Obama plays the Medicare card

President Obama, with Vice President Biden and Speaker Pelosi behind him, delivers a joint address to Congress on September 9 (Alex Wong/Getty)
President Obama, with Vice President Biden and Speaker Pelosi behind him, delivers a joint address to Congress on September 9 (Alex Wong/Getty)

For almost anyone over 50, the central issue of health care boils quickly down to Medicare. Will I keep it? Will it be there when I need it? Will it change?

In his address to a joint session of Congress Wednesday night, President Obama looked straight at the camera while saying he wanted “to speak directly to seniors: Medicare has been here for four decades, and is a sacred trust that must be passed down” to future generations. Then he pointed out to those seniors that the legislators opposing his reform plan are the same “folks who voted against Medicare in the beginning” and this year voted for a budget that would privatize it. He said also that much of the plan will be paid for by reducing waste and inefficiency in Medicare and Medicaid. Anybody who’s had (and thank you, I have) Medicare coverage for more than 15 minutes knows about waste and inefficiency. So cut those, and leave the system, and we should all be happy.

We should all be happy, that is, if such care extends to everyone. And if Mr. Obama’s references to the U.S. being the only developed country that lets its citizens suffer daily for want of adequate health care didn’t communicate the moral wrong that reform will attempt to right, you weren’t listening. What we heard was outline, and the president’s throw-away line about a few details yet to be worked out got an expected congregational chuckle. Some of us are more optimistic than others about whether any substantive change for the common good will remain by the time the final bill is drawn.

The details are ahead for the devil to be in, and he/she is surely ready. Whether public support will be forthcoming seems likely to boil down to a whom-to-believe game. Obama repeatedly stressed that “nothing in our plan requires you to change what you have.” But in delivering the Republican response immediately after the speech, Representative Charles Boustany of Louisiana promised listeners that they would be in for “replacing your family’s current plan with government-sponsored healthcare.” Boustany also tossed in references to “rationing care” and to general “fear and anxiety,” giving a distinct impression that battle lines are still drawn.

About those battle lines: Republicans sat on their hands as Obama once again proclaimed the rumors about bureaucrats who would kill off senior citizens — he skipped dignifying Sarah Palin by using the death-panel words — to be “lies, plain and simple.” And although he got the other side of the aisle to stand when he insisted there must be reform of medical malpractice laws, there were no smiles when he pointed out that the cost of health reform will be less than the tax breaks for wealthiest Americans passed during the previous administration.

Somehow, what truths and certainties do exist must be kept alive in the fray: Medicare is not going away. End-of-life conversations won’t kill off grandma. (Sadly, this provision may be already dead anyway.) The plan’s not going to cover illegal immigrants or pay for abortions. Medical malpractice laws must be reformed. Nothing will adequately replace the public option. A health care plan that offers access to all, imperfect or not, is only common decency.

This senior’s trust is still in Barack Obama.

The Public Option Death Panel

Here’s a death panel even Sarah Palin could love — but maybe we’d better not tell her. You, however, will probably understand its value and possibly want to put it to work for your own benefit. It centers around a form called POLST, for Physician Order for Life Sustaining Treatment (in New York it’s MOLST, for Medical Orders) fast catching on across the country. The panel consists, essentially, of your doctor and yourself.

Initially developed in Oregon in 1991, POLST programs are underway in a handfull of states including Washington, California, New York and North Carolina, and are being developed in over a dozen others.

Erin Henke, POLST Program Manager for the California Coalition for Compassionate Care, outlined the program for a group of healthcare professionals this week in San Francisco, part of CCCC’s efforts to get it efficiently established across the state. The key, she emphasized, is the conversation between individual patient and medical professionals. You don’t get the form signed, in other words, unless and until patient and physician have discussed what the former wants: CPR if you’re not breathing? Feeding tube? Comfort care only, if you’re in bad shape, but you’ve got a pulse and are breathing? Or perhaps every intervention possible — tubes, wires, ventilators, the works, including transfer to a hospital intensive care unit. But the point is, you make your own decisions. Once the form is completed and signed, it follows you as part of your medical record. In California it’s printed on Pulsar Pink card stock, and not easy to overlook.

Rollout of the program, Henke explained, is an ongoing process; it will only work when it is widely known and understood not only by individual patients and physicians but also by the many other members of the profession — nurses, caregivers, ER personnel and others. CCCC’s focus right now is on skilled nursing facilities and hospitals, though Henke and the teams of POLST program advocates around the state are working toward a broad educational spectrum.

The basic POLST approach, as explained in a Journal of Palliative Medicine article by Diane E. Meier, M.D. and health care journalist Larry Beresford published earlier this year, is to provide “actionable information on how to honor the wishes of a patient with a life-threatening condition” on a variety of issues. It goes farther than an Advance Directive (though if there’s a discrepancy, the Advance Directive takes precedence) and it differs from an out-of-hospital DNR (Do Not Resusitate) form because it lets you choose treatment.

