The American Way of Dying

November 23 – Last night on CBS’s 60 Minutes, I learned much of what I knew already, most of it obvious.

I learned,

100 percent of Americans will die eventually;

one day in a hospital intensive care unit costs $10,000;

the last two years of life of Medicare recipients costs Medicare $50 billion each year;

it is human natture to want to live yet another day, no matter what the cost as long as it is Medicare money;

Medicare is rapidly growing broke because it never questions paying for what is done;

Americans overwhelmingly want to die at home, but only 15 percent do while 75 percent die in hospitals;

most relatives, dear ones, and significant others of dying patients support dying in the hospital;

many living wills are ignored, and doctors, backed by patients and relatives and significant others, encourage doctors to to everything they can do sustain life;

the mission of doctors, by law, custom, and training, is to prolong life, and they have the technologies to carry out their mission;

profit margins of hospitals, and fee-for-service payment of doctors, encourages hospitals and doctors to support the prolonging of life;

if paying for health care is to be sustainable, it may be necessary to ration care based on age and cost, to set limits based on clinical and cost effectiveness, quality of life, and estimates of how long life is likely to last, and that, figuratively, society may have to “pull the plug” on people destined to die in the near term;

Americans tend to the deny the realities of inevitable death;

it will be extraordinary difficult to cut Medicare spending because of cultural and political backlash;

cutting Medicare spending is a miasma of moral, monetary, cultural, professional, and personal dilemmas;

Slashing medicare benefits is akin to boiling the polital ocean;

what I did not learn is America is maturing in its attitudes towards dying and death, and through its growing use of hospice services, particularly, end of life care is being administered in homes;

home is where the heart is, and ideally home is where more Medicare money is best spent spent for comfort and compassion for the dying.

Health Reform Debate and the Embers of December

Ah, distinctly I remember it was in bleak December;
And each separate dying ember wrought its ghosts upon the floor.

Edgar Allen Poe, 1809-1849

As we look forward to the December health care debate, it is important to remember other issues – other burning embers – besides health care smolder on the Senate floor and must be dealt with. These embers could flare up, complicate, and even derail the health care train.

The glowing embers are,

• raising the national debt limit, which is very much on the public’s mind and which could create the impression Democrats are out-of-control spenders;

• shutting down the Patriot Act, which could result in accusations of lack of patriotism;

• extending highway construction, part of the controversial Stimulus package;

• Prolonging unemployment programs, a reminder that the Obama administration programs have had no effect on unemployment;


• Continuing the federal estate tax, another burning ember that Democrats are devoted to high taxes;

• Deciding how much to fund the troops in Afghanistan, another potential political firestorm.

On these burning issues, Republicans are sure to argue Congress ought to scrap the health care issue and focus on more pressing spending bills and bills relating to national secuity.

December promises to be a dark and messy month.

Health Reform, Gallows Humor, and the Louisana Purchase

November 22 - The Senate voted last night, 60-39, on a strictly party line vote, to bring the health care debate to the Senate floor, thereby nipping a Republican filibuster in the bud. The debate will start after the Thanksgiving holiday and run through December, perhaps even into the New Year.

The opening of the debate is a serious matter, making the first time health reform has reached this point in the history of the Republic.

• Democrats are deadly serious and regard the whole matter as an historic event. Senator Max Baucus, Democrat of Montana and chief architect of the legislation, declared, “Tonight we have the opportunity, the historic opportunity to reform health care once and for all. History is knocking on the door. Let’s open it. Let’s begin the debate.”

• The Senate Republican leader, Mitch McConnell of Kentucky, was eqaully serious. He declared, “The battle has just begun.” He warned of massive deficits, intrusuve government-run health care, and Medicare gutting.

I’m surprised McConnell did not quote Winston Churchill, who so famously said, “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

Maybe, at such a serious juncture in the health debate, said by Democrats to be a historic moral imperative and by Republicans a horrid economic disaster, it is time for a little graveyard humor.

Dana Milbank, a Washington Post columnist , supplies this humor in a November 22 column, “Sweeteners for the South.”

“Staffers on Capitol Hill were calling it the Louisiana Purchase. “

“On the eve of Saturday's showdown in the Senate over health-care reform, Democratic leaders still hadn't secured the support of Sen. Mary Landrieu (D-La.), one of the 60votes needed to keep the legislation alive. The wavering lawmaker was offered a sweetener: at least $100 million in extra federal money for her home state.”

