#death panels

[democracyunderground]

[gamer2002]

Where does Sarah Palin go for her apology?

A Canadian has a greater chance of dying by MAID than an American has of being shot dead.

Canadian healthcare kills trice as often as American guns

[dreaminginthedeepsouth]

The Bureaucracy of Denial

How privatized Medicare is quietly reshaping access to care—not through refusal, but through delay.

James B. Greenberg

Jul 31, 2025

Something underhanded is happening inside Medicare and Medicaid, and no one’s talking about it, but it’s about to change how millions get treated.

An oncologist I spoke with recently told me something that stopped me cold. Starting next year, she said, every cancer treatment she prescribes for patients on Medicare Advantage or Medicaid will require prior approval. Not just for experimental therapies or risky procedures—everything. Even the routine. The decisions are no longer hers to make. They’re deferred to remote systems, reviewed by people she’s never met, many of whom may not be physicians at all.

She didn’t use the term, but what she described sounded eerily close to what critics once called death panels. It’s probably too strong a phrase. Still, it captures something about the shift underway: the way life-preserving care is now filtered through layers of authorization, delay, and denial. None of it is accountable to the patient.

We’ve been told that privatizing Medicare would lead to innovation, flexibility, and smarter use of resources. It’s a story that’s been repeated long enough to sound like common sense. But for patients navigating serious illness, especially those living on fixed incomes, the promises vanish the moment treatment is needed. Beginning January 1, 2026, a new set of policies will require physicians treating cancer patients under Medicare Advantage and Medicaid managed care to submit for prior approval before delivering care that used to be routine. These changes aren’t theoretical—they’re already being implemented and modeled in anticipation.

What was once a matter of clinical judgment between doctor and patient is being rerouted through an administrative gauntlet. Treatment plans will be paused while paperwork moves through opaque systems. Approvals that used to be immediate will be delayed. Appeals may stretch out over days or weeks. This isn’t about rare procedures or experimental therapies. The requirements will extend to standard care. The review won’t be performed by someone with direct knowledge of the patient—or necessarily by a physician at all. The rationale won’t be medical. It will be financial.

Delay isn’t a side effect. It’s the strategy. Every treatment deferred, every procedure denied, becomes a line of surplus in a system where profit is made not by healing, but by avoiding the cost of it. The fewer approvals processed, the more money retained. These are not decisions shaped by care. They are decisions shaped by silence—by hesitation, by distance, by the absence of resistance.

This is how rationing works in a privatized state. Not through force. Through systems. Through thresholds that move. Through policies that sound reasonable until you need them to respond. And when they don’t, there’s no one to appeal to. The system isn’t broken. It’s sealed.

For those enrolled in Medicare Advantage—plans marketed as more efficient, more integrated, more modern—this is the tradeoff. Lower up-front costs come at the price of discretion. You may no longer be free to act on your doctor’s recommendation without additional steps. Those steps aren’t about safety. They’re about managing expenditures in a system that rewards denial.

This isn’t just a bureaucratic failure. It’s the cultural reengineering of care. What was once an ethic of shared protection has been repackaged as managed risk. The patient becomes a cost center. Illness becomes a data point. Survival is now negotiated—case by case, code by code.

The consequences are not evenly distributed. They follow the same lines they always have—income, geography, race, insurance class. What presents as efficiency is more often a gatekeeping device. Those already on the margins are the first to wait. The last to be approved. The easiest to disappear into the backlog.

This is power not in its spectacular form, but in its administrative mode—the kind that decides who waits and who moves forward, who receives care as a right and who receives it as a favor. It governs not by issuing decrees, but by deciding which lives can afford to be delayed. This is how life is managed, and death is administered—not by violence, but by withdrawal.

From a political ecology perspective, this is a system designed to manage vulnerability, not by addressing it, but by distributing it. It governs not through direct care, but through selective abandonment, allocating life chances through a logic of scarcity. What gets called efficiency is often just rationing by another name.

From an anthropological perspective, these systems don’t impose power from above. They embed it in routine. They normalize it through repetition. Waiting, in this context, becomes a tool of governance—an ordinary mechanism for deciding who can afford to endure delay and who cannot. It is a slow, administrative form of violence, harder to detect than force, but no less consequential.

