While it has been proven that the Affordable Care Act was designed specifically to fail in order to pave the way for Single Payer, one major piece of the Obamacare puzzle has been inexplicably left out of the existing debate, and that is the inevitable rationing that the legislation brings.
This is a reprint from an article I wrote (from a now-defunct website) warning people about how rationing is a key element of Obamacare. It is one of the most important articles I have ever written and proves that the academics promoting Obamacare at the time were also staunch advocates of rationing, which is a necessary part of any government health program.
I am writing this because I think that this topic is urgently important and nobody truly understands what is happening behind closed doors (and open doors) in academia, in conferences, seminars, etc., all to ensure that rationing is “accepted” in the public square. The word “Rationing” has been somewhat marginalized, but one can very easily do a Google Scholar search for rationing and find it all over various academic publications. The idea is to find “code words” in order to make the idea of rationing, i.e., death panels more palatable for Americans.
Make no mistake, it IS going to happen under ObamaCare and is already happening now, in some instances, but will get worse: much, much worse. How do I know? I read their words and I take them at their word.
The way this will be justified will be by using “experts” in the field of bioethics, just like it was to justify abortion – I know this because I have been familiarizing myself with academic journals. Therefore, people must know some basic principlesin bioethics in order to understand the positions and know how to respond.
Justifying Death Panels: (Code Words / Phrases)
|End of Life Care||Fairness|
|Resource Allocation||Care Effectiveness|
|Unsustainable Increases in health care costs||Healthcare is a ‘right’|
|Priority Setting||Tough choices|
|Psychosocial influences||QARYs “quality adjusted remaining years”|
|Setting Limits||Resource Allocation|
Some common arguments for rationing (most deal with cost):
- “Healthcare is already being rationed” referring to people willing to wait for an organ transplants, being turned down for insurance, etc.
- “People do not need all of these tests.” (See the Choosing Wisely Campaign below)
- The last year of life is a costly burden that negatively impacts future generations.
- Many people would rather die at home.1
- It is not fair to use expensive interventions when people will die soon anyway.
The idea of rationing health care became a very popular topic within Bioethics circles after the passage of the Affordable Care Act, aka, “ObamaCare.” Many conferences and journal articles dealt with the issue, particularly surrounding the issues of “fairness” and “end of life care.”
As this report shows, not only do bioethicists advocate rationing, but some have learned to not use the word, and they freely admit that they believe rationing to be inevitable.
One of the scariest articles you will ever read is found here, by renowned bioethicist Daniel Callahan, who founded the Hastings Center, the premiere bioethics think tank in the world. Callahan was given a grant to study abortion in 1968 from the Ford Foundation and the Population Council, and the article from April, 2012 linked above reminisces,
“Clearly, many of my fellow advocates sought euphemisms for the actual procedure, any phrase or word that would avoid acknowledging that abortion is the outright killing of fetuses, often by chopping them up, crushing their skulls, and otherwise destroying them. Better to talk about “emptying the uterine content” or “terminating pregnancy.” A recent and notable addition to the list is to speak not of infanticide but of “post-birth abortion.”
The cleansing of language is how abortion came to be accepted. We need to get ahead of these arguments before rationing is accepted. How would people have felt, at the time of Roe v. Wade, if they saw that statement above made by Callahan?
Regarding rationing, Callahan continues to explain that a euphemism is needed,
“It is not, however, easy to come up with a good euphemism for rationing, though “setting limits” and “resource allocation” are the common code words. The argument, in short, is not whether rationing will be necessary- that is taken for granted- but how prudently to talk about it in the public square.”
Callahan actually uses the term “code words”!
Independent Payment Advisory Board (IPAB)
When Sarah Palin expressed concern over Medicare paying for “optional” conversations about advance directives, end of life care, and living wills, the mainstream media focused on the “death panel” phrase, which has been effectively marginalized, yet hypocritically, rationing is still a huge part of the narrative. “PolitiFact made “Death Panels” their “lie of the year“.
