doctor says unto deaaath!

I think the Nazis did this. Or the Commies. Chaves, maybe?
8.9.2009 6:17am
Oren:

You can change doctors if you don't like them, you can't change to a different all-powerful bureaucrat.

First of all, the severely injured can't do anything.

Second, my point was that if Dan believes that doctors and hospitals are out to make a buck on him, they already have ample (and virtually undetectable) methods for doing so.

Third, where exactly does this bureaucrat come in? The thread was about paying doctors to take 30 minutes and discuss EOL care with their patients. No bureaucrat needed.
8.9.2009 6:18am
DiversityHire (mail):
Doctors are going to get paid to dispense legal advice? Is that a tradeoff for having a lawyer (DeParle) get to pull the plug?
8.9.2009 7:43am
jukeboxgrad (mail):
pseuss:

the govt wants to cut costs by encouraging people to choose early death


We're discussing a section of the bill that does this: define EOL counseling as a reimbursable medical service. Period. How is this support for the claim that "the govt wants to cut costs by encouraging people to choose early death?"

And if a private insurance company did the same thing (define EOL counseling as a reimbursable medical service), would you make the same claim, that the insurance company wants to cut costs by encouraging people to choose early death?

And in either instance, what sort of mind control is being used to get an individual to make a choice they don't want to make, when they are perfectly free to choose otherwise? That is, to participate in counseling they don't want to participate in, and sign forms they don't want to sign? When did conservatives adopt the patronizing belief that Americans are mindless automatons who can't be trusted to think for themselves and make wise decisions regarding their own lives? I used to think that conservatives believed the opposite of that. There must have been a switcheroo while I blinked.

By pretending that this is something humanitarian, officials raise red flags in people's minds


Please tell us about all the conservatives who raised "red flags" when Sen. Isakson (R) came out in favor of "advance care planning" in 2005.

=============
diversity:

Doctors are going to get paid to dispense legal advice?


You seem to think that lawyers have a role in EOL counseling, and doctors don't. Let me guess: you're a lawyer. Maybe even one who likes to dispense medical advice.
8.9.2009 9:37am
Toby:
<wicked impulse>
The law really ought to go full circle and offer forgivenees of inheritance taxes on estates that take the DNR option.
</wicked impulse>
8.9.2009 10:42am
pluribus:
Brian K:

i however lack both the time and inclination to continue arguing when my "opponents" clearly aren't even bothering to read my posts.

Your opponents have made up their minds (altogether now, shout "Just say no!") and don't want to be confused by the facts, which you have ably brought into this discussion. I appreciate hearing from a doctor who actually knows what he is talking about.

I have a durable power of attorney for health care and when I went into the hospital recently for an operation that didn't threaten my life I was asked if I had a living will or other advanced care directive. I thought it was a good question. I willingly answered it. Didn't think of "having fun" by trying to confuse the poor admitting clerk who asked it of me that my life was in immediate jeopardy. My DPA, by the way, provides that no heroic means to save my life be used if the diagnosis at the time is hopeless. And I would tell Michelle, um, that what really creeps me out is the special act of Congress passed by the Republicans and signed by GWB designed to prolong the life of poor Terry Schiavo. That one incident more than any other was what really convinced me that I could no longer consider myself a Republican.
8.9.2009 10:44am
Bad (mail) (www):
People really need to stop confusing "everyone else on your insurance policy won't pay for..." with "we will force you to not get."

Insurance policies aren't pacts by which they agree to potentially pay every single dime out of the entire system to grant you eternal life. If you want to pay billions for experimental treatments you can. No one prevents this.

Government healthcare is not substantially different in this way. You pay into an insurance system so that you agree to get a reasonable and mostly pre-determined level of care. Not the entire world building a magical machine to keep your heart beating and your lungs breathing even after you've had the top of your head blown off.

There is a finite amount of money in any insurance system. Spending millions and millions on uncertain treatments for a few patients far beyond any meaningful hope of recovery would bankrupt any insurance system, public or private... then leaving millions of other people without access to standard treatments that would very reliably save their lives.

THAT is what both government and private insurers are taking into account when determining what sorts of care a policy will provide.
8.9.2009 11:20am
patrick joy:
We need to stop reviewing this as a theory on what will happen. Let us look at places where we have current health care plans run by governments that are financially strapped. In England, NHS routinely denies care based on age or health. The overwight, alcoholics, elderly have choices reduced based on cost factors not Dr and patient consultation. That is not the american model. This is why we rail against HMO's interfering with the patient/Dr choices. There is not way we can do this without taking the worst from the HMO model and imposing it on everyone because of cost.

Also look to Oregon which imposed a "single payer" plan in the 1990s. Cost is a big factor in end of life decisions for medicare aged patients. If you are very old and have only a 25% chance of treatment working, Oregon routinely denies care.
8.9.2009 11:45am
Richard Johnston (mail):

People really need to stop confusing "everyone else on your insurance policy won't pay for..." with "we will force you to not get."

Insurance policies aren't pacts by which they agree to potentially pay every single dime out of the entire system to grant you eternal life. If you want to pay billions for experimental treatments you can. No one prevents this.


I am not sure if this is in response to my previous remarks about ERISA gutting meaningful remedies, but just in case: no one is arguing that an insurance company has to pay for anything more than its policy provides. The point here is that if an insurer refuses to do that there is still no remedy, and in practice they only have to live up to the promises they have already made in the policy if they feel like it.
8.9.2009 11:53am
yankev (mail):
The practice of law is traditionally regulated by the judicial branch, not the legislative branch. In Ohio, at least, the state supreme court has jealosuly guarded this power against legislative attempts to define or regulate the practice of law, or to authorize the practice of law by non-attorneys. Where is the congress's consitutional power to authorize doctors to practice law, particularly when the legal documents at issue are governed by state law, and not federal law?
8.9.2009 12:11pm
pluribus:
patrick joy:

We need to stop reviewing this as a theory on what will happen. Let us look at places where we have current health care plans run by governments that are financially strapped. In England, NHS routinely denies care based on age or health

Even if your comments were factual (what's your evidence for "routine" denial based on "age" or "health"?), this comment would be irrelevant. There is nothing in any of the bills now under consideration in Congress that would create anything like NHS, which is a health care system totally owned, operated, and financed by the government. Under all of the proposals now being considered, doctors will still be private health care providers; private insurers will still provide insurance; private hospitals will still provide hospital care. Please confine your comments to reality.
8.9.2009 12:41pm
pluribus:
yankev:

Where is the congress's consitutional power to authorize doctors to practice law, particularly when the legal documents at issue are governed by state law, and not federal law?

Since when is it the practice of law for a doctor to counsel with a patient about health care decisions? As a lawyer, I have no problem admitting that that is well within the purview of the practice of medicine.
8.9.2009 12:43pm
zic (mail):
Having lived through the death of all four grandparents, one parent, and two siblings, I have a different perspective on this.

Doctors are already having those 'end of life' discussions. It's part of their job. It's time they spend with family members and loved ones that's written off. And often, it's done in the extremely stressful environment of a hospital conference room, if you're lucky, the waiting room if you're not.

This bill simply pays them for that time; and allows these conversations to happen in a more sane, reasonable environment and allows time for people and their families to think about what they want.

And I don't see anything wrong with that.

When my father was on life support, against the wishes of his living will, I had to tell them to pull his respirator. Despite his wishes, terminal prostate cancer, and a broken shoulder that they could not repair due to the damage from the cancer. And he started breathing on his own, lived for another year -- with that broken shoulder making every minute a painful one. He later told me he was angry they put the respirator in in the first place, prolonging his agony.

But go ahead and suggests it "nudges." Disinformation is now the conservative weapon of choice.
8.9.2009 12:54pm
SG:
There is nothing in any of the bills now under consideration in Congress that would create anything like NHS, which is a health care system totally owned, operated, and financed by the government. Under all of the proposals now being considered, doctors will still be private health care providers; private insurers will still provide insurance; private hospitals will still provide hospital care. Please confine your comments to reality.

Sure. And the Iraq war will pay for itself.

Meanwhile, the current level of Medicare benefits is unsustainable ("The HI Trust Fund is inadequately financed over the next 10 years. Its assets are projected to fall below 100 percent of annual expenditures during 2011 and to be exhausted in 2017." - 2009 SSA Trustees report)

The burden is on you to explain how we can extend coverage to 47 million more people when we can not afford the current coverage being provided. Whether or not the providers are private isn't the issue, it's what level of coverage can reasonably provided - there are not funds for unlimited coverage, and furthermore cost reductions are a fundamental part of the proposal.

