Health Care for the Elderly

For approximately 35 years, I have attended the same church with a woman who is now 99 years old and rapidly approaching the magic age of 100.    The woman, who is the matriarch of her family, still lives in her own home.  Unfortunately, she has become somewhat fragile in recent years and does not get out much these days.   Her mind, however, is still sharp as a tack.   She is very bright and keeps up with the world news on a daily basis.   She even reads the articles I write for this blog when her daughter takes printed copies of the articles to her.    

At the age of 88, my church friend had open-heart surgery to take care of blockages in three of her coronary arteries.    She has lived many good, productive, and enjoyable years since her heart surgery.    She has had the opportunity to witness the growth and maturity of her grandchildren, to watch them graduate from college, and to attend their weddings.    In recent years, she has had the opportunity to become a great-grandmother and to hold her great-grandchildren.   

I think frequently about my 99-year-old church friend and others like her when I am reading about President Obama’s plans to reform our health care system.   I wonder if she would be alive today if the health care reforms currently being proposed had been implemented 15 years ago.  My guess is she would not be alive today.   She would have missed all the good times she has enjoyed since her heart surgery, and the members of her family would have missed the good times they have shared with her.   

President Obama strongly contends his health care reforms will reduce the cost of health care while at the same time expanding access to health care and improving the quality of care.   He also has pledged his health care plan will not increase the government’s already staggering budget deficit.  He adamantly contends his health care reforms will not lead to rationing of health care or denial of health care benefits to the elderly.   President Obama, in effect, is promising a free lunch to everyone.   Everyone will get what he or she wants, and we will all live happily ever after.   

You can count me as a skeptic.  President Obama’s promises both defy logic and represent a denial of reality.    I cannot think of a single example where the government has expanded a program to cover more people and at the same time has reduced the cost of the program.   Every government program ultimately costs more than its sponsors predicted.   Almost all government programs grow faster than the ivy and kudzu in my backyard.    Almost all government programs are characterized by waste and inefficiency.   

Despite President Obama’s assurances to the contrary, there are at least three reasons why I think elderly Americans cannot expect to receive the same quality of health care in the future as they have in the past.   First, the existing Medicare program, which is designed to provide health care benefits to citizens age 65 and above, is already bankrupt.   Second, President Obama is promising to pay for his new health care reform package in part by cutting Medicare benefits by $500 billion.   Third, the government is spending more than a billion dollars for “comparative effectiveness research,” which in my opinion will inevitably lead to limitations on expensive medical care for elderly patients.  

In typical fashion, the politicians in Washington are making new spending commitments at a time when they should be focusing on how to meet the commitments they have already made.   According to an article written by Willem Buiter, a professor at the London School of Economics, the federal government already has unfunded liabilities for the Social Security, Medicare, and Medicaid programs in the aggregate amount of approximately $100 trillion.    Professor Buiter’s article was published on June 12, 2009 on the website for the Financial Times.  Professor Buiter emphasizes that these unfunded liabilities are not “contractual commitments or legal obligations” but instead represent “promises made by politicians and expectations of US citizens shaped by these promises.”   Professor Buiter says, “it is obvious” the federal government will default on its unfunded liabilities for Social Security and Medicare benefits.   He predicts the government will “renege on these promises and commitments” in a number of ways, including “rationing of hospital stays and doctors visits” and “denial of expensive treatments and medication to state-insured patients (beginning with the elderly).”    

Then you have President Obama’s proposal to cut Medicare benefits by $500 billion in order to help “pay” for his health care reform plan.   This would be a difficult task even if the number of beneficiaries in the Medicare program were not about to explode due to the demographics of the population.   President Obama thinks he can save $500 billion by eliminating fraud, waste and abuse from the Medicare program.  The government has been trying to eliminate fraud, waste, and abuse from Medicare and other government programs for years under both Democratic and Republican administrations.   It’s easier said than done.   As government programs get larger, it becomes more and more difficult to identify and eliminate fraud, waste, and abuse.  I am completely in favor of efforts to eliminate fraud, waste and abuse.   In my opinion, however, the government will not be able to realize substantial savings in the Medicare program without limiting the benefits available to existing and future Medicare beneficiaries.  

Finally, there is the issue of the comparative effectiveness research currently being funded by the government.    On the surface, comparative effectiveness research makes sense.  Moreover, the legislation authorizing the comparative effectiveness research provides the research cannot be used to set clinical guidelines, or mandate coverage, reimbursement or policies for public or private payers.    In other words, Congress has provided funds to study a problem but has already declared the results of the study cannot be used to make decisions.      

Not surprisingly, many observers believe comparative effectiveness research will ultimately result in limitations on care for the elderly.   One outspoken critic of comparative effectiveness research is Betsy McCaughey, the founder and chairman of the Committee to Reduce Infection Deaths and a former lieutenant governor of New York.  In an article published in The Wall Street Journal on July 23, 2009, Ms. McCaughey said comparative effectiveness research “is generally code for limiting care based on the patient’s age.”    She added, “Economists are familiar with the formula, where the cost of a treatment is divided by the number of years (called QALYs, or quality-adjusted life years) that the patient is likely to benefit.   In Britain, the formula leads to denying treatments for older patients who have fewer years to benefit from care than younger patients.”   

What does the future hold for elderly Americans who need expensive medical care?  In my opinion, the future is grim regardless of whether President Obama is ultimately successful in persuading Congress to pass his health care reform legislation.  The government cannot afford to meet the promises it has already made to the elderly.   It is now making more promises to more people everyday without having the money to meet the promises.   The name of the game is to reap political benefits today by making promises that will come due in the future.  When the day of reckoning arrives, it is highly likely the government will be forced to deny expensive medical care to the elderly.   

The ultimate question is who should decide whether an elderly person has the right to receive an expensive medical treatment that could prolong his or her life.   Would you prefer for the decision to be made jointly by the patient, the patient’s family, and the patient’s doctor?  Or would you prefer for the decision to be made by the government?   In my experience, the people who have control over the money are the ones who generally get to make the decisions.    This is why I believe the government, in the future, will not be willing to pay for someone who is 88 years old to undergo heart bypass surgery, or for someone who is 85 years old to receive expensive treatment for cancer, or for someone who is 80 years old to receive a knee or hip replacement.    The dollars involved in paying for the treatment will not be justified by the government’s view of the value of the patient’s remaining life.     

It is becoming increasingly clear that we work for the government during our lifetime, and we will live at the mercy of the government during our final days.