Before the health care bill ever reached a vote, opponents screamed about so-called death panels. The hysteria spread, helped by people on the right who knew better, that health care would be cut off and elderly people left to die.

Although there never was a plan to unplug Grandma against her will, the provision that spawned the hysteria was dropped from the bill.

The provision, to allow Medicare to pay for a doctor's appointment where the patient just wants to talk about his or her wishes for end-of-life care, will become policy on Jan. 1.

No hysteria, just a provision that alllows patients to talk about something we all will face: the end of our lives and how we want to be cared for.

The advice will help people to think about whether they want to be kept alive through artificial means -- some people can live for years on a respirator, although they may have no quality of life.

Should you sign a do-not-rescusitate order if there's no hope of a good quality of life? Who do you want making the decisions if you are unconscious or unresponsive?

In one study, (http://www.medpagetoday.com/Geriatrics/GeneralGeriatrics/19329), patients who documented their wishes for only limited care or comfort care received it in 83.2% and 97.1% of cases, respectively, according to Maria J. Silveira, MD, MPH, of the VA Center for Clinical Management Research and University of Michigan, both in Ann Arbor, and colleagues who interviewed patients' healthcare proxies.

The few who requested all possible care didn't always get it (five of 10) but were much more likely to get aggressive care than those who didn't request all care possible, Silveira's group reported.

In another study,  (http://www.medpagetoday.com/Geriatrics/GeneralGeriatrics/19196)

hospitalized patients older than 80 who were formally assisted with documenting their end-of-life treatment wishes and with designating a surrogate were almost three times more likely to have those wishes followed (86% versus 30% in usual care, P<0.001).

Billions of dollars are spent every year caring for people who have no hope of recovery but who are kept alive with technology because no one knew what they wanted and no one dares to end it by removing the patient from all the high-tech and high-cost equipment. You can learn more about that by watching "Facing Death":

http://www.pbs.org/wgbh/pages/frontline/facing-death/?utm_campaign=homepage&utm_medium=bigimage&utm_source=bigimage

Every one of us needs to make these decisions, and paying a doctor for taking the time to help someone figure it all out is the right thing to do. As of Friday, Medicare will do just that, minus the "death panel" hysteria.

If you want to know more about end-of-life issues, visit www.fivewishes.org. The site will guide you through the process of making the decisions and help you make a living will and appoint a health care proxy whom you trust to follow your wishes.

Everyone should have a living will; it is as important as your regular will, and now Medicare will help people do that.

Rob and I met Michael this afternoon as we were walking downtown. The temperature was in the low 40s, which fely a little balmy after all the cold weather lately.

As we were walking on Broadway, a young man sitting up against a building tried to get our attention.  We walked a few feet and I felt called to go back and see what he needed. He didn't sound like an average panhandler; something about him was different. He sounded scared and desperate.

He looked pretty young and his eyes were red-rimmed with tears.

I told Rob we needed to go back, and when I asked him what he needed, he started crying, tears dropping in big splatters onto his jacket..

"I don't know," he sobbed. "I'm cold and I don't have anyplace to go."

I asked whether he had been to the shelters, and he said he had been rejected by all the shelters because he had no ID.

Michael was born Nov. 17, 1992 and given up for adoption by his mother. He grew up in foster care in Nashville, Tenn., and was released to the street on his 18th birthday.

When kids age out of foster care in Nashville, they're given a bus ticket to go anywhere they want. Michael had heard people were kind in Asheville, but in his time here, he has seen little evidence of that.

Michael doesn't really look like a kid -- he's about 6'4" and lanky. And people had been walking by him all afternoon.

I asked him whether he had graduated high school and he told me he has a special ed diploma.

In other words, he likely is developmentally disabled. In spite of that, he was released onto the street, left to fend for himself without even a copy of his birth certificate.

"I don't have a Social Security card," he said. "That would be an ID, right?"

As we walked with him, he pushed his hands deeper into his pockets.

"My fingers get numb sometimes," he said.

And what about Buncombe County Department of Social Services, I asked.

"They're helping me get a copy of my birth certificate," he said. "It could take a couple weeks."

Meanwhile, there are no provisions anywhere to give this kid a warm place to sleep. Once you're 18, you're on your own, and a lot of places don't make any attempt to teach kids the skills they'll need to live on their own.

For a kid with the disadvantage of a developmental disability, it should be a crime to dump him on the street, but it isn't. If he freezes to death over the holiday weekend, who will even notice?

