Parsing H.R.3200: End of Life Care Provisions

Typically, I've tried to tackle political issues on this site without the use of ideological talking points; besides the fact that I abhor the concise, pre-packaged way of thinking about the world that is advanced on cable TV networks, I find it much more constructive to 1) assess who is likely to win upcoming elections, and 2) point out blatant dishonesty when I see it. Now, because of the dishonest nature of politics, I was forced to insert the word "blatant" into the previous sentence. That is to say, I only feel like the most egregious acts of political dishonesty are worthy of discussion. That being said, on the eve of President Obama's Congressional address concerning health care reform - an effort that in my opinion will ultimately be viewed as a failure - I'd like to go head first into the topic of HR 3200 and End of Life Care Provisions. Depending upon your political disposition, you may prefer to use the term "death-panels"; I however, will refrain from using this sort of dishonest innuendo-laden terminology.

My assessment of HR 3200 and it's end of life care provisions is based upon a research report prepared by the Congressional Research Service. The CRS is sort of like the policy analysis equivalent of the Congressional Budget Office; it produces objective legislative and policy analysis that is relevant. For those who don't have time to consume the full report, I'll summarize the portions of HR 3200 that deal with end of life care below.

Advance Care Planning
HR 3200 would expand Medicare to cover an advanced care planning consultation with your physician. This consultation would be completely optional, and would allow adults to have a discussion with their doctor about the various stages involved in end of life care. It would also provide patients with the education they need concerning "health care proxy's", or the appointment of a spouse or other family member who can effectuate medical decisions in the event the beneficiary has become incapacitated. This provision would also standardize end-of-life-care preference statements across jurisdictions so as to avoid confusion.

Quality Measures
This provision would incentivize physicians to report on end of life treatments from a quality perspective; that is, whether the treatment rendered helped improve the quality of the patient's life. Since improving quality of life should be the underlying purpose behind any end of life treatment, it seems that a centralized Medicare data collection initiative would have the best chance of maximizing that goal. This provision does not in any way institute panels which would make end of life decisions; it simply gives physicians a 2% bonus for reporting the effectiveness of a procedure.

Educational Aspect
Finally, the bill would update the well-known Medicare handbook titled "Medicare and You" to include language about advanced care planning. A separate House Energy and Commerce Committee amendment would direct the HHS secretary to establish a toll-free national hot-line that would provide answers to questions about advanced care planning.

There you have it. The above provisions are the only ones included in HR 3200 that deal with end of life issues. There will no be no government bureaucrats deciding whether you live or die. The ironic thing about that argument is people pretend there isn't already somebody else making these decisions for them. Given that very few people can actually pay cash for medical procedures, they are always relying on either an insurance company or the government to pay for them. In the case of the elderly, they are on Medicare, so the government is already making judgments concerning their benefits. This is the sort of thing that gets fleshed out in an intelligent debate; however, I haven't seen very many of those occurring. Sphere: Related Content

Parsing the Health Care Reform Polling Data

As Congress prepares to return home from it's cherished recess, the debate over health care reform stands as the most contentious issue the country is currently dealing with. As such, public opinion polls on the subject are being monitored with a level of vigilance which suggests either ignorance or disregard for these polls' margins of error. Nevertheless, the polls are instructive insofar as offering a reasonably representative snapshot of American opinion. The data I'm using in the following discussion was taken from the most recent NBC News/Wall Street Journal Survey, dated July 2009. The poll interviewed 1011 adults; all but 100 were reached via land-line.

The majority of discussion pertaining to health care reform has, in my opinion, fostered an under appreciation for the role that age plays in determining one's stance on the subject. Perhaps this is because it is easier for the media to discuss this issue in terms of either broad ideological preferences of weak v strong government, or class based, "ability to pay v not" scenarios. Whatever the underlying reasons may be, I believe it's distracted us from the obvious reality that voters tend to advocate for - or against - those policies which they perceive to be the most personally advantageous. For voters who are currently Medicare beneficiaries - or are close enough to the age of eligibility to ascertain that the system will still be solvent at the time of their eligibility - the personally advantageous option is to oppose health care reform. The justification is simply that any new health entitlement program would be partially funded through changes to Medicare; this doesn't necessarily mean cuts to benefits, but seniors would prefer not to test the government on this one. Younger voters on the other hand, are well aware that Medicare will not exist in it's current form by the time they are eligible. They are also somewhat cognizant of the fact that rising health care costs have, over the past decade, taken the place of substantive salary increases. That being said, let's look at the age dispersion from the most recent NBC/WSJ poll:

