Shades of Grey

Charlie Ornstein is a senior reporter at ProPublica and board president of the Association of Health Care Journalists. More importantly, he is the son of Harriet Ornstein, who passed away peacefully on January 18th of this year following a short stay in hospital. Last week, Charlie published an article relating his experience – How Mom’s Death Changed My Thinking About End-of-Life Care.

Reading Charlie’s article reminded me of the insights of Dr. John Henning Schumann, which I shared in my post, The Politics of Dying in America. Charlie’s experience is no different than that of hundreds of thousands of families every year. His perspective, however, is uniquely different because he is now in the unfortunate camp of having looked at end-of-life care from both an objective and deeply subjective vantage.

From a public policy perspective, the vulnerabilities of the American healthcare dragon are so easy to identify that you have to marvel at our inability to effectively exploit them. As Charlie points out in his article, about one-fourth of all Medicare expenditures are made during the last year of a beneficiary’s life. We are paying millions and millions of dollars to buy a few extra days. Doesn’t seem objectively reasonable does it?

What would you pay for one more day? Seeing as the day after one more day the collection agencies wouldn’t be able to reach me, I guess I’d pay whatever my credit would allow. That might get me through Good Morning America. On the other hand, my dad always told me that a noble goal was to leave the world indebted to no one while being the poorest soul in the cemetery. So I got that going for me . . .

Without any intention of being disrespectful to the cherished memory of Mrs. Ornstein, I make light of a scary and depressing topic simply because there isn’t much else to do with it that seems logical. And that’s where very often rational discussions of healthcare public policy breakdown: because one person’s calm, objective logic is another person’s emotional reality. I think this is at least partially what Charlie was getting at in his article.

The elasticity of demand for medical care is one of the most capricious concepts we face in analyzing and assessing healthcare public policy. What I would pay to stay alive another day is necessarily going to be different than what I would pay to keep someone I have never met alive. But the reality is that through public healthcare programs supported by taxation (e.g., Medicare and Medicaid) I do help pay to keep someone alive another hour, day – or hopefully, much longer. Fortunately, I’m not directly involved in that decision making because I cannot imagine what it would be like if I had to choose how my tax contributions should be used – or not – on a case-by-case basis.

The point of all this is while some folks involved in healthcare policy debate would have us believe the world is black and white – with clearly delineated focal points for determining what’s right and what’s wrong – it obviously is not. The real world is a thousand shades of grey between black and white and nowhere is that more evident than when the topic is end-of-life care.



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