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Saturday, August 22, 2009

We Are the Death Panel

Who decides if Grandma lives or dies? Under H.R. 3200, Grandma does.

Watching Jon Stewart's interview with death-panel myth originator Betsy McCaughey1, it occurred to me that we are the death panel. You, me, anyone who signs a living will. Ah, but not every living will: only those living wills that ask for the doctors to at some point stop trying.

To the details: McCaughey continually cited "Page 432" of H.R. 3200, the House bill on health care reform.2 Here on the Net, it's not page 432; it's Section 1233(b)(3)(A)3, archived at this URL: http://www.opencongress.org/bill/111-h3200/text?version=ih&nid=t0:ih:2880. The text (which Stewart read verbatim after McCaughey's flustery page-flipping):

For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.

In other words, H.R. 3200 adds living will consultations and adherence to the 153 quality measures that are already part of the Physician Quality Reporting Initiative (PQRI). Doctors get an incentive for reporting this data (2.0% this year).

McCaughey says this provision will give doctors incentive to deny care and let patients die against their wishes. In her nightmare scenario, you sign a living will saying you don't want to be kept alive on a ventilator, then come to the hospital four years later with some serious trauma. Facing death, you change your mind and decide you'll take the ventilator, but the doctor says, "Uncle Sam will slap me if I don't adhere to your living will, so I'm not hooking you up."

But Section 1233(b)(3)(A) causes no such thing. This provision only calls for the doctors to report their assistance in creation of and adherence to living wills. They get their incentive for reporting. Even if a doctor goes ape and doesn't consult on or adhere to a single living will, as long as she faithfully reports that non-adherence, she gets her PQRI incentive.

Under Section 1233(b)(3)(A), the only person deciding that a patient will die—or live, or fight to live, or get treatments A, B, and C but not D—is the patient. The patient chooses to have an advanced care planning consultation (which, under HR 3200, Medicare pays for). The patient writes down her wishes in a living will, a document the patient can modify at any time4. And if the patient comes to the hospital and can't express her wishes, the doctor has her wishes on paper to follow, whatever those wishes may be... or at least may have been when that document was signed.

Not one line of H.R. 3200—not McCaughey's vaunted "Page 432" or "Page 425" anything else—empowers any government official to decide when to "pull the plug on Grandma," a claim that even the progenitor of that snappy phrase, Senator Charles Grassley, has completely repudiated. Senator Grassley agrees: the only person making end-of-life decisions under H.R. 3200 is you.

So who is the death panel? Right now, if you don't have a living will, it could be your kids, your doctors, your obstinate daughter-in-law, who knows who. If you get a living will, it's you... and H.R. 3200 will pay for your effort to get informed and put your choices in writing.

Oh yeah, and H.R. 3200 will help millions of Americans get insurance, save money, and save lives.

1Update 12:05 CDT: The day after her embarrassing performance on The Daily Show, McCaughey resigned from the board of Cantel Medical Corp. What?! a deceptive opponent of health coverage reform was working for the medical industry?!

2She cited it, but after making a show of lugging what she said were the first 500 pages of the bill on stage, she couldn't find it, didn't have it sticky-noted or highlighted or even, apparently, in sequential order. She looked like a novice debater, rolling into a debate round with five tubs of evidence but not able to find her central Disadvantage argument.

3Did you notice that McCaughey tried to make it sound as if Sec. 1233 and "Page 432" were different parts and that if Stewart had only read Sec 1233 he wasn't talking about the part of the bill with which she was defending her position?

4HR 3200 pays for end-of-life consultations once every five years. The bill makes an exception for folks whose medical/care situation changes significantly. And even if you don't qualify for that exception, nothing stops you from going to your doctor or lawyer and changing your living will as often as you want; you just pay for those visits yourself.


  1. Cori,

    The House health care plan as well as the plan being looked at by the Senate have the same problems that most government plans have. The provisions can be interpretted pretty much any way you want.

