health care

Initiative 1029 increasing requirements to be a long term care provider

This measure would require long-term care workers to be certified as home care aides based on an examination, with exceptions; increase training and criminal background check requirements; and establish disciplinary standards and procedures.

Another initiative for which I have experience. However, I’m not nearly so sure about my choice in this case.

On behalf of my mom, I hired and had experience with seven different caregivers during the last four months of her life. In addition, I had a fair amount of contact with hospice workers who would be covered under the act. The initiative will also cover nursing home and care facility workers, and I didn’t have that experience with mom.

No one wants to put their loved ones in a nursing home or care facility only to have the facility cut corners, make ends meet, or increase profits by hiring unqualified help that’s cheaper than needed to do a job properly. But people also don’t want to pay a lot of money for this care.

The same problem exists for the situation mom was in. We wanted qualified people, but my mom also didn’t want to spend a lot of money. At the current going rates, she could actually afford a year+ of full time care, but she’s frugal. Other folks may not have the nest egg mom had, and so cost is a huge issue.

The problem is fairly simple economics. If you limit supply (by imposing a minimum level of quality), prices will rise.

It doesn’t take a lot of training to be able to do the job needed to care for my mother. Not minimally at least. By imposing legal minimums I suspect more folks will just go outside legal providers and use unlicensed providers. I couldn’t find a penalty in the law that would have applied to my family. They all seem to apply to businesses. Three of our seven caregivers were people we hired and put on our own payroll and paid taxes for and everything. Three were self-employed, and I believe they could be penalized, though I’m not sure how they could be caught if they avoided the requirements. But I digress a little. If I can’t afford to hire people who have the minimum legal qualifications through a licensed agency or similar, I would absolutely have to hire unlicensed workers directly. For people who need caregivers, there is little other option. We can’t just go without. Someone has to bathe mom, or brush her teeth, or wipe her bum, or move her so she doesn’t get a bedsore. Under the initiative, legally that could only be a licensed person, or a very close family member. Few families will have enough close family members to provide 24 hour care. They can pony up the extra money for licensed, but if you ain’t got it (and it’s expensive even for unlicensed folks currently) or you got a little but have to make it last, a lot of people will just hire unlicensed folks.

How bad was the caregiving we got? Not awful, but I hated the experience. I would have preferred to pay more and get better care (mom was “frugal” though). Physically, we had few issues. One caregiver was ditzy and mixed mom’s food wrong. And a couple were pretty locked in to their belief that pain medication was the right thing for all terminal patients. Nothing big. The real problem we experienced was that the caregivers all had personal issues that affected their readiness to work. Nothing that would come up in the required background check. Sick days that were called in 1/2 hour after their shift started. Mental health days because the work is stressful. People taking other jobs without telling us and not working for us, last minute. People overestimating how much they could handle. I think with the increased pay that would occur with the increased requirements, some of these issues would go away, because better adjusted people would be attracted by the higher pay.

So, is the initiative worth it? I’m inclined to say no. We could have paid more anyway and gotten higher quality. There’s nothing preventing people from hiring people right now who have 75 hours of training. Sucks for the people who can’t afford it and don’t get assistance (or enough assistance). They will be stuck with lower quality care. But I think that would be the case regardless.

I do like some aspects. I like the idea of a minimal license requiring a background check that could be revoked on misconduct.

I think most of the goals could be accomplished without pricing everyone out. Add an endorsement(s) on that license for additional training. Generous subsidies for people who hire trained folks. Rather than forbid people from working without training, make it worth their while to get it. It would cost a lot, but it would have a lot better chance of succeeding.

A couple of big negatives with the proposed initiative aside from economics. Legally, I wouldn’t be able to care for a family member unless they were a biological, step, or adopted parent or child. I could not care for a brother. My step-father might not legally qualify, since I was never adopted. Perhaps since he cared for me before I turned 18 he qualifies, but if mom re-married after I was an adult, would he be my legal step-father? What about cousins? I couldn’t care for my grandparents legally without yearly training and licensing. The definition of family is pretty narrow.

So I think I will vote NO on this initiative. I think it will only have limited success as currently structured. But I don’t have a crystal ball and I don’t think it will hurt much either if passed. Some folks will just go the unlicensed route. Basically, the government would have to fork out some dough to accomplish the goals, and this doesn’t do it that way.

Initiative 1000 allowing terminally ill competent adults to obtain lethal prescriptions

This measure would permit terminally ill, competent, adult Washington residents, who are medically predicted to have six months or less to live, to request and self-administer lethal medication prescribed by a physician.

I just spent 19 months watching my mom slowly die of A.L.S.