Some argue these policies are necessary to contain costs in an aging society. But cost containment isn’t neutral. It always lands hardest on those with the least time and the fewest resources. While administrators speak of oversight and sustainability, patients are left to wait. Sometimes too long.

This wasn’t the promise of Medicare. It was supposed to be a bulwark—a collective safeguard against the precarity of aging and illness. Medicare Advantage has reframed that promise through market logic. What began as a public good is now filtered through private incentives. What was once a guarantee is now a margin call.

These aren’t simply budget decisions. They’re life decisions, managed through process. A quiet calculus unfolds in the background—who gets to live well, and who can be left to linger in the queue.

This is what happens when governance is reorganized around cost rather than care—when what we call reform becomes a mechanism of controlled exposure. The system doesn’t collapse. It tightens. It hardens. It withdraws.

This is not a malfunction. It’s the system doing exactly what it was built to do.

Suggested Readings

Foucault, Michel. Society Must Be Defended: Lectures at the Collège de France, 1975–76. Edited by Mauro Bertani and Alessandro Fontana. Translated by David Macey. New York: Picador, 2003.

Himmelstein, David, and Steffie Woolhandler. “The Medicare Advantage Scam.” The Nation, October 3, 2022. https://www.thenation.com/article/society/medicare-advantage-healthcare/.

Krieger, Nancy. Ecosocial Theory, Embodied Truths, and the People’s Health. New York: Oxford University Press, 2021.

Mbembe, Achille. Necropolitics. Translated by Steven Corcoran. Durham, NC: Duke University Press, 2019.

Raudenbush, Danielle T. Health Care Off the Books: Poverty, Illness, and Strategies for Survival in Urban America. Oakland: University of California Press, 2021.

Vélez-Ibáñez, Carlos G. The Rise of Necro/Narco Citizenship: Belonging and Dying in the National Borderlands. Tucson: University of Arizona Press, 2025.

[mostlysignssomeportents]

America's largest hospital chain has an algorithmic death panel

It’s not that conservatives aren’t sometimes right — it’s that even when they’re right, they’re highly selective about it. Take the hoary chestnut that “incentives matter,” trotted out to deny humane benefits to poor people on the grounds that “free money” makes people “workshy.”

There’s a whole body of conservative economic orthodoxy, Public Choice Theory, that concerns itself with the motives of callow, easily corrupted regulators, legislators and civil servants, and how they might be tempted to distort markets.

But the same people who obsess over our fallible public institutions are convinced that private institutions will never yield to temptation, because the fear of competition keeps temptation at bay. It’s this belief that leads the right to embrace monopolies as “efficient”: “A company’s dominance is evidence of its quality. Customers flock to it, and competitors fail to lure them away, therefore monopolies are the public’s best friend.”

But this only makes sense if you don’t understand how monopolies can prevent competitors. Think of Uber, lighting $31b of its investors’ cash on fire, losing 41 cents on every dollar it brought in, in a bid to drive out competitors and make public transit seem like a bad investment.

Or think of Big Tech, locking up whole swathes of your life inside their silos, so that changing mobile OSes means abandoning your iMessage contacts; or changing social media platforms means abandoning your friends, or blocking Google surveillance means losing your email address, or breaking up with Amazon means losing all your ebooks and audiobooks:

https://www.eff.org/deeplinks/2021/08/facebooks-secret-war-switching-costs

Businesspeople understand the risks of competition, which is why they seek to extinguish it. The harder it is for your customers to leave — because of a lack of competitors or because of lock-in — the worse you can treat them without risking their departure. This is the core of enshittification: a company that is neither disciplined by competition nor regulation can abuse its customers and suppliers over long timescales without losing either:

https://pluralistic.net/2023/01/21/potemkin-ai/#hey-guys

It’s not that public institutions can’t betray they public interest. It’s just that public institutions can be made democratically accountable, rather than financially accountable. When a company betrays you, you can only punish it by “voting with your wallet.” In that system, the people with the fattest wallets get the most votes.

When public institutions fail you, you can vote with your ballot. Admittedly, that doesn’t always work, but one of the major predictors of whether it will work is how big and concentrated the private sector is. Regulatory capture isn’t automatic: it’s what you get when companies are bigger than governments.