If you assume (per-capita) cost reductions under the public plan and you further assume the providers remain privatized and private insurance continues to largely exist, you're guaranteeing some degree of rationing by the public plan. So what basis will that rationing be done by? I'm guessing it will begin as triage with waiting lists for non-emergency needs by the limited number of overburdened providers willing to accept the reduced reimbursements provided by the public plan.

But it's my guess that won't be politically tenable (at least at first), so there will be laws mandating that all providers accept the public plan on equal footing to private payers. This will end up reducing the utility of private insurance (you won't get better access and you'll be paying the health taxes as well as your insurance premium), so people will start migrating to the public plan. Lather, rinse, repeat. Eventually you wind up with the a de facto single-payer system.

Nor do I doubt that this is the long-run vision of Obama and top Dems - they've stated as much Whether or not you've thought it through, I don't know.
8.9.2009 1:02pm
Dan M.:

"Everything you got" is NOT an accepted answer.


I beg to differ. One of our family friends (Medicare) did, in fact, have a "do everything" directive. She spent 3 months dying in considerable pain.


You're missing the point. The doctor will not receive reimbursement if you immediately answer with "Everything you got" unless he continues to pitch to you all of the other options that the government mandates that he talk about for reimbursement. So he will have a financial incentive to keep talking to you even after you've made your choice unless you tell him to shut the hell up.
8.9.2009 2:07pm
Mac (mail):

I have a durable power of attorney for health care and when I went into the hospital recently for an operation that didn't threaten my life I was asked if I had a living will or other advanced care directive. I thought it was a good question. I willingly answered it.


pluibus,
So, everyone already gets to have this discussion for free. Why do we increase costs by mandating that a Doctor do the counseling? And, 30 minutes? Give me a break. The medical system is going to be so overwhelmed, you would be lucky to get 30 minutes of a Doc's time in 30 visits a year.
Add 47 million people to an already overburdened system and then mandate they do 30 minutes of counseling with every patient on EOL issues. Just brilliant!

As stated above, Doctors generally don't fill out the EOL forms and we spend a lot of time with the family and patient. Why in God's name would you mandate that Dr's do this? If this is the level of intelligence in this bill, I rest my case. Doc's are least suited to do this. They not only don't have law degrees, they don't have counseling degrees either.

The degrees they do have make them very special and unique and make their talents very desirable and it is a whole lot better that they spend their time on healing patients than counseling and filling out EOL forms.

Look at what happened in the so-called stimulus bill and, I believe, the budget. They write an enormous bill with over a 1000 pages and throw in 350 pages at 3 am and vote on it at noon. No one can read it with the changes in particular and no one knows what they are really voting on.

You think this won't be the same way? None of us knows what will end up in this bill at the last minute and a lot of us and most of Congress and certainly the President do not know what is in the bill now.

Add to this the the creepy folks Obama has surrounded himself with like his Science advisor who wrote a text book advocating forced abortions and putting sterilants in the water and who was it who said killing a deformed baby was not the same as killing a person? Sorry, this is creepy and I am not trusting them one iota.



By the way, I personally have no intention of doing everything or even anything perhaps, to stay alive. As ak so well pointed out, you don't want a code blue unless you have a real good chance of surviving and having a good quality of life after because it is really, really awful.

However, even though Brian K et al dismisses me, I have already seen the damn DNR abused mightily. Education is not going to solve the problem.

Let me give you an example. You are perfectly healthy. You go in for hip replacement. They, as they usually do, send you to the Medicare wing of a nursing home for rehab. While there you contract pneumonia or c diff., or MRSA. Happens all the time.

They decide (AND I HAVE SEEN IT HAPPEN), or perhaps buried in this new law, is a ruling that antibiotics are an extreme measures or doing the Heimlich because you are choking is against the DNR. You are perfectly healthy except for the need to get rehab following surgery. The nursing home or hospital makes you sick and then won't treat you because that is how they interpret the DNR or that is how the Gov. changed it when you weren't looking.

We don't know what will come down the pike once this gets going. I'd rather not get it started. To the Government, stay out of my bedroom and out of my hospital room and out of my Doctor's office.
If you want to believe that "I am from the Government and I am here to help you," go ahead. Count me out.
8.9.2009 2:08pm
pluribus:
SG:

Sure. And the Iraq war will pay for itself.

This is just the kind of response I expect from those who want to preserve the status quo at whatever the cost in physical, financial, and emotional suffering for millions of Americans. Some people are making billions, even trillions, off the present health care system, which currently absorbs sixteen percent of the GDP, and is rising steadily faster than inflation. That's trillions of dollars every year as far as the eye can see. And some people are happy to defend the people who are making billions, even trillions, off the present health care system. There is a crying need for reform, and the "just say no" crowd rejects whatever the proposed law says because Bush and Cheney either misrepresented or misunderstood the cost of the war in Iraq. That kind of poisoning the well argument can be used to oppose absolutely everything the government either does or proposes to do. It's fallacious, and it's a transparent and callous defense of the current system.
8.9.2009 2:21pm
Mac (mail):
pluribus,

This bill calls for the creation of 33 new Federal bureaucracies. You really think that will be cheap and will miraculously save money? The bureaucrats all have to justify their positions by coming up with stuff for the worker bees i.e. nurses, doctors and all others involved in direct patient care to do whether it makes any sense or not. I have seen at the VA a one size fits all approach even though we don't do the same jobs the same way and have much different ways in which we get our jobs done. They don't care. All of this is time away from the patient.

Health care costs exploded with government Medicare.

I will repeat my question from above, tell me when the Gov. has ever made anything cheaper and/or more efficient? The Post Office, DMV, Medicare, Medicaid come to mind.
8.9.2009 2:59pm
Richard Johnston (mail):

I will repeat my question from above, tell me when the Gov. has ever made anything cheaper and/or more efficient? The Post Office, DMV, Medicare, Medicaid come to mind.


I don't understand the post office thing. The other day I took a letter, and put it in a little box right outside my house. Someone came and picked it up -- they do this six days a week -- and they are going to deliver it across the continent to a particular place of my choosing. For this they are charging me 44 cents. I think that's pretty efficient. I understand they might cut the service back to five days a week. I still think that's pretty efficient.
8.9.2009 3:18pm
Oren:

So he will have a financial incentive to keep talking to you even after you've made your choice unless you tell him to shut the hell up.


But think about how much satisfaction you will give that killer when you not only foil his plan to off you for cash, but also deny him reimbursement for the discussion!
8.9.2009 3:21pm
Eli Rabett (www):
Oren raises an important point


Like I said earlier, this is just as much an opportunity for the do-everything crowd to make a binding declaration of their will. Otherwise, their ungrateful liberal spouse/sibling/child will be legally empowered to pull the plug!

We need EOL-directives to save these lives!


The real question then becomes who pays? Today, do everything is limited by the insurance policy.
8.9.2009 4:05pm
SG:
pluribus,

Before using me as a stepping stool to climb up on your high horse, you might want to actually ask my opinion.

I do think there needs to be health insurance reform (insurance needs to be divorced from employment in the short-term and over the medium-term advances in genetics will make it cease to be a viable industry), but it's my opinion that the proposed reform will not reduce costs and will increase net human suffering.

What our system does very well (at the cost of lots of money) is create incentives for people to invest in new therapies (drugs, devices, procedures). These new therapies are initially expensive, but they eventually become cheaper.

So while I would like to see costs contained and accessibility improved (and I think there is some role for government in assisting those who can't provide for themselves), I don't want to see the incentives for innovation eliminated - that has the potential to cause unbounded harm due to people suffering from things that could have been helped if only the incentives for innovation had been retained. We may not be at the optimal balance of innovation vs affordability, but the proposal (especially in the likely end state) swings too far in the other direction.
8.9.2009 4:49pm
pluribus:
SG:

I do think there needs to be health insurance reform . . . but it's my opinion that the proposed reform will not reduce costs and will increase net human suffering.


So while I would like to see costs contained and accessibility improved . . . I don't want to see the incentives for innovation eliminated . . .


We may not be at the optimal balance of innovation vs affordability, but the proposal (especially in the likely end state) swings too far in the other direction.

