ACA in the Supreme Court Catch-All

Funkenpants wrote:
jdzappa wrote:

NPR did a fascinating interview with a physician who recently wrote a book about America's problem with end-of-life care.

Yes, but DEATH PANELS!

Yeah, maybe the most important cost-saving part of the ACA dealing with the issue Malor brought up was jumped on for cheap political--and in the case of Sarah Palin, it appears financial--gain:

A quarter of Medicare costs -- totaling $100 billion a year -- are incurred in the final year of patients' lives, and 40 percent of that in the last month.

This would be all taken care of if we implemented the medical program from Logan's Run. Of course, now that I'm almost 40, I think the correct age for people to be "culled" would be 50. Okay, 60.

CheezePavilion wrote:
Funkenpants wrote:
jdzappa wrote:

NPR did a fascinating interview with a physician who recently wrote a book about America's problem with end-of-life care.

Yes, but DEATH PANELS!

Yeah, maybe the most important cost-saving part of the ACA dealing with the issue Malor brought up was jumped on for cheap political--and in the case of Sarah Palin, it appears financial--gain:

A quarter of Medicare costs -- totaling $100 billion a year -- are incurred in the final year of patients' lives, and 40 percent of that in the last month.

Since it's a given that Medicare dollars are being used for senior citizens, I'd say that statistic might be a bit misleading. Not untrue, but not quite the "1/4 of ALL medical spending" that some people might think at first. Wasn't Medicare specifically FOR end of life care? Maybe not specifically the last year, but not that far from it, either.

40% * 25% = 10%. So 10% of Medicare spending is spent on the last month of care? I'm not terribly shocked by that number. I'd have to see more information to determine if that's outside of the norm/expectations.

jdzappa wrote:

NPR did a fascinating interview with a physician who recently wrote a book about America's problem with end-of-life care. Pretty much every other nation in the world tries to mitigate spending hundreds even millions of dollars to prolong someone's life by a few weeks or months, and instead focus on pain management and quality of life. What's worse is it's all big business for the medical industry. No doctor wants to admit that he can't save a patient with a half-million dollar medical treatment, and of course Big Pharma is more than glad to sell those miracle drugs that work maybe 10 percent of the time.

Yeah, but 10% of the time, it works every time.

Jolly Bill wrote:

So 10% of Medicare spending is spent on the last month of care? I'm not terribly shocked by that number. I'd have to see more information to determine if that's outside of the norm/expectations.

People retire at 65 or 67 and live into their mid-80s. So you're talking about 20 years of medical care for seniors.

Jolly Bill wrote:

So 10% of Medicare spending is spent on the last month of care? I'm not terribly shocked by that number. I'd have to see more information to determine if that's outside of the norm/expectations.

I'm not shocked either. Makes perfect sense. Healthy people don't require much medical expenditure. Sick and dying people do.

Jolly Bill wrote:

Wasn't Medicare specifically FOR end of life care? Maybe not specifically the last year, but not that far from it, either.

There's a big difference between "end of life" and "not that far from it." It's the difference between spending the same amount of money to give someone a couple of years of *quality* life as opposed to another year full of trips to the hospital or another month in a hospital bed with the person full of tubes.

(As for it being misleading, I kinda assumed this audience was sophisticated enough to know what's meant by 'Medicare' : )

Quintin_Stone wrote:
jdzappa wrote:

No doctor wants to admit that he can't save a patient with a half-million dollar medical treatment, and of course Big Pharma is more than glad to sell those miracle drugs that work maybe 10 percent of the time.

Yeah, but 10% of the time, it works every time.

The problem is we're taking that 10% shot instead of taking someone else's 50% shot or someone else's 99% shot or someone else's 10% at decades more of life. We've made the decision to have everyone pay for this while making other people with a better shot and/or more years of life ahead of them find their own way to finance their health care costs, and maybe that's not the right decision.

Jonman wrote:
Jolly Bill wrote:

So 10% of Medicare spending is spent on the last month of care? I'm not terribly shocked by that number. I'd have to see more information to determine if that's outside of the norm/expectations.

I'm not shocked either. Makes perfect sense. Healthy people don't require much medical expenditure. Sick and dying people do.