The age dispersion of the poll's respondents indicates that 50 years old is the 50th percentile; in other words, half of respondents are below 50 years old, and half are below 50 years old. While keeping the age of the poll's respondents in mind, let's move to what I consider to be the most compelling question of the survey: Would you find it acceptable to fund the current health care proposal by reducing payments to hospitals and drug makers for the services or products they provide to patients on Medicaid or Medicare? Below is a chart showing how respondent's answered that question:
With a ~3% margin of error for this survey, you can see that the two answers are statistically very close. My guess is that those between the ages of 18 and 49 answered with a majority "Acceptable" response, and those over 50 responded "Not Acceptable". I'd also guess that as you get closer to the 50th percentile (50 years), the rate of those responding "Not Sure" increases.

Now, however, let me introduce the game-changer: those in the 55+ age bracket show up to the voting booths in far greater numbers than any other age group. Furthermore, this group's voting influence increases significantly during mid-term elections (think 2010). Voters over 55 show up in heavy numbers at both Presidential elections and the mid-terms; younger voters have been known to get excited over a Presidential candidate (think Obama) and increase their turnout at that election, only to dissipate,lose interest, etc. by the time mid-terms roll around. Obviously, this has Congress worried.

Perhaps the above dynamic represents the largest flaw in President Obama's strategy of tossing the health care idea to Congress, and settling into a "hands-off" management approach. I'll reserve final judgment of that strategy until all is said and done; however, should the health reform effort fail, fault may lie with the politically powerful President who ceded the majority of the process to a mid-term fearing Congress. Sphere: Related Content

Which Demographics Will Benefit From the Proposed Health Care Reform?

After observing and absorbing the furor which has erupted in opposition to President Obama's health care agenda, I concluded that there are a number of inconsistencies and contradictions inherent to the opposition's argument. As a disclaimer, I'm not speaking from any particular point of view here; simply observing and applying a dose of logic.

First of all I must pose the question of who, exactly, stands to benefit most from a public health care option. Many of my acquaintances, in addition to many in the exasperated town-hall-attending population, are convinced that President Obama's purpose in pushing health care reform is to provide the poorest segment of the American population with free, or heavily subsidized, health insurance. Some of the more ignorant comments - which are not worthy of further examination - attempt to inject some sort of racial angle into the President's calculus.

Another cause for the anger being shown by many is the perception that Medicare will either be viciously trimmed, or in some strange instances, removed altogether. Simply stated, seniors hear the word "inefficiencies" in the Administration's rhetoric, and they immediately interpret this as code for "cuts to benefits".

Some people think that their ability to purchase good old private health insurance will be taken away by any reform effort. I'm not sure why anybody has arrived at this conclusion; most likely they are taking too seriously President Reagan's comments in which he likened a public option to a Trojan Horse, whose ultimate goal is to abolish the private health insurance industry altogether.

Who will benefit from the proposed health care reform? Perhaps the better question is, Who doesn't have health insurance right now? Well, upon turning 65, a citizen is automatically entitled to Medicare; seniors are obviously not the beneficiary. What about the poor? Well, they are eligible for Medicaid; assuming of course that they are eligible under State guidelines. Each State has a separate set of guidelines, but the bottom line is that most people at or below 133% of the federal poverty line will be eligible for Medicaid. For perspective, there are roughly 2.4Million eligible Medicaid recipients in Florida alone. So now we've ruled out both the poor and the old. What's left are the middle-aged and the middle class; my assumption of course being that the upper echelons of society are not overly burdened by health insurance premiums. Why don't people get this? The people doing the most screaming at the town-halls would seem to be those who stand to benefit the most!

