Reich on End of Life Care

Robert Reich Granny Must DieNewsBustersP.J. Gladnick has dug up a 2007 speech by former Clinton labor secretary Robert Reich that purportedly “reveal[s] the brutal truth about what liberals ultimately have in store for the public with their health care plan.”

I’ll actually give you a speech made up entirely, almost on the spur of the moment, of what a candidate for president would say if that candidate did not care about becoming president. In other words, this is what the truth is and a candidate will never say, but what a candidate should say if we were in the kind of democracy where citizens were honored in terms of their practice of citizenship and they were educated in terms of what the issues were and they could separate myth from reality in terms of what candidates would tell them:

“Thank you so much for coming this afternoon. I’m so glad to see you and I would like to be president. Let me tell you a few things on health care. Look, we have the only health care system in the world that is designed to avoid sick people. And that’s true and what I’m going to do is that I am going try to reorganize it to be more amenable to treating sick people but that means you, particularly you young people, particularly you young healthy people…you’re going to have to pay more.

“Thank you. And by the way, we’re going to have to, if you’re very old, we’re not going to give you all that technology and all those drugs for the last couple of years of your life to keep you maybe going for another couple of months. It’s too expensive…so we’re going to let you die.”

Any rational analysis of the costs of our health care system will come to this conclusion:  The lion’s share of the lifetime health care costs for most Americans is spent in the final months of life managing death.  If we’re going to control costs, that’s the most logical place to look.

The problem, of course, is that we’re not purely rational beings.  As Reich notes at the beginning of the quoted remarks above, this is a political non-starter.  A goodly number of liberal politicians may well believe this.  President Obama almost certainly does.  But saying so publicly — much less trying to pass this into legislation — would be political suicide.  So it ain’t happening.

One could argue, I suppose, that something like Reich’s honest plan would be a natural long-term consequence of adopting a British-style national health care model.  But that’s simply not on the table right now or in the foreseeable future.  Americans won’t put up with that sort of system and its elected leaders — who aspire to be its re-elected leaders — aren’t going to push for it.

Instead, we’re likely to see some expansion of the present, insurance-based system with the taxpayers on the hook for most of the people who don’t currently have insurance and those of us currently possessing insurance paying substantially higher premiums.  To be clear: I don’t like any of the bills that have a serious chance of becoming law, preferring a bad status quo to a boondoogle that fails to address its core flaws.  But we’re not looking at a secret plot to enact Reich’s desire to control costs by letting granny die a little early.

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James Joyner
About James Joyner
James Joyner is a Security Studies professor at Marine Corps University's Command and Staff College and a nonresident senior fellow at the Scowcroft Center for Strategy and Security at the Atlantic Council. He's a former Army officer and Desert Storm vet. Views expressed here are his own. Follow James on Twitter @DrJJoyner.

Comments

  1. floyd says:

    So in a perfect system, one would simply pay premiums or taxes all his life for health care, then be denied when he goes to collect on that for which he has paid?

    The article points out a more important point…
    That we now have an unprincipled electorate continuously reelecting an unprincipled government, which is willingly sacrificing all the hard earned liberty and prosperity of this nation for the prize of reelection.
    We now have a nation with more knowledge and less wisdom than any any nation at any point in human history.

  2. anjin-san says:

    When my Grandfather was 85, he had a stroke. Not too serious, but he put a DNR into his medical records. When he was 89 he had another stroke. His DRN was ignored. He had about 8 more months of painful, humilating life. He could not go to the bathroom at that point without help.

    But the hospital he was at got about another 100k out of us, so the system worked as intended. After all, who cares about the dignity of an honest man who worked his ass of for 50 years and never got so much as a speeding ticket when there are profits to be made?

  3. Brett says:

    preferring a bad status quo to a boondoogle that fails to address its core flaws.

    That’s part of the “problem”, so to speak – the status quo is very good for end-of-lifers as of right now. Under NHS-style rationing, they might be denied care after a certain point, or steered to certain types of care that are cheaper.

