My daughter played the song "Chemo Limo" by Regina Spektor for me the other day. I don't particularly like that artist and that song is terribly depressing. It's about a mother dying from cancer, fighting it with chemo, but the chemo is making her intensely miserable and she's wondering if she should just blow the "Crispy Crispy Benjamin Franklins" (money for chemo) on a Limo instead, and "go out in style". It's an interesting tradeoff: live well briefly then die or drag it out as long as possible.
What would you do?
But it got me thinking. Imagine that you're quite old with not so many years left in the best of circumstances. Imagine Medicare didn't exist and you have no other insurance. But you have $200,000 that you had saved over your lifetime to support retirement. Your doctor tells you that you have cancer. You learn that it will cost about $200,000 to fight it in which case you can expect to live a few years or you can let the disease take its course and then you'll die in a couple of months. Assume that you have children. In the first case you'll leave nothing for your children, but if you let the disease take its course, your children will inherit $200,000. Your children aren't starving but they're not particularly well off either and could definitely use the money.
What would you do?
Now assume that you don't have $200,000, but you do have Medicare and/or other sufficient health coverage to get the $200,000 worth of treatment. Your children will be no better or worse off regardless of whether or not you choose to fight the cancer.
What would you do?
If the government (i.e. everybody else) is going to pay for, why not fight it? It doesn't cost you or your children anything. But now let's say the government says, "Yes, we'll pay $200,000 over 5 years for your treatment if you want. But if you choose not to take the treatment and let the disease run its course, we'll make you comfortable and we'll give you $100,000 to bequeath to your heirs when you die. So if you refuse treatment, your children, grandchildren, etc. will be substantially better off.
What would you do?
The federal government estimates that 70 percent of health-care expenditures are spent on the elderly, 80 percent of that in the last month of life -- and often for aggressive, life-sustaining care that is futile. What if we gave the option to those that are dying (but mentally competent to make such decisions) to forego treatment and instead give half the saved healthcare money to their children? There are many benefits for society. Many tens of billions of dollars per year would be saved, yet the children would be better off, doctors would have more time for other patients, hospital beds would be less overbooked, and healthcare facilities would, in general, have more capacity for other patients. All it requires is that some people would say yes to foregoing end-of-life treatment.
What would you do?
11 comments:
So many assumptions cheerfully accepted. Government tells, gives, etc. makes me sicker than chemo would.
I'm pretty old, moving in on 80 in a couple of years, but in reasonably good shape, so I don't have to make any decisions like that yet. If Medicare wasn't inflicted on us, we would have purchased health insurance from a company that best suited us, i.e., we pay everyday costs and get a major medical policy for costs over and above a stated amount. BTW, our free health care cost over $12,000 last year. We’re stuck paying for a huge federal bureaucracy which siphons of most of the money confiscated from us for “health” care and we’re left with treatment we wouldn’t have tolerated for a minute when we were free to seek insurance in a free marketplace.
That said, the lady in question should give all her money away now and throw herself upon Obama’s compassion. She will qualify for all the goodies for freeeeeeeeeeee.
Me? I’m having a couple of minor procedures I’ve been putting off for a while done before the election because when Obama gets re-elected and he will (or orchestrate a crisis which will require canceling the election and/or declaring martial law), I doubt my comfort will play a major role in his plans for me.
To speak to your hypothetical. I would not seek chemo with little promise of success, but neither would throw away my fortune on limos and fast living. I’ve seen a bit of the world, but due to sheer laziness and inertia haven’t covered my entire wish list, so maybe I’d take that trip to Oz and while down there see Antarctica too -- a handful of happy pills followed by a dip in the frozen sea might be a good way go – no fuss, no muss, no body.
erp,
I wouldn't say that the "assumptions" are "cheerfully accepted". It's rather that the blog format limits the level of detail that can be used to describe background information. You know very well I don't much like government solutions either.
One thing I've noted, is that when doing a dispassionate analysis, most people, including myself claim an approach similar to yours. Yet, observing people who actually have cancer or other likely terminal condition, they nearly always choose to fight, at any cost.
