August is usually a quiet month in American politics. Congress and the president go on vacation and the media entertain us with trivia. But this year was different. With the recession having shown some slight signs of easing, at least for Wall Street which seems to have started to enter its boom cycle again, the proposed health care legislation moved to front and center of the public debate. While the substantive issues are clearly important, it has been politicized to such an extent that any agreement between Democrats and Republicans has become unlikely when Congress convenes again in September. The atmosphere has been poisoned to such an extent by the media and town hall meetings that the issue has become a referendum on President Obama. His detractors now see health care as the tool to discredit his administration and pave the way to a Democratic defeat in next year’s Congressional elections.

Let us now look at how Obama allowed himself to be maneuvered into this impasse. One clue resides in his character and the other in America’s political system. For his character and what he really intended to do we have his own words in “The Audacity of Hope.” In the Prologue to the book while talking about how age tends to reveal physical and mental flaws, he wrote, “In me, one of those flaws had proven to be a chronic restlessness; an inability to appreciate, no matter how well things were going, those blessings that were right in front of me.” This restlessness propelled him, within the short span of four years, from an unknown junior senator to the presidency. When we use instead of the word “restless,” “impatient,” it becomes clear that this very American character flaw may result in political failure.

As mentioned repeatedly in theses pages when Obama took the oath of office the country faced unprecedented staggering problems: Two wars that cannot readily be terminated but drain the already depleted treasury; the potential threat of further terrorist attacks; a massive fiscal deficit; the economy teetering on the verge of collapse; unsustainable health care and Social Security costs; an inadequate educational system; and a world that had become increasingly suspicious of America’s motives. All of these problems were to be solved by the mantra of “change” and the hope that through sheer strength of personality the diverse factions which make up our country would somehow see the need to cooperate under an enlightened leadership which steers a rational course. “A more perfect Union” was the goal that has become ever more elusive with each passing month. 

The gauntlet was thrown down immediately after the inauguration by Rush Limbaugh, the widely listened to radio and TV commentator, who declared unabashedly, “I want Obama to fail.” When he was taken to task for this stance, he modified the statement to “I want his policies to fail,” which is obviously a distinction without a difference. When the Obama administration then tried to tackle most of the problems listed above essentially simultaneously, with the only available remedy namely massive deficit spending and some government oversight of the banking and auto industry, it provided the fuel for the fire which broke out in regard to the health care legislation. The final straw was when the Congressional Budget Office, which is non-partisan, projected that the plan which was under consideration would cost approximately $1.6 trillion over the next ten years. This expense would be added to the $9 trillion of the current ten year federal deficit projection.

These are clearly figures which stagger the imagination but, as mentioned in a previous issue (Uncharted Waters. April 1, 2009), are quite meaningless. Economists could not predict the 9/11 tragedy and that the 2000 surplus would morph within one year into ever increasing deficits. But figures of this type do have a purpose. They can be used to scare the public. Nevertheless apart from the projected cost, the bill that was supposed to have been voted on had indeed significant other problems. When one considers what the bill was actually supposed to accomplish it is clear that the administration had left itself wide open to justified, as well as purely polemical, attacks.

Before examining the major bones of contention of that bill let us first look objectively of what is wrong with the way the current health insurance system works. First of all we have again a misnomer. We don’t insure health, nobody can do that, we want the cost of illness to be covered by insurance. This is just another typical example of the euphemisms which pervade our society and prevent straight thinking. Medical care costs have risen astronomically over the past years. This was mainly due to more sophisticated technology, rising medical and malpractice insurance rates as well as medication costs. Insurance carriers have raised their premiums to an extent that catastrophic illness can now bankrupt families. In addition the last quarter of the previous century saw the rise of “Health Maintenance Organizations (HMOs),” another euphemism for limited insurance against illness. The reason why I am saying “limited” is because the particular organization one joins allows one to receive care only by participating physicians and hospitals, rather than the institution one might really want to have take care of oneself in case of a complicated serious problem. Not only do these HMOs limit the choice of physicians but also the diagnostic procedures a given member may receive as well as the type of medications. Their “bureaucrats” already act as gate keepers to keep the HMO profitable rather than the patient as healthy as possible. This aspect is completely overlooked by the opponents of the reform bill who claim vociferously that the Obama plan will, through “socialized medicine,” deprive us of our free choice of physicians. For many, if not most of us, this option no longer exists anyway.