To address those amongst the elderly who are concerned about cuts to Medicare, I would simply propose an either or situation that will occur at some point; I am nearly 100% certain. Either taxes must be raised in the near future to fund Medicare's ballooning cost, or the entitlement program will have to be trimmed down to meet the federal government's capacity to pay for it through tax receipts. If you oppose health care reform because "we can't afford to pay for it", I would respond by saying that we certainly can not afford to proceed with a business as usual attitude. Medicare and it's growing costs could potentially bankrupt this country; something will HAVE to be done about. The choice is, whether the elderly would prefer that reform to occur now, or when the nation has literally reached a crisis point over this program. If I were a Medicare recipient, I would prefer that reform happen now. As history has shown, the United States is prone to reacting irrationally in a crisis. Now at least, baby boomers and Medicare recipients represent a majority of the registered voter population. Keep in mind that in 20 years, this likely won't be the case. Proceeding forward with reform now will at least give boomers and the elderly a majority voice in shaping the characteristics of a more sustainable approach to health care. Sphere: Related Content

Low-Cost Preventive Medical Care Idea: Exercise

One of the more frustrating aspects of the health care reform debate (assuming the discourse is worthy of such a label) is the confusion surrounding preventive medical care. Now, we all know that the Left wants to over-emphasize the efficacy of preventive tactics; primarily to argue that their use - and federal support of - will lower health care costs dramatically, thus making room for their idyllic visions of health for everyone. The Right however, chooses to completely disparage preventive medical care; essentially arguing that there is no such thing. This issue was recently addressed by the now infamous Congressional Budget Office, via a letter to Congress in addition to a friendly blog post on the Director's sounding board. Basically, the CBO's comments on preventive care come down to this: The theoretically cheapest and most effective form of preventive care - wellness services - would take years to show up as cost savings. Furthermore, it is questionable as to whether the government is capable of implementing wellness programs in an effective enough manner to supplant those already offered to the American populace.

This is ultimately not the most palatable of conclusions however, as it would seem to put the onus of staying healthy - to some degree at least - on the individual himself. This is an area of contention that seems to encourage normally intelligent people of differing opinions to trade anecdotal evidence back and forth in the hopes of proving their argument. Example: "I know a man who was healthy his entire life before dropping dead of a heart attack". Counter-Example: "I know a man who exercised his whole life and was still running marathons at age 75". Hopefully you get the point.

Regardless of your stance on this issue though, I would challenge anybody to side with the cave-man reasoning that obesity does not cause a whole host of medical issues that have been, are, and will drive up health care costs for the rest of us. Obesity is, for the vast vast majority of people, a preventable ailment. It is the result of a choice that you have made. That being said, I am prepared to end the entire health care debate by proposing a set of guidelines that, if followed, will lead to improved health for Most people.

1. Exercise. Preferably running, but walking is acceptable in the event of bad knees or hips.
2. Eat grilled chicken. These days, grilled chicken can even be purchased at McDonalds
3. Eat vegetables. They are cheap in the grocery store. I promise.

There you have it. These simple solutions should allow you to make it to Medicare without too much consternation. If issues do arise prior to Medicare eligibility, then no big deal. The population as a whole is much healthier, so you have been able to afford private health insurance your whole life. You're all welcome. Sphere: Related Content

Medicare and Life Expectancy Misconceptions

Some intriguing commentary emerged over the weekend, from the venerable Paul Krugman, via his appropriately titled blog "The Conscience of a Liberal". As we all know, a nascent health care reform bill is struggling to make it out of committee in both the House and the Senate, vaulting all things health care into the position of Contentious Issue #1. Mr. Krugman plays his part in the debate, arguing that the "success" of Medicare reasonably justifies supporter's claims that socialized medical care can in fact work for this country. As evidence for his assertion that the US Government is an efficient manager/administrator of health care for the elderly, Krugman cites life-expectancy statistics in both the US and Netherlands. These stats indicate that at birth, a resident of the Netherlands can expect to live longer than his American counterpart; however, once the age of 65 is reached, it is the American who can expect to live a bit longer (by about 0.4 of a year). From this discrepancy, Mr. Krugman and others conclude that Medicare is socialized medicine at it's best, and that if we could just sign the entire population up for Medicare (or some derivative thereof) then everything would be fine. Basically: If Medicare works for the most medically needy portion of the population, then it should certainly suffice for the (usually) healthier young. To list the first several issues that come to mind when presented with Krugman's logic:

