It’s very interesting being in this caregiving position as the health care debate rages on. One of the big issues in these conversations has been the concept of “rationing” – opponents of reform fear some sort of “death panel” will be making decisions about who does or does not receive treatment, based on some arbitrary criteria of worth to society. Proponents, on the other hand, talk about the irrationality of current treatment protocols, which can end up providing mammograms to 86-year-old female Alzheimer’s patients. Neither side seems to look at the other, instead preferring to stare directly into whatever television camera may be looking their way.
Like most folks I come at the issue with a bias. I’m a self-employed, liberal-leaning Democrat who sees the current health care system as ready for the scrap heap. Anyone who doesn’t think rationing already occurs certainly hasn’t been responsible for their own health care coverage – the current system simply rations care to those who can afford to purchase it. As a healthy 50-year-old, I’m paying more than $400 per month for insurance right now (and I have to have insurance because, like the plans likely to come up for final votes, Massachusetts mandates individual coverage). That gets me a policy with a $2,000 deductible – translation: the first two grand in expenses come out of my pocket, aside from an annual physical – and, once that deductible is met, I still have to pay 20 percent of every bill until my total out-of-pocket expenses hit $4,000. So, add my $4,800-plus annual premium bill to the $2,000 deductible, and I’m out almost $7,000 before the insurance begins to kick in, and almost $11,000 before it’s paying all the bills.
Of course, there are some benefits before I reach the deductible max. A big one is that the doctors and drug stores can only charge me at the rates the insurance company has negotiated with them. Last fall, I came down with Lyme disease (kind of a rite of passage on Cape Cod), and the nearly $700 in tests cost me only $139. But anyone who thinks a freelance writer with an extremely variable income isn’t going to think two or three times before making a doctor’s appointment – even a necessary one – isn’t doing a very good job of looking at life through another’s window. Reform opponents call mine an example of the power of patient choice to limit health care spending. Call it what you want, but I call it rationing.
[/end personal rant]


So, what does all this have to do with my father? Well, I’ve been pretty closely involved with his health care since his six-way bypass (yes, even his bypasses had bypasses) in 2004. And, since he moved out here in March 2008, I’ve been with him to pretty much every doctor appointment he’s had. The number of those appointments has snowballed over the last 6 months, as his kidneys have begun going seriously downhill, his congestive heart failure has begun getting worse and his diabetes has turned foot care from vanity into necessity. In the past three months, he’s had x-rays from head to toe – literally. They photographed his head to check for sinus blockages (they also confirmed the existence of a brain – I’ve questioned this from time to time, so the result was reassuring), his chest to check for fluid build-up and pneumonia and his feet to make sure a toe infection hadn’t gotten to the toe bone. He’s also had an ultrasound of his heart (aka, and echocardiogram) and more blood tests than I can count. All of this for less than $200 per month – what Medicare takes out of his Social Security check, along with the $100 he pays for his Advantage HMO program.

I’ve also taken over managing his prescriptions, which have multiplied as his specialist count has grown. I now have a two-page spreadsheet to consult during my weekly exercise of filling his pillbox. Two different blood-pressure medicines, a diuretic, a prostate shrinker, a pee-encourager, a cholesterol-reducer, a sleep enhancer, a blood-sugar reducer and a fistful of vitamin supplements. All this for an 87-year-old man who refuses to cut back on his drinking, orders veal parmigiana and pie a la mode for lunch when he gets the chance, and refuses to recognize the connection between what he puts in his body and how he feels the next day.

Now, believe me, I don’t begrudge my father his pleasures at his age – good Scotch and the Golf Channel, along with a periodic poker success, are among the very few he has left. But one of the biggest contributors to Medicare’s pending financial distress is that something like 80 percent of a person’s lifetime medical bill is often spent in the last couple years of life. I’m seeing this phenomenon play out right in front of my eyes. Tests lead to other tests, which then lead to more prescriptions. Crises lead to hospitalization, and then to weeks of rehab, before the patient returns home, rarely regaining his or her former functionality.

It’s easy to see how this happens, having been in the middle of it all. Yes, the current fee-for-service payment approach can potentially encourage overly aggressive care. But, beyond that, doctors really are human beings – I’ve certainly recognized the humanity in most of the medical pros who’ve treated Dad. They want to see their patients get better, they want their patients’ families to feel hope and, I think maybe just a little bit, they may want to solve a puzzle.

So, an 87-year-old’s cholesterol starts climbing? Throw a statin into the mix. Hearing a little more fluid in his lungs? Send him in for an echocardiogram. Blood sugar’s getting higher, and you know he won’t change his eating or drinking habits – get him diabetes medication. Oh, and if his urine flow is slowing, how about a drug that may help shrink his prostate over several years.

Yes, that’s right, prostate-shrinking medication for an 87-year-old man who shows no signs of prostate cancer.

Now, I’m not arguing for an elders-onto-iceflows approach. If a treatment or medication helps make a person’s current quality of life better, it makes sense to me. Dad’s Flomax means he often gets six straight hours of sleep before he has to hit the bathroom, where he’s lucky to get two hours’ sleep without it – plus, fewer times in and out of bed means fewer opportunities for falling. But medication that may or may not have an impact on a condition that may or may not happen five years from now, in an 87-year-old man with heart disease, kidney disease and diabetes? That raises questions, to me.

So, I have two different views of the current health-care system visible from my own home right now. Neither of these presents a rational picture, with too little care available to some (well, me) and, arguably, too much being given to others (Dad). All of which makes me think, maybe it’s time to take a step back from conversations about the rationing that’s already going on and see if we can talk about rationality, instead.