In addition to these private insurance carriers there is for veterans the government Veterans Administration (VA) system; for disabled children and some indigents Medicaid, and for everyone above the age of 65 Medicare. With other words we already have three government supplied medical insurance programs, all of which have problems of their own. Leaving the VA aside, Medicaid is the most problematic. Costs are split between the federal government and the various states; it ensures indigents against certain illnesses but not all and pays physicians and hospitals such a pittance that a considerable number refuse to participate because every patient they see is a financial loss. Medicare is, as has been mentioned, automatic and cannot be refused even if one has private insurance. For the elderly population, which is the one most in need of medical services, we now have the anomalous situation that two bureaucracies do the billing if you have private insurance through your former employer’s pension plan. Medicare as the primary provider pays for some services then the bill goes to the secondary insurance which may or may not pick up the rest of the charges. As a result of my hip problem I now get most every other day form letters from Medicare which assure me that “This is not a Bill” but an “Explanation of Benefits” and I have no idea what to do with them. They are frequently vague, contain a lot of “$0s paid” but do provide the phone number to call if one has questions. To anyone who tries to do so one has to wish good luck with maneuvering through “menus” before one gets a human being who may or may not be helpful.

Martha and I are among the fortunate few who have excellent secondary insurance as part of my retirement package from the State of Michigan. It is administered through Blue Cross-Blue Shield of Michigan and out of pocket expenses have so far been minimal. In addition the insurance is “portable” and we can truly go to the physician and hospital of our choice anywhere in the country. This is what should be and is an example what “government” (in our case State Government, but also the Federal Government for its employees) can supply.

Yet this option is not available to the majority of our fellow citizens because everything depends on the plan the employer chooses and this is where cost cutting measures come to the fore. Why chose the best and most expensive plan when you can get by with the minimum HMO? This is another area where unbridled capitalism directly impacts on our lives and we can do absolutely nothing about it. If one happens to be self-employed one can buy private insurance but there are restrictions. A pre-existing condition such as diabetes or epilepsy might either lead to refusal or to premiums which are clearly unaffordable. In addition, as mentioned above, premiums have steadily gone up over the years and middle class incomes cannot keep up with them. As such approximately 46 million (the number is hotly disputed) forego insurance and simply show up in emergency rooms when the need arises. Under these circumstances the hospitals have to absorb the costs for services which might have been handled for considerably less by a private physician.

In view of this situation health care reform has been discussed at least since the first years of the Clinton administration. Hillary was tasked to achieve it but her efforts came to naught. It was noted at the time that the plan was hatched in secret and Congress was expected to sign on the dotted line. The insurance companies rebelled; the media roundly denounced it; TV ads saturated the public with fears of “government take over” and “socialized medicine.” All of this led not only to a defeat for improved medical insurance but also the Republican Congressional victory in the midterm elections of 1994.

This was the example Obama was confronted with and why he decided to do the opposite. He would provide Congress with broad guidelines and let the House and Senate fill in the details. The intent was that the plan would be affordable, available to all and portable (not dependent on employment and free choice of physician anywhere in the country). The costs were to be largely covered by eliminating waste and streamlining bureaucracy. This was regarded as relatively easy to accomplish. With a Democrat majority in the House and Senate passage was expected before the summer recess. But when the House Bill emerged it covered more than 1000 pages and was so complex that hardly anyone who is not a lawyer could understand it. Since the administration knew that any delay in passage would be fatal they tried to ram it though the House but when the price tag appeared even some Democrats got cold feet. Congress adjourned and the media had a field day all throughout August.

Apart from the cost two aspects became the rallying cry for the disenchanted Republicans. One was the so-called “public option,” an insurance system run by the government for those individuals who could not afford the private premiums and the other which was termed the “Death Panels.” The “public option” was derided as “socialized medicine” and government take over of the health care system. Private insurers, it was claimed, would no longer be able to compete on a level playing field and as such it was inimical to a free capitalist society. This was a repeat of what had been called Hillarycare in the Clinton administration and has now been changed to Obamacare. The “death panels” were, however, a new wrinkle and termed as such by the ex-Governor of Alaska, Sarah Palin, who is apparently already running for the presidential elections in 2012. They have an interesting history and the topic requires an open and intelligent discussion.