    Under a more free-market system, they could spend whatever they had (or whatever their insurance covered), but you’d have strong discrepancies in treatment based on income (with the particularly unlucky ending up bankrupt on their death-bed) – and strong incentives working against them having health care coverage (look at coverage rates of seniors before Medicare – it was pretty dismal).

  4. Herb says:

    To be clear: I don’t like any of the bills that have a serious chance of becoming law, preferring a bad status quo to a boondoogle that fails to address its core flaws.

    The honesty…it burns! I gotta hand it to you. You make this integrity thing look easy.

    I think many liberals would prefer doing something…anything, even said boondoggle…rather than maintain our (all can agree) bad status quo, but in an argument that has devolved to who’s more like Hitler, I commend your principled disagreement.

  5. Dave Schuler says:

    Any rational analysis of the costs of our health care system will come to this conclusion: The lion’s share of the lifetime health care costs for most Americans is spent in the final months of life managing death. If we’re going to control costs, that’s the most logical place to look.

    Is that an intrinsic feature of any healthcare system or is it an artifact of ours? anjin-san’s anecdote, not completely out of left field, suggests the latter. A few weeks ago I showed a bar graph over at my place illustrating the costs per age cohort in various healthcare systems. In our system there was an astonishing leap in per person costs at the age that Medicare became available.

    Is it that the greatest demand for healthcare is at end of life or that the greatest application of healthcare services is at end of life? If the federal government paid all healthcare expenses from birth to 3, would the greatest concentration of spending suddenly become at the beginning of life rather than its end?

  6. James Joyner says:

    If the federal government paid all healthcare expenses from birth to 3, would the greatest concentration of spending suddenly become at the beginning of life rather than its end?

    Childbirth and pediatric care are relatively inexpensive under our current system, absent serious complications.

    Longterm hospitalization and experimental or cutting edge procedures, which tend to comprise end-of-life care, are expensive here. Presumably, most of the socialized medicine countries simply don’t permit this expenditure to the degree we do?

  7. mpw280 says:

    Good post Floyd, it sums it up pretty much as it is, especially in big cities.

    Best one I heard on the talking heads this morning was that Republicans haven’t put any plan forward, not one, according to this democrat. You have to love disinformation, do they teach that now in polysci courses, if not they should.

    If they made the system a MSA then young people wouldn’t mind paying into the system as they would get to bank unused allowances every year and when they are old and need them, wow, they would have a nest egg for medical funds. Same goes for social security, if they allowed personal accumulation then maybe they would have a lot less problems. This of course means that you have to allow personal freedom to screw up and fail, which the democrats can’t allow as they know how your life should be run.
    mpw

  8. Zelsdorf Ragshaft III says:

    If government gets to decide when DNR takes place, what stops them from deciding to bring that number down to say 65 or so? The Pilot (Anjin) fails to state it was his grandfathers pilots choice to be tagged DNR. What I have noticed is no one anywhere is bothered by government having control of retirement accounts (Social Security) and having control over healthcare. Seems to me there might be a conflict there. In perusing the founding documents, I am having difficulty finding the authority to mandate the purchase of what is essentially a product or service. I have no intention of paying any fine or buying anything I do not wish to buy. The fact I am a Viet Nam era vet only makes it so I do not have to, I think. Anyone, in my opinion, who thinks Robert Reich’s ideas are valid has been educated beyond their intelligence and their humanity. Pity the fool who tell me my life is not worth saving for he will have sold his for about $.50 or whatever a .45 costs at that time. I was train in violence by our Government. I have not forgotten my training. There are millions just like me.

  9. Charlotte says:

    So, why don’t we just decide that “regular” people…say, at the age of 65…just be put to sleep? That way, we won’t have to worry about them.

    Oh, now let’s just change the equation. It’s your Mother.

    And then, let’s change the equation further: it’s a premie baby who will need a million dollars worth of care to have a life (which may not be really productive because lots of premies have lung problems and brain problems among others) So, hey, let’s put “IT” out of it’s misery. How about if it’s YOUR baby?

