Health reform does many good things, but any claims that it protects Medicare and keeps government at bay are nonsense. In fact, health reform will drain Medicare resources, exert tight controls over medical decisions identified as high cost or high volume, and restrict care of older people in the name of prudent social policy. Doctors, under government's thumb, will be pressured to comply or risk lower payment and humiliation. The Department of Health and Human Services could deny cancer screening based on age, as suggested by the mammogram battle a few months back, or cut Medicare payments to hospitals that don't limit sick patients' readmissions. Medical, economic, and moral judgments by government-chosen experts will prevail, even if they're at odds with other medical experts.
This is a seismic change. For decades, and with enthusiastic public support, seniors have had universal health coverage through Medicare. Though Americans have been constitutionally resistant to single-payer national health insurance, Medicare has been special from the outset: It helps our aged parents, after all, and, as framed in 1965, was to come with little or no federal meddling with hospital policies or physician autonomy. But Medicare is now too juicy a target. As Congress siphons off Medicare dollars to pay half of the roughly trillion-dollar health reform tab over the next 10 years, the government, unbeknownst to many seniors, will rein in their health expenditures ever further by imposing cost-benefit hurdles. Cost to the U.S. Treasury versus health benefits for patients. Here's how:
Comparative effectiveness research. Health reform heavily invests in CER, which balances cost, say of a new cancer treatment, with estimated years of life saved, adjusted for length and quality. This would help doctors make smarter decisions case by case, but if it is used by government to categorically deny care, the elderly will be the most vulnerable. HHS actuaries in December opined that real savings from CER will occur only if the government can make binding payment and coverage decisions, which is not yet part of health reform. Baby steps toward British-style rationing?
Reducing routine cancer screening. Cost-benefit analysis drove the recent flap over new guidelines nixing access to mammograms for women under age 50 or over 74. With reform, an HHS task force rules. We'll also see upper age cutoffs for colon-cancer screening, and PSA testing for prostate cancer will be cut entirely. Medicare savings will be big, false-positive scares lessened, and cancer debility and death moderately but significantly increased.
[Why the new mammogram guidelines would mean 100,000 lives lost.]
Restricting hospital care. To tame the billions spent on hospital care for chronic, incurable conditions such as heart failure, advanced lung disease, Parkinson's, and Alzheimer's, health reform will cut reimbursement to hospitals if doctors readmit their sick elderly more often than Medicare thinks they should—even if the care is lifesaving. (Some 93 percent of Medicare readmits are alive one year later.) Noncompliant hospitals will be listed on the Medicare website, shaming doctors into practicing differently. But what happens to elders like 91-year-old Sen. Robert Byrd, whose numerous hospital readmissions during the past two years sufficiently rescued him to make a crucial midnight December vote to pass health reform?
[Here's more on why health reform is too tough on hospital readmissions.]
Expanding palliative and hospice care. One way to reduce spending is to move the incurably ill into palliative care. Hospice is beloved for offering pain relief, comfort, and spiritual and emotional support to the dying, mostly from cancer. But hospice spreads its wings more broadly under health reform. Medicare will offer its services free to patients not on their deathbed but in slow, irreversible decline due to failing hearts, lungs, brains, or immune systems. This can be dicey: It's hard to say, as hospice does now, that death is not accelerated when patients with end-stage lung disease get morphine or those with advanced Parkinson's receive sleep-inducing drugs for so-called terminal sedation. To some, this is a humane choice that also conserves resources. To others, it is slow euthanasia.
Clearly, what lies ahead is not your parents' Medicare but something new. A place where government will trump doctors, and it will be sold as safer, better, less wasteful care. There's not much patients can do except be informed as never before. Take advantage of health reform's offer of free regular end-of-life counseling to know your options. Have a living will that makes your views quite clear, and line up family members plus a good doctor who will support your wishes. Whatever Uncle Sam says, "Enough is enough" is a judgment that should be made patient by patient, one by one.