Redesign of Healthcare for the End of Life

The unfunded liabilities of Medicare ($30 trillion), dwarfs that of Social Security which is projected at $12 trillion.  This compares to our “official” national debt of $7 trillion. This year the Federal government will have to transfer 3.6% of Federal tax receipts to the Social Security and Medicare Funds, as they will for the first time spend more than they will receive in tax receipts.  Projections show Medicare eating up 35% of the Federal budget within 25 years.  This trend is due primarily to the large number of baby boomers who will retire shortly, and will continue until reforms are adopted and enacted into law.  Simultaneously, health care costs are rising at an annual rate well above inflation. The collision course of available funds and need is going to test our social contract resolve, and will create tremendous pressure on our current system of resource allocation and our moral commitment to the sanctity and dignity of life.  It is time to face reality.  Unprecedented challenge requires perspective and good judgment, and we must find solutions quickly.

Consider the stark math. In 1900 the average life span was 47 years; today it is 75 years.  Many have forecast that the average life span will continue to increase and will likely reach 100 in the near future.  Currently, 75% of the people who live to be 100 are active at 95.  Older people can live quite well with serious chronic illness. Medicare pays for most physician and hospital expenses at the end of life, which comprises the majority of all health care expenses, expenses that, in the past, were largely the responsibility of families.  About 20% of Medicare enrollees account for 80% of the total amount spent.  (In an analogous situation in the non-Medicare population, one-half of all health costs related to obesity are borne by the taxpayer.)

Society struggles to address the issue of how to maintain end of life care with dignity in a new economic landscape where rationing currently exists.  Nurses are often pressured to discharge patients as soon as possible and sometimes prematurely.  Also, the present reimbursement formula, and a fragmented health system often result in pressure on families to let the patient die with less medical intervention.

If Americans are living longer, it is no thanks to a health care system that has questionable priorities and provides little incentive or reward for conscientious individual efforts to improve personal health habits.  The Surgeon General has recently stated that 50% of the variance in individual life expectancy is due to lifestyle. Nevertheless, though the facts are in about the manifold benefits of controlling high blood pressure, diabetes, and high cholesterol in avoiding expensive hospitalizations, these strategies are not emphasized.  Consequently, the health care professional is endowed with almost talismanic powers by a populace inbred with the cult of healers rather than the ethos of healthy living.  Renowned health economist Rene Dubois has stated, “to ward off disease or recover health, man as a rule finds it easier to depend on healers than to attempt the task of living wisely.” Moreover, when the individual is removed from direct financial responsibility by a third party dominated health care structure; the tendency is to consume more resources and services.

Practical solutions that could be explored by health care policy makers include the following:

  1. Provide incentives and motivation in the areas of prevention, and self-management of disease.  Self-management would involve the ability to mange symptoms, treatment, physical and social consequences, and lifestyle choices that go with chronic conditions.  Disease management would begin to heal the problem of our fragmented system of care.
  2. Explore Healthcare Savings Accounts as a means to solve the shortfall of funds in Medicare for the younger population.  A Healthcare Savings Account would allow younger people who live a healthy lifestyle to accumulate considerable funds over their lifetime.
  3. Further develop programs designed to manage chronic illness more efficiently.  Find additional ways to balance curative treatment with palliative measures.
  4. Develop creative programs involving all parts of our pluralistic healthcare system.  Realize that our physical health is interdependent with our spiritual, emotional, and mental health.  Encourage the development of programs like church based parish nursing to help better navigate through the fragmented healthcare system.

All Americans are stakeholders in the issues surrounding end of life health care.  We all want a system that allows the elderly to count on living comfortably and meaningfully in their last years.  Urgent changes need to be made to avoid a collision between that goal and the reality of the resources to meet that goal.

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