If you want small governments, in other words, you need small companies. Even if you think the only role for the state is in enforcing contracts, the state needs to be more powerful than the companies issuing those contracts. The bigger the companies are, the bigger the government has to be:

https://doctorow.medium.com/regulatory-capture-59b2013e2526

Companies can suborn the government to help them abuse the public, but whether public institutions can resist them is more a matter of how powerful those companies are than how fallible a public servant is. Our plutocratic, monopolized, unequal society is the worst of both worlds. Because companies are so big, they abuse us with impunity — and they are able to suborn the state to help them do it:

https://www.cambridge.org/core/journals/perspectives-on-politics/article/testing-theories-of-american-politics-elites-interest-groups-and-average-citizens/62327F513959D0A304D4893B382B992B

This is the dimension that’s so often missing from the discussion of why Americans pay more for healthcare to get worse outcomes from health-care workers who labor under worse conditions than their cousins abroad. Yes, the government can abet this, as when it lets privatizers into the Medicare system to loot it and maim its patients:

https://prospect.org/health/2023-08-01-patient-zero-tom-scully/

But the answer to this isn’t more privatization. Remember Sarah Palin’s scare-stories about how government health care would have “death panels” where unaccountable officials decided whether your life was worth saving?

https://pubmed.ncbi.nlm.nih.gov/26195604/

The reason “death panels” resounded so thoroughly — and stuck around through the years — is that we all understand, at some deep level, that health care will always be rationed. When you show up at the Emergency Room, they have to triage you. Even if you’re in unbearable agony, you might have to wait, and wait, and wait, because other people (even people who arrive after you do) have it worse.

In America, health care is mostly rationed based on your ability to pay. Emergency room triage is one of the only truly meritocratic institutions in the American health system, where your treatment is based on urgency, not cash. Of course, you can buy your way out of that too, with concierge doctors. And the ER system itself has been infested with Private Equity parasites:

https://pluralistic.net/2022/11/17/the-doctor-will-fleece-you-now/#pe-in-full-effect

Wealth-based health-care rationing is bad enough, but when it’s combined with the public purse, a bad system becomes a nightmare. Take hospice care: private equity funds have rolled up huge numbers of hospices across the USA and turned them into rigged — and lethal — games:

https://pluralistic.net/2023/04/26/death-panels/#what-the-heck-is-going-on-with-CMS

Medicare will pay a hospice $203-$1,462 to care for a dying person, amounting to $22.4b/year in public funds transfered to the private sector. Incentives matter: the less a hospice does for their patients, the more profits they reap. And the private hospice system is administered with the lightest of touches: at the $203/day level, a private hospice has no mandatory duties to their patients.

You can set up a California hospice for the price of a $3,000 filing fee (which is mostly optional, since it’s never checked). You will have a facility inspection, but don’t worry, there’s no followup to make sure you remediate any failing elements. And no one at the Centers for Medicare & Medicaid Services tracks complaints.

So PE-owned hospices pressure largely healthy people to go into “hospice care” — from home. Then they do nothing for them, including continuing whatever medical care they were depending on. After the patient generates $32,000 in billings for the PE company, they hit the cap and are “live discharged” and must go through a bureaucratic nightmare to re-establish their Medicare eligibility, because once you go into hospice, Medicare assumes you are dying and halts your care.

PE-owned hospices bribe doctors to refer patients to them. Sometimes, these sham hospices deliberately induce overdoses in their patients in a bid to make it look like they’re actually in the business of caring for the dying. Incentives matter:

https://www.newyorker.com/magazine/2022/12/05/how-hospice-became-a-for-profit-hustle

Now, hospice care — and its relative, palliative care — is a crucial part of any humane medical system. In his essential book, Being Mortal, Atul Gawande describes how end-of-life care that centers a dying person’s priorities can make death a dignified and even satisfying process for the patient and their loved ones:

https://atulgawande.com/book/being-mortal/

But that dignity comes from a patient-centered approach, not a profit-centered one. Doctors are required to put their patients’ interests first, and while they sometimes fail at this (everyone is fallible), the professionalization of medicine, through which doctors were held to ethical standards ahead of monetary considerations, proved remarkable durable.