My wife, who works in healthcare, points out that part of the reason is that the doctors tell the patients that they must accept the treatment. It takes a very strong and confident person to refuse a course of action when being bombarded with such advice.
So probably more important than financial incentives (to heirs) is the changing of the attitude of doctors to not necessarily prolong life at great pain and great cost, but to at least consider and provide as an option a less painful and shorter final journey.
Correct. Your wife might be surprised at how all of it looks from the other side of the examing table. We geezers see most doctors now as working for the government, against, not for us.
I wonder if you speak for a majority of "we geezers"?
I speak for those we meet at doctor's appointments which are becoming more and more frequent, so far I’ve never talked to a single person who’s happy with what’s become of our formerly excellent health care.
For instance: I am having a repair of a trigger finger (middle left hand). I had a similar problem about 10 years ago with my right hand. At that time, the surgeon called and told what time to show up at the hospital and then had a follow-up visit.
This time round, it's five separate doctor's visits. 1. GP - for EKG and release (his nurse did the scan and then he asked me if I had any problems – I hadn’t seen him in five years! – I said no, he signed the sheet); 2. Hospital for blood work and who knows how many more releases I will need to sign; 3. Surgeon's office for a pre-procedure visit (must be 30 days before the scheduled procedure); 4. Hospital for procedure; 5. Follow-up visit to the surgeon. All make work paper pushing to justify hiring more union thugs.
When left hand is healed, I need something similar on my right wrist and of course, none of the prelim stuff will be in effect, so I'll do the same round robin a second time within probably a month's time.
The new Medicare info sheet makes me even more furious than the one which preceded it. I don't fill in anything that doesn't pertain to my health, but the questions are getting so outrageous, I've had to change my long-standing N/A to NOYB (None Of Your Business) – next up it’ll be NOYDB.
I'm waiting for the goon squad to take away my Medicare card and hand me my blue pills.
Imagine that you're quite old with not so many years left in the best of circumstances. Imagine Medicare didn't exist and you have no other insurance. But you have $200,000 that you had saved over your lifetime to support retirement.
...
Now assume that you don't have $200,000, but you do have Medicare and/or other sufficient health coverage to get the $200,000 worth of treatment.
PJ O'Rourke colorfully explained that there are four ways to spend money:
1. Your own on you: you will always spend it so as to maximize both satisfaction and value.
2. Your own on someone you know (e.g., a birthday present): you will maximize value, but worry less about satisfaction.
3. Someone else's on you (e.g., a "mistress"): you will maximize satisfaction, while caring much less about value.
4. Someone else's on another party altogether (e.g., social "safety net"): You won't care about either satisfaction or value.
Clearly, the first hypothetical is of the first type. (Perhaps "arguably" is a better word, but whether it is of the first or second, or somewhere in between, doesn't matter.
On the surface, the second hypo appears to be type 3, so like any self-respecting kept woman, you will heap the crispy Benjamins into large piles and set fire to as many as it takes to extend your life. However, go a little deeper, and it isn't quite the same. After all, you will have already paid at least some of that $200,000 cost in the form of Medicare taxes or insurance payments. So if you completely forego treatment, you will have created a new class of spending: your own money on another party altogether — handing piles o' Benjamins to passersby.
In this case, whether it is the government or an insurance company is irrelevant, so long as the premium paid by the risk pool is sufficient to cover the shared risk. That the government is paying the bill is immaterial. If your house burns down, everyone else (i.e., all purchasers of fire insurance) is paying to rebuild it, but that is no reason not to.
In the case of Medicare, it isn't. (As a rough guess, by the time I turn 65, I will have paid roughly $75,000 in Medicare taxes. Statistically speaking, that should be enough to cover me, but I am both healthier, and financially better off, than most.) Which is the half of the healthcare problem for which non-collectivists have no ready answer. Since any form of health coverage is essentially a risk-adjusted cost-shifting mechanism, the average person must pay enough over a working lifetime to just cover the average lifetime cost to the risk pool. Unfortunately, the average healthcare life-cycle cost is sufficiently high to make self-funded cost-shifting out of reach of those who are less lucky in life. (Flip side question for healthcare collectivists: why did an MRI on my right knee a few months back cost $1800 — more expensive per unit time than renting a business jet, with fuel and pilots, BTW — while a whole body MRI for my neighbor's dog cost $300?)