    IMHO: The bottom line is that passing this bill is pretty much suicide for the Dems. Anyone who thinks otherwise must be smoking some good herbs.

  10. gustopher says:

    Just to check, Mr. Joyner, you are supporting Death Panels?

    Any rational analysis of the costs of our health care system will come to this conclusion: The lion’s share of the lifetime health care costs for most Americans is spent in the final months of life managing death. If we’re going to control costs, that’s the most logical place to look.

    and

    To be clear: I don’t like any of the bills that have a serious chance of becoming law, preferring a bad status quo to a boondoogle that fails to address its core flaws. But we’re not looking at a secret plot to enact Reich’s desire to control costs by letting granny die a little early.

    Am I misreading this, or drawing the wrong conclusions? It certainly seems like you’re implying that the key feature missing from the various boondoggles in congress is the lack of Death Panels.

  11. James Joyner says:

    It certainly seems like you’re implying that the key feature missing from the various boondoggles in congress is the lack of Death Panels.

    Rationalizing end-of-life care is likely necessary in a public-run system. It can be done in other ways in an insurance based system.

    My objection to the current legislation is that is spreads coverage by forcing most of us to pay more without doing anything to address the escalating costs that make the system unsustainable.

  12. kth says:

    Ragshaft, you raise an interesting point for once. But of course Medicare or some future quasi-socialized iteration would have no reason to insist upon a DNR order. Medicare simply wouldn’t pay for the heroic measures, ICU stay, etc, all of which a patient could still have if he paid for it out of pocket, or bought supplemental insurance that covered it. That’s no more a “death panel” than when private insurers refuse to pay for treatment today.

  13. Dave Schuler says:

    Childbirth and pediatric care are relatively inexpensive under our current system, absent serious complications.

    You’re missing my point which is that prices in healthcare are not determined by competitive pressures or true value (whatever that means). If you throw enough money at something (as we do in Medicare) and restrict its supply (as we do in our healthcare system), its cost will rise.

  14. Our Paul says:

    This one is in honor of anjin-san (October 14, 2009 | 10:56 am) and a gentle reminder to James Joiner of a previous exchange we had over end of life issues. That exchange centered on medical assisted suicide, and ended with this advice:

    Just be sure you have a legally accepted document which outlines the treatment you wish to receive in the future, if not your fate may be decided in court, your family members may squabble over what should be done, or you may spend the rest of your life with treatments that you never wished to have.

    As a physician, I have encountered more than one family being torn asunder as to what should be appropriate treatment for an incapacitated loved one. Take it from this wretch, if you become incapacitated to the point where you cannot communicate with your physician, your family can, and will be torn unless your treatment wishes are fully expressed.

    Equally distressing is when excessive treatment is being administered despite prior expressed wishes, only because they were not documented in a proper legal form. I once was caught in a situation with a patient who had a legal paper, valid in its day, which directed care she wished to have. Not good enough said New York State Health Department, it does not meet the criteria we have outlined. But, (cough, cough) the criteria came into law after my patient became so demented she would not have the capacity needed to fulfill your criteria. The solution, to the court, and the legal system, and a four month ordeal.

    In a world where the weight of the brick you hurl is more important than the weight of your argument, assuredly ignorance is the strongest catapult. Thus, Medicare is the model for end of life expenses, when the same cost are incurred with private insurance. And the cry, they will ration Medicare is raised, when every Insurance Company engages in this practice daily.

    And, it does not take Willy Sutton to tell you that if you are going to sue, you go where the money is — and that is the hospital. And if you cannot produce a DNR form, you are going to get full cardiopulmonary resuscitation, and without treatment guidelines you will be placed on a ventilator, and of course, the treatment we can all admire, artificial nutrition and hydration, aka gastric feeding via a tube will be utilized. No hospital will deny treatment, even if long term success is impossible, without firm, legal, prior expressed treatment guidelines. Anjin-san’s grandfather is but another casualty in the way we practice medicine.