Partly that was because doctors generally worked for themselves — or for other doctors. In most states, it is illegal for medical practices to be owned by non-MDs, and historically, only a small fraction of doctors worked for hospitals, subject to administration by businesspeople rather than medical professionals.

But that was radically altered by the entry of private equity into the medical system, with the attending waves of consolidation that saw local hospitals merged into massive national chains, and private practices scooped up and turned into profit-maximizers, not health-maximizers:

https://prospect.org/health/2023-08-02-qa-corporate-medicine-destroys-doctors/

Today, doctors are being proletarianized, joining the ranks of nurses, physicians’ assistants and other health workers. In 2012, 60% of practices were doctor-owned and only 5.6% of docs worked for hospitals. Today, that’s up by 1,000%, with 52.1% of docs working for hospitals, mostly giant corporate chains:

https://prospect.org/health/2023-08-04-when-mds-go-union/

The paperclip-maximizing, grandparent-devouring transhuman colony organism that calls itself a Private Equity fund is endlessly inventive in finding ways to increase its profits by harming the rest of us. It’s not just hospices — it’s also palliative care.

Writing for NBC News, Gretchen Morgenson describes how HCA Healthcare — the nation’s largest hospital chain — outsourced its death panels to IBM Watson, whose algorithmic determinations override MDs’ judgment to send patients to palliative care, withdrawing their care and leaving them to die:

https://www.nbcnews.com/health/health-care/doctors-say-hca-hospitals-push-patients-hospice-care-rcna81599

Incentives matter. When HCA hospitals send patients to die somewhere else to die, it jukes their stats, reducing the average length of stay for patients, a key metric used by HCA that has the twin benefits of making the hospital seem like a place where people get well quickly, while freeing up beds for more profitable patients.

Goodhart’s Law holds that “When a measure becomes a target, it ceases to be a good measure.” Give an MBA within HCA a metric (“get patients out of bed quicker”) and they will find a way to hit that metric (“send patients off to die somewhere else, even if their doctors think they could recover”):

https://en.wikipedia.org/wiki/Goodhart%27s_law

Incentives matter! Any corporate measure immediately becomes a target. Tell Warners to decrease costs, and they will turn around and declare the writers’ strike to be a $100m “cost savings,” despite the fact that this “savings” comes from ceasing production on the shows that will bring in all of next year’s revenue:

https://deadline.com/2023/08/warner-bros-discovery-david-zaslav-gunnar-wiedenfels-strikes-1235453950/

Incentivize a company to eat its seed-corn and it will chow down.

Only one of HCA’s doctors was willing to go on record about its death panels: Ghasan Tabel of Riverside Community Hospital (motto: “Above all else, we are committed to the care and improvement of human life”). Tabel sued Riverside after the hospital retaliated against him when he refused to follow the algorithm’s orders to send his patients for palliative care.

Tabel is the only doc on record willing to discuss this, but 26 other doctors talked to Morgenson on background about the practice, asking for anonymity out of fear of retaliation from the nation’s largest hospital chain, a “Wall Street darling” with $5.6b in earnings in 2022.

HCA already has a reputation as a slaughterhouse that puts profits before patients, with “severe understaffing”:

https://www.nbcnews.com/health/health-news/workers-us-hospital-giant-hca-say-puts-profits-patient-care-rcna64122

and rotting, undermaintained facililties:

https://www.nbcnews.com/health/health-care/roaches-operating-room-hca-hospital-florida-rcna69563

But while cutting staff and leaving hospitals to crumble are inarguable malpractice, the palliative care scam is harder to pin down. By using “AI” to decide when patients are beyond help, HCA can employ empiricism-washing, declaring the matter to be the factual — and unquestionable — conclusion of a mathematical process, not mere profit-seeking:

https://pluralistic.net/2023/07/26/dictators-dilemma/ggarbage-in-garbage-out-garbage-back-in

But this empirical facewash evaporates when confronted with whistleblower accounts of hospital administrators who have no medical credentials berating doctors for a “missed hospice opportunity” when a physician opts to keep a patient under their care despite the algorithm’s determination.