I too would like to see perfect health reform, but knowing that perfect doesn't exist I am willing to settle for good. When a genuine effort is made to reform the health care system that is now causing so much suffering (some in my own family) and reduce the frightening spiral of costs (one-sixth of the GDP quickly escalating ahead of the inflation rate), objections are raised. "This won't work. It will cost too much. The incentives are wrong. Better to do nothing than to make mistakes." I think it was the good Republican senator from North Carolina, Senator Di Ment, who said recently (paraphrasing)that if the Republicans can raise enough objections, the whole effort at reform will fail, and Obama will be tarred with the failure. Objections after objections--the one that started this thread is an example. Paying doctors to counsel patients about end of life health decisions is unacceptable. We have to defeat the bill. The Ohio Supreme Court would never stand for it. I can see through these objections--it is an effort to kill the bill so reform will fail, Obama will fail, and the statuts quo--with the billions and trillions of profits made by the existing insurance companies and provides--will prevail. With all of the ideas that Obama's opponents are now bringing up, I ask why they didn't bring up the ideas when the Republicans were in control of Congress and Bush was president and they could actually have passed them into law. The answer is obvious. Their ideas are merely objections to reform, not genuine efforts to improve health care reform.
8.9.2009 5:51pm
Mac (mail):

I do think there needs to be health insurance reform (insurance needs to be divorced from employment in the short-term and over the medium-term advances in genetics will make it cease to be a viable industry),



SG,



Cease to be a viable industry? Have you ever watched a teen ager or young adult, esp. male, drive? Then there are the Darwin awards for complete, absolute stupidity. Of course, you only get that award if you are dead or otherwise incapable of passing on your genes to offspring.
Then there are drugs and alcohol and drunk and impaired drivers.

I really hope you are correct, but I think we will manage to find ways to still need insurance.

I agree completely with your first sentence above. However, I think part of the problem of getting to genetic medicine has been the FDA. They don't know how to regulate it and it doesn't fit into the mold they are used to, so it may take eons to get them to change and approve genetically engineered drugs or treatments, and by that I mean, treatments geared to each individuals medical problem, just to make myself perfectly clear to the non-medical person.

As for your last paragraph. You nailed it. Innovation and Government are mutually exclusive. There are practically no blockbuster drugs coming out of any country with socialized medicine. Where did I read that the fantastic cancer hospital in Texas, M.D. Anderson spends as much on research every year, all by itself, as does the entire nation of Canada? Welcome to
Government run health care.
8.9.2009 5:52pm
Mac (mail):
Richard Johnston wrote,


I don't understand the post office thing. The other day I took a letter, and put it in a little box right outside my house. Someone came and picked it up -- they do this six days a week -- and they are going to deliver it across the continent to a particular place of my choosing. For this they are charging me 44 cents. I think that's pretty efficient. I understand they might cut the service back to five days a week. I still think that's pretty efficient.


I guess you missed that even though the Government is dealing with a fairly simple set of responsibilities here, the Post Office is GOING BROKE and is going to have to cut back on services (think rationing).

So please tell me how the Government is going to run a highly complex entity i.e. health care, and do it efficiently and save money when they can't run the Post Office without going broke? Those union nurses will really help bring down the cost and improve efficiency, won't they? Just like the union employees at the Post Office have done. NOT!
8.9.2009 6:03pm
Mac (mail):

Objections after objections--the one that started this thread is an example. Paying doctors to counsel patients about end of life health decisions is unacceptable. We have to defeat the bill. The Ohio Supreme Court would never stand for it. I can see through these objections--it is an effort to kill the bill so reform will fail, Obama will fail, and the statuts quo--with the billions and trillions of profits made by the existing insurance companies and provides--will prevail.


Kind of like the Democrats acted when Bush tried to reform Social Security, eh?
They are in charge of everything now, and still won't pass any SS reform legislation and Social Security is still going bankrupt.
Then again, maybe this health care is their idea of SS reform. Off all the old people through socialized medicine and SS cures itself. Brilliant!
8.9.2009 6:07pm
Mac (mail):
PS folks,

We haven't even touched on the fraud and abuse in the current Medicare and Medicaid system, including organized crime. Hmm. Organized crime, health care, now why does that make me think of Chicago?

No tort reform and the only bad guys, according to Obama, are those evil doctors taking out tonsils when a cough syrup would do.

Now, I am wondering why there is no plan in the Bill to do away with and counteract fraud and abuse? Well, I guess it could be there. Who knows, it's a 1000 pages. Anything could be in there. Oh, I think that was my point to start with, wasn't it?

Never, ever doubt the Government's ability to take a bad situation and make it a whole lot worse.

Pluribus,

You might want to take a look at the pharmaceutical companies who are contributing a 150 million in ad campaign to support Obama's health care. I believe we have a back room deal done that if they support the plan, the Dem's won't kill them when they write the Bill. Quid pro quo and all that. No doubt there will be campaign contributions to influential Democrats coming. There is probably a reason Obama of the "most transparent administration is history" won't release the names and/or dates of the health care CEO's etc. who have visited the White House. I think Fox News got them to release one list, either dates or names, but not both.
8.9.2009 6:19pm
PC:
I guess you missed that even though the Government is dealing with a fairly simple set of responsibilities here

lolwut. Delivering mail, door to door, for 300 million people is a "fairly simple set of responsibilities?"

Right.
8.9.2009 6:53pm
SG:
but knowing that perfect doesn't exist I am willing to settle for good. When a genuine effort is made to reform the health care system that is now causing so much suffering (some in my own family) and reduce the frightening spiral of costs (one-sixth of the GDP quickly escalating ahead of the inflation rate), objections are raised.

I'm willing to settle for good too, but this isn't good reform - this is bad reform. The following is not a valid syllogism: There is a problem and we must do something. This is something, therefore we must do it.

And as far as Reps presenting reforms, their plan when in power (for better or worse) was to tackle the comparatively easier problem of Social Security reform first and Dems kicked them in the teeth with exactly the same tactics you're now decrying. Neither side has pure motives, both are looking for political advantage.

And for the record, I'm fighting with the current system for my family too. I've got a HELOC that's balance is slowly creeping up as I pay for necessary therapy that my (gold-plated) insurance coverage doesn't want to cover. Things aren't perfect, but I don't see this plan making it better. If it covered it for me and everybody else then there's no way the nation can afford it. If it doesn't cover it, then do those providers even exist? Next year, sure - in 10 years? I don't know...

Ultimately there's finite resources. Health care will always be a scarce good. We can't provide everything to everyone; there will have to be rationing at some level. So far, no one has come with a better mechanism for allocating scarce goods than free markets. I think it's somewhat telling that the health care sectors that have gotten cheaper (vision correction and plastic surgery) are those not subject to government/insurance.

Which, again, is not to say that I'm opposed to helping out people in need. But as a general policy we should be looking for greater exposure to the costs of health care, not less. Another reform I'd like to see is a government mandate of open price schedules. What other industry doesn't let the customer see the price tag?
8.9.2009 8:00pm
pluribus:
SG:

I'm willing to settle for good too, but this isn't good reform - this is bad reform.

First off, the bill is currently in a state of flux. Ideas are being advanced for changes, and some may well be incorporated. The basic outlines of the plan seem to me good.

The following is not a valid syllogism: There is a problem and we must do something. This is something, therefore we must do it.

Depends on the problem. If there is a crisis--if my house is on fire, for example--doing nothing is far worse than done something that you don't agree with. I believe there is a health care crisis. It's been building for the last 45 years at least. Doing nothing at this point would be almost criminal.

And as far as Reps presenting reforms, their plan when in power (for better or worse) was to tackle the comparatively easier problem of Social Security reform first and Dems kicked them in the teeth with exactly the same tactics you're now decrying. Neither side has pure motives, both are looking for political advantage

I agree, but I condemned the Dems then and I condemn the Reps now. Two wrongs don't make a right. I condemn the Reps now because now is today, and then was yesterday. And the fact that both sides are lookin for political advantage doesn't mean that both sides are equally wrong. The country desparately needs health care reform. If the Dems are trying to effectuate it, I don't care if they get political credit for doing so--it's the right thing to do--and to oppose it for political advantage is the wrong thing to do.
8.9.2009 8:16pm
Mac (mail):


lolwut. Delivering mail, door to door, for 300 million people is a "fairly simple set of responsibilities?"



I have no idea what Iolwut means. Probably the vast majority of posters here don't either.

Yes, it is a simple set of responsibilities. It is a finite universe of fairly simple tasks when they are taken apart.

