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Obama's "Night of the Living Will"

July 29, 2009 (LPAC)—Members of the American Association of Retired Persons (AARP) got bald evasions and wooden formulations from President Obama on their worried pleas for the truth about the rationing and suicide-promotion in his health-care reform.

Introducing Obama, AARP president Jennie Chin Hansen said "many of our members ... are expressing confusion, skepticism, and even fear about what Congress has been doing on health-care reform legislation.... We've heard questions ... like, are they going to cut Medicare so that my doctor will leave the program? Or, will they ration our care so that it's because of my age?..."

Obama first hammered at the need to cut costs: "....I don't want to do anything that will stop you from getting the care you need, and I won't. But you know and I know that right now we spend a lot of money in our health-care system that doesn't do a thing to improve people's health, and that has to stop.... We ... want to start rewarding doctors for ... not just the quantity, of care that they provide. Instead of rewarding them for how many procedures they perform or how many tests they order, we'll bundle payments so providers aren't paid for every treatment they offer ... to a patient with a chronic condition ... but are paid for, how are they managing that disease overall?

After several soft-ball questions, an AARP leader forwarded a query that begged a very specific, direct answer. It "has to do with the knowledge that there will be billions of dollars of cuts in Medicare over the years to accommodate baby boomers.... Does this translate into dictation of what can and cannot be given to a senior in service? For example, will there be fewer hip and knee replacements? EVEN IF I DECIDE WHEN I'M 80 THAT I WANT A HIP REPLACEMENT, AM I GOING TO BE ABLE TO GET THAT? AM I GOING TO BE ABLE TO SEE A CARDIOLOGIST OR — IF I HAVE A HEART CONDITION OR OTHER SPECIALIST? OR IS THAT GOING TO ALL BE PRIMARY CARE? I'm calling it rationing of care. I'm coining it that."

Obama's weasel response (emphasis added):

"Yes, no, I think it's an excellent question, Carolyn. And I appreciate it, because I do think this is a concern that people have generally.

"My interest is not in getting between you and your doctor, although, keep in mind, right now, insurance companies are often getting between you and your doctor. SO IT'S NOT AS IF THESE CHOICES AREN'T ALREADY BEING MADE. It is just they're being made by private insurance companies without any real guidance as to whether the decisions that are being made are good decisions to make people healthier or not.

So what we've said is, we just want to provide some guidelines to Medicare [i.e., guidelines for payment, not just advise] and, by extension, the private sector, about what works and what doesn't.

"Some of you may have heard we wanted to set up what we're calling an IMAC, an independent medical advisory committee, that would on an annual basis provide recommendations about what treatments work best and what gives you the best value ...

And this is modeled on ... MedPAC, which, by the way, Jennie, [the AARP president] is currently on and gives terrific recommendations every year about how we could improve care to REDUCE THE NUMBER OF TESTS or to make sure that we're getting more generic drugs in the system IF THOSE work and ARE CHEAPER ....

"SO WE DON'T WANT TO ration by dictating to somebody, 'OK, you know what? We don't think that this — this senior should get a hip replacement.'

"WHAT WE DO WANT TO BE ABLE TO DO is to provide information to that senior and to her doctor about, you know, this is the thing that is going to be most helpful to you in dealing with your condition.

[Now the answer:] "SO LET'S SAY THAT PERSON IS DIABETIC [!] It turns out that if hospitals and doctors are providing reimbursements for a nurse practitioner or a social worker to work with that diabetic to control their diets and their medications, then they may avoid having to get A FOOT AMPUTATION. That's a good outcome."

Three sentences after this incredible evasion, Obama exchanged jokes with the moderator about his almost being old enough to get an AARP card, trying to break the tension in the audience, on the Web and in the hall.

He then tried the scare tactic about the Medicare system going broke if costs are not contained, and that Congress would likely make big cuts "without science" unless his program is put through now. He ended this appeal with an amazing analogy as a clincher:

"[R]ight now we reimburse hospitals for the amount of time that you're there without checking to see if they're doing a good job in the first place, so they have no penalty — if you go into the hospital, they're supposed to fix you. Suddenly, you have to go back three weeks later. That hospital gets paid all over again, even though they didn't get it right the first time.

