Tuesday, November 9, 2010

Advocating for the Future of Medicare

I've admired Randy Cohen's "The Ethicist" column in the New York Times Magazine ever since he started it more than ten years ago. I don't always agree with him, but I love the verve of his writing. He has an unusual gift for turning thoughtful ethical analysis into engaging prose! (See here for a previous post about Randy.)

But what caught my attention in a recent column was the question posed by a reader:
At 65 years old, I am facing a final diagnosis for lung cancer and the prospect of a 15 percent survival rate. If this is confirmed, would it be ethical to put myself through painful long-term treatment and to have the people who love me endure this? At my age, is it ethical to consume the health care dollars involved? What is the tipping point to elect aggressive care? Thirty percent? Sixty percent? G.M., JACKSON HEIGHTS
In my 45 years of practice I was struck by how often my patients - especially those in GM's phase of life - made similar comments. "Doc - you should be spending your time with young patients - I'm not the future - they are!" These comments were not symptoms of depression or low self esteem - they reflected an ethical perspective that I, now in that age group myself, share.

In my view, giving priority to the younger segments of the population is correct moral reasoning, but it's neither politically correct nor tactically wise. When the health reform process proposed support for conversations between older patients and their physicians about the values they wanted to guide their treatment by, right wing zealots fulminated against "death panels," and much of the public believed their misinformation. And in the election campaign we've just been through, Republicans made hay with scare tactics about the "assault on Medicare." (See here for a post on the campaign.)

I see great potential value for an advocacy process that brings together progressively-minded folks who are Medicare recipients or who are, like me, Medicare eligible but still receiving health insurance through employers, to advocate for clinically informed, ethically justifiable, and potentially socially acceptable Medicare reforms. The Affordable Care Act contains the potential for a better future for Medicare in programs like the Independent Payment Advisory Board, the Center for Medicare and Medicaid Innovation, and other initiatives.

The Republican strategy for the new Congress is to "starve" these promising programs by withholding funds. The Republicans will present their effort as "protecting the elderly." But it's not. The status quo for Medicare ensures unsupportable cost increases for Medicare itself and undermining of other social efforts that seniors largely support. In our personal financial lives the elderly population hopes to preserve a legacy for the next generation(s). The progressive aim is to do the same at the societal level. We can't do this without substantial Medicare reforms, many of which are promoted by the Affordable Care Act.

I'm planning to explore the world of Medicare advocacy and will write more about it as I learn and get involved.

(Randy Cohen's column has a happy ending: "Exploratory surgery determined that G.M. does not have lung cancer. He recently returned to work. His doctors continue to monitor him.")

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