The mentioned House Bill had a provision which allowed Medicare payments for a consultation with a physician about “end-of-life care.” If an elderly person had previously wanted to do this, it would have been an out of pocket expense. It is well-known that the major medical expenses occur within the last six months of life during terminal illnesses. From society’s point of view significant savings could be achieved if terminally ill patients, who may or may not be mentally competent, were to receive compassionate care but not extraordinary measures of life support such as artificial ventilation and feeding. The proposed bill intended to make the elderly aware of what options are available to them by making what is called a “living will;” giving a trusted family member “durable power of attorney;” and acquainting them with local hospice rather than hospital care. The consultation, as envisioned in the Bill, would be voluntary and initiated by the patient. After five years, or drastically changed life circumstances, another one would also be paid for by Medicare.

From a purely rational point of view this provision is good for the patient as well as society. All or at least most of us have a “Last Will and Testament,” which informs our heirs what to do with our property, and some of us have even bought burial lots and made arrangements for the funeral. Yet, when it comes to the choice how we want to be treated when accident or illness deprive us of our decision making capacity this aspect of our lives seems to be out of bounds; even for discussion. Every intelligent person ought to ask him/herself to what extent resuscitative measures should be undertaken after cardiac or respiratory arrest. Does one really want to linger unconscious in a hospital bed on a ventilator with tubes in every natural and artificial orifice and when what was previously called “the friend of the aged,” pneumonia, arrives it be combated with antibiotics? But this is what happens in America on a daily basis.

Let me relate a relevant personal anecdote. In the 1980s when I was in charge of the Clinical Neurophysiology Laboratory of Harper Hospital in Detroit one of my duties was to certify that in a given comatose patient “brain death” had occurred because its electrical activity had ceased. Once I did so physicians and nursing personnel could tell the family that the patient had died. Permission was then given to “pull the plug.” The respirator was disconnected and the patient was officially declared dead. There was usually no problem, but in one instance the son adamantly refused for several days to give the requested permission. The reason was that he still wanted to get the father’s end of the month Social Security check! I don’t know if he really needed it or whether it was pure greed but the fact remains that this is what can happen if a person has not previously made the appropriate legal arrangements about end-of-life care. The Terry Schiavo case, which has been discussed previously,(Pain and Suffering. April 1, 2005) ) is, of course, another example.

Without such a declaration one becomes part of what I call “the system.” It operates on laws of its own and these are geared nowadays mainly to do everything possible to avoid a law suit. “Standards of Practice”, which may or may not be reasonable have evolved for every conceivable contingency and unless these are adhered to, the malpractice lawyers would have a field day. The recent hip surgery is a case in point. I have a living will, Martha has durable power of attorney for me and I not only supplied the hospital with copies of the forms but also told the anesthetist and the surgical personnel before lying down on the operating table that in case of cardiac or respiratory arrest no resuscitative measures were to be taken. In addition there had earlier been an animated discussion with the surgeon over the pre- and postoperative “standard of care protocol.”

Surgical procedures can be followed by blood clots in the legs, due to immobility, and the Society of Orthopedic Surgeons has decreed that patients have to be placed on the blood-thinner “warfarin,” which is its generic name. The drug is relatively expensive but in addition, and this is the main problem, unpredictable in its effect. The same dose may not prevent clotting in one patient and can produce increased bleeding in another. As a physician I was aware of this problem and I also knew that aspirin is a very effective blood-thinner without leading to increased bleeding. When I discussed this with the orthopedic surgeon he told me that he was obliged to follow the official recommendations but I was equally adamant that I would go with the aspirin after, rather than before, the operation. I could not fathom why I should encourage bleeding by taking warfarin prior to an operation which by necessity will lead to increased bleeding. As a physician I could discuss these aspects rationally with my colleague the orthopedist, he could put it in writing, to protect himself and everybody was happy. After three weeks when the staples came out the nurse was surprised to see how clean the wound was; there was none of the bruising and swelling she usually sees at that time in other patients. I couldn’t help but feel that the aspirin rather than warfarin regimen, which I had opted for, may well have played a role in better healing. Yet, the warfarin discussion was an option which was available to me, as a physician; the average patient might not have such a choice. Treating physicians have to go by the book, but the studies which lead to the dogma of “Standard of Care” for a given condition may not be all that reliable. This aspect was in part covered in Faith and Science (June 1, 2009).