He said he met someone the other day who offered to let him stay at his place for a bit, but Michael had to come up with $50. He had some; we gave him the rest. I bought him a pair of knit gloves.

"My fingers are getting warm," he said, smiling, a few minutes after he slipped them on. 

We asked when he had eaten last and he told us he had a meal yesterday afternoon, about 4 o'clock. We offered to get him something at Subway, but he said he's not welcome ther because he was panhandling.

Actually, he had tried to take the tips jar and the manager called the police. Michael was arrested for $4.

He was right. They wouldn't let him in; he waited outside while Rob got him a 12" steak and cheese sub, chips and a Coke.

We left him on his way to the place he was supposed to stay tonight. I hope it was a genuine offer and not a ruse to get $50 out of the kid.

He's supposed to call me on Monday, after I make a few calls to see if I can get him some help. With several years' experience writing about social justice issues for the newspaper here, I hope I know someone who will find a way to get him a warm place to sleep.

I hope he feels like somebody cares about what happens to him now. That can make Christmsas a little brighter in a gloomy life.

Asheville holds its annual candlelight vigil tonight, the longest night of the year, to honor the memories of the 18 people who died on the street this year.

That's 18 that we know of.

For the most part, these human beings died of neglect; from a lack of health care for chronic illnesses, especially psychiatric illnesses. The state's mental health system has fallen apart because of the so-called reform that started eight years ago, when the system was privatized.

Like other aspects of health care, a private model just doesn't work to offer care to people who need it unless they have money.

More than half of people who have nowhere to live have either a psychiatric illness, an addiction or both. Of those who have addiction, more than half didn't abuse drugs or alcohol until AFTER they were on the street. If you've ever lived without hope, you might understand the pain involved, and the reason people turn to substances that can dull that pain. Our jails are filled with people who need mental health care or treatment for addiction. That's about the most expensive and least appropriate way to treat these chronic illnesses.

People can go to the Emergency Room, but no one gets comprehensive care there. There is no follow-up. People are stabilized and released unless they need to be admitted to be stabilized. The day before we learned Mike was dying, a man in Asheville died because he was treated for pneumonia and released. There was nothing more the doctors could do for him. He refused to leave, insisting he was too sick, and so he was arrested. He died later that night in his jail cell. At least he was somewhere warm.

We who have a warm, safe place to be at night don't understand what a blessing that is. Imagine never being able to get out of the cold, to be chased out of restaurants on rainy days, even if you have the money for a sandwich and a cup of coffee. I know it happens because I've seen it. The giveaway is the backpack. That's where people stow all the things they'll need during the day -- sometimes all they own.

Perhaps what bothers people about those who are homeless is that when we see them, we see our own vulnerability in these troubled times. Even when the economy is good, most Americans are little more than six months away from homelessness.

So we pretend not to see them. We petition governments to make it illegal to be without a home so we can drive "those people" out of our sight. Police and others break up their camps in the woods, shoo them out of public spaces and villify them. We say they've made wrong choices so they deserve what they get. We call them "bums" and accuse them of being lazy.

I don't know any bums out on the street. I know people who are sick and can't get care. I know people who can't find a job that will pay them enough to get a small apartment. I know people who turn to drugs and alcohol, to prostitution, to panhandling to try and keep themselves alive.

I can't find everyone a home and decent medical care, but I can offer a bit of dignity by smiling and saying hello when I see someone on the street. I can make eye contact and allow people to feel as though they're not invisible. I can buy a few pairs of socks at the discount store and drop them off at one of the shelters, at the day program, or at the public park where some people spend their days. I can make hats and scarves. I can offer a little respect.

Most of us can do these little things; others of us can support programs like Homeward Bound of Asheville or the Salvation Army or other agencies that offer shelter to people with nowhere to go.

As a Christian, I think often about the description of Judgment Day in the Gospel of Matthew. Jesus said, "Whatever you do for the least of these, you do also to me. Conversely, he said, "Whatever you do TO the least of these, you do also TO me."

The US Senate passed the Food Safety Bill by unanimous consent Sunday, increasing its chances of being passed in the waning days of this session.

The nation's food safety legislation hasn't been upgraded in nearly a century, and with new, powerful pathogens emerging, new means of controlling safety and cleanliness in food processing plants are necessary.

