I have had some experience with this recently as well. It's not pleasant.
Silver wanted someone to make the decision to say 'no' to continuing care for some individuals. I just want to know how that decision will be arrived at. Will it be done by something like the transplant committees at many hospitals, or by a loss mitigation specialist at an insurer? What will be the criteria used to decide when care gets cut off? What sort of treatment is to be provided for those who are cut off?
Does a cutoff of care apply only to care covered by insurance? Can a wealthy, effectively self-insured person buy care without a cutoff? Could someone buy supplemental insurance to prevent being cut off?
How much cost containment are you going for? Currently, 27% of Medicare expense goes to people in their final year of life. Would palliative care for the terminally ill be a permissible expense (remember, there were severe political objections to this recently)? Would you be willing to permit a doctor receiving Medicare payment to discuss palliative treatment or hospice end-of-life care with a patient, or inform them of the availability of living wills (What noted expert Sarah Palin interprets as a 'death panel')?
If folks are big fans of the Hoche-Binding thesis, I'd really like to know, preferably well in advance.
There are many examples of decisions being made that a large percent of people would say 'this is to much' that are not done...
With this discussion, I remembered one of the news magazines who had a show on the costs that society had to pay because of the way we allow people to decide something without paying... they had two families showing the decisions...
The first one was a man who (IIRC) fell off a ladder and hit his head... they got him to the emergency center and was able to keep his body alive... but he was brain dead... the family had the decision to keep him on life support or take him off... he had private insurance, so it was not a taxpayer issue, but an insurance issue... from what I remember, the insurance would pay to keep him on machines for as long as the family wanted... they decided to take him off in a day or two... I think most of us would make the same decision....
The other was a welfare mom who had a brain dead baby... they spent millions of dollars to keep the infant 'alive'... this went on for many months.. the welfare mom coming to the hospital every day... it was not costing her a thing... but it was costing 'society' millions and millions of dollars...
Now, if she had a private insurance policy that allowed this to go on... fine by me... even though it would not be the decision I would make... but she did not... and I do not think that society has an OBLIGATION to keep a brain dead baby alive because the mother can not deal with it... all that money was wasted.. period... it could have been used to immunize many hundreds of thousands of people... and I bet if you could figure it out, there were other people who died because of this lady's decision... why
Because we will go to the extreme to 'save' this one life, but will not spend the needed funds to protect healthy people who might need a vaccination for something... they catch it and die...
Sure, sure... this is an extreme example.... but if we can not even agree on these extreme examples, how are we going to get the problem fixed....
And BTW, in other countries they do not worry about it as much as we do... my wife lost her first husband to cancer... he was in a country that had 'universal coverage'... he was told to go home, they could not help him (state 4)... they did not even give any pain medication... so he went home to die... I wonder why we seem to have this big issue when others do not...