Single-payer. Insurance-based. Socialized medicine. Free-market reform. A lot of terms are flying in the debate over what shape healthcare reform should take in the U.S. Ask two people to tell you how it should be approached, and you’ll get six answers. But at this stage in the process, it’s important to put all ideas on the table. With that in mind, we present three viewpoints on what a new system should -- and shouldn’t -- look like.

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Here’s a way for America to cut its spiraling healthcare costs: ice floes.

This idea isn’t mine. It’s President Obama’s. Or rather, it’s where we’re likely to end up if the president prevails on Congress to pass the adventurous healthcare reform proposal currently being discussed, which the Congressional Budget Office estimates will cost about $1 trillion over the next 10 years. That’s on top of Medicare’s annual $327-billion budget, whose massive deficits, if they continue at the same rate, are predicted to bankrupt the Medicare system by the end of the next decade.


In looking for a way to fund healthcare, Obama has set his eye on the oldest and sickest. You see, according to the Centers for Medicare & Medicaid Services, about 30% of Medicare spending -- nearly $100 billion annually -- goes to care for patients during their last year of life. What if there were no “last year of life,” the president seems to be asking. The Eskimos used to set their elderly and sickly adrift on the ice or otherwise abandon them during times of scarcity, and that, metaphorically speaking, is what Obama would like us all to start doing.

The scarcity of resources to pay for expensive medical procedures will only increase under a plan to extend medical benefits at federal expense to the 47 million Americans who lack health insurance. So why not save billions of dollars by killing off our own unproductive oldsters and terminal patients, or -- since we aren’t likely to do that outright in this, the 21st century -- why not simply ensure that they die faster by denying them costly medical care? The savings could then subsidize care for the younger and healthier.

Sound too draconian? Enter the ghost of Obama’s late maternal grandmother, Madelyn Dunham, who died of cancer at age 86 two days before her grandson’s election to the presidency. Dunham’s health issues first surfaced in a New York Times interview with the president on May 3. There, Obama questioned the appropriateness of a hip replacement that his grandmother had undergone after falling and breaking her hip shortly after being diagnosed with terminal cancer last year. The alternative to such surgery is typically excruciating pain and opiate dependency. Obama made it clear that he loved his granny and would have paid for the surgery out of his own pocket if he had to, but he said there ought to be a “conversation” over whether “sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model.” Obama suggested that such decisions be made not by patients or their relatives but by a “group” of “doctors, scientists, ethicists” who are not part of “normal political channels.”

Obama brought up his grandmother’s hip replacement a second time in his June 24 town hall event on healthcare on ABC. The “question was,” Obama said, “does she get hip-replacement surgery, even though she was fragile enough they were not sure how long she would last?” At that point I was thinking: If he says, “No hip replacement for you, Grams” one more time, it’s going to be a drinking game.


An audience member, Jane Sturm, told the story of her 99-year-old mother, who had initially been turned down for a pacemaker on account of her age. Sturm’s mother persuaded a second physician impressed with her joie de vivre to perform the life-extending operation -- and she’s still hale today at age 105. “Outside the medical criteria,” Sturm asked, “is there a consideration that can be given for a certain spirit ... and quality of life?”

Nope. “I don’t think that we can make judgments based on people’s spirit,” Obama said. “That would be a pretty subjective decision to be making. I think we have to have rules that we are going to provide good, quality care for all people.”

If that sounds cold, or like an interference with the traditional physician-patient relationship, in which doctors make decisions -- call them “subjective” decisions, if you like -- about the most appropriate care for their patients on an individual basis, that is the very point. Obama and those who support his healthcare reform proposals have embraced a concept called “comparative effectiveness research.” The idea behind comparative effectiveness research is basically a good one: Use large-scale scientific studies to determine which medical procedures produce the best patient outcomes in the aggregate, and whether some expensive tests, drugs and surgeries might not be as effective in the aggregate as cheaper alternatives.

Such information -- sometimes called “evidence-based medicine” -- can be helpful to doctors in deciding what treatments would be best for their patients and maybe save them some money. But Obama and his healthcare supporters do not want to stop there. Their implicit proposal seems to want to turn comparative effectiveness research into the “rules” that Obama was talking about on ABC: one-size-fits-all procedures that physicians would have to follow at the risk of not being paid by the government. And the government would increasingly be the payer if Obama’s proposed “public option” health insurance crowds out, as it inevitably will, private health insurers forced to compete with a tax-subsidized government entity. A pacemaker for your otherwise tough-as-nails 99-year-old mother? Forget it, Mom, you die.


That’s what Obama means when he talks about “difficult decisions at end of life,” as he did on ABC, or “reining in costs,” as he did in his New York Times interview. Congress has already slipped $1.1 billion into the economic stimulus law it passed in February to set up a Federal Coordinating Council for Comparative Effectiveness Research. Under Obama’s healthcare plan, physicians participating in Medicare and Medicaid would be paid extra to turn over their patients’ medical records to a central federal databank, effectively turning their patients into unwitting research subjects for comparative effectiveness.

Bioethicists are clambering aboard the aged-based rationing bandwagon, including Daniel Callahan, co-founder of the Hastings Center, who published two essays in the New York Times last November proposing “age cutoffs” or other “unpleasant solutions” to trim Medicare costs. Some of those solutions are already the order of the day in that single-payer paradise, Britain, whose National Health Service doesn’t even provide for annual screening mammograms -- something U.S. physicians strongly recommend to detect and treat breast cancer before it becomes virulent. The National Health Service allows mammograms only every three years, and then only for women between 50 and 70. The service’s guidelines recognize that risk rises with age, but women over 70 must nevertheless explicitly ask to continue having the triennial scans -- a not-so-subtle way of discouraging the screening.

Britain also set up a National Institute for Health and Clinical Excellence in 1999, whose bureaucrats assign “quality-adjusted life years” in deciding whether it is “cost effective” to pay for cancer drugs and other treatments. They’re the people who decided that if you’re going blind in both eyes due to age-related macular degeneration, the government will pay for sight-restoring photodynamic therapy for only one of your eyes.

Now, I’m well aware that having 47 million people who can’t afford medical care is a genuine social problem -- although many of those millions are illegal immigrants, people between jobs and young folks who choose to go insurance-bare. I’m also aware that I can’t necessarily have everything I want, whether it’s a dozen pairs of Prada boots or a pacemaker at age 99. I know that Medicare is on the greased rails to a train wreck, and not just because of spiraling costs but because doctors are fleeing the system because they’re sick of below-cost reimbursements and crushing paperwork. There are ways to solve some of these problems: healthcare tax breaks, malpractice reform that would lower the cost of practicing medicine, efforts to make it easier to get cheap, high-deductible catastrophic coverage, steps to encourage fee-for-service arrangements of the kind that most people have with their dentists.


In short, as someone who’s not getting any younger, I’d like to be the one who makes the “difficult decision” as to whether I can afford -- and thus really want -- that hip replacement in my extreme old age. Sorry, President Obama, but I don’t want “society"-- that is, government mucky-mucks -- determining that I’ve got to go sit on an ice floe just because I’m old and kind of ugly, no matter how many fancy degrees in medicine or bioethics they might have.