1. Older people are much more likely to vote; 63% of those older than 55 vote v. 22% for those between the ages of 18 and 24. This is why Social Security and Medicare are not tampered with by the politicians. Lawmakers are scared by old people because the elderly both pay attention and vote.
2. You're telling me that our country spends more - per capita - on health care than any other country in the world? And all we get out of it is a fraction of an additional year of life, likely spent institutionalized?
3. The statistics concerning US v Dutch life expectancy could simply mean that the American elderly are more risk averse, i.e less prone to engaging in "dangerous" behavior. Or perhaps, the data shows that American youth are so at risk, that many simply die before ever reaching the statistical pool of 65 years olds; they have in effect "Weeded" themselves out of the sample.
4. At what point does life-expectancy cease to function as a gold-standard? Spend some time in a nursing home and you'll quickly decide that, while you can "buy" life-expectancy, it doesn't come with a free sample of happiness or quality of life.
   

Sphere: Related Content

Who is the Secret "Oxygen Payments" Lawmaker?

For the second time in just a handful of days, the Wall Street Journal has mentioned a specific Washington event - recalled by White House budget chief Peter Orszag - that detailed a certain lawmaker's reaction to his assertion that health care costs must be kept under control. Members of Congress play a special role insofar as health care costs are concerned, as they control Medicare's bidding processes (or lack thereof), as well as the level at which Medicare will reimburse doctors for certain procedures. Anyways, Mr. Orszag reportedly told Laura Meckler of the WSJ that, during a recent meeting with lawmakers, his message of "cost savings" was interrupted by a representative who stated that her highest priority was "winning higher payments for oxygen suppliers". It appears as if Mr. Orszag, intent on avoiding the uproar that would result from his stating the actual identity of "oxygen supplier" lawmaker, has chosen to take a high road of sorts - and let somebody else figure out who this mystery lawmaker really is.

Thanks to the internet, we believe that we have developed a list of suspects, based on the small number of facts afforded us. The first bit of evidence to turn up is that the American Association for Homecare - an association that "advocates" (lobbies) on behalf of the homecare community (to Congress) - has been an ardent supporter of H.R.1077, the Medicare Home Oxygen Therapy Act of 2009 the Medicare Respiratory Therapy Initiative Act of 2009. The AAH even provides you with talking points, conveniently located on their website (and below) The AAHomecare's main thrust seems to be preventing the process of competitive bidding in the Medicare arena. As you can see, the talking points are very Obama-like; a.k.a assertions of savings are made without providing any supporting evidence.

Now, we assume that any lawmaker bold enough to introduce her oxygen-tank-payment concerns into a Cost Savings Meeting would be very likely to have sponsored or co-sponsored H.R.1077. A little research shows that this bill was sponsored and introduced by Rep.Mike Ross (D-AK), and co-sponsored by 23 other members of Congress. But wait; Mr. Orszag's account of the mystery reimburser identifies the Congressperson as a female, of which there are only a handful who have signed onto this bill. We have taken the liberty of listing them below:

• Rep. Tammy Baldwin (D-WI)
• Rep. Lois Capps (D-CA)
• Rep. Lucille Roybal-Allard (D-CA)

So there you have it; by the power of deduction, we have determined that this infamous, mysterious Congressional grabber of pork is, in all likelihood, one of the Congress persons listed above. We will continue, in unrelenting fashion, to find out who this individual is. Tips welcome of course.

edit @ 2:30pm*Note: As was pointed out by a reader below, HR 3220 is a bill that would seem to be more directly applicable to the issue of the actual "oxygen". The problem is that HR 3220 is light on co-sponsors (only 1); therefore offering zero worthwhile "evidence". Our opinion diverges from the lobbyist commented below when he/she states that HR 1077 and HR 3220 are about completely different issues. It seems obvious to us though that providing Medicare coverage of respiratory therapists(HR 1077) is Quite related to reforming the reimbursement for home oxygen therapy services(HR 3220). For all practical purposes, we fail to see how there is actually any difference between the two, aside from the fact that HR 1077 appears to be the more inclusive of the two. Thank you for the comment though; we did get a bit sloppy on the reporting of this. Next up: an investigation into Rep. Tom Price (R-GA)

AAHomecare Competitive Bidding Talking Points 4.30 Sphere: Related Content