I asked Henke if the patient/doctor conversation which is necessary in order for this extraordinarily useful document to be completed is covered by most insurance companies. She says that to her knowledge there is no specific code for such a conversation, although she understands there are other codes under which physicians can bill. Let’s hope Betsy McCaughey and Sarah Palin don’t find out. Or Chuck Grassley.

Though I am only terminal just now in the same sense that all of us mortals are, I talked about the POLST form with my Kaiser primary care physician just to be sure we remain on the same page. Wouldn’t it be nice if everyone had that same opportunity.

Healthcare: Sorting Fact from Fiction

House legislation on health reform is a win-some-lose-some proposition for those over 65. Especially, as outlined in The New York Times yesterday, when it comes to Medicare drug benefits.

Medicare beneficiaries would often have to pay higher premiums for prescription drug coverage, but many would see their total drug spending decline, so they would save money as a result of health legislation moving through the House, the Congressional Budget Office said in a recent report.

Premiums for drug coverage would rise an average of 5 percent in 2011, beyond the level expected under current law, and the increase would grow to 20 percent in 2019, the budget office said.

“However,” it said, “beneficiaries’ spending on prescription drugs apart from those premiums would fall, on average, as would their overall prescription drug spending (including both premiums and cost-sharing).”

The Congressional Budget Office report set off an immediate battle between Republicans and Democrats, each side eager to convince seniors — those vocal voters — that the other was representing the devil incarnate. Republicans swear the House bill will threaten Medicare beneficiaries in order to cover the uninsured, Democrats say the bill will help them by eliminating a gap in Medicare drug coverage.

On this particular segment of the impossibly complex bill, maybe seniors would do well to listen to their own purported champion:

Nancy LeaMond, an executive vice president of AARP, the lobby for older Americans, welcomed the report as evidence that “health care reform will lower drug spending.”

“Opponents of reform may use today’s projections to try to stall reform,” Ms. LeaMond said, “but we hope they will look at all the facts before jumping to a false conclusion.”

And there, some would suggest, is the problem. The facts have been virtually obscured by misstatements, misrepresentations and outright lies. Death panels? A lie that served its scary purpose. Rationing? It’s already here, folks; it’s done by insurance companies that deny coverage in sometimes arbitrary ways. Socialized medicine? Hello? Does anyone over 65 remember those screams before Medicare was signed into law in ’65? When half the population over 65 had no insurance coverage at all?

Set aside the fact that providing healthcare for all is simply the right thing to do. Millions of American seniors (whether you begin that definition at 65, 60 or — to their horror as it sometimes happens — 55) were motivated to support President Obama by not only their hearts but also their brains. If those brains can be called into play to sort fact from fear-mongering, we may yet get the health reform common decency requires of this otherwise civilized nation.

Health Bill Would Cut Drug Spending for Many on Medicare, Budget Office Says – NYTimes.com

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Counseling Improves Life's End. Surprise!

Knowledge, care and compassion really do bring peace. Why should this be a surprise? And why should a few strident opponents prevent those approaching life’s end from having this benefit?

A study appearing in today’s Journal of the American Medical Association points out the benefits of end-of-life counseling, although the widespread misinformation loose in the land may have doomed what should be a significant piece of health reform.

As a political uproar rages over end-of-life counseling, a new study finds offering such care to dying cancer patients improves their mood and quality of life.

The study of 322 patients in rural New Hampshire and Vermont also suggests the counseling didn’t discourage people from going to the hospital.

The Senate bill provision axed by Finance Committee chair Charles Grassley would have allowed coverage for conversations with physicians about things like hospice care, advance directives and treatment options.  But to opponents of reform, it was a handy attack mechanism. They enlisted a few standard bearers like former Alaska Gov. Sarah Palin and media darling Rush Limbaugh to twist the issue into menacing “death panels,” and in no time at all Sen. Grassley had his excuse to excise.

Losers in this are all of us. Eventually, 100% of us will die. Aggressive treatment and expensive, futile procedures are common today to that experience; compassion and peace are harder to come by.

In the new study, trained nurses did the counseling with patients and family caregivers using a model based on national guidelines. All the patients in the study had been diagnosed with terminal cancer. Half were assigned to receive usual care. The other half received usual care plus counseling about managing symptoms, communicating with health care providers and finding hospice care.

Patients who got the counseling scored higher on quality of life and mood measures than patients who did not.

Could someone please get this information to Sarah Palin?

Study: End-of-life advice aids terminally ill.

Fitness & Health Reform: Stay Flexible

Flexiblility is the new necessity. Political flexibility if one is to make the loop from truth to Sarah-Palin fiction, emotional flexibility if you’re following the market from day to day, mental flexibility just to stay sane with it all.

So maybe we’d better look at the physical. If you can just acquire and maintain a little physical flexibility you’re on the way to fitness, health and inner peace. At least, that’s what the yoga people tell me. Plus a lot of gym people, personal-trainer people and public park people. It is these last whom I tend to believe. I failed yoga (tried and just flat-out failed; I was too itchy for sunlight and speedier movement) and can’t afford a personal trainer. But parks! What a gift to the flexibility and fitness of the world and may we please not be closing them.

