A basic principle of politics is that the rules don’t matter if they inhibit your progress or agenda, but the rules are sacrosanct if they inhibit your opponents’ agenda or progress.
The Republicans have installed a Debt Clock at their convention in Tampa as a way to visually highlight their disdain for fiscal irresponsibility. The Republicans, with a Democrat in the White House and Harry Reid leading the Senate, are now deficit hawks. Even Condoleezza Rice, in her speech last night to the delegates, stressed the importance of getting our financial house in order. But it has only been a few years since Paul Ryan was voting for Medicare Part D and bailouts and Vice-President Dick Cheney famously declared that “Deficits don’t matter”.
Hypocrisy and the total absence of intellectual honesty are just as common on the other side. Up is down and down is up when it is politically expedient. The current Medicare debate is a perfect example.
Let’s take a two second detour to the “Bush Tax Cuts”. Congress, especially Republicans, like to pretend that revenues will increase if the tax rates decrease. But knowing that that is all BS, the cuts of 2001 and 2003 were made temporary and designed to end within ten years. This allowed Congress to ignore the fact that the legislation was not revenue neutral. They didn’t have to acknowledge the debt they were creating. Congress has been fighting about retaining those cuts for the last few years.
The Patient Protection and Affordable Care Act (PPACA) was billed as revenue neutral, too. It never was. Part of the funding for the PPACA came from the CLASS program, the ill-fated long term care policy that has already been eliminated. Part of the funding was to come from the new 1099 rules, which have also been repealed. There are still numerous fees and taxes sprinkled like fairy dust throughout the law. And 716 million dollars comes from future Medicare spending.
Ah Ha! The Republicans are right. He is gutting Medicare.
No, not really. As David Wessel notes in today’s Wall Street Journal, both Obama and Ryan remove a similar amount of future funding from Medicare. Mr. Romney has now backed himself into a corner and pledged to restore the money. That too will change.
The problem is that none of these men are at all credible when discussing this issue. The numbers never add up. The details never include the HOW something will work.
Where are we now?
1. Medicare was designed to pay about 75% of a senior’s health care expense
2. Our current system incentivizes care
3. Our current system creates an environment where fraud and abuse are almost inevitable
4. We have no way to cap expenses currently
5. About 30% of Medicare dollars are spent on a person’s last year of life
How do you control costs? The obvious answer is to reverse as much of the above as possible. How do you lose an election? The obvious answer is to attempt to reverse any of the above.
The President has proposed the creation of the Independent Payment Advisory Board (IPAB). By setting standards in both care and pricing, the government would begin to get a handle on unnecessary procedures and costs. The IPAB will classify certain questionable treatments as elective or self-pay. If you want it and can pay for it – go ahead.
Mr. Ryan would have you buy a private insurance policy. He would give you just enough to purchase a basic policy, the second worst in the marketplace. If you want more coverage, a plan that might pay for certain physicians or medications, you will make up the difference. The insurer will classify certain questionable treatments as elective or self-pay. If you want it and can pay for it – go ahead.
The results are about the same. The wealthy will always have access to care. The rest of us should be OK. If all of this looks vaguely familiar, think about the number of prescription medications that are now available over the counter. OTC doesn’t require a prescription, so the government (Medicare, Medicaid, and government employee coverage) and the insurers save money. No doctors’ visits. No coverage for the cost of the drug. If you want Prilosec, pay for it.
Albert Brooks, in his dystopian novel 2030, offered a vision of the U.S. where the Right To Life movement shifts its focus from abortion to preserving, at any cost, the lives of the elderly. Is it that far fetched to envision warehouses of comatose elderly connected to expensive hardware, alive in name only? Would a Republican Party ready to extend the protections of the 14th Amendment to the unborn require unlimited care for the brain dead? And if that care is mandated by the government, will it also be unfunded?
The answer – Perhaps. See all of those rules about small government vs. large government; regulations vs. the free market are only as strong as the special interests pushing our politicians. The good news is that our politicians occasionally surprise us.