All of this is a hound's breakfast way of saying Sarah was right. Death panels are in our future. SFAIK, all universal health care systems increasingly ration care with age. However, that is a feature, not a bug.
Because, contrary to your assertion that spending like a mistress "[Will leave my children] no better or worse off regardless of whether or not you choose to fight the cancer", aggressively extending the last months of elderly life will certainly make my children, and everyone else's, worse off.
So what would I do? Hope that, in the event, I have enough courage to call a knock-it-off.
Hey Skipper wrote: "... aggressively extending the last months of elderly life will certainly make my children, and everyone else's, worse off."
The elderly in general? Yes.
Your old self's life in particular? No, not significantly (at least financially).
One thing I'm sorta gettin' at here is that I also see Palin's "Death Panels" coming, but bribing people to skip treatment by giving some fraction of the expected medical expenses to heirs seems like a way to make a more voluntary.
... bribing people to skip treatment by giving some fraction of the expected medical expenses to heirs seems like a way to make [rationing care] more voluntary.
In theory, perhaps.
But there are at least several (IMHO) insuperable barriers.
First, class. Imagine, if you will, the shrieking -- not completely unjustified, BTW -- from the collectivists that such a policy would selectively price the lives of the the poor and vulnerable.
Second, it is impossible to know a priori what those expected expenses might be, or even where to draw the line. For example, let's say that knee replacement surgery is a waste on an 87 year old woman, so she elects to forego the surgery, and her heirs get 50% of the cost.
Fine. However, the sequelae of her now permanent immobility entail medical procedures also presumably to be foregone, each of which in turn are worth something to the heirs.
Until she dies, that is. The problem is that you don't know in advance when that is going to be. Yes, there are cases where that is obvious, but no matter where you draw the line, there will be instances just the tiniest bit outside the boundary. [It is probably worth a separate post, but IMHO the greatest cause of health care inflation is that the universe of what constitutes health care has expanded dramatically over the last 40 years, in part due to court decisions. That same phenomena faces your idea, no matter how sound it is in theory.]
Finally, we can't manage essentially the same thing even when the payoff is much clearer. There would be vastly more organs available for transplant if they could be sold by their owners, or heirs.
Yet we insist they be given away, and their is absolutely no chance that will ever change.
Hey Skipper,
On your first point, people would be price their own lives. Those with children would be more likely to forego treatment (as opposed to the poor and vulnerable).
On you second point, that's what insurance actuaries do all the time. They price that sort of thing and it's done relatively accurately. Also, there are two limitations that I've suggested that I think you're overlooking: 1) the heirs are only paid at the time of death; and 2) only terminal diseases are considered (so knee-replacement isn't a valid example).
On your first point, people would be price their own lives. Those with children would be more likely to forego treatment
At least arguably true, but that seems to lead to the very perverse outcome that people without children, or with children they regret, would value their own lives higher than the child privileged.
Yet the goal is to avoid beggaring allwho are not in the throes of death in the quest of fetishizing a pulse rate for those who are.
On you second point, that's what insurance actuaries do all the time.
Actuaries calculate population based risk. Given some number of people with a set of pertinent characteristics, they aim to tell you how many (or what rate) will experience a certain outcome.
So actuaries are good at costing pooled risk -- which should mean that the elderly pay more for health insurance than younger and healthier people.
But actuaries can't tell you anything about a specific person, because statistics break down at the individual.
Also, there are two limitations that I've suggested that I think you're overlooking: ... 2) only terminal diseases are considered (so knee-replacement isn't a valid example).
Why not? If her knee isn't replaced, she becomes effectively immobile, which, in turn, will greatly reduce her remaining lifespan.
(I took this example from my grandmother, who survived 13 years following a knee replacement, but probably wouldn't have made it another five without. In what way is her worn out knee not terminal?)
BTW, This could be right on point.
I needed to add
... without treatment) to that parenthetical.
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