In our nearby urban park there is a par course. An array of exercise stations installed usually several hundred feet apart along an outdoor trail, the par course is the Everyman/Everywoman route to flexibility, especially for Boomers and Beyonders. It features a number of stretching posts (each station comes with illustrated instructions about what to do and how many times to do it) plus a variety of sturdily-equipped stations for things like chin-ups and sit-ups and other ups. I am addicted to the par course.

For the first five decades, fitness and flexibility aren’t all that hard to come by. Thereafter, one needs encouragement in this obesogenic (my new favorite word) society in which we live. Par courses are all about encouragement. You can’t manage to hand-walk more than halfway on the parallel bars? Last week you couldn’t get past one-third! Or you’re near despair at the chin-up station, and the hunky twenty-something at the adjacent bar applauds as you master a tiny new fraction of an inch.

By the time the final health reform bill is hammered out the issue of preventive medicine may be hopelessly lost in the shuffle. “Takes too long to produce results.” “Isn’t really worth the cost or the effort.” I don’t buy any of those arguments. Until we tackle the need for lifestyle changes like quitting smoking, losing weight and getting fit we’ll just keep pouring money down the drain of preventable illness. E-mail your senator. Write your representative.

Meanwhile, I recommend staying flexible.

Tracking Down a Rumor

Rumors come, and don’t seem to go. Jim Rutenberg and Jackie Calmes of the New York Times have weighed in again today with a few facts… just in case anyone is interested in facts:

The stubborn yet false rumor that President Obama’s health care proposals would create government-sponsored “death panels” to decide which patients were worthy of living seemed to arise from nowhere in recent weeks.

Advanced even this week by Republican stalwarts including the party’s last vice-presidential nominee, Sarah Palin, and Charles E. Grassley, the veteran Iowa senator, the nature of the assertion nonetheless seemed reminiscent of the modern-day viral Internet campaigns that dogged Mr. Obama last year, falsely calling him a Muslim and questioning his nationality.

Rutenberg and Calmes point out that the doggedly persistent rumor “was not born of anonymous e-mailers, partisan bloggers or stealthy cyberconspiracy theorists.

Rather, it has a far more mainstream provenance, openly emanating months ago from many of the same pundits and conservative media outlets that were central in defeating President Bill Clinton’s health care proposals 16 years ago, including the editorial board of The Washington Times, the American Spectator magazine and Betsy McCaughey, whose 1994 health care critique made her a star of the conservative movement (and ultimately, New York’s lieutenant governor).

This is the core of what all reasonable people know:

There is nothing in any of the legislative proposals that would call for the creation of death panels or any other governmental body that would cut off care for the critically ill as a cost-cutting measure.

But as T/S Contributor Andy Geiger points out, the real issue in health reform is that people are suffering because they don’t have health coverage. Opponents to any reform at all have found a handy way to create this smokescreen by keeping everyone riled up with an utterly false rumor.

I’ve spent much of my adult life working for better end-of-life care, including being forever on a soapbox urging everyone, not just seniors, to consider their end-of-life options, have conversations, create advance directives and then get on with living. I strongly, fully support the good provision in the health care bills that may indeed now get cut.

But we need not to lose this forest for a tree. Rational people have got to continue fighting for a decent system, a decent bill.

False ‘Death Panel’ Rumor Has Some Familiar Roots – NYTimes.com.

Straight Talk Q&A on Health Reform

One of the best fact-checks re health reform I’ve seen lately was just sent out by Ricardo Alonso-Zalvidar for the Associated Press:

Former Republican vice presidential candidate Sarah Palin says the health care overhaul bill would set up a “death panel.” Federal bureaucrats would play God, ruling on whether ailing seniors are worth enough to society to deserve life-sustaining medical care. Palin and other critics are wrong.

Nothing in the legislation would carry out such a bleak vision. The provision that has caused the uproar would instead authorize Medicare to pay doctors for counseling patients about end-of-life care, if the patient wishes. Here are some questions and answers on the controversy:

Q: Does the health care bill promote “mercy killing,” or euthanasia?

A: No.

Q: Then what’s all the fuss about?

And here’s where it all started:

A: A provision in the House bill written by Rep. Earl Blumenauer, D-Ore., would allow Medicare to pay doctors for voluntary counseling sessions that address end-of-life issues. The conversations between doctor and patient would include living wills, making a close relative or a trusted friend your health care proxy, learning about hospice as an option for the terminally ill and information about pain medications for people suffering chronic discomfort.

The sessions would be covered every five years, more frequently if someone is gravely ill.

Alonso-Zaldivar covers all the basics in this brief, to-the-point article. My personal favorite opinion is also in there. It’s a comment made by Monsignor Charles Fahey, 76, a Catholic priest currently chairman of the board of the National Council on Aging:

“What I have said is that if I cannot say another prayer, if I cannot give or get another hug, and if I cannot have another martini – then let me go.”

Maybe we should put that martini provision in the bill.

via Health care overhaul bill Q&A.