From our favorite nurse:
Maybe something has changed or maybe it is because it is 4AM, I don’t see how to reply directly on the blog anymore. Alll the icons below seem to be sharing places.
This may seem cold, but this is my reply that has sort of been my mantra lately. Why am I torturing people, why are families torturing these people? We are constantly admitting and readmitting people who are 70s to 90s, who no longer have any quality of life to just be scanned and vented and poked and prodded all over again, for what?? So they can be propped up in front of the grandchildren next holiday so they can kiss them and tell them they love them?? Is this really love or selfishness because they are “not ready” or is it even fraud??
Another thing that bothers me is rehab. Rehab for those who cannot do rehab no how, no way. A fine example was my father in law. A year ago February he was in the hospital for a week for something very treatable, but at the same time very debilitating to a 90 year old, so they sent him to rehab. I sat with him a couple times in therapy in that Florida rehab. He was being tortured!! He already suffered from failing strength and mobility in his left side (reason unknown) so this added weakness made it so hard for him to endure 3 hours of therapy a day which was required. He kept needing to rest after just a short exercise period or walking period, often he would fall asleep. I felt like an accomplice to their torture by trying to keep him awake so he could go home. Finally, after a few days of this and talking with his family, I convinced them this is not a dignified way for their father to spend his last days, we knew the end was going to be soon even then. The rehab then stopped. But not until that nursing facility made lots of money from Medicare from that physical and occupational therapy he had for months. Fraud. There was no way this man really “met criteria” before admission. All it takes is one case manager or one social worker to say that he did. My rule here would be, give them a week. If the patient is not meeting standards of stamina for therapy, needs frequent rest periods or just plain keeps saying “I don’t want this” then STOP!! Trial over, explore the next option.
I feel for a lot of people, my father in law included, hospice is the way to go. Yes, it is Medicare funded, but some nice drugs, comfort care and people that come and care for you one on one at intervals is a whole lot cheaper than CTs, MRIs, ultrasounds, a list of 20 meds that are no longer effective and oh, yes, definitely surgery that they are not going to survive anyway, along with the post op torture that goes along with that. Who is making the decisions for these patients probably around 80% of the time?? The family that is “not ready” to let go. Why are they making the decisions?? Because the patient is not able to because of their already debilitated state.
I encourage families to just talk to Hospice as a consult and reinforce the premise that Hospice is not just for the patient, it is for them too, to help them to get ready as much as possible.
I never did like the idea of government choosing how we do health care, but it is here to stay, so might as well get used to it. But when it comes to Medicare paying for all this torture, perhaps there needs to be guidelines met regarding the overall health and co-morbidities that exist before certain tortures are implemented or trialed.
Yes, you, the Republicans and the Democrats hit a nerve with this one.
Holly
Brilliant!
Dave, once again you hit the nail on the head. No– you hit the whole (hospital) bed of nails! Thanks for this moment of sanity.
As for presidential responsibility alone to create (or fix) government deficits, that’s like blaming the dog ornament on the Mack truck for the accident. How many pile ups will it take for people to wake up to reality???
Having had to put the wheels in motion to pull the plug on my father and watch him flop like a fish until he expired because neither his attorney or my mother had a DNR in place, and having participated in final home care for several people, I can tell you that more and more, when elderly folks get a terminal diagnosis, they are opting out of the hospitals and nursing homes.
Instead, they go on one last vacation, travel to visit the kids and grand kids, and catch a few last fish out at the lake. Then they engage a fine outfit like Western Reserve Hospice and end up passing on to the next life from the comfort of their homes, surrounded by family, memories and familiar rooms… with dignity. I find it natural and a much more satisfactory way to pass on at home, rather than in sterile and soulless hospital environment.
Let’s not push the elderly into medical choices that do little but destroy what little savings they have and that leave the surviving spouse with a mountain of bills and paperwork they s/he doesn’t understand.