Two pieces on the front page of the Washington Post's Sunday "Outlook" section illustrate some of what's wrong with the terms of current debates around health care costs and health care for the elderly. The juxtaposition of these two commentaries, which appeared side-by-side under a photo of a sunset and the heading "The Dying of the Light," sends an insidious message about the need for "rationing" treatment to the very old and very sick: To keep health care costs from bankrupting our society, it suggests, we may have no choice but to pull the plug on the geezers.
The Post feature is only the latest of a growing volume of commentary on so-called age-based health care rationing. Even beyond any core ethical questions, the problem with these discussions is what they too often fail to mention: the role of private profits in creating, or at least seriously exacerbating, the supposedly intractable problem of health care costs. Like everything else in the public debate over health care policy, the "dying of the light" has become subject to the lying of the right, where corporate interests trump even questions of life and death.
There's nothing inherently objectionabale about one of the two pieces, written by doctor at a Minneapolis hospital who cares for "patients struggling through the winter of their lives." Craig Brown writes:
Today, thanks to myriad medications and interventions that have been created to improve our health and prolong our lives, dying has become a difficult and often excruciatingly slow process.
The author questions the prevailing practice of using extreme measures to prolong the lives of the "threadworn elderly," when "what's waiting for them at the end of this illness is just another illness, and another struggle." Mercy, he says, demands that we change our attitude and our approach toward death. I've got no argument with this, which is why I support end-of-life choice for the chronically and terminally ill.
Craig Brown is careful to say that "nothing in my medical training qualifies me to judge what kind of life is satisfying or worth living." He also states clearly that his position "isn't about euthanasia. It's not about spiraling health care costs. It's about the gift of life--and death. It is about living life and death with dignity, and letting go."
The same is not true of Post health and science reporter David Brown (also a physician), who wrote the companion piece. He points out that health care costs are growing faster than the economy, due largely to advances in medical care. "Each year, there's more that can be done and more that's judged worth doing"--and it's all terribly expensive. At the same time, life expectancies are lengthening and the population is aging. As a result, he says:
We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish. Whether we can somehow avoid the collision is perhaps the most important domestic issue of this century. From now on, health care costs will be up there with globalization, terrorism and climate change as a force shaping our world.
While David Brown doesn't blame this all on old people, per se, he does point to the growth in Medicare's costs, and warns that "unless something changes, in about 75 years, Medicare alone will cost as much as the sum of all our federal income taxes." And while he says he has no solution to offer that will "rescue us from the Malthusian Spectre of health care spending," the implicit solution is clear--if not from the article itself, then from its placement alongside Craig Brown's piece on the tormented lives of the chronically ill elderly. The obvious way to slow our progress toward economic and social destruction is for old folks to stop having all those expensive interventions and just give up the ghost. And if the geezers won't make the decision to do this voluntarily--well, then, society might have to make it for them.
In blog for the American Prospect, Dean Baker of the Center for Economic and Policy Research lays out why the underlying terms of this debate are fatally flawed. Criticizing David Brown's Post piece for "telling readers that there is nothing we can do about health care costs," Baker writes:
Remarkably, this lengthy column never once notes the fact that the United States pays more than twice as much per person for health care than the average of the other wealthy countries, all of whom enjoy longer life expectancies.
This is a hard to overlook piece of evidence suggesting that the United States could do a great deal to lower its health care costs. Among other things, we have a hugely wasteful insurance system (noted in the column), pay close to twice as much for prescription drugs as people in other wealthy countries, and pay our medical specialists close to twice as much as they earn in other wealthy countries.
Overpaying for drug and doctors not only directly wastes money by causing us to pay more for the same services. The huge rents created by these over-payments leads drug companies and specialists to find ways to promote excessive use of their products and services. The result is really bad and really expensive medicine.
Studies comparing health care in the United States and other industrialized countries--including those conducted by the World Health Organization, Congressional Research Service, Kaiser Family Foundation, and Commonwealth Fund--consistently find dramatically higher spending in the U.S. (both per capita and as a percentage of GDP), and poorer performance on a host of important health measures, from life expectancy to infant mortality to medical errors. All of these other countries, of course, have public single-payer health care systems, while we have medicine for profit.
I'm as public spirited as the next person, and I have a Gen-X son. So I'd like to think I'd be willing to give up some expensive, life-prolonging medical treatment if the future of humanity depended upon it. But I'm certainly not going to do it so that some pharmaceutical company executive can take another vacation in Bora-Bora, or so that an elected official can get another big campaign contribution from the insurance industry.
So here's my advice to anyone who suggests that American geezers should do the right thing and accept age-based health care rationing: Institute a single-payer system, cut our national health care costs in half--and then get back to me.
This post also appears on James Ridgeway's new blog, Unsilent Generation.