Nat Hentoff is finally afraid of a White House administration

Nat Hentoff:

I was not intimidated during J. Edgar Hoover's FBI hunt for reporters like me who criticized him. I railed against the Bush-Cheney war on the Bill of Rights without blinking. But now I am finally scared of a White House administration. President Obama's desired health care reform intends that a federal board (similar to the British model) - as in the Center for Health Outcomes Research and Evaluation in a current Democratic bill - decides whether your quality of life, regardless of your political party, merits government-controlled funds to keep you alive. Watch for that life-decider in the final bill. It's already in the stimulus bill signed into law.

The members of that ultimate federal board will themselves not have examined or seen the patient in question. For another example of the growing, tumultuous resistance to "Dr. Obama," particularly among seniors, there is a July 29 Washington Times editorial citing a line from a report written by a key adviser to Obama on cost-efficient health care, prominent bioethicist Dr. Ezekiel Emanuel (brother of White House Chief of Staff Rahm Emanuel).

Emanuel writes about rationing health care for older Americans that "allocation (of medical care) by age is not invidious discrimination." (The Lancet, January 2009) He calls this form of rationing - which is fundamental to Obamacare goals - "the complete lives system." You see, at 65 or older, you've had more life years than a 25-year-old. As such, the latter can be more deserving of cost-efficient health care than older folks.

Don't know why this OP made me think of behavorial economics. It has probably been discussed in this forum. Behavorial economics and health care seem to fit with a Center for Health Outcomes concept.

behavioral economics of course is already practiced to some extent with the tax code.

The really silly part about this whole debate is that we ALREADY have a system to decided, via the numbers, who gets what kind of health care. If the government does, they will eventually be accountable to the voters. But who at the HMOs and insurance companies are accountable?

Do you think DOCTORS and nurses came up with living wills? Or ethicists? Bah. Doctors are not reimbursed for fixing certain people and certain problems. Dying people are expensive, and the sooner they die, the cheaper it is for the companies who end up paying the tab. Dying people rarely ever see a doctor, unless they already have a personal relationship to the doc. Even then, doctors are pretty scarce around death beds. The notion of giving them tons of meds to die with is, on the other hand, pretty lucrative for the people who make haldol, ativan, versed or other anti-anxiety agents.

Folks, we already have death panels.

The really silly part about this whole debate is that we ALREADY have a system to decided, via the numbers, who gets what kind of health care. If the government does, they will eventually be accountable to the voters. But who at the HMOs and insurance companies are accountable?

I have an idea. Since publishers already decide what books to publish, what's wrong with the government deciding what books to publish? At least the government is accountable to the voters!

Since when could the average person not afford a book they wanted to buy? And since when could the average person afford to pay for an "experimental" procedure (or even a regular one) that might save their life?

Apples and orangutangs, my friend. The comparison does not work.

Following the US debate about health care is really, really weird. I've seen Michael Moore's Sicko and some of the funnier parts of it is the scare propaganda used to make people afraid of the "socialist" system of public health care. But seeing how many of you actually believe it, is not funny.
(Just for the record: I live in Denmark so don't listen to me since I'm probably brainwashed by the socialist state propaganda :-)

Is it true that in Denmark, each man can have a Danish wife?

I think some people are overplaying the fear angle on this. Health care costs are just way out of proportion for too many people. We need a system that covers a lot more people than we do now and if it comes at the expense of some of the extras that those who do have it now have come to expect--so be it. At least that's how I would vote. Affordability is a key issue.

The euthenasia--death panel thing isn't on the table--it's just hysterical overreach--though I will say that people should have a choice to end their lives if they choose if the quality of their life has diminished because of illness or injury or because there's no real hope except for a lingering but very painful end due to say something like an incurable case of cancer which by the way is what the dutch writer Hugo Claus did last year.

Everyone knows we can have a deal if we remove the price signals from an industry. That is, to the best of my knowledge, the only way to keep prices low.

One of the aspects of the healthcare debate which is rarely mentioned is that many folks believe things we will be as they are with the only exception being everyone has "free" healthcare. Well, that's not true. A massive healthcare system like the one being proposed will entail costs. And since it is a government bureaucracy, the costs of maintaining the system will only increase over time. And since this system will cover everyone, regardless of ailment, it's only reasonable to assume the costs of the new healthcare system will surpass the costs incurred today.

