Tuesday, November 9, 2010

Advocating for the Future of Medicare

I've admired Randy Cohen's "The Ethicist" column in the New York Times Magazine ever since he started it more than ten years ago. I don't always agree with him, but I love the verve of his writing. He has an unusual gift for turning thoughtful ethical analysis into engaging prose! (See here for a previous post about Randy.)

But what caught my attention in a recent column was the question posed by a reader:
At 65 years old, I am facing a final diagnosis for lung cancer and the prospect of a 15 percent survival rate. If this is confirmed, would it be ethical to put myself through painful long-term treatment and to have the people who love me endure this? At my age, is it ethical to consume the health care dollars involved? What is the tipping point to elect aggressive care? Thirty percent? Sixty percent? G.M., JACKSON HEIGHTS
In my 45 years of practice I was struck by how often my patients - especially those in GM's phase of life - made similar comments. "Doc - you should be spending your time with young patients - I'm not the future - they are!" These comments were not symptoms of depression or low self esteem - they reflected an ethical perspective that I, now in that age group myself, share.

In my view, giving priority to the younger segments of the population is correct moral reasoning, but it's neither politically correct nor tactically wise. When the health reform process proposed support for conversations between older patients and their physicians about the values they wanted to guide their treatment by, right wing zealots fulminated against "death panels," and much of the public believed their misinformation. And in the election campaign we've just been through, Republicans made hay with scare tactics about the "assault on Medicare." (See here for a post on the campaign.)

I see great potential value for an advocacy process that brings together progressively-minded folks who are Medicare recipients or who are, like me, Medicare eligible but still receiving health insurance through employers, to advocate for clinically informed, ethically justifiable, and potentially socially acceptable Medicare reforms. The Affordable Care Act contains the potential for a better future for Medicare in programs like the Independent Payment Advisory Board, the Center for Medicare and Medicaid Innovation, and other initiatives.

The Republican strategy for the new Congress is to "starve" these promising programs by withholding funds. The Republicans will present their effort as "protecting the elderly." But it's not. The status quo for Medicare ensures unsupportable cost increases for Medicare itself and undermining of other social efforts that seniors largely support. In our personal financial lives the elderly population hopes to preserve a legacy for the next generation(s). The progressive aim is to do the same at the societal level. We can't do this without substantial Medicare reforms, many of which are promoted by the Affordable Care Act.

I'm planning to explore the world of Medicare advocacy and will write more about it as I learn and get involved.

(Randy Cohen's column has a happy ending: "Exploratory surgery determined that G.M. does not have lung cancer. He recently returned to work. His doctors continue to monitor him.")


Danny Pettry said...

Thank you for posting comments at your blog.
I always appreciate reading them.
Your comment about the man who wished for money to be spent on younger people reminded me of a sad story when I was younger, which I think was fiction. It may have been part of a school assignment in middle school. It consisted of a group of diverse people who were stuck on a submarine. There were only enough resources to save 50% of the people on the submarine. The question or problem was to decide who’d be saved.
I can’t remember all of the facts from this story. It may have been a movie I saw when I was younger. I do recall a person who was elderly willingly sacrificing himself. He had the same “internal moral” argument that a younger person who had much more life ahead of him should be selected first.
I wouldn’t want to be the person to make a decision for other people. I’m fairly healthy and happy 30-year-old man. I’d want a younger person to make it over myself. And I don’t think I could live with myself if I left anyone behind. What if the people who were elderly were someone I knew and loved like my own parents?
I’m not very keen on politics and funding.
I do my best to keep up on updates from the Centers for Medicare and Medicaid (CMS) because I’m a Recreational Therapist and patient advocate. I advocate that patients receive Recreational Therapy (RT) services when medically necessary, evidenced-based to be beneficial, and ordered by a physician. RT is most often provided in three in-patient settings: skilled nursing, rehabilitation, and psychiatric.
My big point is: There has to be an ethical and cost-effective way to assure all people have access to services (including the person you commented on with the lung issues). It reminds me of a neighbor friend who is retired. She has little income and no insurance. She could purchase insurance, but it would take all of her income because she has a pre-existing condition (a leg problem). She can’t go back to work for long periods of time or for many jobs because the pain from the leg would be too much to handle.
There must be a solution for people in this group. There are many more people who are retired, without insurance, and with little income. There must be a way to assure that people in this group get coverage and services, too.
I hope you’ll post more thoughts and ideas on this topic in the future.
Your friend,

Jim Sabin said...

Hi Danny -

Thank you for your thoughtful and compassionate comment.

Re the submarine, you are probably remembering a school assignment. "Lifeboat ethics" (or "submarine ethics") questions - in which not everyone can survive and choices must be made, make VERY engaging questions that middle schoolers, and even younger children, can form opinions about. If there's a lull in Thanksgiving conversation I may try out the question with my grandchildren.

In terms of your comment "There has to be an ethical and cost-effective way to assure all people have access to services," I agree. Paradoxically, acknowledging the ethical requirement to set limits is the key step in providing access to all. Fear of runaway costs has been the main barrier to universal access, and we can only address that fear by understanding the need for limits and defining limit-setting as an ethical requirement! The book Norman Daniels and I wrote ("Setting Limits Fairly") proposes an approach to the challenge.

As a recreational therapist you must encounter one of the "pathologies" of our health system regularly - we'll pay anything for high tech interventions which may offer nothing to the patient, but won't pay for low tech interventions which could have a major bearing on quality of life.