Obama raises hard question of end-of-life care

The Medicare health program for seniors jeopardizes the country's fiscal health a lot more than the fiscal stimulus or Wall Street bailouts.

At Medicare's present rate of expansion, according to the Government Accountability Office, Americans living in 2080 will have to pay 10 percent of their incomes just to cover cancer surgery, heart operations and other care for old people, many of whom will die a few months after treatment.

How can we avoid the worst? President Barack Obama has made the first move by starting a tough conversation about the high costs and questionable benefits of care at the end of life.

In an interview to be published in Sunday's New York Times Magazine and available on the Web, Obama talked about his grandmother, Madelyn Dunham, who died just before November's election.

She had been diagnosed with terminal cancer and given three to nine months to live when she broke her hip. Naturally, her doctors wanted to spend thousands of dollars to give her a new hip and charge it to taxpayers.

"I don't know how much that hip replacement cost," Obama told the Times. "I would have paid out of pocket for that hip replacement just because she's my grandmother. 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, is a very difficult question."

But it's a question the country must ask. As he did a year ago in his speech on race, Obama has broached a taboo topic and launched an overdue discussion.

We spend ungodly sums treating people who will soon die anyway. A fourth of all Medicare dollars are spent in the last six months of life, according to the Dartmouth Institute for Health Policy and Clinical Practice. That'll come to $100 billion this year, enough to pave a lot of roads, build a lot of schools and fight a couple of wars.

A couple of years ago, Medicare paid an average of $85,729 at Johns Hopkins Hospital for each patient in the last two years of life, a statistic that underscores the Baltimore medical-industrial complex's stake in this debate. At the University of Maryland Medical Center, it was even higher - $94,901. Both figures are from Dartmouth.

So do we start "rationing" care for people like Obama's grandmother? Should a terminal diagnosis limit patients' taxpayer-financed medical options?

Dr. Albert Woo, a professor at the Johns Hopkins University's Bloomberg School of Public Health, says it's not that easy. In the mid-1990s, he and other researchers tracked thousands of patients at several hospitals who had been given six months to live.

While on average the group did indeed survive six months, "for any individual person, the results were very hard to predict," Woo says. "Is care futile? It's very difficult to figure out. The person could live for six months, or the person could live for a year and a half."

Or longer. At some point, after all, we're all terminal.

Woo thinks doctors can save taxpayers money and show more compassion at the same time by communicating better. Some critically ill patients don't want heroic, expensive measures, but the doctors provide it anyway. In the 1990s study, only 47 percent of the physicians knew when their patients didn't want cardiopulmonary resuscitation, or CPR.

The larger solution is to stop paying for ineffective or unneeded procedures among all patients, not just the dying, Woo says. Woodlawn's Centers for Medicare and Medicaid Services are chock-full of underused data on what works and what doesn't for operations such as tonsillectomies, hysterectomies and prostatectomies.

"Is it time to start rationing care?" Woo says. "I think we should ration care by whether or not treatments are effective."

Easy to say. Madelyn Dunham's hip operation, one could argue, was effective. The new hip worked two weeks and then, Obama told The Times, "things fell apart" and his grandmother veered toward death.

One person's ineffective medical treatment is another person's inalienable right. The dollars spent on end-of-life care are about to balloon as baby boomers start dying in greater numbers. The first boomers become eligible for Medicare in two years.

Things can't go on as they are, and only one thing is for sure.

"When it comes to Medicare and Medicaid, where taxpayers are footing the bill," Obama said, "we have an obligation to get those costs under control."

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