Since the cost of maintaining the new system will invariably increase over time (I'm pretty arrogant about this claim. It will happen. This claim, however, isn't anymore arrogant than the claim that costs will be manageable), the government will have to do one or several things to cover expenses: 1) raise taxes, 2) go further into debt, or 3) cut expenses. The first option probably has the highest chance of occurring, but it is a difficult thing to do because voters don't like having even more of their paychecks garnished by the government. The second option is a gimme; it's exactly what we are doing today. But since China and other creditors have been making quiet noises about diversifying away from the dollar, the prospect of going further into debt to pay for consumption today seems all the more unlikely. The third option is one of those issues in which domestic policy may have ramifications for foreign policy. Unless we can continue to rely on China, Japan, and other nations to continue to buy American debt indefinitely, the US government will have to search for ways cut costs. Some of those costs to be cut may very well be snipped may American defense commitments to our European and Asian allies. I don't think that is such a bad thing, though.

At least that's how I would vote. Affordability is a key issue.

The problem is that you can't just vote affordability into existence. Rather, over the past few decades, voting for affordability has had the opposite of its intended effect. Dead Ted's HMO legislation in the 1970s was intended to make HMOs artificially affordable, but at the expense of killing off the competition which would naturally help keep costs down. And providing Medicare benefits results in rampant overuse with no evident improvement in the state of one's health which, along with the underpayments provided by Medicare for services, incentivizes insurance plans to engage in cost-shifting that makes healthcare more expensive for everyone else. An emotional process like voting is incapable of addressing such problems and will likely make things worse.

Since when could the average person not afford a book they wanted to buy? And since when could the average person afford to pay for an "experimental" procedure (or even a regular one) that might save their life?

We keep books out of government control not because of their low price but because government control of something so central to intellectual life shouldn't be controlled in the hands of government, however benevolent it is. If books were really expensive, like healthcare, and everyone really ought to have access to them, like health care, would you support the government running publishing?

I would be more comfortable with government-run medicine if its proponents recognized the problems it raises, and took them seriously. "Accountable" medicine is political medicine, and political control of medicine has its drawbacks. It was the government, after all, who at the height of the AIDS crisis set aside 50% of all federal AIDS money for the study of pediatric AIDS--billions wasted on an essentially epiphenomenal problem, and one much harder to study. But at least, the unstated reasoning went, the government was on the side of the innocent kids, not the guilty, disgusting gays!

At least that's how I would vote. Affordability is a key issue.

The problem is that you can't just vote affordability into existence.

Health care cost in this country are 40 percent higher than in the next most expensive country. Now part of that could be that we keep people alive longer, or that we do more complicated procedures. But a simple test can set you back a few weeks pay. That is just not true in other nations, even if you take into account the cost the government pays.

It is much cheaper to fly to India to get many procedures done. How can they do it cheaper? They don't have a massive insurance industry hiking up costs, for one. (There are many other factors as well.)

The government might have "wasted" billions on pediatric AIDS, but most of the research ended up being used on all people. It was just easier to get it.

Granted there are situations where political concerns will come into play--like they don't now? I seem to remember a certain national political body voting recently to keep a cerain Terry Schaivo alive.

We are talking about a HUGE industry, especially when you include pharmeceuticals. Finding problems with either government or private problems is like finding pee in the kiddie pool. Neither side has the market cornered on a perfect system.

But the one we have now is proving itself terribly inadequate. I see its inadequecies every day...every single today. The reason I didn't pick up on the real difference between books and health care is that I spent part of the afternoon with gentleman whose mother was dying, and he was fighting having her move to a hospice room. The reason? Insurance issues. Instead of focusing on his mom, he was spending part of her last day on earth trying to make sure her death did not bankrupt his family.

That sucks.

You guys have no idea how much time I have to spend on insurance issues...and I don't bill people for my services. When I read that health care is 40 percent higher here, I was not surprised, but I am sure that as much as 40 percent of the hospitals work resources goes to billing, insurance, social workers who do nothing but walk people through insurance, meetings about how to get around really stupid insurance requirements, finding ways to afford to treat people who are not insured without going broke, and ...well you get the picture. Most people have very little idea of what the OTHER departments in hospitals do. Those are partially why an aspirin costs ten dollars these days.