There is a reason they call it "the art and practice" of medicine. It is not cut and dried to start with. All humans can react differently, not only to different diseases, but to different cures. It is highly complex. There is still a lot we don't even know about how the body works. I could go on and on, but you get my drift.

Yes, the Post Office has it easy delivering mail to 300 million people, which is an exaggeration as I don't think babies and kids get all that much mail.

The health care system will have to treat 300 million people. And, as I said, given they can't even run the POST OFFICE without going broke, I have no faith in their running Health Care.
8.9.2009 8:17pm
Mac (mail):
pluribus,


First off, the bill is currently in a state of flux. Ideas are being advanced for changes, and some may well be incorporated.

Yes, it is in a state of flux. Obama does not know what is in it, as he has been caught either lying or exposing ignorance to what is in the bill. Congress does not know what is in it. They are "too busy" to read it and need two lawyers to tell them what it means".

Therefore, how can there be any "dissemination of false information" about the bill when no one even knows what is in it or what may get taken out or put in?
What the American people have seen that is in it, they don't like. You can only keep private insurance until your employer switches carriers or you switch employment to and get a new carrier. Except you won't be able to. The bill says you will have to go into the public option.

Don't yell at me because that is in the Bill. The Democrats wrote the darned thing and then lied about it. "If you are happy with what you have and happy with your Dr. you can keep them" Well. not exactly. Well, not at all if you go by, and one must, what is in the bill.
8.9.2009 8:29pm
SG:
Depends on the problem. If there is a crisis--if my house is on fire, for example--doing nothing is far worse than done something that you don't agree with.

Of course not. There is no crisis that can not be made worse. Try extinguishing your burning house with lighter fluid.

You're happy with the broad outlines of the bill - that's fine and that's your right. My prediction (not necessarily of this exact bill but of the destination that this bill is intended to move us towards) is that we will end up with health care that is more expensive yet perversely harder to obtain. We will have a reduction in the pace of medical innovation. We will fundamentally alter the relationship between the citizen and the state and see an increase in the amount of regulation/taxation of what we eat and how we play. We will see an increase inter-generational, inter-gender and inter-racial strife as national health care budget budget priorities become set via the political process. There will be the occasional leak of health care records to damage political opponents. And we will still have a two-tiered system, only the higher tier will now be reserved for those with political influence.

But other than that, the bill seems fine.
8.9.2009 9:08pm
Richard Johnston (mail):

You can only keep private insurance until your employer switches carriers or you switch employment to and get a new carrier. Except you won't be able to. The bill says you will have to go into the public option.




No it does not say that. It says you can select any of the various plans in the Health Insurance Exchange, of which the public option is one. The others are what you call "private insurance," albeit to be in the Exchange they will have to meet certain minimum standards. See section 201 et seq. of HB 3200.
8.9.2009 9:14pm
Mac (mail):

No it does not say that.



There are a whole lot of folks out there who say that it does say that.

Remember it was the Michigan Congressman, Democraat who said you need two days to read it and two lawyers to tell you what it means.

Also, single-payer government run health care is the stated goal of Obama and he has said so many times.

Barney Franks just gave a speech to his supporters (and it is amazing that he has any left) and said it will be a single payer system but it may take 10 to 12 years to get there.

Now, I wonder why there is so much disinformation about this bill? Trouble is, most of the so-called disinformation is coming from the Dem's because they really, really don't want people to know what is in this thing.
8.9.2009 9:37pm
Mac (mail):
All you really need to know is that Congress won't ever be under the public option and they have granted dispensation to Federal Employees and Unions.

My, my. If this is so great, why will Congress not be under it and why have they exempted their favorite special groups?
8.9.2009 9:40pm
pluribus:
SG:

Of course not. There is no crisis that can not be made worse. Try extinguishing your burning house with lighter fluid.

Are you here just to make inane points in an argument or to sensibly discuss the issue? When I say "do something" about a house on fire I'm talking about putting it out, not making the fire worse. I suspect you knew that already. Somebody would be insane to try to put out a fire by adding fuel to it. I suspect you knew that too. And it's no answer to a burning house to say let's do nothing--or let's talk about it for ten or fifteen years and then decide what to do. I suspect you knew that too.
8.9.2009 10:12pm
DiversityHire (mail):

Somebody would be insane to try to put out a fire by adding fuel to it.

If, in the analogy, escalating costs are the problem, than extending coverage (i.e., subsidizing care) to more people is precisely adding fuel to the fire: increased demand + static or reduced supply -> higher prices.


And it's no answer to a burning house to say let's do nothing--or let's talk about it for ten or fifteen years and then decide what to do.

If doing nothing is the least worst option, then it's an answer: first, do no harm. Trashing all the existing fire trucks and replacing them with fancy, right-hand drive fire trucks from countries who can't afford to support or defend their own fire systems seems a lot more risky than sticking w/ the existing clunkers.

Assuming there is a healthcare crisis, the sensible thing to do is incremental, targeted reform. Sweeping reform is destined to fail, why the urge for comprehensive reform?
8.9.2009 10:27pm
Mac (mail):

Assuming there is a healthcare crisis, the sensible thing to do is incremental, targeted reform. Sweeping reform is destined to fail, why the urge for comprehensive reform?


DiversityHire,

Quite right. And, pluribus, not only is there no reasonable expectation that this plan is not going to make things a whole lot worse than it is right now, it will kill innovation and research and technology. We will be stuck with 2009 medicine forever. That is worse than doing nothing.

You invited SG's comments by insisting that always doing nothing was worse than doing something. He just proved you wrong. Don't get mad at him.

Some states have experimented with reform that has had some promise of working without breaking the bank. Obama should be encouraging the states to experiment and then, when we know what works, take that Federal.

Of course, it won't give total control of the health care system to the Dem's. and the Federal Government, so it won't matter if it works or not.
Not to mention access to those ever so desirable computerized health care records. Wonder if we can opt out? Nah, I didn't think so.
8.9.2009 11:10pm
SG:
When I say "do something" about a house on fire I'm talking about putting it out, not making the fire worse.

Lots of stupid things get done in a sincere, well-intentioned effort to do good. Leaches used to be considered good medicine. Just because you're trying to be make a positive contribution is no guarantee that you're not making the problem worse. The road to hell and all that.

If you read the paragraph following the one you quoted, you'll see that I am of the opinion that this is going to make it worse. "My prediction (not necessarily of this exact bill but of the destination that this bill is intended to move us towards) is that we will end up with health care that is more expensive yet perversely harder to obtain." The intended direction is absolutely adding more fuel to the fire. It's going to increase net human suffering.

Listen, you're already convinced this is decent (if not perfect) reform bill. I'm not convinced, and your repeated assertions of "but we have to do something" isn't even an attempt to persuade me that I'm wrong. We'll just have to agree to disagree and since your side has the votes in Congress and the White House, I'm likely the one who'll end up disappointed, Bully for you.

But if it does come to pass, remember this conversation in say, 10-15 years, when health care consumes a ridiculous portion of the budget, there's long delays in receiving care and new drugs and therapies look to be drying up.
8.9.2009 11:11pm
SG:
To continue with pluribus' analogy...

Somebody would be insane to try to put out a fire by adding fuel to it. I suspect you knew that too.

Not always. Controlled burns are a well established fire control mechanism. There are times and places, albeit not house fires, where it is exactly the right thing to do.

And that's exactly what I think is happening here. There's a place for some governmental funding of health care (the poor and indigent), and people have thought, "If it works in that case, let's extend it to the whole system". They're taking a solution that works in one circumstance and using it where it no longer applies.
8.9.2009 11:19pm
Mac (mail):

But if it does come to pass, remember this conversation in say, 10-15 years, when health care consumes a ridiculous portion of the budget, there's long delays in receiving care and new drugs and therapies look to be drying up.



Well, thanks SG, that'll be just about the time I'll really be needing it. How comforting.

However, you are right, dang it! On the bright side, I live pretty close to Mexico. I know a lot of folks who go there now for dental care. I can see a time when Americans will be sneaking into Mexico for medical care just like the Canadians are coming here. I will probably be one of them.

SG, the complete lack of logic in the arguments of pluribus plus the impassioned, "we have to do something". suggests a young person either in or just recently out of college. They are teaching them this stuff these days including the complete lack of information on how to think critically and build a coherent argument. My daughter survived her first two years of community college with her thinking process quite intact. She has lost it almost entirely since switching to ASU and the School of Journalism there. Heaven help us all. Her argument for gay marriage was "I don't care if they get married! The emphasis was on the "I". When I explained that that was not a persuasive argument, nothing. That seemed to be the best she could do. Oh well, she'll be a great journalist in terms of fitting right in with the rest of them. She is bright, just as pluribus is bright. With luck. they will both come out of it, eh?