The issue is when we ignore the difference between the sick who could get better and the sick and dying, the sick who are going to die of that sickness or a complication or just are never going to get un-sick ever again. Especially when at least some of it happens because people don't consider their end-of-life options until it's too late to make a rational decision where every minute of indecision is costing money.

Jonman wrote:
Jolly Bill wrote:

So 10% of Medicare spending is spent on the last month of care? I'm not terribly shocked by that number. I'd have to see more information to determine if that's outside of the norm/expectations.

I'm not shocked either. Makes perfect sense. Healthy people don't require much medical expenditure. Sick and dying people do.

Yeah, it being "last" is a red herring. People don't die from nothing. They get seriously ill (which happens to be expensive) and they die of it. This is kind of like being shocked that 20% of all sick days are taken on a Monday.

momgamer wrote:

Yeah, it being "last" is a red herring. People don't die from nothing. They get seriously ill (which happens to be expensive) and they die of it. This is kind of like being shocked that 20% of all sick days are taken on a Monday.

It's not just Mondays! 40% of all sick days border a weekend! Lets crack down on those slackers!

CheezePavilion wrote:
Jolly Bill wrote:

Wasn't Medicare specifically FOR end of life care? Maybe not specifically the last year, but not that far from it, either.

There's a big difference between "end of life" and "not that far from it." It's the difference between spending the same amount of money to give someone a couple of years of *quality* life as opposed to another year full of trips to the hospital or another month in a hospital bed with the person full of tubes.

I agree with you. No issues there. And that's what 75% of Medicare spending is going for. As momgamer said, health care generally becomes exponentially more expensive the closer you get to death.

CheezePavilion wrote:

(As for it being misleading, I kinda assumed this audience was sophisticated enough to know what's meant by 'Medicare' : )

I almost missed it myself. :-/ Only reason I said anything.

momgamer wrote:
Jonman wrote:
Jolly Bill wrote:

So 10% of Medicare spending is spent on the last month of care? I'm not terribly shocked by that number. I'd have to see more information to determine if that's outside of the norm/expectations.

I'm not shocked either. Makes perfect sense. Healthy people don't require much medical expenditure. Sick and dying people do.

Yeah, it being "last" is a red herring. People don't die from nothing. They get seriously ill (which happens to be expensive)

Dropping dead of a heart attack is not expensive. Dying peacefully in your sleep is not expensive. Palliative care is not as expensive. Hospice care is not as expensive. You can't pretend that everyone's life ends with a serious illness that has an equally good chance of being cured and made healthy again by full hospital care.

End of life care is a touchy subject for just about everyone. Recently one of my wife's uncles was kept alive at great expense, in a coma and essentially brain-dead, for about a week so that family members could make it in to "say goodbye". At the same time this is going on they're talking about how they have no idea how his surviving wife is going to pay these huge medical bills. If I'd said to my wife that maybe it would've been better if they'd just let him pass on naturally and avoided all of the artifical support she'd have called me a heartless monster.

It's easy to see the waste in end of life spending with other people but when it's someone they know and care about, people are far to quick to jump on the "spare no expense!" train.

As long as we, as a society, are perfectly fine with spending a hundred thousand dollars to keep a corpse filled with blood and oxygen so that family members can kiss it on the forehead it's going to be hard to seriously regulate end of life care. Any cutbacks are greeted with shouts of "Death Panel!" and cartoons of bureacrats in grim reaper costumes rolling dice to determine which old person they're going to kill today.

Kehama wrote:

It's easy to see the waste in end of life spending with other people but when it's someone they know and care about, people are far to quick to jump on the "spare no expense!" train.

Yeah especially when they are not the ones that have to pay the expense.

I'm not disagreeing with you on the face of it Cheeze, but I do want to point out it's not quite that simple.

Dropping dead of a heart attack costs quite a lot. Or do you not pay ambulance fees and the bills generated by the frantic trip to the ER where you live? And even unexpectedly dying in bed can also be counted as somewhat expensive when you count in the investigation/coroner etc costs.

End of life issues require we take into account more than just the health-care system, per se. And as Kehama says, it's a touchy subject. We can't just make this call in a vacuum.

momgamer wrote:

I'm not disagreeing with you on the face of it Cheeze, but I do want to point out it's not quite that simple.