This is the true “AI Safety” risk. It’s not that a chatbot will become sentient and take over the world — it’s that the original artificial lifeform, the limited liability company, will use “AI” to accelerate its murderous shell-game until we can’t spot the trick:

https://pluralistic.net/2023/06/10/in-the-dumps-2/

The risk is real. A 2020 study in the Journal of Healthcare Management concluded that the cash incentives for shipping patients to palliatve care “may induce deceiving changes in mortality reporting in several high-volume hospital diagnoses”:

https://journals.lww.com/jhmonline/Fulltext/2020/04000/The_Association_of_Increasing_Hospice_Use_With.7.aspx

Incentives matter. In a private market, it’s always more profitable to deny care than to provide it, and any metric we bolt onto that system to prevent cheating will immediately become a target. For-profit healthcare is an oxymoron, a prelude to death panels that will kill you for a nickel.

Morgenson is an incisive commentator on for-profit looting. Her recent book These Are the Plunderers: How Private Equity Runs — and Wrecks — America (co-written with Joshua Rosner) is a must-read:

https://pluralistic.net/2023/06/02/plunderers/#farben

I’m kickstarting the audiobook for “The Internet Con: How To Seize the Means of Computation,” a Big Tech disassembly manual to disenshittify the web and bring back the old, good internet. It’s a DRM-free book, which means Audible won’t carry it, so this crowdfunder is essential. Back now to get the audio, Verso hardcover and ebook:

http://seizethemeansofcomputation.org

If you'd like an essay-formatted version of this thread to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2023/08/05/any-metric-becomes-a-target/#hca

[Image ID: An industrial meat-grinder. A sick man, propped up with pillows, is being carried up its conveyor towards its hopper. Ground meat comes out of the other end. It bears the logo of HCA healthcare. A pool of blood spreads out below it.]

Image: Seydelmann (modified) https://commons.wikimedia.org/wiki/File:GW300_1.jpg

CC BY 3.0 https://creativecommons.org/licenses/by-sa/3.0/deed.en

[fenrislorsrai]

“The Human Psyche Was Not Built for This”

How Republicans in Montana hijacked public health and brought a hospital to the brink

During the Delta surge

The doctor wanted to transfer the patient to the ICU. But the unit was full.

Harkins quickly convened a video meeting of the Scarce Resources Committee. As doctors began to weigh in, the committee realized the crisis ran deeper. There were an additional four critically ill patients in other parts of the hospital who also should be transferred to the ICU.

The math was brutal: Five patients and zero beds.

The committee began the process spelled out by an allocation algorithm in Montana’s crisis standards of care guidelines. Factors like age and preexisting conditions were fair to consider, but vaccination status was not.

Harkins quarterbacked as the committee deliberated: How old? Other serious health conditions? How long in the hospital? What is the latest status?

One critically ill non-COVID-19 patient had a serious heart condition. “I feel the heart patient will not survive. How do you feel?” one doctor asked. Everyone agreed that the heart patient would not get an ICU bed and could be treated in another unit.

After about 20 minutes, the committee decided the woman in the emergency room had the most urgent need and should go to the ICU. They could make a bed available by moving a dying patient too ill to survive to another unit. But they had promised the patient’s family they would wait until everyone arrived to say their goodbyes before removing life support. One family member was not there yet. The hospital was running out of time.

Suddenly, a piercing code blue alarm sounded in the emergency room. “Wait a minute, guys,” an attending physician told the committee. “The patient is coding.”

Then, “the patient has died.”

The committee took a moment to absorb the news. Then it began deliberating again. The call lasted an hour. In the end, the terminal ICU patient’s family members were able to gather to say their goodbyes. When that bed was free, another patient discussed during the call was moved into the ICU but died a few days later.

Of the five patients who had been vying for a bed, four ultimately died.

“Under normal circumstances we would have moved all five into the ICU,” Harkins later told ProPublica. “But we just couldn’t.”

Being forced to make such profound decisions changed Harkins and others on the call.

Kimberly Pepper, the hospital chaplain who served on the committee, described seeking solace in the “thin places,” a Celtic belief that there are spots where the distance between heaven and Earth is at its slimmest. Hers was in the Montana mountains. She noticed her hikes had become longer and longer.

