End-of-life care is the topic that President Barack Obama finds himself forced to address as he markets his health-care plan around the country this week. Democrats and Republicans are alleging hypocrisy by the other party as they debate how to pay the costs that attend citizens' last days and hours.
The reality is, both parties are being hypocritical.
Consider first the Democrats. The legislation party leaders are putting forward includes a section allowing Medicare to pay for voluntary counseling about end-of-life care. Democrats are right that offering an on-demand counseling session is hardly the same as establishing a "death panel" to determine which senior lives or dies. To equate the two, as Sarah Palin has done, is to utter, in Obama's term, "outlandish rumors."
One challenge for the Obama administration has been the involvement, in the health-care discussion, of Ezekiel Emanuel, a doctor, White House adviser and brother of Obama's chief of staff. Emanuel, while working at the National Institutes of Health, focused in part on how to allocate medical resources, Bloomberg News reported in a March profile. In other words, rationing care.
In an article earlier this year for the medical journal Lancet on the topic of allocating medical procedures, Emanuel and two colleagues wrote, "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." Grim statements like that have made it easier for Republicans to vilify Obamacare.
Money and Life
Rationing does not need to happen in health care generally. Each of us could, and some of us do, spend all our wealth to stay alive longer -- or, for that matter, to die earlier, which is in effect what Michael Jackson did when he paid doctors to make potentially dangerous prescription drugs available to him.
When hospital bureaucracy gets in our way, we or our families often can find a way to get around that bureaucracy -- if we choose to allocate our resources to that end. Sometimes, what we want isn't available at all. More often, the treatment is available, just not under our insurance plan.
Matters are different when it comes to publicly funded health-care programs such as Medicare. There are limits to public funds, so spending must be limited. When it comes to Medicare, Zeke Emanuel is completely right.
Under Medicare, end-stage triage has to happen. Triage for all illnesses at all stages of life has to happen in a Medicare- and Medicaid-funded emergency room. The only question is how much we deceive ourselves and others about this triage.
Democrats tend to talk about Medicare in positive terms, assuming it is pretty good and therefore worthy of expansion. What they don't mention is that sustaining it has drawn resources from the private sector.
Costs of Medicare
At its creation in the 1960s, Medicare was presented as a program of plenty. The reality of costs intruded soon. By the 1980s, the program began to set per-diagnosis rates it would pay to hospitals.
As David Cutler of Harvard University has documented, those lower payments for procedures led to shortfalls, which the hospitals made up for by charging non-Medicare patients more. That in turn led insurers to demand and collect higher premiums. Later, hospitals stopped passing on the costs of servicing Medicare this way and absorbed the pain themselves.
In short, the Democrats shouldn't be stressing the word "voluntary" or backing off from Zeke Emanuel. They should be championing him as telling a necessary truth.
What about Republicans? The Grand Old Party is correct to point out, as former House Speaker Newt Gingrich did Sunday on ABC's "This Week," that government-proffered counseling could eventually become regulation, even the "death panel" of which Palin warns.
Trust the Government
"You're asking us to trust the government," Gingrich said. His point: governments generally tend to expand their mandates, not restrict them.
As for triage, it certainly happens in other nations where government runs health care, such as the U.K. To dismiss Republican analogies as scaremongering is to assume the U.S. can never be like the U.K. That's arrogance.
Where Republicans are hypocrites is in failing to acknowledge that the problem is in their own tolerance of the existence and expansion of government health programs.
Sure, Palin can talk about sparing no expense for a person's health needs. But she and the rest of the party should then also talk about where the money will come from to pay for those government-funded outlays. Republicans vilify the Zeke Emanuels of the world to keep the need for tax increases in the shadows, not to mention the abolition of Medicare.
Need to Choose
The reckoning of Reaganomics was always that it was possible to have both tax cuts and revenue growth. But it would be dangerous to bank on that equation when it comes to federal health care. The amounts at issue are too high. Republicans are hiding behind the old Reagan banner rather than acknowledging this. They're missing an opportunity to talk about widening the private sector, where there is less triage and more choice.
This month of congressional holiday is supposed to be when parties ponder serious issues, not perpetuate stereotypes. To get to a productive reform, you have to recognize that it's those stereotypes that need to go before a death panel.
(Amity Shlaes, senior fellow in economic history at the Council on Foreign Relations, is a Bloomberg News columnist. The opinions expressed are her own.)
This article appears in full on CFR.org by permission of its original publisher. It was originally available here.