Dropping dead of a heart attack costs quite a lot. Or do you not pay ambulance fees and the bills generated by the frantic trip to the ER where you live?

Why would you take a dead person to the ER? That's why I said "Dropping dead." And speaking of heart attacks, that's one of the serious illnesses that *doesn't* cluster towards the last year of life does it? People who die of heart attacks in their last year of life I would guess have probably already had one and had quite a bit of heart-related medical care over the years, while a lot of people who have had heart attacks don't die of them: they get the bypass or angioplasty or whatever when it hits them in their 50s and 60s and probably die of something else a decade or two later.

And even unexpectedly dying in bed can also be counted as somewhat expensive when you count in the investigation/coroner etc costs.

Can be if we're comparing it to a calling to a plumber (or not, maybe). It's hard to say difference in cost of someone unexpectedly dying in bed and someone who needs a neurologist and a ventilator is just 'expensive' vs. 'somewhat expensive'.

End of life issues require we take into account more than just the health-care system, per se. And as Kehama says, it's a touchy subject. We can't just make this call in a vacuum.

Sure--and if you follow the link I provided, it talks about just that: making these decisions when everyone is still healthy and feeling good and have all their faculties.

CheezePavilion wrote:
momgamer wrote:

I'm not disagreeing with you on the face of it Cheeze, but I do want to point out it's not quite that simple.

Dropping dead of a heart attack costs quite a lot. Or do you not pay ambulance fees and the bills generated by the frantic trip to the ER where you live?

Why would you take a dead person to the ER? That's why I said "Dropping dead." And speaking of heart attacks, that's one of the serious illnesses that *doesn't* cluster towards the last year of life does it? People who die of heart attacks in their last year of life I would guess have probably already had one and had quite a bit of heart-related medical care over the years, while a lot of people who have had heart attacks don't die of them: they get the bypass or angioplasty or whatever when it hits them in their 50s and 60s and probably die of something else a decade or two later.

Not really. If the majority of someone's medicare cost is related to a heart attack, having 1 previous heart attack and 1 in the last year of your life means something like a 40/40/20 split of health care costs for heart attack/heart attack/other care. Even 2 previous heart attacks skew something like 27/27/26/20. Either way you're still above the 25% of costs that the statistic mentioned and pulling the average up. Yes these are hypotheticals and pulled out of my bum.

This is also a complete derail at this point anyway.

I'm very anxious to hear the decision, do we know when it will come?

June

If they died of it, by definition it happened in the last year of their life. That's why using that as a metric is so risky. Yes, there is a point of diminishing returns, but finding it is a whole lot more complicated than you are making out.

And why do you take a heart attack victim to the ER? Because you have to prove that they're dead. Sometimes they're only MOSTLY dead. Last time I took CPR class the resuscitation rate was about 30% if I remember correctly. You can't be saying we shouldn't bother to try!?

The rules for declaring someone dead at the scene are pretty strict, from what I understand. And even they, they fall into the "died in bed" expenses we listed above. Maybe some of the law enforcement types around here could speak to that.

Jolly Bill wrote:
CheezePavilion wrote:

People who die of heart attacks in their last year of life I would guess have probably already had one and had quite a bit of heart-related medical care over the years,

Not really. If the majority of someone's medicare cost is related to a heart attack, having 1 previous heart attack and 1 in the last year of your life means something like a 40/40/20 split of health care costs for heart attack/heart attack/other care.

You're forgetting about the part that I bolded: stuff like the extent to which a cardiologist's check-ups and tests are paid for by Medicare.

I'm very anxious to hear the decision, do we know when it will come?

From what I've been reading, June. It may even be longer if they decide to rule some parts constitutional while striking down the individual mandate. They'd have to unspool what parts of the (from what I'm to understand) gargantuan bill depend on the individual mandate and which ones can survive on their own.

momgamer wrote:

If they died of it, by definition it happened in the last year of their life. That's why using that as a metric is so risky. Yes, there is a point of diminishing returns, but finding it is a whole lot more complicated than you are making out.