Harkins said hospital staff had found their “cry spots” to deal with the anguish. Hers was in an empty office. “The human psyche,” she said, ”was not built for this.”

The virus was forcing cracks in the hospital’s usual care.

Nurses at St. Peter’s had to bathe patients and clean rooms to make up for the large number of nursing assistants who had quit. Kari Koehler, who was serving as the acting chief of nursing during the surge, told ProPublica that the exodus had left the hospital with two assistants per shift instead of the desired 10.

[mitchumsstinkums]

Brainsleeve – The EARL

We're playing tonight, and we'll be on first! C'mon down!

[republicanidiots]

These are the same people who refuse to vote for MFA, but will eventually show up in hospitals for long term care at the taxpayers expense, and claim Dems will use “death panels” to deny them coverage.

[tomorrowusa]

Americans are dying because no hospital will take them

The country’s pandemic failures have sometimes led to deadly health care rationing.

Remember when idiotic Republicans like Sarah Palin were complaining that Obamacare meant that there would be “death panels” in the US?

Years into Obamacare, Palin and her crew must feel disappointed. But the right-wing resistance to mask mandates and vaccination mandates have led to a type of death lottery in parts of the country resistant to common sense pandemic precautions.

The states with the worst outbreaks in confirmed cases per capita right now — Tennessee, Kentucky, Alaska, Wyoming, and West Virginia, according to the New York Times’s tracker — have either set new hospitalization records in the last several weeks or are near their previous highs from the winter wave. All of them have vaccination rates below the national average. Throughout the South, hospitals are reporting they have more patients in need of ICU care than ICU beds available, as the Times reported on Tuesday.

America, the richest country in the world, is not supposed to be a place where patients are left at the door to die. Yet that is exactly what’s happening now — 18 months into the pandemic.

It’s not just COVID patients who are suffering from the overcrowding of hospitals. Maybe you remember the case of Daniel Wilkinson.

In Bellville, Texas, 46-year-old military veteran Daniel Wilkinson was rushed to the emergency room. He was diagnosed with gallstone pancreatitis, which is treatable but which his local hospital was not equipped to treat, according to KPRC. The doctor called all over the region — to hospitals in Texas, Oklahoma, and Arkansas, among others — but could not find a hospital that would take him.

Mr. Wilkinson finally found a hospital that would take him – but it was too late. He died of pancreatitis which could have been successfully treated on time if hospitals in Texas were not overflowing with anti-vaxxing COVID patients

Daniel Wilkinson is certainly not alone in being unable to to obtain prompt medical care.

On Monday, the Washington Post reported that a 73-year-old Alabama man died of a cardiac emergency after being turned away from more than 40 hospitals. The closest hospital that would take him was 200 miles away in Mississippi. 

In addition to the overcrowding problems caused by anti-vaxxing morons, the US has no system to serve as a clearinghouse for available hospital space.

Other countries appear to have avoided unnecessary deaths because they have a real system to coordinate care. In Britain, hospitals are currently able to handle more emergency care than the average volume prior to the pandemic, according to recent research by the Nuffield Trust, though elective surgeries are still sometimes being canceled.

“Hospitals have been incredibly stretched but have always been able to offer urgent and emergency care,” Nick Scriven, a UK doctor and past president of the Society of Acute Medicine, told me. “People were not turned away if they needed a hospital bed.”

The pandemic laid bare how disastrously disorganized the US health system is. But that’s always been true. It just usually reveals itself in more subtle ways.

We have no such system in the US because the loony right would start braying about socialism or something like that.

Too much medical and pharmaceutical care in the US is still in the hands of entities whose primary goal is to make big profits – not to cure people. We’ve seen graphically how the plague of opioid deaths in the US has been caused by greedy drug companies acting as pushers.

The people who claim that the US has the best healthcare system in the world try to get you to ignore the fact that the US still has the highest number of deaths from COVID-19. As of Thursday morning the US had 666,618 COVID deaths. We’re still ahead of Bolsonaro’s Brazil with its 588,597 pandemic fatalities.      

For now, all we can do is encourage vaccination mandates. But next year there will be an opportunity to vote Republican COVID-19 Death Panels out of office.