Without this law, which now muxt be passed by the House of Representatives, the federal government has no power to force food producers to recall tainted products. The Food and Drug Administration and the Department of Agriculture don't have the staff or the funding to inspect processing plants regularly; some get inspected no more than once a decade.

Each year between 25 and 30 percent of Americans are sickened by the food they eat. Slaughterhouses allow cattle to stand knee-deep in their own feces before being killed, tainting the meat with antibiotic resistant E-coli bacteria.

Chickens, kept in spaces where they can't even stand and move, are pumped so full of antibiotics that people who eat them show traces in their systems. Meanwhile, super strains of salmonella develop.

The bill, should it become law, won't stop all the abuses, but it will give the federal government the power it needs to keep our food supply safer.

Big agribusiness doesn't care about whether you get sick; it exists only to make a profit. Its lobbyists often fight labeling that tells you whether the milk you're buying contains bovine growth hormones and other questionable substances or whether it has been genetically modified, because that could cut into profits.

The law has bipartisan support -- a rarity in today's reality. It needs to pass, and it just got one step closer.

Now we need to call out representatives in the House and tell them to get it passed.

Our so-called health care system -- ranked 37th in the world -- really is nothing more than a profit machine.

To say we can't afford to make it work is just not right, not when we can spend trillions of dollars on wars, give tax breaks to the richest Americans and bail out Wall Street.

The truth is that we refuse to make it a priority, and pharmaceutical companies, big insurance and others in the medical-industrial complex are making big money.

We talk about cutting costs, yet we refuse to manage chronic illnesses like diabetes, high blood pressure and psychiatric illnesses. We let people go until they're in crisis and it's a lot more expensive to treat them.

Well, where do you think the money goes? Why do we spend more per capita on health care than any other nation -- even the ones that offer access to quality health care for everyone?

Wellness is cheaper. If people are able to control and monitor chronic illness, it lowers costs dramatically. If diabetes isn't managed, you need more drugs, kidney dialysis, even amputation. If cancer isn't caught early, you have to have more expensive chemotherapy.

If Mike had been able to have the colonoscopies he needed, the cancer could have been caught before he even needed chemo. Instead, he stopped paying taxes because he was too sick to work, and he used hundreds of thousands of dollars worth of medical care before he died.

  Our problem is that we're happy to put our money toward other things.

It's not that we don't have the money to pay for it; it's that won't pay for it.

It's all about priorities.

If you want to read more, check out this post by Stephan A. Schwartz:

http://www.huffingtonpost.com/stephan-a-schwartz/the-illness-profit-system_1_b_796314.html

The truth is that insurance companies don't want the mandate stripped out of the health care law.

Wendell Potter, the former insurance company executive turned whistle-blower, knows the business like none of the rest of us. In a column on Huffington Post (http://www.huffingtonpost.com/wendell-potter/insurers-spin-court-decis_b_796605.html?ir=Health), Potter talks about how happy the insurance industry was with the individual mandate: It sent everyone to them, and with no public option, that means they get all the business, not just some of it.

Potter was in favor of the public option, as was I, because it would provide competition to a business that has none and has abused its exemption from the nation's anti-trust laws. Without that public option, the only way to get coverage to millions more Americans and contain costs was to rein in insurance company abuses.

The mandate does that by making sure everyone has insurance, not just people who are sick or have disabilities. It makes insurance companies cover everyone. The only way to do that effectively is to make sure even healthy people are in the pool.

What the insurance companies want is to get rid of the entire law, especially the consumer protections. If they have to cover everyone and people aren't made to buy their products, they could make a lot less money, and that scares them and their investors.

We need the balance of the mandate if we want to have a better system. Without it, the new law could fail, and we're left with more of the same mess we have now.

A judge in Virginia has ruled that a key component of health reform is unconstitutional.  The judge,  Henry Hudson, a George W. Bush appointee, concluded that Congress can’t regulate “economic inactivity,” the failure to buy health insurance, as if it were “economic activity” that affected interstate commerce.

It's a technical point, and it wouldn't reverse the entire law, just the individual mandate. Two other judges already have ruled that the mandate is constitutional, saying Congress has a right to regulate the purchase of health insurance because it is for the greater economic good, and a dozen more judges have dismissed cases.

This decision means that the case likely will go to the conservative-leaning Supreme Court, where under the leadership of John Roberts, anything can happen.