Palin stood her ground and reaffirmed her concern on Facebook on 25-June-2012, with reference to the Independent Payment Advisory Board (IPAB).
The LA Times clarifies that “The IPAB, as created by the Affordable Care Act, will create a 15-member panel of health experts, appointed by the president and confirmed by the Senate“. According to an essay in the New England Journal of Medicine (NEJM) –See Wesley J. Smith’s criticism of the NEJM further in this article, “the panel will be charged with ensuring that Medicare expenses stay within limits set by the healthcare reform law, and must also recommend to Congress how to control healthcare costs.”
Bioethicists will most likely be prominent on the IPAB board.
Politifact notes that The IPAB is not allowed to submit “any recommendation to ration health care, as Section 3403 of the health care law states.” However, according to the Committee on Ways and Means,
“the Democrats chose not to define what they meant by “ration,” and such a definition does not appear anywhere in the Medicare statute. So, rationing is in the eye of the IPAB beholder. IPAB would be free to cut reimbursement rates for procedures and services that IPAB deems “unnecessary” to levels so low that no physician would provide the care.”
Clearly, those chosen to be on this committee will be very important, and if ObamaCare continues, they should be heavily vetted. IPAB must submit its first draft recommendations to the Health and Human Services Secretary by September 1, 2013, but the members have not yet been chosen. Have they been chosen yet? I cannot find anything on this, perhaps the IPAB is still pending based on all of the legal concerns.
In a video, seen here, Obama’s former Director of the Office of Management and Budget, Peter Orszag said regarding the IPAB, “This institution could prove to be far more important to the future of our fiscal health than, for example, the Congressional Budget Office. It has an enormous amount of potential power.”
Bioethics (a very brief history)
Bioethics as a respected field of study can trace its roots to Nazis, as the “Nazi atrocities in World War II drew attention to the lack of international standards on research with human participants and led to the formulation of the Nuremberg Code.” The code states that “the voluntary consent of the human participant is absolutely essential,” and was followed by The Belmont Report. The three basic ethical principles – arose from this report and is a key part of understanding bioethics.
- autonomy/respect for persons,
- beneficence (do good)
- nonmaleficence (do no harm) (added later by Tom Beauchamp and Jim Childress, but traced back to the ancient Greek Hippocratic Oath)
To win the argument in bioethics, it is important to know the above four principles.
As time has gone by, unfortunately the lines have become fuzzy and many of the noble beginnings of bioethics have morphed into a continual academic justification of death and the idea of “personhood”, particularly, who has the right to live, justification of abortion (even of “post-birth” abortion), justification of physician-assisted suicide and euthanasia, even endorsing the death of those who may be disabled or otherwise cannot fend for themselves. In other words, many of the bioethicists have become similar to those they should abhor, the idea of “do no harm” has been debated endlessly, as well as the idea of all of the above principles.
Just like the environmental movement, the idea of global standards for healthcare is more about “fairness” and “justice” and the idea is not necessarily to make healthcare better, but to make it available for all people, which would bring the standard down for some in the name of “social justice”, “distributive justice” or to resolve perceived “health or socioeconomic disparities”.
Culture of Death
Bioethics has been long feared as promoting a “Culture of Death”, as noted in the book by Wesley J. Smith (Lawyer and prolific author), “Culture of Death: The Assault on Medical Ethics in America”. Smith is one of the good guys and he has stated, “bioethics has, generally, crystallized into an orthodoxy, perhaps even an ideology.”
Smith is particularly critical of Peter Singer, a prominent bioethicist at Princeton, who famously believes in the idea of “consequentialism” (reminiscent of Alinsky, ie, the ends justify the means). Singer also famously believes that animals have the same moral right to exist as people.
In a wonderful, short recent article, Wesley J. Smith sums it up. He states,
“The New England Journal of Medicine leads the technocratic pack . To illustrate from where the publication is coming, it has supported rationing, helped push the assisted suicide movement, respectfully published the Dutch infanticide checklist known as the Groningen Protocol, and pushed hard against medical conscience rights in the name of ‘patient rights.'”