Hint, please say, yes they will.
8.9.2009 11:30pm
Johnny Canuck (mail):
"just like the Canadians are coming here"

I don't think there are all that many Canadians going to US for medical care. A few who have the money and don't want to wait their turn.
8.10.2009 12:19am
Dan M.:


So he will have a financial incentive to keep talking to you even after you've made your choice unless you tell him to shut the hell up.




But think about how much satisfaction you will give that killer when you not only foil his plan to off you for cash, but also deny him reimbursement for the discussion!


So you admit that he won't get reimbursement unless he keeps bothering you after you've made your decision, in effect trying to persuade you to reconsider your decision to request life-saving treatment?
8.10.2009 12:32am
jukeboxgrad (mail):
yankev:

Where is the congress's consitutional power to authorize doctors to practice law


Where is the text in HR 3200 (or any other bill) that shows Congress is attempting to authorize doctors to practice law?

================
mac:

Why do we increase costs by mandating that a Doctor do the counseling? … Why in God's name would you mandate that Dr's do this? … it is a whole lot better that they spend their time on healing patients than counseling and filling out EOL forms


Why in God's name are you pretending that the bill says something it doesn't say? HR 3200 says explicitly (pdf, p. 428) that EOL counseling doesn't need to be done by a doctor. It can also be done by "a nurse practitioner or physician's assistant."

Now, I wonder why there is so much disinformation about this bill? Trouble is, most of the so-called disinformation is coming from the Dem's because they really, really don't want people to know what is in this thing


What a joke. It looks like the one who doesn't "want people to know what is in this thing" is you.
8.10.2009 1:18am
pluribus:
SG:

Lots of stupid things get done in a sincere, well-intentioned effort to do good.

This is a valid point, of course. But doing nothing is a rational response to a problem (or a crisis) only if there are no good solutions. If there are good solutions, then choose one and don't hold out for the perfect.

If you read the paragraph following the one you quoted, you'll see that I am of the opinion that this is going to make it worse.

And you are entitled to that opinion, which I happen to disagree with. So far we know that the majority of the members of the House of Representatives disagree with it too. They won the last election, and elections do have consequences (sorry for the cliche, but it expresses a point). The President of the United States disagrees, and he also won the last election. The AMA and the AARP also disagree, having expressed support for the substance of the reform proposal. The Senate has yet to be heard. Yes, you are entitled to your opinion, but so am I and so are all the others I referred to above.

Mac:

[T]he complete lack of logic in the arguments of pluribus plus the impassioned, "we have to do something". suggests a young person either in or just recently out of college.

Guessing isn't your strong point, Mac. The first president I ever saw in the flesh was FDR. I graduated when Eisenhower was president and took my law degree under LBJ. And, by the way, I spent most of my adult life as a Republican, switching my registration to Independent in 1995. I have never been a Democrat, though I believe the Democrats are in the right on the current effort to achieve health care reform. I long for the old Republican Party of Lincoln, Theodore Roosevelt, Eisenhower, and, yes, much of Ronald Reagan, which seems only a dim memory to me now.
8.10.2009 6:51am
yankev (mail):
jukeboxgrad:

Where is the text in HR 3200 (or any other bill) that shows Congress is attempting to authorize doctors to practice law?


If as reported above, the bill tells the health care provider to give the patient

"an explanation of . . . living wills and durable powers of attorney, and their uses"
then the provider is being instructed to provide advice that, in the State of Ohio at least, constitutes the practice of law.
8.10.2009 9:28am
SG:
If there are good solutions, then choose one and don't hold out for the perfect.

Agreed, but that still assumes the current proposal is net good, an opinion I don't hold.

Did you read the list of negative outcomes I predict at the end of the road this bill leads us down? Without asking you to agree that those predictions will occur, would you agree that if my predictions do come to pass then the situation would be worse than the current situation? Can you see how those predictions might (might, not inevitably) be realized by a fully nationalized health care system, which is what Obama and leading Dems have stated as their long-term goal, with the currently proposed "public option" being a first step on that path?

And as I said before, "We'll just have to agree to disagree and since your side has the votes in Congress and the White House, I'm likely the one who'll end up disappointed, Bully for you." I expect to be sorely disappointed by the outcome, all I ask is that the people leading the charge stop and think about what might happen if they get what they wish for.

And for the record, I've brought up a few notions of reforms that I think would improve the current situation. Fundamentally I think we need to increase individual awareness of and sensitivity to health care costs. That's the only way I can see to get health care costs under control without unduly harming the incentives for the people and companies that provide it. The current proposal moves us in exactly the opposite direction as it seeks to further insulate people from those costs. It's exactly wrongheaded in that regard. Regardless of how urgent it may be to "do something", I can't support something that goes in the wrong direction.
8.10.2009 11:24am
Oren:

So you admit that he won't get reimbursement unless he keeps bothering you after you've made your decision, in effect trying to persuade you to reconsider your decision to request life-saving treatment?

Yes, but symmetrically if you've already got a DNR, he won't get paid unless he keeps bothering you, in effect trying to persuade you to reconsider you decision to forgo life-saving treatments.

No matter what your previous EOL-care decision is, the Doc is out of luck.
8.10.2009 12:11pm
pluribus:
SG, I like your reasonable tone. I wish some others "on your side" would adopt a similar tone--e.g., stop drawing comparisons between the pending healthcare reform bill and Nazi Germany. That seems to be the mode of attack on certain talk shows these days.

If all the dire consequences you predict come true, yes, you will be right and I'll be wrong. I don't think they will, however. In the meantime, there are people suffering under the current system. Right in my house, we are confronted with life-threatening cancer coupled with astronomically high bills, many of which the substandard insurer refuses to pay for, and inability to change insurers because of rules on preexisting conditions. This while we continue to pay premiums and taxes, as we have all our adult lives, in a country that spends more per capita on healthcare than any other, while costs escalate and tens of millions are either uninsured or underinsured. I hope that the cancer in my house can be cured. This morning we are off to another CAT scan which will cost several thousand dollars. Whether the insurer will pay for it or not I don't know--we need the scan either way. I do not look with favor on another sixteen years of the status quo (the last major try at healthcare reform failed in 1993, as I recall). Figuratively speaking, my house is on fire, and I want somebody to help me save it before it is gone.
8.10.2009 12:31pm
yankev (mail):

Some people are making billions, even trillions, off the present health care system,
Who? Name one such person. Then force him to get out of health care and earn his money more responsibly.

Maybe by making movies, or playing pro ball.



which currently absorbs sixteen percent of the GDP, and is rising steadily faster than inflation.
In part because of government involvement dating back to WWII era wage controls, as well as post-war medicare and medicaid. I am not convinced that we can lower costs by entrusting government bureaucrats with medical care decisions, extending fee coverage to illegal aliens (or undocumented workers, if you prefer), and driving private plans out of business, nor am I convinced that we will not end up with rationing, poorer quality (already suffering because of cost restrictions imposed by private insurance and by medicare),fewer choices, and less accountability -- if you think that ERISSA makes private insurers unresponsive and irresponsible, just wait until you are dealing instead with civil servants.

If we ARE in a crisis demanind immediate action, is it so urgent that it cannot even wait for our elected representatives to read, digest and debate the bill?
8.10.2009 2:54pm
Richard Johnston (mail):

...nor am I convinced that we will not end up with rationing, poorer quality (already suffering because of cost restrictions imposed by private insurance and by medicare),fewer choices, and less accountability -- if you think that ERISSA makes private insurers unresponsive and irresponsible, just wait until you are dealing instead with civil servants.


Apropos of which, here is the Richard Johnston-approved alternative health care plan, designed to avoid the involvement of civil servants and make private insurers responsive and responsible:



1. No public plan.
2. Guaranteed issue: insurers can't decline coverage due to pre-existing conditions.
3. Mandatory coverage: everyone has to have coverage (similar to auto insurance).
(Note the insurance industry has already signed off on this; they are willing to give up declining converge of sick people in exchange for the universal coverage mandate).
4. Some sort of appropriate subsidy so lower-income people can afford the required coverage (which would certainly cost less than HB 3200). And/or favorable tax treatment for employers who provide coverage.
5. Mandatory minimum level of coverage in policies, so insurers can't get away with building in limitations and exclusions which would render the coverage illusory (indeed I think perhaps they should be treated much like public utilities, although I have not yet thought that one through completely). More comprehensive coverage at higher cost available at the insurer's/customer's options.
6. Amend ERISA or repeal preemption to achieve a meaningful enforcement mechanism to help keep insurers honest; i.e. no more immunity from liability for fraud and bad faith, etc.
8.10.2009 3:30pm
Oren:
Richard Johnston, that is quite acceptable aside from the repealing preemption.