    The example you cite reads the way you want it too. Living wills have priority, but that provision can also be read this way, an unknown board sets patient standards for end of life care taking into consideration the wishes of the patient, but the wishes of the patient are not the overriding consideration.

    So Sarah Pallin is right and you are right but the only one who will be right is the unknown federal panel, who in the end will decided what that paragraph really means.

    Our President, who I greatly admire, has to insist on a plan that is clearly written, easy to understand and subject to little interpretation.

    I still feel the solution is simple, expand medicaid to the unemployed and mandate exployee coverage. Employers have not been challenged to manditorily provide coverage and will find a way to do so if challenged, they always have.
    If you don't like your insurance find a company whose insurance you do and go to work for them, much like if you want to earn more money, switch employers. Free enterprise continues and everybody has insurance.

    Joseph G Thompson

  2. No, Joe, I respectfully disagree. This is not a situation where opponents of the bill can turn the relativism of language around on us and claim that black says white. There is no unknown board. The end-of-life consultation gives the patient information; the patient then chooses what to write into the living will. The bill says what it says. Betsy McCaughey is reading what she wants into the bill; I'm reading the bill itself.

    But I'm all for a simpler bill.
    Rep. Weiner's proposed amendment would get the job done, reducing HR 3200 from 1000+ pages to 28.

    So would the McGovern proposal for a one-page health reform bill: "Everyone gets Medicare." How's that for clearly written and easy to understand?

  3. CAH:

    Bill Moyers Journal had a really great program last night on the health care system:


    Check it out. Very good.

  4. Cori,

    Tell me what a consensus-based organization is?

    In the 1960's the left wing of the Democratic party called me a baby killer--today if I don't agree with them I am an unpatriotic idiot, and a right wing terrorist.

    There is no civil discourse in this country because people refuse to look at or to understand an opposing view or fear, the death panel is just one of many. It's just "Joe's too stupied to understand what is best for him, so we will do what's best for him even if he doesn't want us to."

    I do believe in universal health care, but some one has to show me how a nation of 300 million people can provide, fiscally, a single payer system-which is the long term intent of both bills--without significantly changing the lives of my grandchildren.

    I do not care if the powers that be pull the plug on me, I am an old man, but I do care about the future of your daughter and my grandchildren.

    The effects the House bill or the Senate bill, as currently written, are at least a generation away, but I am the keeper of my grandchildren's future and until someone can show me that their future is not what exists in Europe today, I will be adamently opposed to any more government control, not regulation but control,or ownership of what should be private enterprise.

    By the way I don't think a death panel or rationed health care will ever exist in the United States, nor do I believe either bill provides for a death panel or rationed health care. Citizens of the United States are too caring and compassionate to allow either. That said any bill that passes both houses of Congress is subject to the law of unintended consequences. A wise Judge once told me that in civil law he could find case precident to justify any decision he made.

    Understand the worries and concerns of those who oppose your view and do not just discard their fears.

    Joseph G Thompson

  5. I understand the worries, and I'm trying to dispel them with facts.

    Sure, I don't know who the "consensus-based organization" refers to a group. But the line you're looking at does not authorize that group to walk into your hospital room and administer or deny you any care. The group only sets the criteria for the quality measures that the doctors need to report. You still decide what to put in your living will, or whether to have a living will, or even to talk about a living will. HR 3200 increases choice and increases your access to information to support that choice.

    I will never pull your plug, Joe. And I will never vote for legislation that would empower me or anyone else to do so. HR 3200 increases liberty, and that's why I would vote for it.

    (And remember, the "caring andd compassionate" citizens of the United States are allowing private bureaucrats with no public accountability to ration care right now. Say, how come the private insurance executives controlling my health care decisions don't have to hold town halls?)

  6. Show me where HR3200 increases choice.

    Bottom line is Core, you can adopt the Democrate propaganda on socialized health care all you want, the government CAN NOT run medicare or properly fund the VA system, there is no way on earth they can run health care for 300 million people.

    Tim Higgins

  7. How many times do I have to say that the VA is the best health care in America, Tim? How many times do I need to respond to general assertions with actual evidence before you'll abandon the "government can't do anything right" fallacy? How hard is it to accept that patients rate VA care higher than private care?