I visited her daily. I took care of her. I was present for every doctor visit for the final year, and many before that. I am pretty damn familiar with Whatcom County hospice now. Mom’s decline was not pretty.

My mom would never make use of this law were it on the books. I’m pretty certain she would have voted no had she lived another few weeks (her absentee ballot arrived the day she died). Mom was a devout Catholic. She believed in the sanctity of life. I understand believing that it isn’t right to take one’s life. I think that’s perfectly legitimate, even for religious reasons.

But having seen what mom went through means I do not want to go through it, at least not the last couple of months. So I am voting YES. I don’t have mom’s religious convictions.

Unfortunately, if the initiative passes and I get the same form of A.L.S. mom had and progress similarly, it won’t help me. Mom did not have the use of her hands or mouth the last six months she was alive. I wouldn’t be able to self-administer a lethal prescription.

It’s still a good first step.

I write this even knowing that I would be pretty happy even in a paralyzed body. Give me a computer with an internet connection that I can operate and I would get by as far as intellectual stimulation. Once I was certain my breathing had taken it’s final turn for the worse though, I’d want to avoid the final weeks of pain and discomfort.

One of the arguments I’ve read against the initiative is that palliative care has advanced to the place where pain is no longer an issue. This is not true. Pain management comes with a cost that some people may find even more unpalatable: being mentally slowed. Even with the best morphine drip management around (and according to Whatcom County Hospice, pain management is accomplished essentially through morphine), a person’s intellectual and emotional well being is affected. Mom did not want to be drugged. I don’t think I would be so averse to it, but there are still limits to what I would accept. After that, my choice is still pain or early death.

One other argument is that it opens the door to pressure from family members and others to commit suicide. A terminal patient does not want to be a burden. According to this argument, while it might be acceptable (for the sake of argument) to commit suicide to avoid pain, it isn’t okay to avoid being a burden. The thing is, it’s not so black and white. On one end you could have family members actively trying to convince someone to off themselves so they’d get more money, and a vulnerable person might agree where they wouldn’t absent the pressure. And on the other end I think it’s perfectly legitimate for a person to factor being a burden into their decision, provided that the patient makes the decision without duress. There’s a big gray area where distinguishing discussions between family members from duress by people who have something to gain (time, money, other lovers, etc.) could be really tough. The only sure solution is to not enact the initiative. Which is, of course, the argument. However, that’s throwing out the good that giving the choice to people will accomplish. I think that outweighs the mostly theoretical bad. I’m pretty certain at some point someone will kill themselves under duress. We don’t decide to avoid war because one person dies. We weigh the gains against the losses. One life is not so precious as to be invaluable. I’m a pragmatist. Life is very valuable, but it’s not infinite. Plus, this doesn’t change the situation from the way it is right now. A person could kill themselves right now. They could do it under duress from a family member, under current law. The initiative doesn’t change that.

There’s also slippery slope arguments. If we do this, we are on the road to wanton euthanasia. I doubt it, but if it comes to that, we can reverse the law. All it takes is political will.

The law doesn’t give me as a terminally ill person additional options. I can already kill myself or choose extended palliative care. What it does is make it easier for me to make that painless, to assure that my family and doctors are protected, and to preserve my heirs insurance money.

I wish it allowed for a person to actually assist, but that can be done later if we have the will.

An emphatic, if regretful for the necessity, YES.

Clinton vs. Obama: Health Care

Both Clinton and Obama are proposing making changes in how we pay for health care. I’d love to see single-payer, but we aren’t going to get that.

The best piece of information I know of regarding their two plans is a blog entry by Paul Krugman. Both candidates propose subsidizing health insurance. Clinton would force people to sign up for insurance, though how people would be forced is not clear. Obama would not. While it is bad for freedom to force people to get health insurance, economically speaking there’s a free rider problem if you don’t. Only sick people would get insurance. Insurance costs would be way up there. Basically, mandated insurance is a tax. Without the tax, it falls apart.

One other big health care issue that I care about is stem cell research. My mother has fairly advanced ALS. She will likely die before stem cells cures could do anything for her. She also is probably against opening up funding for stem cells, as many stem cell lines are the results of abortions. I, however, am strongly in support of opening up stem cell research. I’d hate for anyone to go through my mother’s illness unnecessarily.

Both Clinton and Obama are strongly for opening up stem cell research beyond the limits imposed by the Bush administration.

One thing that has driven up health care costs is the high prices of drugs, imposed through patent monopolies. Dean Baker has proposed that we fund drug innovation differently, rather than through monopolies. I don’t know if that would work well or not, but no candidate will get on board that right now. However, we could import drugs from Canada. We could also allow medicare to negotiate drug prices, which they are currently forbidden from doing.

Both Obama and Clinton have supported these ideas.

Advantage: Clinton.