ERISA's lack of remedies is bad. Having 50 different regulatory schemes (some of which ebb and flow with the whims of the venirepeople) seems decidedly worse.
8.10.2009 3:41pm
Richard Johnston (mail):

ERISA's lack of remedies is bad. Having 50 different regulatory schemes (some of which ebb and flow with the whims of the venirepeople) seems decidedly worse.


Point taken. What I actually have in mind is to repeal preemption as to state law remedies against insurance companies. This would not effect plan administrators or employers, just the insurers from whom they purchase insurance. I would also, I think, exempt self-funded plans and plans that really are trusts. But insurance companies have much experience coping with varying jurisdictions, and so far as I understand them I do not believe the rationales supporting ERISA preemption make any sense as applied to third-party vendors of insurance policies.
8.10.2009 3:48pm
yankev (mail):

3. Mandatory coverage: everyone has to have coverage (similar to auto insurance).


In return for the state granting me the privilege of operating a motor vehicle, I must carry liability coverage for the protection of those whom I might injure by my negligence.

Must I buy health insurance in return for the privilege of -- what? Merely being alive? That may indeed be a privilege, but it is not granted to me by the state. And my failing to carry health insurance -- or my failure to be healthy -- injures others in exactly what respect?

Our current health insurance system has a lot of flaws. There is no justification for tying it to your employer, or encouraging the underwriter to make coverage decisions based on the short run with the expectation that you will be someone else's problem when the long term costs are incurred. E.g. companies that refuse to pay for diabetes monitoring, or treating sleep apnea, on the gamble that you will be insured by some other company, or by the government, or uninsured, when it's time to pay the much higher cost of dealing with the resulting chronic or catastrophic consequences of neglect. But how does that justify the state in demanding that everyone carry coverage? What part of Article I gives Congress the power to say "Every person in the United States must carry health insurance acceptable to the government?"
8.10.2009 5:44pm
Richard Johnston (mail):

Must I buy health insurance in return for the privilege of -- what? Merely being alive? That may indeed be a privilege, but it is not granted to me by the state. And my failing to carry health insurance -- or my failure to be healthy -- injures others in exactly what respect?


I will acknowledge these are salient points, and I will also acknowledge I am not a constitutional scholar. If this proposal is unconstitutional then of course forget it but it certainly seems as constitutional as anything else that's been proposed.

There is an undeniable impact on society by you not having insurance. Unless we are prepared to let people die on the streets then at some point we will be providing care to those who have no insurance and cannot otherwise afford it. I honestly don't know whether that is cognizable in determining constitutionality.

But if universal coverage is one of our goals, and you don't want civil servants involved, then I am not sure how we get there without somehow mandating that everyone have private insurance coverage. It may be that your solution is to jettison that as a goal, which of course would lead to more flexibility in what the realistic options are. And if we don't care about universal coverage then perhaps doing nothing becomes a more attractive option. I must say however that omitting consideration of the plight of the uninsured seems to me to be quite hard-hearted. Real lives are ruined because of this.

I also agree, BTW, that there is no reason for insurance to be tied to employment. There is an historical explanation for it, but no present justification. But here as elsewhere pragmatic concerns run head on into theory. The fact is that most people do get their coverage through their employment, which as I have argued previously, given ERISA's gutting of any real way to enforce insurance contracts, means those people don't really have enforceable insurance coverage. I do not see a way to make all this non-employment related by decree. It is what it is.
8.10.2009 6:05pm
Richard Johnston (mail):

Must I buy health insurance in return for the privilege of -- what? Merely being alive?


It occurs to me as well that the quid pro quo is that the insurers must give up the right to decline coverage because of your health status. Guaranteed issue is the flip side of mandatory coverage. I understand your point remains about whether the government is empowered to impose this bargain on you, but practically speaking there is a benefit we would all realize which would not be there in the absence of mandatory coverage.
8.10.2009 6:11pm
John Moore (www):
Richard Johnston, I agree with your proposals. Interestingly, Dr. Charles Krauthammer predicts that they will be the core of what ultimately comes out of Congress.

Without mandatory coverage, we have the young free-riding in the following senses:

1) they are not putting enough into the system for their share when they get older (recognizing that this only works if *their* young do the same thing)

2) when some inevitably do get sick or injured, we all end up paying.

If we also want cost savings, the mandatory (and must-insure) coverage would have high deductibles. One could have a backup, low-deductible program for low income folks and for anyone who wants to pay for it.
8.10.2009 7:11pm
Oren:

Must I buy health insurance in return for the privilege of -- what? Merely being alive? That may indeed be a privilege, but it is not granted to me by the state. And my failing to carry health insurance -- or my failure to be healthy -- injures others in exactly what respect?

Because you may trip down the stairs while shopping at the mall . Then you you will be taken to a hospital, where herculean efforts will be made to keep you alive and patch you up. Finally, statistically speaking, you will not pay the bill -- most likely because it will vastly exceed your disposable income at the time.

So, in a sense, you are already insured. We, as a society, refuse to let you die for lack of being able to post a bond (or get an immediate loan, given an uncertain future ability to pay) sufficient to cover the cost of your treatment.
8.10.2009 7:57pm
Oren:

Richard Johnston, I agree with your proposals. Interestingly, Dr. Charles Krauthammer predicts that they will be the core of what ultimately comes out of Congress.

That is the most spiritually uplifting thing I've heard all day.
8.10.2009 7:59pm
pluribus:
I wrote:

Some people are making billions, even trillions, off the present health care system,

yankev replied:

Who? Name one such person. Then force him to get out of health care and earn his money more responsibly.

You do recognize the difference between "people" and "person," don't you? I said "some people" are making billions, even trillions. They are the people who are on the receiving end of this country's astronomical health care expenditures, both public and private. That does not mean "one such person," so I cannot force "him" to get out of health care. Please read more carefully.
8.10.2009 9:02pm
Dan M.:

Yes, but symmetrically if you've already got a DNR, he won't get paid unless he keeps bothering you, in effect trying to persuade you to reconsider you decision to forgo life-saving treatments.

No matter what your previous EOL-care decision is, the Doc is out of luck.


Yes, you are correct. I have a sneaking suspicion that there will be some other incentive for him to not bother you once you decide to forgo life-saving care. But I don't have proof, so I'll just say that I suspect the government will always manage to nudge toward the decision that they want that will save them money, because saving government money is good for America.
8.10.2009 10:07pm
jukeboxgrad (mail):
pluribus:

I have never been a Democrat … I long for the old Republican Party of Lincoln, Theodore Roosevelt, Eisenhower, and, yes, much of Ronald Reagan, which seems only a dim memory to me now.


I first voted in 1974, but I never registered as a Democrat until 2004. And part of what kept me from registering as a Democrat was the fact that I had a lot of respect for "the old Republican Party of Lincoln, Theodore Roosevelt, Eisenhower, and, yes, much of Ronald Reagan." It took GWB to 'radicalize' me, and help me decide that I wanted to be counted as a Democrat. FWIW. Just mentioning this because I see some parallel between your experience and mine.

Right in my house, we are confronted with life-threatening cancer coupled with astronomically high bills, many of which the substandard insurer refuses to pay for


That can't possibly be, because that would mean that you're facing a death panel, and everyone knows that we don't have death panels, and won't have them unless Obama gets his way and establishes the Obama Death Panel (which is described in a portion of HR 3200 that is written in invisible ink).

I ran into someone else who is very confused, like you, and also thinks that we already have death panels.

===============
yankev:

If as reported above, the bill tells the health care provider to give the patient …


It would be nice (and would save everyone some time) if you looked at the relevant pages in the bill itself, instead of relying on what was "reported above." Because the bill explains (p. 427) that it is only talking about counseling being done by a medical professional who is "acting within the scope of the professional's authority under State law." That is, a medical professional in a State which provides these forms to medical professionals and gives them authority to sign them. In other words, the people who wrote the bill gave some thought to the problem you described.

