Fiat

By lex, on December 26th, 2010

Unable to move his signature health care bill through Congress with “end of life” counseling embedded therein, the president has decided at the lamest duck moment of the 111th Congress to implement it through bureaucratic regulation:

When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system. But the Obama administration will achieve the same goal by regulation, starting Jan. 1.

Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.

Congressional supporters of the new policy, though pleased, have kept quiet. They fear provoking another furor like the one in 2009 when Republicans seized on the idea of end-of-life counseling to argue that the Democrats’ bill would allow the government to cut off care for the critically ill.

The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.

End of life care is a relatively expensive element in the US health care system. By some estimates, 27% ($88 billion) of the gross Medicare budget each year is spent on patients in their last year of life, although the costs can vary widely by state. In Miami, the cost of treatment for the final six months of a patient’s life has been quoted as $23K, while in Portland, Oregon, where an advance direction scheme known as the Physician’s Order for Life Saving Treatment (POLST) system is in effect the cost is only $14K. Presumably, this is the example President Obama is contemplating for nation-wide roll-out.

Two thoughts on this: First, this would have been a neat thing to hash out when Obamacare was part of the national dialogue, and it’s kind of a weaselly thing to do to take such a controversial issue off the table in the name of compromise – or political expedience – only to reinsert it by presidential fiat.

Second, it is in our very nature to avoid thinking about the last year or six months of our lives when we’re hale and healthy. It’s one thing to blithely say, “pull the plug” in cocktail party conversation when the actual prospect of is theoretical and remote. Quite another thing to be lying on a hospice bed forced to tacitly acquiesce to a decision made by someone else – you – who had no personal experience of what you are now going through.

My mother was a fiery Irish red head from the Pennsylvania coal country who surmounted numerous obstacles, cast aside barriers and knocked down doors wherever she went. Like all of us, she couldn’t get by the last one though. Towards the end there though, good Catholic girl that she was, what I saw most in her eyes was terror. I think she would have willingly spent a little more of the Medicare fund that she’d payed into all her working life for another month or two on this side of the veil, no matter what she said or thought back when the issue of palliative care was entirely theoretical.

Being my own mother, I would have said that she deserved it.

Farewell to that.

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Filed under Best of Neptunus Lex, by lex, Carroll "Lex" LeFon, Carroll LeFon, Lex, Neptunus Lex, Politics

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