The Political Interest Pulling the Plug

By Michael Kramer

"I haven't told my husband yet," Hillary Clinton said as the President wolfed rice beside her at a luncheon with journalists last week, "but we're going to have a living will."

"I need one in my line of work," Clinton cracked. His guests laughed, and a discussion about living wills, in which the signer declares that his dying life should not be artificially prolonged, was deftly deflected. The Clintons deny that their reform program would limit medical services in any way, but their own recent brush with what the First Lady calls "a crazy system" supports the experts' view: serious rationing is coming.

Last March, as the White House rushed to craft its health-care proposals, Mrs. Clinton had to leave Washington abruptly to be with her ailing father. The victim of several strokes, Hugh Rodham had been failing for some time. With the end near, the President's 82-year-old father-in-law was admitted to St. Vincent's hospital in Little Rock, where he remained until he died three weeks later. "There was really nothing to do for him," says an Arkansas physician familiar with the case. "He would normally have been discharged after a week because that's all the treatment Medicare would cover for someone in his condition, but he stayed on because of who he was. The hospital ate the bill, about $10,000."

Roughly 30% of all U.S. health costs are incurred in the last six months of life, far more than in other countries, a consequence, largely, of the American notion that there is no such thing as too much health care. But there's something else, something pernicious. "A lot of defensive medicine is practiced in those last six months," says Mrs. Clinton, "extraordinary efforts used on patients who doctors know will not recover, because of fears that families will think they should have done something they didn't do" -- and who then sue if it wasn't done.

Malpractice reform would help, but the Administration's new proposals are essentially lame since Clinton has refused to adopt a California-style cap on awards for pain and suffering. On the other hand, Clinton's plan to extend at- home and nursing-home benefits will lower costs. As the First Lady points out, Medicare does not pick up those tabs now, "so that doctors, as favors to families, keep people in hospitals."

The Clintons' true goal is the most ambitious of all, a change in the culture of dying. "That's why Hillary's talking up living wills and advance directives," says an Administration official. "She hopes to spur others to get comfortable with pulling the plug."

Choice in Dying, the nation's largest distributor of living wills, sent out 400,000 forms last year. But no one knows how many living wills have actually been signed or executed, and doctors are often reluctant to act even when the document is in order, lest a relative sue. "And even if the family bows to the patient's wishes as expressed in the will, it often takes days or weeks to get agreement," says Stephen Sullivan, a physician on the clinical faculty at Stanford University Hospital, "during which time costs continue to rise."

While some health-care rationing is already a fact of life, more people will feel its bite as universal coverage leads to lower reimbursements. Insuring all Americans will be easier only if more people come to grips with the expense of prolonging life artificially. The Clintons can lead, but no symbolism and no legislation will suffice unless others follow.