Everyone needs to know, therefore, that once you enter “the system” you have given up significant portions of your autonomy and the sooner you can leave “the system” for your home the better off you are. In my situation I limited the stay to a total of 48 hours. This was both cost-effective and provided peace of mind as well as rest that would be unavailable in the hospital where nurses are obliged to check your vital signs during the night when all you want is to sleep. These are today’s realities which the “health care reform” is supposed to fix.

One would think that from a few paragraphs which basically allowed payment for “end-of-life discussions” with your physician to Sarah Palin’s “death panels” is a large jump. But not so large if one enters the conservative mindset as expressed on November 23, 2008, barely three weeks after Obama’s victory at the polls. On that day the Washington Times (a conservative daily newspaper) published an Editorial with the headline “No 'final solution,' but a way forward.” The author linked Hitler’s euthanasia program, which was enacted at the beginning of  WWII, with this country’s abortion issue, which the author feared would become worse as a result of Obama’s election. Hitler’s team of physicians and administrators which decided who could be euthanized, as being a drain on society, became Sarah Palin’s “death panel.” The phrase showed remarkable viability in spite of the fact that it has absolutely no bearing on the plan as considered by the House. Palin, mother of a child with Down syndrome, was, apaprently struck by a quote from  Rev. Briane K. Turley in the mentiond Editorial, which stated,

 “Here in North America, since the 1970s, we have discovered a far more efficient means of weeding out those with disabilities. ’Were God's design for us left unhindered,’ he says, ‘we could naturally expect to welcome 40,000 or more newborn infants with Down syndrome each year in the U.S. And yet we have reduced that number to just under 5,500. These data strongly indicate that, in North America, we have already discovered a new, 'final solution' for these unusual children and need only to adapt our public policies to, as it were, 'cure' all Down syndrome cases."

On August 7 Mrs. Palin published on her Facebook account this comment, “The America I know and love is not one in which my parents or my baby with Down syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care. Such a system is downright evil.”

            The issue was then joined by Senator Chuck Grassley of Iowa, who was not known to be a firebrand, with a comment on August 14 that, “We should not have a government program that determines if you're going to pull the plug on grandma.”

            On August 17 Betsy McCaughey (former Lt. Governor of the State of New York) weighed in with an article in the New York Post under the title Deadly Doctors, “The health bills coming out of Congress would put the decisions about your care in the hands of presidential appointees. They'd decide what plans cover, how much leeway your doctor will have and what seniors get under Medicare.”  

These are outright falsehoods and to their credit Palin as well Grassley have subsequently retracted their statements. Nevertheless the fact that a secret program which was initiated in a totalitarian state at the outbreak of WWII is equated with a bill which is discussed in Congress and to be voted on by elected representatives shows the level of hatred which exists in some circles and which is regularly stoked by some radio and TV commentators.

Leaving aside the deliberate political distortions there are two genuine concerns in regard to the insurance issue. One is what type of health care reform plan should be adopted, and what is our society’s attitude towards death? The latter can be summed up in one sentence. Many of us are literally deathly afraid of dying. This seems to be a peculiarly American situation because it does not hold true to the same extent for the other cultures I am familiar with. In our country any and all efforts are frequently made to keep someone alive even in the face of an aged patient with obvious terminal illness. Why should this be so? Theoretically approximately 75 per cent of our citizens are Christian for whom death should present no problem because according to that faith Jesus had died for our sins and if we place our faith in him we will go to our reward. Muslims accept death as the will of God, while Hindus and Buddhists are re-incarnated anyway. Of our approximately 3.6 per cent Jews, and whatever number of atheists, some may have a serious problem because their faith does not allow for an after-life, but they should not dictate policies.

In this area we are clearly at the intersection of faith and politics. While a faith in God, under whatever name, will remove fear, its absence promotes it. Faith in God has been replaced in some quarters by faith in Man, whom we have, however, every reason to distrust as past history has shown. While physicians generally do the best they can, they also know the limits of their art, and medical science is a work in progress. All of us should realize that we live on “death row.” We have not given life to ourselves and we don’t know when this gift will be withdrawn. We should cherish it while we can, but we ought not to cling to it when its purpose has been served. We are part of nature so let nature take its course. When the apple is ripe it falls to the ground and the deer or other creatures eat it. What we are doing with artificial life support is akin to fastening the apple with duct tape to the branch. It will prevent the apple from falling but just leaves it to rot on the tree where it won’t even be healthy for the birds.