And why do you take a heart attack victim to the ER? Because you have to prove that they're dead. Sometimes they're only MOSTLY dead. Last time I took CPR class the resuscitation rate was about 30% if I remember correctly. You can't be saying we shouldn't bother to try!?

The rules for declaring someone dead at the scene are pretty strict, from what I understand. And even they, they fall into the "died in bed" expenses we listed above. Maybe some of the law enforcement types around here could speak to that.

And all of that compares to the cost of a week on a ventilator and a diagnosis of brain death how?

CheezePavilion wrote:
momgamer wrote:

If they died of it, by definition it happened in the last year of their life. That's why using that as a metric is so risky. Yes, there is a point of diminishing returns, but finding it is a whole lot more complicated than you are making out.

And why do you take a heart attack victim to the ER? Because you have to prove that they're dead. Sometimes they're only MOSTLY dead. Last time I took CPR class the resuscitation rate was about 30% if I remember correctly. You can't be saying we shouldn't bother to try!?

The rules for declaring someone dead at the scene are pretty strict, from what I understand. And even they, they fall into the "died in bed" expenses we listed above. Maybe some of the law enforcement types around here could speak to that.

And all of that compares to the cost of a week on a ventilator and a diagnosis of brain death how?

Why does it need to compare? They are all expensive things that happen at end of life care.

Jolly Bill wrote:
CheezePavilion wrote:
momgamer wrote:

If they died of it, by definition it happened in the last year of their life. That's why using that as a metric is so risky. Yes, there is a point of diminishing returns, but finding it is a whole lot more complicated than you are making out.

And why do you take a heart attack victim to the ER? Because you have to prove that they're dead. Sometimes they're only MOSTLY dead. Last time I took CPR class the resuscitation rate was about 30% if I remember correctly. You can't be saying we shouldn't bother to try!?

The rules for declaring someone dead at the scene are pretty strict, from what I understand. And even they, they fall into the "died in bed" expenses we listed above. Maybe some of the law enforcement types around here could speak to that.

And all of that compares to the cost of a week on a ventilator and a diagnosis of brain death how?

Why does it need to compare? They are all expensive things that happen at end of life care.

Only one of them happens *only* at end of life care. Lots of people go on after a heart attack to have a pretty healthy and happy life; obviously the same is not true of people who get a diagnosis like "brain dead."

Jolly Bill wrote:
CheezePavilion wrote:
momgamer wrote:

If they died of it, by definition it happened in the last year of their life. That's why using that as a metric is so risky. Yes, there is a point of diminishing returns, but finding it is a whole lot more complicated than you are making out.

And why do you take a heart attack victim to the ER? Because you have to prove that they're dead. Sometimes they're only MOSTLY dead. Last time I took CPR class the resuscitation rate was about 30% if I remember correctly. You can't be saying we shouldn't bother to try!?

The rules for declaring someone dead at the scene are pretty strict, from what I understand. And even they, they fall into the "died in bed" expenses we listed above. Maybe some of the law enforcement types around here could speak to that.

And all of that compares to the cost of a week on a ventilator and a diagnosis of brain death how?

Why does it need to compare? They are all expensive things that happen at end of life care.

This.

And before you ask, those other costs are related. I don't know about you, but our local ambulance services charge and my health insurance plan has opinions about when/how you call them and how much they cover of that. And if your local fire or police department runs your local ambulance service the lines get even blurrier.

There are more things in heaven and earth, Horatio.

What's interesting is that a lot of popular stuff that is in the bill will go away. The fixes for the prescription drug "donut hole" are in the bill - are seniors going to have to pay that back? People seem to like having their kids on their insurance to age 26 - do they realize that will go away? What about the rule that says people can't be dropped because they got sick, or denied based on pre-existing conditions?

People love the benefits, and see the value. They just don't know they come from the ACA.

momgamer wrote:
Jolly Bill wrote:
CheezePavilion wrote:
momgamer wrote:

If they died of it, by definition it happened in the last year of their life. That's why using that as a metric is so risky. Yes, there is a point of diminishing returns, but finding it is a whole lot more complicated than you are making out.

And why do you take a heart attack victim to the ER? Because you have to prove that they're dead. Sometimes they're only MOSTLY dead. Last time I took CPR class the resuscitation rate was about 30% if I remember correctly. You can't be saying we shouldn't bother to try!?

