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Friday, August 14, 2009

Who's Working on Remaking the Health Care System?

Ezekiel Emanuel, White House official, is working to remake the health care system. Dr. Emanuel is a special adviser to the budget director, Peter R. Orszag. He is also the older brother of Rahm Emanuel, the White House chief of staff. The following are quotes from papers that he has written.

From: Principles of allocation of scarce medical interventions, January 31, 2009
"Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect. The death of a 20-year-old woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life. The 20-year-old has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects.... Adolescents have received substantial substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments.... It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies, and worse still when an adolescent does."

"Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not."

"Ultimately, the complete lives system does not create 'classes of Untermenschen whose lives and well being are deemed not worth spending money on,' but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible."

"When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated."

"Every favor to a constituency should be linked to support for the health-care reform agenda. If the automakers want a bailout, then they and their suppliers have to agree to support and lobby for the administration's health-reform effort."

From: What Are the Potential Cost Savings from Legalizing Physician-Assisted Suicide? New England Journal of Medicine, July 1998
"There is a widespread perception that the United States spends an excessive amount on high-technology health care for dying patients. Many commentators note that 27 to 30 percent of the Medicare budget is spent on the 5 percent of Medicare patients who die each year. They also note that the expenditures increase exponentially as death approaches, so that the last month of life accounts for 30 to 40 percent of the medical care expenditures in the last year of life. To many, savings from reduced use of expensive technological interventions at the end of life are both necessary and desirable."

"Many have linked the effort to reduce the high cost of death with the legalization of physician-assisted suicide. One commentator observed: "Managed care and managed death [through physician-assisted suicide] are less expensive than fee-for-service care and extended survival. Less expensive is better." Some of the amicus curiae briefs submitted to the Supreme Court expressed the same logic: "Decreasing availability and increasing expense in health care and the uncertain impact of managed care may intensify pressure to choose physician-assisted suicide" and "the cost effectiveness of hastened death is as undeniable as gravity. The earlier a patient dies, the less costly is his or her care."

"Although the cost savings to the United States and most managed-care plans are likely to be small, it is important to recognize that the savings to specific terminally ill patients and their families could be substantial. For many patients and their families, especially but not exclusively those without health insurance, the costs of terminal care may result in large out-of-pocket expenses. Nevertheless, as compared with the average American, the terminally ill are less likely to be uninsured, since more than two thirds of decedents are Medicare beneficiaries over 65 years of age. The poorest dying patients are likely to be Medicaid beneficiaries. Extrapolating from the Medicare data, one can calculate that a typical uninsured patient, by dying one month earlier by means of physician-assisted suicide, might save his or her family $10,000 in health care costs, having already spent as much as $20,000 in that year."

"Drawing on data from the Netherlands on the use of euthanasia and physician-assisted suicide and on available U.S. data on costs at the end of life, this analysis explores the degree to which the legalization of physician-assisted suicide might reduce health care costs. The most reasonable estimate is a savings of $627 million, less than 0.07 percent of total health care expenditures."

From: Where Civic Republicanism and Deliberative Democracy Meet, Hastings Center Report, Nov.-Dec.1996
"This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources. Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity-those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic. Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia."

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