President Obama believes theprovision will be upheld:  "I'm confident that this will be upheld in the courts. Keep in mind, we had already had two other federal courts rule that it was constitutional, we have had 12 other courts that have dismissed challenges to the health care law. So this was one opinion that we strongly disagree with, but we already have the majority of other lower-court [decisions]."

If the decision is upheld, it would mean Congress can't require people to buy insurance. That would keep a lot of young and healthy people out of the pool, driving up costs for everyone else. Plus, if some of those young, healthy people get sick and then wanted to have insurance pay the tab, it would drive up costs even more because these people would be expensive coming in.

Without a public option (let me buy into Medicare), the individual mandate is our only hope of reducing costs.

At the same time this is happening, Medicaid, the government plan for the poor, is stretched to the breaking point. Because of job losses, the number of people who qualify for Medicaid is at an all-time high -- the program serves about 58 million. States with billion-dollar deficits are trying to cut corners to spread the care around as far as they can. Dental care usually is the first to go. In California, people can't get root canals to save their teeth; all they can do is get the tooth pulled. Then they can't get dentures.

In Arizona, transplant surgeries have been cancelled.  

Mental health care already has been cut to the bone.

Across the country, people who receive Medicaid can't find a doctor because the reimbursement levels are so low that doctors can't pay their costs. So they wait until they're sick enough to go to the emergency room, where care is far more expensive.

Medicaid doesn't just help the poor; elderly patients in nursing homes get care because Medicaid picks up the bills rather than forcing children and grandchildren to pay.

These are serious problems, and we're not going to fix them by giving tax cuts to the rich -- or anyone else, for that matter. If we don't lower costs AND raise revenues, the system will fall apart before it has a chance to be fixed.

For people who are homeless in Buncombe County, area shelters and day programs have enacted Code Purple to help people get out of the cold.

Some shelters will be open during the day to allow people to stay inside, and most shelters will have extra cots set up to allow more people to stay inside at night.

Code Purple is put in place when the temperature falls below freezing, or when the wind chill temperature falls below freezing to help ensure no one dies of exposure.

Here are the shelers that are participating:

A-Hope Day Center

www.hbofa.org

19 N. Ann St., Asheville, NC 28801

828-252-8883

On CODE PURPLE days, the A HOPE Day Center will open to everyone  7 a.m. - Noon.

ABCCM Veteran’s Quarters

www.abccm.org/vets-place.html

1329 Tunnel Road Asheville, NC 28805

828-299-8791

People seeking shelter can get into the Veteran’s Quarters emergency shelter starting at 4 p.m.. The shelter will accommodate extra people in the lobby and dining room areas.

Salvation Army

204 Haywood St., Asheville NC, 28801

828-253-4723

The Salvation Army will offer their space for people to come inside and sit during the day.  People can come to the agency for overnight emergency shelter services  starting at 4 p.m. The Salvation Army will offer overflow spaces with cots, mats, and blankets.

Swannanoa Emergency Shelter

Swannanoa Christian Ministry

828-669-9404 or Bill Walker at 828-273-0025

Purple flags will be flown at First Baptist Church in Swannanoa, Swannanoa Valley Christian Ministry, and soon at Tolley Insurance in Swannanoa on days that the shelter is open. Guests are admitted to the volunteer-run, 16-bed shelter between 6 and 7 p.m. with dinner being served at 6:30 p.m. Guests who arrive after 7 p.m. will only be admitted if they have made prior arrangements or if they are brought by law enforcement or a pastor from a local church. The shelter closes at 7 a.m.

Western Carolina Rescue Ministries
www.westerncarolinarescue.org
225 Patton Ave., Asheville, NC 28801 
828-254-1529

The agency will post a CODE PURPLE on the top right-hand corner of their website and post a CODE PURPLE indicator on the front door of the shelter each night that CODE PURPLE is in effect.  During CODE PURPLE, regular services are enhanced by extending the number of evening overflow spaces through the use of cots, mats and blankets, allowing clients to remain indoors throughout the day in the chapel, encouraging police, paramedics, and other agencies may bring people needing shelter after the normal “closed door” time of 6 p.m.

The above organizations and others in the community will offer other services to help people who are homeless throughout the winter.

The CODE PURPLE effort stems from the collaborative work of the Homeless Coalition, which is a collective of agencies, faith groups, and individuals experiencing homelessness that works to address the needs of people who are homeless or at risk of homelessness.  Meetings are held on the first Tuesday of every month at 12:30. To learn more, contact co-chair Brian Alexander at brian@hbofa.org.