Thursday, June 25, 2009

Who should decide Grandma's new hip? -- June 25, 2009 column


Madelyn Dunham was 86 and her grandson, Barack Obama, was running for president when she was diagnosed with terminal cancer. Doctors said she had six to nine months to live. A few weeks later, she fell and broke her hip, perhaps after a mild stroke.

Doctors offered the dying woman a hip replacement despite her fragile condition, and she agreed. She did well for two weeks following the surgery, then “things fell apart,” Obama said. His grandmother died two days before last November’s election.

The president shared the story at a town hall forum on health-care reform Wednesday to illustrate the tension between the personal feelings and the public policy needs of health-care reform.

Republicans complained that the forum, which was broadcast in prime time on ABC, amounted to an “infomercial” for Obama’s plan, but they needn’t have worried. The forum highlighted key, troubling questions at the heart of the debate: How much medical care is too much and who should decide?

“If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life, that would be pretty upsetting,” Obama said.

But he also conceded that whether such expensive care for the terminally ill is a sustainable model for society is a very difficult question.

“The problem that we have in our current health system is that there is a whole bunch of care that’s being provided that every study, every bit of evidence that we have indicates may not be making us healthier,” he said.

Obama has downplayed changes that reform will bring to people who currently have health insurance. But how specifically will we stem the runaway inflation in health care costs?

Republican critics insist that rationing is inevitable. Obama is beginning to engage people on this issue. He told his story about his grandmother’s final months of life in nearly the same words in an interview in The New York Times magazine in early May.

Since then, he read and recommended to members of Congress Dr. Atul Gawande’s compelling article in the June 1 New Yorker magazine, explaining why expensive health care is not necessarily the best.

A consensus is developing around the idea of scaling back “overtreatment,” which will mean setting limits on medical tests, surgeries, scans and treatments. Obama sent a letter to Senate leaders June 2 saying reform should promote “the best practices, not simply the most expensive.” He praises the Mayo Clinic as an example of high-quality, low-cost care.

Republicans say they too want to cut health-care costs but Obama’s public plan option puts bureaucrats in charge of health decisions.

As Obama’s story about his grandmother demonstrates, overtreatment is something that happens in other people’s families, not ours. Like everyone, Obama wants the best medical care for his family.

At the town hall, Dr. Orrin Devinsky, an epilepsy specialist from New York University, noted that in the past politicians who have tried to reform health care have tried to limit costs by reducing tests and access to specialists, but they haven’t taken their own medicine.

“When they or their family members get sick, they often get extremely expensive evaluations and expert care,” Devinsky said. He tried to get Obama to commit to living within the limits. He asked the president: If a national health plan were in effect and your wife or a daughter became seriously ill, would you pursue private treatment not covered under the plan?

Yes, Obama said, he’d “always want them to get the very best care.”

As a Dukakis moment, Obama passed the humanity test with flying colors. During a presidential candidates’ debate in 1988, the moderator, Bernard Shaw, asked Democratic contender Michael Dukakis if his wife Kitty were raped and murdered, would he favor the death penalty for the murderer?

“No, I don’t,” Dukakis said, “and I think you know that I’ve opposed the death penalty during all my life.”

The answer, while consistent with Dukakis’ views about the death penalty, was shocking. How could he be so cold and bloodless? The episode was a nail in the coffin of the Dukakis presidential bid.

Obama said decisions about care should be guided with input from ethicists and others on an independent commission. But when it was his grandmother, Obama wasn’t worried about the cost. Other people facing such a situation with their grandmas or moms and dads aren’t worried about cost either.

And that’s a problem for Obama and health-care reform.

(Marsha Mercer is an independent columnist writing from Washington. You may contact her at

© 2009 Marsha+ Mercer. All rights reserved.

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