Fear of death has been with the human race for millennia and is probably one of the reasons why religions flourished. But one does not necessarily need to subscribe to a specific one; the Stoics of ancient Greece and Rome provided a rational answer. Epictetus (ca. 55-135 AD) wrote,

When death appears an evil, we ought to have this rule in readiness, that it is fit to avoid evil things, and that death is a necessary thing. For what shall I do, and where shall I escape it? . . . . I cannot escape from death. Shall I not escape from the fear of death, but shall I die lamenting and trembling? For the origin of perturbation is this, to wish for something, and that this should not happen.

What conclusion should rational adults draw from the foregoing? Since death is inevitable prepare yourself and your family mentally for it. Don’t live in denial because when you do so you give up your most valued possession, your autonomy. Others will deal with you according to their needs and this may not be what you or your family really wanted. In our day and age a “living will” should be part and parcel of one’s Last Will and Testament and it will be honored by authorities as long as we have an elected rather than despotic government.

What should Obama do now to extricate himself from the mess the health care reform is currently in? First of all he should re-read pages 183-189 of his Audacity of Hope. Let me just quote the first key sentence, “We could start by having a nonpartisan group like the National Academy of Science’s Institute of Medicine (IOM) determine what a basic, high quality health-care plan should look like and how much it should cost.” If Obama had adhered to this idea he might have saved himself a great deal of grief. But under pressure from his supporters and in the belief that his popularity would overcome whatever obstacles his detractors might put in his way he had turned the matter over to Congress, where the process was doomed to fail. His fundamental mistake was the assumption that the American people at large trusted him and thereby his administration. He had not realized to what extent faith/trust in government had already been eroded by previous government actions and that it cannot be restored overnight by well-meant speeches. This message was conveyed loud and clear, in the various town hall meetings that had been conducted by senators and representatives during the past month. In addition Obama had underestimated the intense personal animosity which his victory in November has elicited in some as well as the profound polarization of politics. The center seems to have disappeared in public discourse and those who try to make the voice of reason heard get literally shouted down. Some commentators, even on CNN, can hardly hide their glee when they report on Obama’s falling popularity poll numbers.

There were two other aspects in Obama’s book he might profitably ponder at this time. The mentioned Prologue quote was followed by, “Someone once said that every man is trying either to live up to his father’s expectations or make up for his father’s mistakes, and I suppose that may explain my particular malady as well as anything else.” Yes indeed; Obama is trying to live up to his father’s expectations. But just as his father’s political hopes for Kenya were wrecked by tribal politics, the son’s political future is here being determined by party politics. This is one lesson he needs to take to heart and learn why his father had failed in that respect. The other is the question Obama has raised at the end of the Prologue, “how I, or anybody in public office, can avoid the pitfalls of fame, the hunger to please, the fear of loss, and thereby retain that kernel of truth, that singular voice within each of us that reminds us of our deepest commitments.”

 These are character issues and will determine either success or failure of Obama’s Presidency. What he needs above all in the current climate of lack of trust in government, is that rare virtue: patience. He must not allow himself to be stampeded by either the right or the left into decisions which, once they are made, are irrevocable and may not conform to the best interests of the American people.

In regard to the current health care proposals the Democrats have already dropped the “public option” and the “end-of-life counseling” provision. It seems that in their eagerness to get some type of legislation passed in the fall, further compromises will be made and a Bill will be passed which is likely to compound, rather than solve the problem. Any reform that does not address the excessive profit motive of insurance companies, trial lawyers and the pharmaceutical industry is doomed to fail. I have left out physicians and hospitals because if they charge exorbitant fees, patients will not use them.

Instead of creating new bureaucracies on top of existing ones the government could provide a genuine “public option” for patients who cannot afford or obtain private insurance. Medicaid could be abolished and instead Medicare would cover all patients, regardless of age, who do not have access to private insurance. In the private arena some version of the Blue Cross-Blue Shield model could be made available to everyone and not merely to government employees and its pensioners. The immediate outcry will be, “but we can’t afford that!” The answer to this financial problem will require a re-thinking of our priorities and an awareness of how our government really works instead of how it was intended to work. To explain this to the public, honestly and in simple language, ought to be Obama’s task in the coming weeks and months.