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Thursday, August 13, 2009

Palin Responds

On Tuesday, I said that if Governor Palin wanted to be taken seriously she needed to do more than merely offer some drive by criticism of the President's health care bill. She has begun to do that with another Facebook note. This one is also rather wonky and that's also what I said she needed to do.

If Palin wants to be taken seriously, she must add more than vague provocative statements like "death panel". Palin must explain what she means. Her Facebook
statement is four paragraphs. If she wants to be taken seriously, she must add more than four paragraphs. She must explain how and why rationing will lead to the "death panel". She must explain how and why the old and the weak will be the first to go in such a case. If Palin wants to help promote conservative principles her moment has arrived.

In this note, Palin does a fair job of analyzing pages 425-430. Those are the now very controversial pages that deal with "Advanced Care Planning Consultations". The president, and his supporters, proclaim that all of this is voluntary. I have my doubts. Here's how Palin frames the argument.

The provision that President Obama refers to is Section 1233 of HR 3200, entitled “Advance Care Planning Consultation.” [2] With all due respect, it’s misleading for the President to describe this section as an entirely voluntary provision that simply increases the information offered to Medicare recipients. The issue is the context in which that information is provided and the coercive effect these consultations will have in that context.

Section 1233 authorizes advanced care planning consultations for senior citizens on Medicare every five years, and more often “if there is a significant change in the health condition of the individual ... or upon admission to a skilled nursing facility, a long-term care facility... or a hospice program." [3] During those consultations, practitioners must explain “the continuum of end-of-life services and supports available, including palliative care and hospice,” and the government benefits available to pay for such services. [4]

I have pointed that one of the most corrosive effects of this bill is the ambiguous language. Palin appears to agree with my assessment. On the one hand, all of this is "voluntary" and yet, Medicaid is authorized to have a practioner conduct an "advanced care planning consultation" every five years. That's not, as Governor Palin suggests, entirely voluntary. Palin continues.

Now put this in context. These consultations are authorized whenever a Medicare recipient’s health changes significantly or when they enter a nursing home, and they are part of a bill whose stated purpose is “to reduce the growth in health care spending.” [5] Is it any wonder that senior citizens might view such consultations as attempts to convince them to help reduce health care costs by accepting minimal end-of-life care? As Charles Lane notes in the Washington Post, Section 1233 “addresses compassionate goals in disconcerting proximity to fiscal ones.... If it’s all about alleviating suffering, emotional or physical, what’s it doing in a measure to “bend the curve” on health-care costs?” [6]

Therein lies the rub, as Shakespeare would say. This bill is supposed to "bend the cost curve". Yet, 80% of all costs come in the last year of one's life. That's the point that Palin is making. What are these "voluntary" consultations doing in a bill that is supposed to be all about "bending the cost curve"?

Palin then goes onto cite a column by liberal columnist Eugene Robinson, who also had all sorts of qualms about this provision.

That's the reason people are so frightened and enraged about the proposed measure that would allow Medicare to pay for end-of-life counseling. If the government says it has to control health-care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending. It's irresponsible for politicians, such as Sarah Palin, to claim -- outlandishly and falsely -- that there's going to be some kind of "death panel" to decide when to pull the plug on Aunt Sylvia. But it's understandable why people might associate the phrase "health-care reform" with limiting their choices during Aunt Sylvia's final days.

Then, Palin again references Dr. Ezekial Emanuel, who has become a sort of boogeyman of the Conservative movement in the health care debate.

who are irreversibly prevented from being or becoming participating citizens....An obvious example is not guaranteeing health services to patients with dementia.” [10] Dr. Emanuel has also advocated basing medical decisions on a system which “produces a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated.”

In Palin's view, all of this shows that this health care reform is nothing more than a bureaucratic take over of the health care system which will invariably lead to rationing. I would also add that with in the bill, there is the creation of a new bureaucracy, the Health Benefits Advisory Committee, with the power to regulate just about anything within health care. On page 335, there is something called the "outcomes based measures" which will measure the cost effectiveness of every procedure done in medicine. Of course, it isn't very cost effective to give an 88 year old with little time left a hip replacement and so this bill would give a new bureaucracy the power to eliminate such a procedure.

The president can hide from this all he wants but he can't hide from the facts. He's the one that said that most of this will be paid for by cutting medical costs in Medicare. We have baby boomers turning 65 in the millions. You can't cut costs to a growing part of the population without rationing care. That's what this plan will do and all the authority to do it is right there in the 1000 plus pages.

As for Governor Palin, she has taken an important step in the health care debate, however it must be the beginning for her not the end. This was a well thought out rebuttal that used specific portions of the bill as evidence. That's the sort of wonky analysis that her detractors claimed she wasn't capable of. Clearly, she is, but if she really wants to be taken seriously she must do more. She has inserted herself into this debate and it still must be all the way. If she is to be taken seriously in this debate, and on all debates, she must make such analysis a regular occurrence.

Politico also has coverage of Palin's statement.


Anonymous said...

It's voluntary but it's not? I think it's your language that is ambiguous. You know and I know that you could have stopped at "it's voluntary." The rest is YOU trying to invent something that is not in the bill.

Anonymous said...

Sometimes proposals are so bad they just need to be abandoned. Such is the case with this monstrocity proposed by Obama and Palin honed on it's wrost feature -the centralized life and death decision panels and the rationing mentality that places a price on human life. That was enough to say about it. Enough to send the liberals into a frenzy and the majority opposing it grateful.

If she decides to run for office, or if Republicans in power offer an alternative plan that is not socialist (big if), I am sure she will have her ducks in order as health care is an issue she dealt with as governor and mother. If we are able to ditch Obama thousand page web of horror, then we can talk about sane proposals. There is no "deal" to be made out of Obamacare - it is that bad.

Anonymous said...

Ok, so if I understand you correctly, the idea is that the government is going pressure sick seniors into accepting end of life care rather than treatment for their illnesses?

That's an awfully immature assessment of the legislation, in my opinion. It makes me wonder if you've ever had to watch someone you love sell everything they own because Medicare doesn't cover assisted living so they have to intentionally impoverish themselves to qualify for Medicaid.

Not to mention the most significant point that you have never even attempted to address: how can the government pressure seniors into end of life care if the person they consult DOESN'T WORK FOR THE GOVERNMENT? We are talking about insurance, after all, and insurance is to pay for your own doctor, nowhere does it say anything about government bureaucrats.

mike volpe said...

Really, I'll just quote from the bill. This is where the Health Choices Administration is created on page 41-42.

"There is here by established as an independent agency in the executive branch by the Government


Duties include the establishment of qualified health benefits and standards under this title, including the enforcement of such standards in coordination with state insuruance regulators and the Departments of Labor and Treasury."

Boy, that sounds like if the HCA wants to make these mandatory they can.

Here's another part right from the bill.

This is from page 502 establishing the Center for Comparative and Effectiveness Research

"The Secretary shall establish with the Agency for health care Research and Qulaity Center for Comparative Effectiveness Research to conduct, support, and synthesize research with respect to the outcomes, effectiveness, and appropriateness of healht services and precedures in order to identify the manner in which diseases, disorder, and other health condition can most effectively and appropriately be diagnosed, treated, and managed."

that sure sounds as though this particular NEW bureaucracy can do anything it wants. So, is all of this "voluntary" or is it voluntary until one of these, among 53 new bureaucracies, decides not to make it voluntary.

mike volpe said...

let me respond to the last anonymous comment. I wrote a detailed piece about this. It's much more complicated than merely these "advanced care consultations" and I wrote as much here.