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Death on the installment plan

Is so-called ‘death with dignity’ — now legal in 10 states and Washington, D.C. — destined to become the prerogative of the well-to-do?


I am fan of Dr. Christopher Schifeling’s “Auscultation” podcast. Schifeling, a specialist in geriatric and palliative care, recently discussed medical assistance in dying while commenting on an excerpt from “Death’s End,” the last book in a science fiction trilogy by Cixin Liu.

In the novel, a terminally ill character decides to use a new Chinese law that allows his doctor to end his life to avoid placing a financial burden on his children and their families, who would have to sell their homes to pay for his end-of-life care.

Schifeling comments that concerns about the cost of terminating one’s life are hardly limited to China. In the United States, he says, “Most insurances don’t cover MAID, and the cost of the medicines is several hundred dollars, which puts it out of reach for many patients who are already struggling with the financial burden of serious illness.”

Is this true? Is so-called “death with dignity” — now legal in 10 states and Washington, D.C. — destined to become the prerogative of the well-to-do? (In Massachusetts, a bill modeled on Oregon’s first-in-the-nation 1997 Death with Dignity Act has been filed in the Legislature.) The short answer appears to be yes. “Aid-in-dying medications cannot be paid for by Medicare, and almost all insurance policies do not cover them,” Dr. Lonny Shavelson, chair of American Clinicians Academy on Medical Aid in Dying, said in an e-mail.


California has the most patients — 677 in 2020 — requesting prescriptions for MAID. But, as the website of the University of California, San Francisco’s health service explains: “Unfortunately, these [life-ending] medications are not covered by most insurance plans or hospice care, and they can be costly. Typically, the medications cost $700 for the prescription, plus delivery fees.”


This isn’t entirely accurate. The national advocacy organization Compassion and Choices Action Network says that large California private insurers such as Kaiser Permanente and Anthem Blue Cross will cover some MAID costs, which can exceed $2,000, including doctors’ fees. On its website, Kaiser answers the question “Is [MAID] a covered benefit?” with the observation: “Every patient’s medical benefits and overage are different.”

Without apparent irony, UCSF Health reports that “If you have Medi-Cal, however, the cost may be covered.” Medi-Cal is California’s Medicaid plan for “children and adults with limited income and resources,” i.e., poor people.

The 1997 Assisted Suicide Funding Restriction Act prevents Medicare, which insures 97 percent of Americans over 65, from spending federal dollars on MAID. That means veterans who receive their health care from the Veterans Health Administration cannot get MAID. “That fries my potatoes,” said the Rev. Valerie Lovelace, executive director of Maine’s Death With Dignity, an education and support group. She receives health care through the Veterans Health Administration, “so that means my PCP (primary care physician) can’t help me if I need it.”

But states can allocate Medicaid funds to MAID. In California, those dollars were immaterial: Only 2.1 percent of the patients who asked for the life-ending prescriptions in 2020 were covered by Medi-Cal.

Each state that allows doctors to help patients die publishes program reports, often with revealing statistics. A national study in the Journal of the American Geriatrics Society revealed that just over 60 percent of patients who requested a life-ending prescription chose to use it. That makes sense; second thoughts abound. The study’s authors noted that “Most MAID requesters must pay for MAID prescriptions out-of-pocket, as Medicare and other federal health insurance programs do not cover aid in dying costs. These out-of-pocket costs have risen dramatically.”


More disturbingly, a 2018 Kaiser Permanente report concluded that one-third of California MAID patients died “before completing the law’s time-consuming, multi-step process, including many during the 15-day waiting period,” according to USA Today. In 2021, California amended its End of Life Option Act to streamline that process.

Who wants to end their life ingesting a chemical cocktail? Exactly no one, I’d say. But, heaven forfend, in extremis, it would be nice to have the option. And it would be nice to have it paid for by insurance programs like Medicare, which working Americans have been supporting their entire lives.

Alex Beam’s column appears regularly in the Globe. Follow him on Twitter @imalexbeamyrnot.