    When the House of Representative’s bill contained a reimbursement clause for discussing end of life issues, the brick throwers loaded their catapults. Instead of a rational discussion as the importance of these issues we got death panels, genocide, and pulling the plug on granny. This may come as a mild surprise to some people, but age does dictate medical outcome. This surely will come as a shock, without treatment guidelines that meet legal criteria, you will get maximal medical treatment.

    What the House bill was doing was to reimburse health care providers for their efforts in protecting their patients from treatment most would never want. Without prior expressed wishes you will be kept alive on a respirator, and you will be kept alive with a stomach tube. Congratulation to the brick throwers, they have “won” this one.

    Brother Dave Schuler has this to say:

    A few weeks ago I showed a bar graph over at my place illustrating the costs per age cohort in various healthcare systems. In our system there was an astonishing leap in per person costs at the age that Medicare became available.

    I, for one, would like a link to that graph. To accompany Dave’s comment, I would like to point out that there is data establishing that health of individuals improve once they enter the Medicare pool. I would further point out that European health care is more integrated, aimed at providing care in the least expensive locus (home), with an entirely different community philosophy.

    One simple example, in the US the flow is to the hospital for primary care, then to the nursing home for rehabilitation or long term stay. You need a three day stay in the Hospital before Medicare will cover a Nursing Home rehabilitation stay. Medicare will not cover Home Care services without a hospital or nursing home stay. Ah yes, but after 21 days in the Nursing Home for Medicare rehabilitation, co-pay clicks in. Guess what, your Insurance will not cover that…

    In Sweden (a system I am most familiar with), and most of Europe, these loci of care are interchangeable, your real need defines where you go, with no economic imposition. But then, that is socialized medicine!!!

    I for one, do not think you should go here, James (October 14, 2009 | 11:44 am):

    Childbirth and pediatric care are relatively inexpensive under our current system, absent serious complications.

    Infant mortality is higher in the US than in most OECD countries. And if you wish to go the way most Center Right folks go, we cannot trust those statistics, you still have to deal with our internal statistics. Infant mortality in the US correlates with poverty. In Rochester, NY, a relatively affluent community with a world class University Medical Center, infant mortality in the black population is three times that of the white population.

    Correspondent Charlotte (October 14, 2009 01:13 pm) comes up with this zinger:

    And then, let’s change the equation further: it’s a premie baby who will need a million dollars worth of care to have a life (which may not be really productive because lots of premies have lung problems and brain problems among others) So, hey, let’s put “IT” out of it’s misery. How about if it’s YOUR baby?

    It is no secret among the cognoscenti that the primary cause of prematurity is inadequate pre-natal care. Few Insurance plans cover such care, and indeed, the trend is to exclude pregnancy from commercial medical insurance. A secondary, but real issue is in-vitro fertilization. The in-vitro fertilization complex is the least regulated medical area in the USA. Multiple births are common, prolonged stay in Pediatric ICU’s are the norm for these baby’s. Would you be willing to accept the norm in Sweden for an infertile couple: Only one embryo implanted per infertility trial? Or do we leave the decision up to women desperately seeking a child, and those clinics where success is measured by the number of successful pregnancies?

    Pssst 1#: It is impossible to compare European health care delivery to that in the US unless the underlying societal structure is examined. If life is a group of people living in a leaky life boat, in Europe every life in that boat is equal. In the US it not quite so, it is the rugged individual who triumphs in the life boat, he with the most chips…

    Pssst #2 If you are still out there Dave, I sure would like a link to the graph you quoted.

    Pssst #3 If you are interested in the issue of terminal care, or assisted physician suicide my link at the top of this ponderous post should prove instructive.

    R. Paul Miller, MD

  15. anjin-san says:

    Come on Paul, you are only a doctor. Do you really have the gall to suggest that you know more about health care than Rush Limbaugh and Glenn Beck? 🙂

    Many years later, my family still lives with the pain of having watched my Grandfather, an extraordinarily kind and humble man, suffered through those last few months of life that he never wanted.

    But somebody got a pretty good payday out of the deal. Guess thats what health care is all about…