In graduate school, I wrote my thesis on the legislative creation of the End Stage Renal Disease program, our first and only disease-specific treatment initiative enacted and funded by Medicare in 1972. My health policy graduate degree came from the University of Washington in Seattle, where the Northwest Kidney Institute, a South African renal physician named Chris Blagg, and his colleague, Belding Scribner, MD, called home. Life, one of the most popular weekly magazines at the time, had just issued a cover story entitled "Who Shall Live, Who Shall Die." The published story chronicled the birth of kidney dialysis and how its scarcity required expert panels to determine who was worthy of dialysis and who wasn’t.
NBC produced a documentary about Seattle’s 7-person Life/Death committee that selected candidates for dialysis between the ages of 18 and 45. "Who Shall Live" was NBC’s 1965 broadcast that dove deep into the challenging ethical issues of determining which adult’s life was worth extending. This emotionally-charged drama repeated itself in other cities when the first human heart transplant, artificial lung or pig organ candidates surfaced.
Scarcity, tradeoffs, who’s deserving of a benefit… these are all life and death issues for seniors in Medicare’s supplemental benefits for the chronically ill (SSBCI) program, the very same government-funded initiative in which #Healthrageous operates. A similar process of picking program winners and losers occurs today in the 4000+ Medicare Advantage (MA) plans that choose from over 70 different options featured in today’s SSBCI.
Here are the criteria considered in Seattle when dealing with a scarce medical resource that extends life, such as dialysis. Many of these health, economic, lifestyle, and environmental factors are used now as SSBCI inclusion criteria:
As it is, Medicare is one of the largest budgetary items on the Treasury’s balance sheet. Making it Medicare for All, as Senator Bernie Sanders promotes, would seriously strain our nation’s resources. Hence, MA plans work with pre-defined budgets established by the government to determine which supplemental benefits will yield the greatest good for the largest segment of needy Medicare beneficiaries. It’s a mixing and matching process that is as much about health plan membership growth as it is about improving the health of seniors in Medicare.
Sarah Palin received much attention when she contorted the Accountable Care Act’s promotion of end-of-life planning into an un-American use of panels to decide who lives and who dies. She called the ACA’s compassionate use of counseling by ethicists and professional therapists, "death panels." Her stunt aside, we do have health plan executives making life and death decisions regarding the allocation of benefits to seniors under Medicare. They also confer on dental versus eyeglasses and hearing versus free transportation to the doctor’s office.
Excuse me for intruding into an issue – free will – that incites tremendous passion. Should my health plan offer me 14 free meals a week that are all good for my type 2 diabetes, or should I receive a $100 “flex” card that affords me the “freedom” to buy sodium-infused potato chips and other unhealthy processed food? Should our Medicare Advantage plans set criteria for program participants or should it be first come, first served… 100% based on identifiable need? Do we want our plan executives to behave paternalistically with the funds in the Medicare Trust Fund, which includes our lifetime of contributions?
My own two cents on this topic is to be mindful of Maslow’s hierarchy of needs where food, shelter, air, and water inhabit the bottom rung of must haves for humans. Mind you, nothing on the lowest rung about dental care or eyeglasses. Under Medicare, there is a subset of its population that qualifies for both Medicare and Medicaid; they are called “Duals.” At least one-third of Duals suffer from food insecurity, i.e., not having a reliable source of nutrition for thriving. I applaud MA plans that invest in healthy meals that are nutritious and conveniently prepared in a microwave. Such plans act cognizant of Who Shall Live/Who Shall Die by carefully meting out the limited resources from the Medicare Trust Fund. And BTW, they also boost Healthrageous as a preferred SSBCI option for Duals.
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