“And so it came to pass that Landrieu walked onto the Senate floor midafternoon Saturday to announce her aye vote -- and to trumpet the financial "fix" she had arranged for Louisiana. "I am not going to be defensive," she declared. ‘And it's not a $100 million fix. It's a $300 million fix.’"

Dana went on to explain how Senator Reid has also purchased the vote of Blanche Lincoln of Arkansas and other Democratic Senators, lest they stray from the party line,

“Landrieu and Lincoln got the attention because they were the last to decide, but the Senate really has 100 Blanche DuBoises, a full house of characters inclined toward the narcissistic. The health-care debate was worse than most. With all 40 Republicans in lockstep opposition, all 60 members of the Democratic caucus had to vote yes -- and that gave each one an opportunity to extract concessions from Senate Majority Leader Harry M. Reid.”

Dana concludes:” By the time this thing is done, the millions for Louisiana will look like a bargain.”

For those of you out there who are unfamiliar with the Louisiana Purchase, in 1803 the United States paid France $15 million dollars for over 800,000 square miles of land, more than doubling the size of the United States. This land deal was the greatest achievement of Thomas Jefferson's presidency.

Similarly health care deals struck with wavering Senate Democrats, like the $300 million for the Landrieu vote, may be the greatest achievement of Barack Obama’s presidency. In this case, Obama hopes to more than double the size of government control over health care and double the cost to government,now running more than $1 trillion for Medicare and Medicaid. As Shakespeare might say, "Double, double, toil and trouble; fire burn and cauldron bubble." Well, Will, the cauldron is bubbling.

Health Reform: It's Cultural Expectations Stupid!

This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.

Kevin Sack, “Screening Debate Reveals Culture Clash in Medicine,” New York Times, November 20, 2009

For at least three years, starting with Voices of Health Reform and more recently with Obama, Doctors, and Health Reform, I have been writing American Culture and American’s Health Care Expectations profoundly influence the health reform debate. This is no secret, but you don’t hear much about these cultural expectations in the media or in the Congressional debates. Now that the august New York Times has brought up the culture issue, perhaps I can talk about it again.

Although Americans are in a funk right now over the economy, unemployment, and the national debt, they retain their belief in the powers of modern medicine. This belief explains why so few Americans believe they are “over treated” or that doctors do “too much.”

If anything, people feel doctors don’t do enough. Americans expect doctors to prescribe a drug, order a mammogram, do a pap smear, or refer them for a CT or MRI scan. Americans expect access to the best, to the brightest, and to those death-preventing, life saving, or function-restoring, even sexual-preserving technologies.

And why shouldn’t they? America has the best high medicine in the world. The media talks incessantly of the latest medical advances, of lives miraculously saved, of erectile dysfunction resurrected, or people diagnosed with some rare and exotic disease. Hospitals market their high-tech wares on television – robots that perform surgery, gamma knives that cut like a laser to the cause of the cancer, surgeons that operate bloodlessly and non-invasively.

There is plenty of hype and hope abou modern medicine’s wonders. Expectations run high.

And to doctors, there always some mythical future lawyer out there who might ask, “Why didn’t you do this procedure, doctor?” “If you had, wouldn’t my client be alive and well? Didn’t you know this test was available?” “Why didn’t you discuss all the options with my client” "Why is there no record of your having done so?” "Why and Where do you go to medical school?" "Didn't they teach you what to do?"

Besides, in the words of the New York Times reporter, “For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.”

The reports of the federally-sponsored and paid-for Preventive Services Task Force on new rules for mammography and pap screening are raising the specter of government health care rationing. And, in the minds of the public, it may be a stick in the eye to the concept of comparative research effectiveness and the government paying only for “what works.”

Medicine is highly personal and emotional. It does not lend itself to detached objectivity or to “scientific based evidence.” As Sally Fields says in her TV Boniva ads, “It’s my body, and I’m going to take care of it.” This might be paraphrased in the present health reform climate to read, “ It’s my health, and I don’t care what the government says. I am going to do what I consider best for me.”

Cooking Health Reform Books

How does one cook health reform books?

One, you make costs seem less than they really are.