"Now, IF YOU GOT YOUR CAR FIXED AT A MECHANIC and, three weeks later, you had to go back and you had to pay again to get your car fixed all over again, you'd be pretty mad, wouldn't you? And yet, when it comes to health care, that happens all the time. That happens all the time, and the hospital gets reimbursed for the second time or the third time, even though they didn't get it right the first time.

"And so what we're saying is, let's incentivize the hospitals. We'll pay you a little bonus if the person is not readmitted because you got it right the first time...."

(Of course we know that the car goes on the junk pile if it's not worth the repair cost.)

A bit later, the in-person audience appeared grim and transfixed with the following exchange, over THE PROVISION IN OBAMA'S BILL THAT PAYS THE DOCTOR TO TRY TO CONVINCE THE PATIENT TO AGREE IN ADVANCE NOT TO GET LIFE-SAVING CARE. The Obama riff quoted here will have helped convince millions of seniors that theirs lives are in danger.

QUESTION: I have heard lots of rumors going around about this new plan, and I hope that the people that are going to vote on this is going to read every single page there. I have been told there is a clause in there that everyone that's Medicare age will be visited and told to decide how they wish to die. This bothers me greatly, and I'd like for you to promise me that this is not in this bill.

OBAMA: "You know, the — I guarantee you, first of all, WE JUST DON'T HAVE ENOUGH GOVERNMENT WORKERS TO SEND TO TALK TO EVERYBODY TO FIND OUT HOW THEY — THEY WANT TO DIE.

"I think that the only thing that may have been proposed in some of the bills — and I actually think this is a good thing — is that it makes it easier for people to fill out a living will.

"Now, Mary, you may be familiar with the principle behind a living will, but it basically is something that my grandmother, who you may have heard recently passed away, it gave her some control ahead of time so that she could say, for example, if she had a terminal illness, did she want extraordinary measures even if, for example, her brainwaves were no longer functioning? Or did she want just to be left alone? You know, that gives her some decision-making power over the process. The problem is, right now, most of us don't give direction to our family members and so, when we get really badly sick, sadly enough, nobody is there to make the decisions and then the doctor, who doesn't know what you might have preferred, they're making decisions in consultation with your kids or your grandkids and nobody knows what you would have preferred.

"So I think the idea there is to simply make sure that a living will process is easier for people. It doesn't require you to hire a lawyer or — or to take up a lot of time, but everything is going to be up to you.

"And if you don't want to fill out a living will, you don't have to, but it's actually a useful tool, I think, for a lot of families to make sure that, you know, if, you know — you know, Heaven forbid, you contract a terminal illness, that you or somebody who's able to control this process in a dignified way that, you know, is true to your faith and true to how you think, you know, that end-of-life process should proceed?

"You don't want somebody else making those decisions for you. So I actually think it's a good idea to have a living will. I'd encourage everybody to get one. I have one; Michelle has one. And we hope we don't have to use it for a long time, but — but I think it's something that is sensible.

"But, Mary, I just want to be clear: Nobody is going to be knocking on your door. Nobody is going to be telling you, you've got to fill one out. And certainly nobody is going to be forcing you to make a set of decisions on end-of-life care based on, you know, some bureaucratic law in Washington."

The moderator now intervened to turn the screw.

MODERATOR: "Mr. President, she mentioned — not in her question, but in her preview — that she's talking about Section 1232 [actually 1233], the infamous page 425, which is being read as mandatory end-of-life care advice and counseling for Medicare.

As I read the bill, it's saying that Medicare will, for the first time, cover consultation about end-of-life care and that they will not pay for such a consultation more than once every five years. This is being read as saying, every five years, you'll be told how you can die.

OBAMA: Well, that would be kind of morbid. I think — I think that, you know, the idea in that provision, which may be in the House bill — keep in mind that, you know, we're still having a whole series of negotiations. And if this is something that really bothers people, I suspect that members of Congress might take a second look at it...."

Having floundered to this extent, Obama now plunged on for another section on hospice care, etc.

A wooden Barack Obama then went through the motions with his silent audience on cost percentages and tangential issues, for the seemingly endless remainder of the hour.


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