If health-care reform was ever the subject of anything so civilized as a "debate," it has become the center of a gaudy spectacle of artifice and outrage. This is the televised picture of our democracy at work: a Potemkin "town hall" filled with party plants, Astroturf activists, and the quavering raised voices of voters unnerved by cable news talking-point tall tales. The tallest of these is the tale of the impending "death panel" — a government committee convened to determine which lives are worth saving at what cost. "Um, I am not in favor of that," President Obama has said.
The fact that the President felt he needed to say anything at all on the topic proves the degradation of our public discourse, as many Democrats suggest. Indeed, the whiff of dystopia in "death panel" makes anything so labeled hard to love. But would a death panel by any other name smell so foul? The American health-care system, as it already exists, makes the ideas that first inspired talk of death panels very much worthwhile.
As it developed, the specter of the death panel, first conjured by Sarah Palin in a characteristically classy Facebook note, confuses two separate ideas. First, there's Medicare reimbursement for "end-of-life counseling." That's a good idea. Then there's government rationing of care. We've already got government rationing under Medicare and, frankly, the government is way too soft about it. There's nothing at all about current proposals for reform that ought to make these issues more interesting or important now than they were in the calm before the town hall storm. But now that we've gotten all worked up about it, why not think it through like civilized people? Can we do that?
One now-discarded section of one of the bills before the House, would have allowed Medicare recipients to bill the government for a session with a doctor devoted to discussing the patient's wishes in the event that he or she require extraordinary measures to be kept alive. Such sessions allow individuals to decide whether to "pull the plug" in a variety of scenarios while still in a sound, reflective frame of mind, but it takes the help of a doctor to really understand the range of dire situations one might face. The idea is that if well-informed individuals are able to make these decisions in advance and write a "living will," the government will not need to step in and make end-of-life decisions on the behalf of Medicare patients. It's a way of keeping individuals, not the government, in charge of their own lives and deaths.
Could Medicare-funded end-of-life counseling save money for Medicare? It could, if enough Medicare recipients decided to decline extraordinarily pricey and often futile attempts to eke another few days, weeks, or months out of life. Let's suppose it would save the government money. What then? Would doctors then urge patients to swiftly give up the ghost? Why would they? Doctors are paid by Medicare for providing treatment, not for not providing treatment. Both the professional and pecuniary motive of doctors tilts in the direction of doing too much, not too little.
And, as a matter of fact, too much is done. Medicare is going broke, and one thing that's breaking it is overconsumption of useless treatments toward the end of life. If current trends continue, the U.S. government will soon spend a greater portion of GDP on Medicare and Medicaid than Canada now spends on its entire single-payer government-run system. According to the Congressional Budget Office, income tax rates will have to double by 2050 to pay for the promises the government has already made. Unless something can be done to cut Medicare's cost, we can forget about new promises.
As Princeton ethicist Peter Singer explained recently in the New York Times Magazine, "The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it." He's right.
That means the government is going to have to become more aggressive about denying coverage for a great deal of unnecessary end-of-life care. In becoming more aggressive, Medicare will have to set out clear rules for determining what kinds of end-of-life treatments are and are not worth paying for out of the public purse. Real people will have to come up with these rules. And real people will have to apply the rules in particular cases. There will be plenty of hard cases — though the kind of end-of-life counseling that helps individuals settle on a living will might make some of these cases easier. A good set of Medicare coverage rules will cut out a great deal of waste and put the system on a more sustainable footing. But some people who would have died later under our current over-generous rules will die sooner. There's just no way around that.
It doesn't add up to "death panels." But the idea of newly aggressive government rationing is nevertheless unsettling to current Medicare recipients who shaped their expectations around the unsustainable level of coverage they now enjoy. Nobody wants to look selfish, so it's easy enough to understand why beneficiaries of the current deluxe system would tend to overdramatize the prospect of reductions in their benefits. And nobody wants to dwell too much on death, much less on the possibility of a painful and drawn-out death. So it's easy enough to understand why the mere thought of end-of-life counseling could be frightening, with or without Medicare-funded counseling sessions.
But, again, these issues have nothing much to do with reforms now under consideration. If most Americans don't want their government meddling in hard choices about medical care near the end of life, then they don't want Medicare. We've known that Medicare is unsustainable for a long time now. People flipping their lids about death panels and about government-funded doctors trying to sell seniors on suicide should have been flipping their lids years ago. If these are reasons to kill Obamacare, then, logically, they are also reasons to kill Medicare. But, as the town hall shenanigans show, democracy is anything but logical.