Wesley J. Smith sums up the Bioethics Health Plan:
1. Centralize Insurance Coverage and Medical Decision Making;
2. Use “evidence based medicine” to determine whole categories of treatment or tests that should be refused as wasteful;
3. Then, require dissenting doctors and patients to appeal to bureaucratic bioethics boards staffed by technocratic true believers.”
Quotes from Bioethicists in Favor of Rationing
In 2012 alone, there have been approximately 200 scholarly articles that address health care rationing from a bioethical perspective (Just from a quick Google Scholar search) and about 100 more on “health priority setting” and over 500 on Euthanasia. There are no doubt many more that could be found using the various “code words”. Bioethicists have been justifying the rationing of healthcare for years, just as they justify euthanasia, physician-assisted suicide, infanticide, organ donation (before donor has even died), abortion, etc.
Some articles try to reframe the argument from “ethics of rationing” to “ethics of waste avoidance” (Howard Brody, cited below) or some other concept that puts opponents on the defensive. It is important to know the arguments and the basic principles of Bioethics. A book could be written on just the quotes, but here is a sample:
Bioethicist/physician Howard Brody
“In the end, the ethics of rationing and of waste avoidance are complementary, not competing. Perhaps at present, waste avoidance could save enough money to permit both universal coverage and future cost control. As medical technology advances, especially with personalized genomic medicine, we will almost certainly arrive at the day when we cannot afford all potentially beneficial therapies for everyone. The ethical challenge of rationing care will have to be faced sooner or later, particularly when we confront inequitable distribution of health care resources globally.”
Bioethicist Peter Singer:
“Priority setting was called “rationing” 20 years ago, and “resource allocation” 10 years ago—and will be called “sustainability” 10 years from now, as our language about this problem becomes progressively sanitised.”
“Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs#, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money.”
Bioethicist Lawrence Schneiderman, MD
“Rationing Just Medical Care,” The American Journal of Bioethics 11 [July 2011]:
“I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with “health care,” the terminology used in the current debate, but with the more modest and limited topic of medical care. Integral to this rationing proposal–which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society–is a definition of a “decent minimum,” the basic package of medical treatments everyone should have access to in a just society.”
“Americans may not be aware that this relentless pursuit of life at any cost and condition is not universal. As anthropologist Sharon R. Kaufman points out, “The assumption of intervention in late life is not as pervasive in many parts of Europe, where the limitations to health care are widely acknowledged.”
Bioethicist Arthur Caplan:
VIDEO: On a CNN news report, “Who should get transplants?”, Art Caplan can be seen here at 1:17 stating,
“I think the question that we have to face as a society is, given scarce resources, given that there not enough hearts to go around, why aren’t we trying to make sure they are going to younger people as opposed to older people?”
“We can’t give everything to everyone even now. We only did it in the past by excluding people. Every nation on earth has to ration, they all do. We will too. We’re going to have to make some hard choices at the end of life and the demand curves indicate that that’s just a necessity.”
“Health reform is in the ethics. It will only occur if those who favor it can win the fight to recognize a right to health care.”2
“If health care is recognized as a right, then the details of how to achieve affordable health insurance reform will follow. If it is not, then efforts to move reform forward will simply die under the weight of nitpicking, fear-mongering, sloganeering, and the invocation of details as obstructions to change.” and “Those who oppose reform should have to answer why they believe health care is not a right rather then using a false concern about the details to bog reform down.”