Aside from that, it's a distortion (and a very common one) to flatly say the bill 'tells' the medical professional what to say. This implies the counseling is mandatory. But it's not. The bill only 'tells' the medical professional what to say if the patient expects to be reimbursed. In other words, the counseling session is defined as a reimbursable medical service only if certain elements are present.

nor am I convinced that we will not end up with rationing


pluribus explained how his insurance company is not paying for cancer treatment. Is there some reason this phenomenon shouldn't be described as rationing?

It's nice to hear from all the people who are worried about death panels and rationing, and who seem to not realize that we already have death panels and rationing.

is it so urgent that it cannot even wait for our elected representatives to read, digest and debate the bill?


Certain "elected representatives" aren't 'debating' the bill. They're lying about the bill. Where is the virtue in giving liars more time to tell more lies? Unless we can get various cancers to agree to stop being cancerous while we wait for the liars to let us know that they're all done lying. Because we should wait patiently until they're done, right?

And we should believe the GOP is not just stalling, but is sincerely interested in health care reform. Because that's why they gave us health care reform when they were in charge, right?

What part of Article I gives Congress the power to say "Every person in the United States must carry health insurance acceptable to the government?"


The part that references the concept of general welfare. Various people have explained some of the ways that your health decisions are connected to the general welfare of the society around you.

===============
dan:

I suspect the government will always manage to nudge toward the decision that they want that will save them money


I suspect that it would be a good idea to pay attention to the actual text of the actual bill, and not to what you vaguely "suspect." I hope you will described the magical force the government will use to "manage to nudge" things if there is no text that gives them the means to do so.

On the other hand, if we view our government as an autonomous beast that does whatever it likes, without regard to law, then we should simply destroy the government. Say, by drowning it in a bathtub. Of course it's interesting to notice that this is what the GOP would actually like to do, and it's also interesting to notice how they promote this process by ignoring the law when they're given a chance to be in charge of the government. Then they get to say 'see, we need to kill the government because the government can't be trusted to follow the law.' It's a pretty brilliant strategy, given that a large number of voters are complete suckers.

Aside from all that, there is a basic illogic in what you "suspect." Bureaucracies (both public and private) generally love to grow, which generally means spending more money, not less money. As conservatives often remind us, government bureaucrats are often not pursuing policies that will "save them money." On the contrary. They're in the business of doing the exact opposite. Because it's not their money, right?

It's always fun to notice the way the GOP turns its own talking points inside out without even realizing that it's doing it. Another topsy-turvy maneuver is the way Americans are suddenly mindless puppets who will submit to voluntary counseling they don't really want to have, and sign forms they don't really want to sign. This is somewhat at odds with the normal narrative that Americans are rugged individualists who know how to be in charge of their own choices.
8.11.2009 3:43am
pluribus:
jukeboxgrad:

It took GWB to 'radicalize' me, and help me decide that I wanted to be counted as a Democrat. FWIW. Just mentioning this because I see some parallel between your experience and mine.

Yes, our experiences are similar, though you became a Democrat and I became an Independent. Newt Gingrich did more than GWB to push me out of the GOP. The comments on healthcare he made over the weekend brought back to mind why I dislike him so. Anyway, I like all of your comments on this issue.
8.11.2009 8:53am
yankev (mail):

The part that references the concept of general welfare.
First, the general welfare is referenced in the preamble; it is not one of Congress' enumerated powers under Article I, Section 8. Congress has no power to take any action unless authorized by Article I, Section 8 or by one of the amendments, whether or not the action is meant to advance a purpose listed in the preamble. This is pretty elementary stuff.

Second, under your conception of the general welfare clause, what could Congress NOT do, unless specifically prohbited? It seems that you would move us from a government of enumerated powers to a government that can do whatever it pleases unless specifically limited. By so doing, you transfer both power and liberty away from the people and into the hands of government.

Finally, you seem to think I am a fan of the insurance companies. I am not. The current system is imperfect even when administered as it should be, and there are many instances, insurance companies act arbitrarily or violate their own contracts, so that it is not administered as it should be. That's a poor reason to make the system worse by centralizing the power in the hands of government bureaucrats. By you defininiton of "rationing", food is also "rationed." After all, people who can't afford to buy food often have to go without. The food I may want to buy is not always avaialbe at my local store when I want it to be. Some food may cost more than I care to pay, so I decide to go without, substitute something else, or eat less. But I'd have to be an idiot to say that's a reason to put the federal government in charge of selection, pricing, growth, production, distribution, menu planning and diet. Although I suppose that under your concept of general welfare, Congress would have the power to tell me how many calories I can consume, how often I can eat, and what kinds of foods I can and cannot eat. After all, what I eat affects everyone else too.
8.11.2009 9:18am
yankev (mail):

You do recognize the difference between "people" and "person," don't you? I said "some people" are making billions, even trillions.

Really? So you were not speaking of specific individuals? I had no idea. Silly me.


They are the people who are on the receiving end of this country's astronomical health care expenditures, both public and private. That does not mean "one such person," so I cannot force "him" to get out of health care. Please read more carefully.
So what you really mean is that some collective number of people -- who for all we know number in the billions, making $1,000 per year each, are making this money. Or more to the point that health care is an industry that generates billions or trillions of dollars in profit. My, how precise.

In other words, there are companies, who are owned by, run by, and employ people, and those companies are making billions, even trillions.

Please write more carefully.
8.11.2009 9:38am
pluribus:
Yankev:

If you really want to know what I mean (I admit I'm a little doubtful), let me put it in other words:

Total spending for healthcare in the United States was $2.4 trillion in 2007, or $7,900 per person. Total health care spending represented 17 percent of the gross domestic product (GDP). In 2008, total national health expenditures were expected to rise 6.9 percent, or two times the rate of inflation.

http://www.nchc.org/news/press_releases/

"People" (plural, not singular) who provide this healthcare receive this money. You tell me how many there are. However you want to divide it among the providers--doctors, hospitals, insurance companies--enoprmous profits are being made from this $2.4 trillion. Can you think of another industry that currently receives 17 percent of the gross domestic product and whose revenues are rising at two times the rate of inflation? If you really want to contribute to the discussion, please provide an answer to this question.
8.11.2009 11:27am
jukeboxgrad (mail):
pluribus:

Newt Gingrich did more than GWB to push me out of the GOP.


During the Gingrich era I had my attention focused on matters other than politics, for various reasons. But if I had not been distracted, my reaction to Gingrich probably would have been similar to yours.

I like all of your comments on this issue.


Thanks for your kind words. Someday the GOP will be back in the hands of people like you and Orin Kerr, and that will be a happy day for the country and the world.

=============
yankev:

the general welfare is referenced in the preamble; it is not one of Congress' enumerated powers under Article I, Section 8. Congress has no power to take any action unless authorized by Article I, Section 8 or by one of the amendments, whether or not the action is meant to advance a purpose listed in the preamble. This is pretty elementary stuff.


The general welfare is referenced in the preamble, but it is not only referenced in the preamble. It is also referenced in Section 8, as follows:

The Congress shall have power to lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defence and general welfare of the United States


So Congress's power to provide for the general welfare is indeed authorized by Article 1, Section 8. This is pretty elementary stuff. Please write more carefully.

under your conception of the general welfare clause, what could Congress NOT do, unless specifically prohbited?


A long list of things that have no connection to the general welfare.

By you defininiton of "rationing", food is also "rationed."


Then please give us your own definition of "rationing," and explain why it doesn't apply to what insurance companies have been doing for years.

That's a poor reason to make the system worse by centralizing the power in the hands of government bureaucrats.


Yes, it's much better to keep the power centralized in the hands of corporate bureaucrats who are essentially answerable to no one, especially as long as they manage to generate obscene payoffs for themselves and other major shareholders.

So what you really mean is that some collective number of people -- who for all we know number in the billions, making $1,000 per year each, are making this money.


$1.6 billion for one person (link, link) works out to a lot more than "$1,000 per year." And there are lots of other health company executives and owners who are collecting obscene payoffs.

Do you really not understand where your health dollar is ending up? Where do you think that $1.6 billion came from? And a portion of your health dollar is ultimately invested in political contributions (to both parties) that are a very effective (so far) and worthwhile investment in making sure the gravy train never ends. We have the best government money can buy.

I'd have to be an idiot to say that's a reason to put the federal government in charge of selection, pricing, growth, production, distribution, menu planning and diet.