The rules for declaring someone dead at the scene are pretty strict, from what I understand. And even they, they fall into the "died in bed" expenses we listed above. Maybe some of the law enforcement types around here could speak to that.

And all of that compares to the cost of a week on a ventilator and a diagnosis of brain death how?

Why does it need to compare? They are all expensive things that happen at end of life care.

This.

And before you ask, those other costs are related. I don't know about you, but our local ambulance services charge and my health insurance plan has opinions about when/how you call them and how much they cover of that. And if your local fire or police department runs your local ambulance service the lines get even blurrier.

There are more things in heaven and earth, Horatio.

If you've got no preference between getting hit with a bill from your local ambulance service or from your neurologist, one of us needs to move. I'm not sure which, but if there's a place where people look at a week on a ventilator or a ride in an ambulance as financially indistinguishable, it's no place I've ever heard of apart from a Robin Leach show.

Robear wrote:

What's interesting is that a lot of popular stuff that is in the bill will go away. The fixes for the prescription drug "donut hole" are in the bill - are seniors going to have to pay that back? People seem to like having their kids on their insurance to age 26 - do they realize that will go away? What about the rule that says people can't be dropped because they got sick, or denied based on pre-existing conditions?

People love the benefits, and see the value. They just don't know they come from the ACA.

I think this is a big question. I think it's possible the Medicare enlargements could be upheld while the individual mandate is struck down (or they could be struck down for different reasons). I could see the extension of insurance coverage to offspring under 26 making it: that's a pretty straightforward regulation of interstate commerce that looks like the kind of thing Congress could have intended to just make insurance companies foot the bill (or spread the risk yadda yadda yadda). The rule about pre-existing conditions...might be harder. It really depends on how much the Supreme Court sees the individual mandate as tied to the individual provisions. My guess would be that the more a "free rider by choice" problem is created by a benefit, the more likely it will go down with the individual mandate.

Like making insurance companies cover people under 26 on their parent's plan: that should provide no problem for insurance company actuaries to know how much to charge. It's basically not a self-selected pool and they're young people, who are cheap to cover anyway. The pre-existing condition one...that seems a lot more tied to the individual mandate because it's basically the opposite kind of pool from the 'under 26 with a parent with health care insurance' pool.

The two concepts are far from mutually exclusive.

Of course it is vitally important to make decisions about end of life care while one is still heathy and be certain that family members know of them. We don't need to go to extremes, but obviously the responsible thing is to make one's wishes known.

IMAGE(http://i.dailymail.co.uk/i/pix/2011/09/07/article-2034647-0DC08B8500000578-289_468x471.jpg)

On the other hand, of course no one should be shocked that people near the end of their lives consume more health care than healthy people. It is precisely this fact that causes so many to talk about preventative medicine. It is relatively cheap to avoid needing treatment for lifestyle diseases. It is relatively expensive to treat them.

Unless someone has a suggestion for how to reduce the cost of end of life care that isn't obvious (such as making legal arrangements beforehand) and isn't a brainless parody (death panels) There is no apparent conflict. Both concepts are true and do not contradict each other.

The problem I see is that if the Justices are inclined to ditch the Commerce clause reasoning, they could roll back a whole boatload of things besides the ACA. The Civil Rights act is grounded in the power to regulate interstate commerce. So is the Fair Labor Standards Act of 1938, which created the minimum wage and put a limit on the work week. And the National Labor Relations Act, which prevents discrimination against union members. And the Child Labor Act. And regulation of things like interstate trucking. And putting Federal regulations regarding commerce above state ones. (This is actually a big deal - some states have tried to price-fix products for sale in their state to disadvantage products made in other states.)

How much of a power grab will Thomas and the others go for, I wonder?

CheezePavilion wrote:

If you've got no preference between getting hit with a bill from your local ambulance service or from your neurologist, one of us needs to move. I'm not sure which, but if there's a place where people look at a week on a ventilator or a ride in an ambulance as financially indistinguishable, it's no place I've ever heard of apart from a Robin Leach show.

If you can't tell that there is more to this question than your bill from the neurologist I'm afraid I can't help you either.