    Now, here's how HR3200 increases choice:
    1. If end-of-life planning and living wills are important to you, HR 3200 makes consultations more affordable and creates incentives in reporting for doctors to give you more information to help you deiced and to follow your written orders.
    2. Moving beyond living wills, HR 3200 eliminates exclusions for pre-existing conditions, making it easier for me to hang onto my health insurance and thus have more choice of insurance plans instead of having to hang on to whatever policy I'm lucky enough to have.
    3. HR 3200 creates a public option, Uncle Sam Insurance. I will be able to keep that insurance when I change jobs, giving me more choice as an actor in the free market. I can stay at DSU, go work for Credit Soup, or start my own business, without the health insurance worries artificially constraining my evaluation of where best to apply my labor. Kind of like how paying taxes to fund a fire department frees me up from having to maintain my own fire truck and hydrant. I can do other work that I'm better at. Good for me, good for my family, good for the economy.

    Ah, smells like freedom to me! Feel free to identify whatever parts of that you think are mere propaganda.

  8. Corey:

    You can tell yourself the VA system is the best health care in America until the cows come home. That does not make it true. Statistics can be manipulated any way you want, so as to skew the data. As far as opinion polls go, you can get the results a pollster wants just by the way the question is asked, or by the demographic you poll.
    I have first hand experience with this. A few months ago, I was called at home and asked if I would be will to participate in a poll concerning abortion. I was told there were 10 questions, yet I was only asked 1 question. The question? Am I pro-life? when I responded yes, the polling institution disconnected the call. So Corey was the data they collected shewed? I kind of think so.

    Getting back to the VA systems. I'm sure you will have the answer to this question, because the VA after all is the best. A good friend of ours, and elderly gentleman who fought in WWII was recently denied admission to a VA hospital. Why?

  9. One thing I hear from the Democrates concering socialized medicine is that services will not be denied.

    What does it mean then when Obama states that maybe you should just take pain medication instead of having surgery?

    What does it mean when Obama states, that the elderly and terminally ill may have to come to embrace hospice?

  10. One other thing, yes Corey I have little or no faith in government run programs. Name one entilelment program that is not in financial trouble.

    In spite of what you think and all the internet links you point to, Medicare is failing. I see it every day at work. Maybe you should educate yourself on Medicare, first and then give an opinion as to you really think the government can run health care for 300 million citizens.

  11. Tim, I totally agree that there are people and orgs that do scientifically inaccurate (or deliberately deceptive) polls. But the numbers I give you on customer satisfaction with the VA come from the American Consumer Satisfaction Index, a pretty well-established independent group. You can't deny every statistic that disagrees with you. Yes, I can find plenty of examples where the VA and Medicare screw up. But I can also find private insurers screwing up (and screwing people over for profit, something the VA doesn't do, can't do). And when we look beyond our individual anecdotes at the big picture, as ASCI does, the VA and Medicare are still rated by Americans (all Americans together, not just liberals) as the best care available.

    That's not spin. That's not manipulation. I don't do that. I'm interested in solving problems, not promoting some ideology or big government at all costs. When government is ineffective, I'm all about eliminating it (just ask the Lake Herman Sanitary District). But when it comes to health insurance, I see a situation where the private market can't solve, and where we need to act through our government to protect the interests of all of our fellow citizens.

    Entitlement programs are in financial trouble because they are trying to do something really hard that no one else can. A big part of the fiscal problem is that baby boomers are getting older and demanding more services. If baby boomers will give up their entitlements, we'll be fine. But I don't hear baby boomers calling for the elimination of Medicare... and I don't see any other entity (private companies, charities, etc.) clamoring for the opportunity to try to provide those services. If you can provide a non-government alternative to Medicare, by all means, the floor is yours.

  12. Cori,

    Entitlement programs are not in trouble because they try to do too much, they are in trouble because the Federal government has run out of money, except for that which they can borrow from the Chinese.

