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Ageist Health 'Reforms' Can Be LethalBy Margaret Morganroth Gullette
Friday, November 13, 2009
(WOMENSENEWS)--A recent Boston Globe cartoon by Joe Martin shows two people sitting at a table, a balding man looking up from a paper at a woman.
He says, "According to this, '70 is the new 50' . . . And 90 is the new 'older than dirt.'"
A lot of women 50 and over, were they to know more about congressional health care plans, would be feeling 90.
The ageist details have nothing to do with the sessions the Republicans called "death panels," which refer to conferences between a doctor and a patient about future care the patient might want if unable to make her wishes known.
But two likely "reforms"--one affecting low-income "boomers" right away and the other affecting frail elderly people down the line--would leave gaps in coverage that could really be lethal.
The first of these reforms affects millions of Americans, as young as 50, who are poor.
The House public option bill passed last weekend--already problematic for younger women--is going to charge people 50-plus twice as much as those under 50.
Massachusetts' coverage, considered a model, already does this. No law makes such age discrimination illegal. It is called age rating.
Insurance coverage based on age rating is dangerous, especially for midlife women, who are poorer than men and less likely to have health coverage.
The Uninsured Are Dying FasterBefore they crawl across the finish line to Medicare at 65, people without insurance, according to a forthcoming report from the American Journal of Public Health, are likelier to die. The group between ages 55 to 64 died at the highest rate, 10.7 percent.
Where is the outrage that millions of midlife people with chronic conditions are likely to be priced out of the market?
OWL, an organization for midlife and older women, has argued for the egalitarian alternative--called "community rating"--where everyone pays the same, as in Medicare. The argument against equality is supposedly that premiums would go up for younger individuals. But data from New York state show younger people don't in fact opt out.
The other problem in the current health care reform plans arose for frail elderly people as soon as the government announced $450 billion cuts in Medicare and Medicaid. Pundits and public-health strategists started talking about how to cut costs for those over 65.
There are some good ways, such as reimbursing primary caregivers more and specialists less, managing preventive care better, or bargaining, as Veterans Affairs does, for cheaper drugs.
But one likely solution is capitation, aka "global payments." Whatever you call it, this is a controversial alternative to fee-for-service, criticized decades ago for giving incentives for under-treatment.
Global payments mean paying providers the expected amount their patient population should cost. This can force them to refuse coverage, most predictably to the oldest and sickest. Reimbursements can also be cut under the name of "efficiencies" or "regional overuse."
Efficient Cutting of LifelinesThe Congressional Budget Office in 2006 explored strategies for identifying which kind of Medicare enrollees are likely to be "future high-cost beneficiaries." These strategies, gerontologist Robert Binstock warns, could be "a preliminary step for identifying those whose care might be rationed."
If we don't find ways to cut costs without cutting care, one top hospital administrator told me, it will be "hospice for all," meaning that seriously ill Medicare and Medicaid beneficiaries might more often be steered toward palliative care.
The Hastings Center Report published an article by Dr. Muriel Gillick describing--approvingly--how denial of coverage might be instituted through regulation.
"National Institutes of Health consensus conferences will be required to determine a new standard of care for patients with a variety of chronic conditions, such as dementia and heart failure, in the last phase of life," Gillick wrote in the article. Then, she said, Medicare and Medicaid administrators would "need to give teeth to the practice guidelines" by reimbursing only for treatment that met the new guidelines.
"Consensus conferences" could be true death panels. And they could threaten with under-treatment a disproportionate number of women, since women, on average, live longer than men and have more ailments.
Ethicists disagree with Gillick's recommendation that "the way to deal with the minority of patients who might want to try treatments that have a vanishingly small chance of working is simply not to offer such interventions. This decision should be made at the policy level."
More Humility in Life-and-Death IssuesSuch decisions should be made by doctors, who can better estimate whether a treatment has a "vanishingly small chance of working" in a particular patient. A little more humility by policymakers is in order in cases of life and death.
The Hastings Center has become a magnet for duty-to-die advocates. John Hardwig notoriously argued in the Report that people after their late 70s or 80s should simply refuse treatment. Daniel Callahan, director of the center, agrees. (If many of us would off ourselves, or refuse life-extending treatment, that would cut costs considerably.)
But mainstream commentators too are obsessed with the supposed expense of
end-of-life care. Gerontologists are keeping quiet about age rating and under-treatment. Such "details" are ignored in the progressive press, out of concern for the 47 million people uninsured.
But why shouldn't women--and men--who support this know what else to be wary about and what to fight for? These may be long battles.
Health care should be available to the sick even if they are considered "old." The only relevant criteria-I quote Felicia Nimue Ackermann, an ethicist at Brown University--are a desire to stay alive, medical need and a reasonable chance that the procedure will work.
The principles for true health reform include equally shared responsibility and advocacy for the vulnerable.
Want me to guess your age? Say whether you think "hospice for all" after 80 sounds "great" or "perilous."
Margaret Morganroth Gullette's most recent books are "Aged by Culture" and "Declining to Decline." Her upcoming book is "Agewise: Fighting Ageism in America." She is a resident scholar at the Women's Studies Research Center at Brandeis University.
For more information:"High-Cost Care Beneficiaries" report, 2005
"Our Aging Societies: Ethical, Moral, and Policy Challenges" study, 2007
Gillick, Muriel, "Is Death Optional?" May 27, 2009
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