Daniel Callahan, PhD, Director of International Programs at The Hastings Center, wrote in his June 1994 article, “Setting Limits: A Response,” that appeared in The Gerontologist:
“We could not possibly guarantee indefinitely to the growing number and proportion of the elderly all of the potentially limitless fruits of medical progress at public expense without seriously distorting sensible social priorities…”
Leonard Fleck, PhD, Professor of Philosophy at Michigan State University, wrote in his May-June 2006 article “The Costs of Caring: Who Pays? Who Profits? Who Panders?” that appeared in The Hastings Center Report:
“…We need to reject the view that we have a moral obligation to spend any amount of money to save all lives and life-years that medical technology permits. The result of adopting this view would be a gross distortion in our society’s health care priorities that would not be just, compassionate, or prudent…”
Henry Aaron, PhD, Senior Fellow at The Brookings Institution, wrote in his Jan. 30, 2006 article titled “A Healthcare Prescription That’s Hard to Swallow; Rationing May Be the Only Way to Ensure That Access for All Remains Affordable,” published in Los Angeles Times Commentary:
“The truth is that sensible rationing may be the only way to make sure that fair access to healthcare for all remains affordable. The U.S. can no longer afford to offer every available service no matter how high the cost or how small the benefit to the patient”.
The Euthanasia link: http://euthanasia.procon.org/view.answers.php?questionID=000205 has some good arguments against rationing. A good summary of beliefs of certain bioethicists can be found here, as well (starting on Page 12).
Eliminating Wasteful Tests (Choosing Wisely Campaign) (aka “unnecessary tests”)
Additionally, articles have been repeatedly noting that doctors often give too many tests in the effort to avoid malpractice suits. Instead of looking at medical malpractice reform, doctors have been involved in a campaign to encourage patients to ask if tests are really necessary.
Rationing (aka, eliminating “wasteful” tests) is advocated in the Choosing Wisely campaign led by the American Board of Internal Medicine Foundation.
“Some doctors may be used to prescribing these seemingly “routine tests,” but the “Choosing Wisely” initiative from the American Board of Internal Medicine Foundation says these procedures are often unnecessary and besides driving up the country’s skyrocketing health care costs, can put patients at risk.”
The New York Times reported,
“Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.”
Conferences / Major Players in Bioethics Advocating Rationing
At the 20TH ANNUAL MEDICAL ETHICS UPDATE 2011: Ethical Issues in Health Care Reform, keynote speaker Mary Ann Baily, PhD, Fellow, Hastings Center, gave a presentation called, “The Ethics, Economics and Politics of Rationing: Death Panels, Mammogram Guidelines and Chemotherapy” on April 15, 2011.
Some of her main points:
- Why is rationing necessary? Limits on beneficial care are needed because:
- Resources are scarce.
- Exempting health care from limits would require too much sacrifice in benefits from other uses of the resources.
- Types of non-price rationing:
- Limits on care provided to members of private insurance risk pools.
- Limits on care provided at public expense out of a sense of collective moral obligation.
- How can we counter attempts to use the fear of rationing to undermine health system reform?
- Health care rationing is not done TO people, it is done FOR people.
- NO: Provide all beneficial care without regard to cost (pure patient advocacy model)
- YES: Advocate for individual patient’s fair share, adjusted to patient’s circumstances and Advocate for a societal process to establish a fair rationing system and cooperate with it.
- If Americans want an affordable health care system, then they have to learn to accept the moral legitimacy of taking cost into account in managing it.
(Video) National Discussion and Series Debates – Miller Center, University of Virginia
Debate Statement: “The United States must ration costly end-of-life care”
Video can be found here: (A good heated discussion starts around 26:54, awesome rebuttal around 36:00, Great statement from Marie Hilliard at 52:24)
Transcript can be found here
Highlights of the Debate:
At the time, Arthur Caplan was the Emmanuel and Robert Hart Director of the Center for Bioethics and the Sydney D. Caplan Professor of Bioethics at the University of Pennsylvania.
Ira Byock is Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center and Professor at Dartmouth Medical School. He is a past president (1997) of the American Academy of Hospice and Palliative Medicine.
Ken Connor is Chairman of The Center for a Just Society, and a board certified civil trial attorney affiliated with the law firm of Marks Balette & Giessel, P.C., which represents victims of nursing home abuse and neglect. Connor is the author of Sinful Silence: When Christians Neglect Their Civic Duty (2004).