    You can tax the "rich" into oblivion but still not get enough money to pay annual entitlement costs.

    Years of government expanding programs, that initially made sense, to pander to special groups in an effort to gain votes have left us in the position we are in.

    Unearned entitlements are nice but some one has to pay for them.

    After serving over 20 years on active duty, I am not eligible for VA medical care. The VA financally means tests applicants without combat injuries or disabilities. I make too much money and probably always will. Would you call that rationing in a government program?

    "If baby boomers give up their entitlements we'll be fine". Couldn't agree with you more, but maybe your words will help explain to you why many people are so afraid of any medical "reform" at the Federal government level.

    Joseph G Thompson

  13. Just heard that the US Government just sent out 1700 stimulus checks, to prisoners.

    Big screw up, and we should trust the government with our health care?

    Tim Higgins

  14. Cash for clunkers, trade in an old cluncker and get a 4500.00 rebate. To get the rebate the dealership has to fill out paper work to the tune of 69 pages for each car.

    Can you imagine the paper work required for health care?

    You really want to trust your health with the federal government? Not me.

  15. Why should baby-boomers give up their entitlement of Medicare and SS. They were forced to pay into all the years they worked. They had no choice the money was confiscated from them. So why should they not expect to get it back?

  16. Yes, I trust the government to run health care better than the private system, which covers up its mistakes so as not to lose customers.

    Stimulus checks to prisoners -- yup, big oops. The U.S. military has also made mistakes and killed civilians in Iraq and Afghanistan, but I still trust the U.S. military to fight wars more than I trust Xe/Blackwater or other private mercenaries.

    Paperwork for health care: walk into the hospital in Canada, and you do no paperwork. Walk into the hospital in Britain, and you pay no bill. And folks live longer. Show me the paperwork HR 3200 creates instead of imagining what you want.

    No, baby boomers agreed to pay for their parents' retirement. They aren't getting their money back; they'll be getting my money. And I'll work and pay it. I would just rather pay for a more efficient system that covers every American, without taking a thing away from my parents.

    And Joe, the entitlement programs wouldn't have borrowed all that money if they weren't trying to do so much. The feds didn't just say, "Oh, what the heck, let's borrow trillions from China just for fun." They said, "Oh crap: all our constiuents want Medicare and tax cuts. Guess we can't convince people we need to pay our own way, so let's borrow money to cover the programs and tax cuts that help get us elected."

    I have not once advoated deficit spending for health care reform. I remain convinced that a single-payer system would make better use of our natinoal wealth than the wasteful status quo.

    But Joe, if we can't obtain enough tax dollars to pay current entitlement costs, then what's goin to give? What programs are we going to cut? Which generation of Medicare and VA health recipients is goin to say, "No thanks, we'll go without even though we've paid in taxes and blood for our country"? (That's not a political argument: that's an honest question about what alternatives we have.)

  17. Cori,

    You finally asked a question that should have been asked years ago, except since the 1950's we have had politicians and not statesman setting in the U.S. Senate and the House.

    What the alternative? Nothing positive. I apologize for being pessimistic but since the early 1990's many people have seen the train wreck coming.

    I can promise you that the day before the fall of the old Soviet Union many members of the Politbureau said "it can't happen here", but it did.

    Most citizens of the United States, including some of your posters, are political illiterates who couldn't tell you the difference between a republic, a representative democracy and a democracy, let alone what facism, national socialism, communism, or socilialism are. Just try to get them to define let alone understand the terms liberal and conservative. Most have no idea where the terms left wing and right wing came from. Remember, we used to have liberal republicans and conservative democratics.

    You have to know where you came from before you can know where you are going and since we have chosen to be ignorant of where we came from we are lost and the path back is too difficult for most people, so we continue down the same path as the old Soviet Union.

    Sorry to rant but it's early morning and I just saw what the democrats may try to do in Mass.

    To answer your question, "whats the alternative?". Hold on to your hat cause the ride has just started and the end of the ride is not pretty.

    Joseph G Thompson


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