Two, you announce OMB-estimated 10 year costs at $849 billion from 2010 to 2019.

Three, you don’t start real spending until 2013. From 2010 to 2013, you spend only $9 billion – a drop in bottomless federal bucket.

Four, in 2014 you start real spending. By 2016, OMB estimates you are pouring $147 billion out of the bucket.

Five, from 2014 to 2023, you know the OMB says costs will run $1.8 trillion, but you don't say to and you don’t care because this is 2009, and you have a bill to pass. Besides, by 2023 the present Congress and present president will be gone. That is for future legislators and generations to worry about.

Six, from 2014 to 2023, you can covertly hike taxes by $892 billion, drain more than $500 billion from Medicare, freeze doctor pay, and increase the federal budget deficit. But you don’t tell the American people you are cutting existing programs and creating higher deficits, and raising taxes.Your mission is to cook the books now, not to be concerned about future thens and theres.

There once was a Senate majority leader named Harry Reid,
He waved his magic wand to accomplish this political deed.
To make true reform costs appear low,
He would start true spending very slow,
By waiting until 2013 to bring true costs up to speed.

Let the "Historic" Debate Begin

November 20 - When the Senate votes tomorrow whether to engage in further health reform steps, the stage is set for an historic debate. Before we engage in this debate, let us be clear what this debate is about.

It is about,

• the balance of power between government controls and individual freedoms.

• how to make health costs for government and individuals “ sustainable" and how to manage those costs for perpetuity.

• cost controls and how government may be forced to adopt techniques of private plans to limit fraud and abuse and expenses of paying for pre-existing chronic disease and experimental drugs and procedures.

• use of statistics to limit and manage costs versus individual needs and expectations - there is no better example of this conflict than the current flap over mammography guidelines suggesting delay to screening until after age 50.


• the status of the United States as a “moral nation” and whether universal coverage should be the leading indicator of that morality.

• who should care for the sick - government bureaucrats or physician and nurse caregivers.

.whether the United States needs a public option, an alterntive government plan, when 1300 private plans are available and await to opened across state lines for competitive bidding.

. whether is the obligation and duty of the federal government to help subsidize care of 62% of American families making up to $88,000 each year.


• the constitutionality of government to impose mandates on employers and individuals who do not buy insurance and the right of government to fine or imprison non-payers for tax evasion.

• power of government to burden states with Medicaid expenses state budgets cannot tolerate; to restrict payment of Medicare strictly to Medicare – and to not allow patients to contract with doctors separate; to pay the same Medicare rates in locations without regional variations and to homogenous and standardize care regardless of poverty levels and hospital and practice expenses; to dictate the contents and comprehensiveness of health plans and to impose the same premiums on all individuals regardless of age, sec, and health status; to tax “Cadillac” health plans, medical device companies, the pharmaceutical industry, hospitals, and those providing or paying for cosmetic procedures to pay for increased coverage.


• the ability of those health care entities who are taxed to pass on their increased expenses to consumers and how average Americans will tolerate increased costs and decreased access when they were promised otherwise.

• the diversified United States culture, its status as the greatest immigration destination in the world, and its ability to handle and pay for this diversity.


• “health care” versus “medical care” and the expenses therein; only about 15% of a nation’s “health” depends on its medical system, the remainder rests on socioeconomic conditions, personal behaviors leading to obesity and other health threatening disorders, and social cohesion and expectations.

• our legal and malpractice system, which increases health costs by roughly 10% through the practice of defensive medicine and excessive malpractice premiums and drives many specialists to other states or to early retirement and non-clinical careers.


• the doctor shortage and the mal-distribution of primary care doctors and specialists and the looming political health care crisis as aging boomers and greater numbers of the now covered uninsured seek access to doctors.

• how to explain to Americans that taxes and expenses will go up in 2010 but benefits will not kick in until 2014.


• The wishes and ambitions of politicians – 60% of whom say overall reform is necessary – and the will of the people - only 40% of whom approve of current health reform bills, 17% of whom say health reform is not their first priority, and most of whom who regard the economy, unemployment, and the national debts as greater threats to America.

• who should make clinical decisions - government, caregivers, or the people themselves – the latter through health savings accounts and high deductible plans that encourage them to spend their own money wisely, to insist on cost transparency. and freedom to chose their own doctors and hospitals.