Marie Hilliard is Director of Bioethics and Public Policy at the National Catholic Bioethics Center.
Some Quotes from Art Caplan (For Rationing):
- “I don’t believe they want that technological blitzkrieg in their final days, many do not, and one form of rationing is to ask people to forgo. But we can’t continue the way we are. We rob our young to treat our dying”.
- “Not Congress, I mean what’s Congress good for? Maybe the victims of rationing, I don’t know, we should try rationing them first. But short of that, we need to come up with a transparent open discussion, out, no star chambers, no hidden committees, where people say this is what the decent minimum is.”
Some Quotes from Ken Conner (Against Rationing):
- “Now let’s not kid ourselves, folks, about what rationing at the end of life means from a government standpoint. It’s an embrace of a philosophy that was advocated by Governor Richard Lamm, who said that the elderly have a duty to die and got out of — out of the way.”
- “Government simply can’t be trusted to make life and death decisions for the infirm. It’s already shown itself to embrace a utilitarian disposable man ethic. The folks who brought us the disposable man mentality of Roe versus Wade and the Tuskegee experiments won’t hesitate to apply the yardstick of inconvenience to those whose quality of life is diminished or who costs more to maintain than they produced.”
- “What we’re suggesting very simply is that there is nothing that equips government bureaucrats to make quality of life decisions about people who are dying.”
- “… end-of-life decision-making ought to be made by the physician at the bedside, by the family of the patient and by the patient themselves.”
Some Quotes from Ira Byock (For Rationing):
- “Both as a father and as a citizen, I would readily accept some rational limits on treatment for my own far advanced condition, heart disease, lung cancer, liver disease in order for my daughters and their children to have access to health care that they need.”
- “Both as individuals and collectively as a society, we must understand that some treatments are, when they are intended to save or prolong life, make no sense at some point.”
The bias is clear, as a white paper shows in the statement,
“Deep-seated aversion to economic, governmental, or any other outside influence favoring decisions to withdraw life-sustaining treatment help to explain how the health care debate of the last year and half was overtaken at one point by the accusation that the federal government would establish death panels for the elderly…conservative politicians claimed that the elderly would be encouraged to refuse life-saving care in order to contain costs.” (Interesting, because that is exactly what this debate was rationalizing – the “pro-ration” side won, no surprise).
Note that in the article itself, it attempts to shoot down all anti-rationing arguments, the arguments they use are all associated with costs, none for the value of human life.
The Healthcare “as a right” Argument
In order to make people accept ObamaCare, bioethicists will use a very simple concept that will be pounded into American people, prominent bioethicist Art Caplan states that people must come to believe that “Healthcare is a human right”.
I believe there is a simple way to win this argument.
Pro-Rationing Advocate: Healthcare is a right
Anti-Rationing Advocate: Does the government have to pay for it?
Pro-Rationing Advocate: Yes, it is our moral duty.
Anti-Rationing Advocate: Is food a right? Is housing a right? Is clothing a right? Is a job a right? Is education a right? Does the government have to pay for those things?
The “Rationing” Argument
In order to make people accept rationing, bioethicists use the simple argument, “resources are finite” and healthcare costs are only getting higher.
I believe there is a simple way to win this argument.
Pro-Rationing Advocate: Resources are scarce. Rationing is inevitable and it is already happening. Healthcare costs are only getting more expensive. Resources need to be allocated so everyone benefits.
Anti-Rationing Advocate: That is why we have to deal with medicare fraud and government waste, which costs taxpayers billions of dollars every year. Only until we can be sure that all waste is addressed, can we ethically start to ration healthcare. People’s healthcare should not be compromised until all other cutting-cost avenues are explored.
Bioethics and their Meddling
I believe this is going to get bigger as time goes on, we should anticipate and get ahead of these arguments.