It turns out that the federal government has a lot of influence over those things, via the FDA. But I realize that one of the GOP's fantasies is to dissolve the FDA. After all, if you're dumb enough to buy peanut butter containing Salmonella Typhimurium, that's your problem.
8.11.2009 11:41am
jukeboxgrad (mail):
pluribus:

Total spending for healthcare in the United States was $2.4 trillion


A more direct link to that important and helpful material is here.
8.11.2009 11:52am
yankev (mail):

It turns out that the federal government has a lot of influence over those things, via the FDA.
Not quite the same, is it?

But I realize that one of the GOP's fantasies is to dissolve the FDA.
What planet do you live on?

We have the best government money can buy.
And the solution, in your mind, is to expand the size and power of the government. Yeah, that'll reduce cost and corruption.
8.11.2009 12:52pm
jukeboxgrad (mail):
Not quite the same, is it?


What are you getting at? You seem to be saying that HR 3200 embodies a level of federal control over the health care system that is much more extreme than, say, the level of control the FDA has over our food system. Really? If that's what you're trying to say, where's your evidence? And if that's not what you're trying to say, what are you trying to say?

What planet do you live on?


The planet where many people have said we should abolish the FDA. Are those people generally Democrats? I don't think so.

I also live on the planet where the GOP talks about its wish to drown the government in a bathtub. Or did Norquist mean drown the government, but not drown the FDA? Maybe he thinks FDA isn't part of the government. Kind of like how some people seem to think that Medicare isn't part of the government.

And the solution, in your mind, is to expand the size and power of the government.


When something we rely on is broken, the proper response is to fix it, not break it and cripple it further (via drowning, or any other means). And the government overall doesn't need to be bigger. We need to have the government put less energy into things it shouldn't be doing, like breaking things on the other side of the world (bill: $3 trillion), and more energy into things that it should be doing, like helping Americans get access to health care.

Let us know when you're ready to take responsibility for saying the Constitution doesn't say what it says.
8.11.2009 1:23pm
pluribus:
The same site that juekboxgrad and I linked to above estimates that the annual cost of healthcare in the United States will rise to $4.3 trillion in 2017, or 20 percent of the gross domestic product. In the next ten years, the United States will spend between $24 trillion and $44 trillion dollars on health care. And I hear loud howls when the costs of the current reform proposals are estimated to be $600 billion to $1.2 trillion over the same ten years. This amounts to an increase of plus or minus 2 percent. But the "just say no" crowd believes this is too high a price to provide health insurance coverage for everybody, to provide insurance portability, to do away with exclusions for pre-existing conditions, and to provide long-term mechanisms for reducing costs. Confronted with this kind of reality, and with life-threatening cancer already in my family, I don't want to wait another sixteen years (it has been sixteen years since health care reform was last proposed) to consider another reform proposal.
8.11.2009 1:28pm
jukeboxgrad (mail):
the "just say no" crowd believes this is too high a price


The GOP isn't truly worried about the cost. After all, they were perfectly happy to burn up $3 trillion in a needless war. They like the idea of the government going bankrupt. It's part of their concept of destroying the government. When GWB doubled the national debt, there was a method to his madness. Likewise for when Reagan tripled it.

What really worries the GOP is that Obama might succeed in improving health care. That's a terrifying prospect, because it's another reason for Obama to win in 2012. The GOP has no chance in 2012 unless they can prevent Obama from cleaning up the mess they handed him. They need him to fail, and they want him to fail, and they've said so. It's really that simple.
8.11.2009 2:20pm
John Moore (www):

The GOP isn't truly worried about the cost. After all, they were perfectly happy to burn up $3 trillion in a needless war.

Bull. The GOP felt the war was necessary, and were not happy that it cost whatever it cost - and were not happy that it cost far more than projected.

The idea that they were "happy" to burn up $3 trillion is a Daily Kos sort of fantasy - so its not surprising it comes from our resident Kos: JBG.
8.11.2009 3:01pm
jukeboxgrad (mail):
The GOP felt the war was necessary, and were not happy that it cost whatever it cost


If I pursue a pointless course of action that ends up costing my family or community or country 3 thousand or million or trillion dollars, and then do essentially nothing to express remorse and take responsibility for my bad judgment, then it's perfectly appropriate to use a colloquialism like "perfectly happy" to describe my attitude about what I created.

our resident Kos


I'm not sure what a "Kos" is, but I know what a Moore is: someone who routinely makes false claims (example) and refuses to take responsibility for doing so. Speaking of refusing to be responsible.
8.11.2009 3:15pm
yankev (mail):

If I pursue a pointless course of action that ends up costing my family or community or country 3 thousand or million or trillion dollars, and then do essentially nothing to express remorse and take responsibility for my bad judgment, then it's perfectly appropriate to use a colloquialism like "perfectly happy" to describe my attitude about what I created.
The war in Iraq was more necessary, more responsible and more successful than the War on Poverty. I'm waiting to hear you express remorse for creating a permanent underclass of disfunctional families dependent on goverment largesse.

And although I did miss the general welfare purpose in Art. 1, Sec. 6, I still maintain that under your broad definition of general welfare, there is little or nothing that Congress could not do.
8.11.2009 8:06pm
newscaper (mail):
This touches on of the gray areas that makes me depart from a purer libertarianism: encouraging rational thought about serious subjects and getting people to actively rather than passively make choices is normally a good thing -- and for the record I heartily support the *individual* patient choosing an assisted suicide -- but do we want to inch toward a system where all of the machinery is set up to guilt grandma into killing herself?

In the same, however much a pure libertarian society would have to allow voluntary killing thru honor duels and bloodsports, i would not want to live where such is considered perfectly accepted as the norm, much less possibly encouraged.

Only partly on a tangent, I note that any efforts to require similar counseling on embryonic development, adoption etc for women seeking abortions are met with extreme horror by the Left.
8.11.2009 11:39pm
Oren:

The war in Iraq was more necessary, more responsible and more successful than the War on Poverty.

Yup, and Jimmy is the fastest sprinter --- in the special olympics.

Maybe we can get a comparison to the War on Drugs while we are at it?
8.12.2009 2:16pm
jukeboxgrad (mail):
yankev:

The war in Iraq was more necessary, more responsible and more successful than the War on Poverty. I'm waiting to hear you express remorse for creating a permanent underclass of disfunctional families dependent on goverment largesse.


I'm waiting for you to show proof that there is "a permanent underclass of disfunctional families dependent on goverment largesse" and that this "permanent underclass" is a direct consequence of the War on Poverty. (And I wonder how they compare to the permanent underclass of defense contractors who have been earning soaring profits due to "government largesse.")

What an outrageous, inappropriate comparison. Even if I accepted at face value your unsupported claims about comparative necessity and comparative success, how many Americans were killed and injured as a direct result of the War on Poverty? Can you show that the answer is a number greater than zero? Because in your war, the answer is over 35,000. And this is aside from at least 100,000 dead Iraqi civilians.

The fact that you would make such an absurd comparison, and that you would associate words like "necessary," "responsible" and "successful" with the Iraq war is enough to demonstrate my point: the GOP refuses to take responsibility for the monumental debacle it created, and is still in denial about the enormity of the debacle.

And although I did miss the general welfare purpose in Art. 1, Sec. 6, I still maintain that under your broad definition of general welfare, there is little or nothing that Congress could not do.


(I know you mean Section 8.) Under what "broad definition?" I haven't offered a "broad definition." I haven't offered any definition at all. I've simply pointed out what the Constitution says: that Congress has the power to provide for the general welfare. Maybe you should consider the possibility that a broad term was used because a broad power was intended. If you don't like what the Constitution says, then feel free to start a movement to rewrite it.

And feel free to tell us how you manage to define "general welfare" in a manner that excludes the issue of health.

I don't think you will offer a definition. I notice you're also declining to tell us how you define "rationing," even though you chose to use that word in this discussion.

==================
newcaper:

any efforts to require similar counseling on embryonic development, adoption etc for women seeking abortions are met with extreme horror by the Left


Why did you slip the word "require" in there? This is yet another instance (one of many) of people falsely implying the HR 3200 makes EOL counseling mandatory. But it doesn't.

Can you show an example of "the Left" reacting with "extreme horror" to the idea of women seeking abortions being offered voluntary counseling on "embryonic development, adoption etc?" I would be surprised if you could, since (for example) Planned Parenthood makes information about adoption readily available. In their main introductory page on the subject of abortion, adoption is mentioned.

There's a big difference between 'voluntary' and 'required,' so it would be better to not gloss over the difference.
8.12.2009 3:02pm

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