#10--'can't just vote affordability into existence'--is a valid point--but the problem as I see it is there are no real cost controls. Not only are there some 40 million + going without health care as of now but there is likely to be more joining that number. The present system is not working and one of the major reasons IMO is that at bottom health care has become more and more about making huge profits and less about health care itself as Arctic's #12 aptly illustrates. BTW I know numerous people whose parents estates were wiped out in a matter of weeks by health care providers--particularly nursing homes but including hospitals. It's not right. Between the government, pharmaceuticals, insurance companies, hospitals, private practice clinics, dentists and eyedoctors and nursing facilities the costs are exceeding what most people can afford to pay and the medicare system as currently constructed has become outdated as far as providing for the needs of the future. It's complicated and constructing a bill that will pass in both the house and senate that the president will sign complicates it even further. From my POV we definitely need the reform--but as to the particulars of the final bill (if it happens) I'm not sure all that many (including myself) are going to be all that pleased.

timspalding said,
We keep books out of government control not because of their low price but because government control of something so central to intellectual life shouldn't be controlled in the hands of government, however benevolent it is. If books were really expensive, like healthcare, and everyone really ought to have access to them, like health care, would you support the government running publishing?

We already have the government provision of books to people who can't afford to buy them, the public library system. And, yes, librarians get to decide what books to stock. Would we all be better off if the library system were run on a private, for-profit basis? Mostly though, as Arctic-Stranger said, this is a poor analogy.

I would be more comfortable with government-run medicine if its proponents recognized the problems it raises, and took them seriously.

Since when do we get to talk about government-run medicine? We don't even get to talk seriously about the government pooling of medical risk (single-payer insurance). I suspect that many advocates of public health care would be more than happy to discuss potential problems in exchange for the idea of public health care being taken seriously.

All bureaucracies (corporate and government) have problems. Medicine is a special problem because the usefulness of a test or treatment is often uncertain in any particular case. Any system of insurance will have to provide a balance in between covering everything that could be remotely beneficial and allowing payment for only that which is guaranteed success. I wouldn't give our current system very high marks on this question. I good discussion might start with an honest appraisal of the pros and cons of the other systems currently in use around the world.

Can anyone recommend a book?

#12: The thing is that in #10 I pointed out a couple of reasons why insurance companies have become a problem and why their cost is out of control and then you respond by saying "But insurance companies are a problem!" That tells me there's a break down in communication somewhere.

Sorry. Sounded more like you were talking about government sponsored programs.

I do agree that an emotional process will not work. Nor will shouting down congressmen at town hall meetings.

Basically, I think we are screwed. There is no way the Insurance and Pharma companies are just going to fold up their tents and vanish into the sunset. Nor should they. But there is no way that they, on their own, will shift to actually providing Health Care, rather than doing what a company is supposed to do...maximize profit. (Did you know that the best remedy for quitting smoking is Welbutrin...and that many insurance providers research Welbutrin claims to make sure they are NOT used for smoking cessation? I guess it makes more economic sense for people to die of cancer.)

#3

Do you think DOCTORS and nurses came up with living wills?

I'm damn sure it wasn't the staff doctor for the expensive nursing home in which my 93-year-old grandaunt spent her last months. When she suffered a massive stroke, he had her transferred to a hospital, ordered a slew of expensive tests, and insisted that the staff try to resuscitate her if she died. When we spoke to the hospital administrator, telling him that this was not what she'd wanted (it was the opposite of what she'd wanted), he told us that his hands were tied unless she happened to have executed a living will. A doctor we knew had taught the specialist who has done some of the tests, and told him that the tests had been pointless, and that the doctor who'd ordered them was well known for keeping patients alive as long as possible in order to keep billing medicare.

I don't know who came up with living wills, but I want to thank him or her! I saw a lawyer and executed mine the next day.

Now that we live in The Age of the Lawyer, I wouldn't dare let a patient die without some substantiation that that's what s/he wanted. That sounds like a recipe for having every last stitch of clothing sued off your back.

#18

I have doubts that you could find a jury who would award damages for not trying to resuscitate a 93-year-old whose brain had been destroyed. (That's what the neurologist said the scan showed.)

But I agree that there are people who will sue for any crazy thing, and lawyers who will take the case. And insurance companies that will settle even where all of the evidence favors the doctor; I've seen that.

Even if the person is brain dead, we need the family's permission to take them off life support. Unless they are an organ donor, which is then taken as consent.

And even if the person has a living will, if the immediate family makes a stink, they are not taken off of life support. So, yes, have the will but also make sure people know what you want.

In Canada, drs. assembled the family (siblings, a niece in lieu of deceased sibling) to decide on final care for a bachelor uncle who, in their opinion, after two months, had lost his best chance against MRSA. We followed guidance of his brother and sister who opined that more "was not what Murray would want".