Based on the research, it seems to me that from the perspective of the bioethicist,
- ObamaCare is necessary to ensure healthcare for all,
- Healthcare coverage is a “right,”
- In order to achieve healthcare for all, some level of rationing must take place,
- Resources are scarce,
- The rationing will most likely come from:
- Reducing perceived excessive testing,
- rationing “end of life” care.
Some anti-rationing or patient advocacy positions:
- The pro-rationing cost argument: I believe the “resources are scarce” argument needs to be backed up by bioethicists, particularly in light of waste in the government and medicare fraud. (bioethical principle: Justice)
- People are individuals, not one “body” is the same, all people have different needs. (Bioethical Principles: Autonomy / Respect for Persons)
- Decisions should be made by a physician who is most equipped to understand the needs of the individual patient (Bioethical Principles: Autonomy / Respect for Persons)
- Rationing is morally wrong, as there is potential to do harm to the patient without proper medical treatment (bioethical principle: nonmaleficence)
- Rationing could potentially take away a treatment that would do good for the patient (bioethical principle: beneficence)
- Rationing may only be used for average people, wealthy people will still have access to better treatment (bioethical principle: Justice) *Can use other countries as an example, such as New Zealand.
- Individuals in all stages of life and health should benefit from the same right to exist (i.e., personhood) and should therefore, have the same access to treatment (bioethical principle: Justice)
- ObamaCare may provide better access to healthcare, but since rationing would surely come with ObamaCare, it is not the answer, ethically.
- To win the argument, it is urgently important to propose solutions to ensure that the current gaps in America’s healthcare system get filled. What are the biggest problems?
- Medical Malpractice,
- Attorney fees, trial lawyers,
- no competition for health insurance companies across state lines,
- government waste,
- Medicare/medicade fraud.
THESE are the issues that need to be addressed, so that healthcare costs do not escalate. ObamaCare does not deal with these issues.
I submit that if one believes that decisions about health care should be made by the patient, the doctor and the families, they should ask the following question about rationing, if one is allowing one to die early, isn’t rationing at the end of life really just another way of saying Euthanasia? What is the difference?
Some Arguments FOR ObamaCare*:
- “Affordable Choices for uninsured.”
- “Insurance companies repeatedly deny healthcare for families.”
- Not having ObamaCare will “decrease choice and give insurers more power.”
*This was sponsored by progressive group “Families USA,” which trains journalists how to report on Healthcare policy the “progressive way”
An excellent reframing of the conversation by Frank Luntz can be found here
- Call for the “protection of the personalized doctor-patient relationship.”
- Recommend the phrase “government takeover” rather than “government run” or “government controlled”
- “In countries with government run healthcare, politicians make YOUR healthcare decisions. THEY decide if you’ll get the procedure you need, or if you are disqualified because the treatment is too expensive or because you are too old.”
- Advocate “A balanced, common sense approach that provides assistance to those who truly need it and keeps healthcare patient-centered rather than government-centered for everyone.”
- What Americans are looking for in healthcare that your “solution” will provide is, in a word,: “more access to more treatments and more doctors…with less interference from insurance companies and Washington politicians and special interests.”
I found an seemingly innocent article that spoke of this, “Several factors determined how the patients and their caregivers rated their quality of life at the end. Among the most important: not dying in the intensive care unit or hospital; not having to endure aggressive, life-prolonging treatments at the end, such as feeding tubes or chemotherapy…” by Holly Prigerson. I was immediately suspicious and sure enough, I found her quoted here, saying what she REALLY means, “We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive . . . care like being on a ventilator in an ICU, to less costly comfort care.”
Former Obama appointed Administrator of the Centers for Medicare and Medicaid Services, Donald Berwick said, while addressing (and lauding) The British National Health Service, “You could have been spending 17% of your GDP to make health care unaffordable as a human right instead of spending 9% and guaranteeing it as a human right.” Recently, Berwick said ObamaCare “tries to make health care a human right in America.”