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September 15th, 2009
03:42 PM ET

Collateral damage in the ruckus over health care reform

Steven M. Asch, Karl Lorenz, and Diane Meier
RAND Corporation

What can you choose when life restricts you to the narrow width of a hospital bed and your view is one of life’s final horizon? None of us can choose to live forever. But we can, usually, choose how to make the most of our remaining weeks, months, or years.

Helping patients choose how to live well at the end of life lies at the heart of advance-care planning. This is when patients, doctors, and loved ones talk things over and draw up a plan to match health care services to the patient’s goals. Such honest information, discussion, and choice were at the heart of the now-defunct provision in the proposed healthcare reform legislation that would have reimbursed doctors for counseling patients and their families at this crucial time. And yet, something so seemingly straightforward has still ended up at the center of a volley of political charges and countercharges, including a prominent mention in President Obama’s address to Congress on Wednesday night.

One of the provision’s critics, Sarah Palin, says she, not government bureaucrats, should choose what sort of medical care her developmentally delayed son might get. What parent would dispute her? Just this week Palin reiterated her opposition to advance-care planning provisions in health care reform in a Wall Street Journal commentary. But when a child is facing difficult medical treatment, Ms. Palin and virtually every other parent would need honest information about the medical alternatives and likely effects.

Ironically, the advance-care-planning provision would have helped ensure true freedom of choice for Americans facing different but equally momentous decisions. The provision called for paying doctors, once every five years for each Medicare patient, for providing information about living wills, healthcare proxies, pain medication, and hospice. It involved no coercion of patients or physicians involved, no “death panel” review - just honest talks in the privacy of the bedside or office that produce more, not fewer, choices. Such conversations can happen today, and sometimes do, but Medicare does not pay for them unless they are blended with other services. Medicare also does not count them as part of “quality care.”

Data show that the choices many people make about the end of their lives are not heard. Most patients say they would not want to have machines breathing for them at the end of their lives, yet many do. Most Americans say they would choose to die at home, yet most don’t. Half of patients dying with cancer don’t avail themselves of Medicare’s home hospice benefit.

One likely reason for these missed connections is that fewer than half of those over 65 have ever had an advance-care discussion with their doctor. If reimbursement for such discussions were even a reasonable fraction of what we pay for the myriad of procedures dying patients endure, the discussions would no doubt happen more often.

Critics also claimed that the advance-care provision constituted a cloaked cost-saving tactic. True, research shows that about a third of Medicare spending occurs at the end of life. Since many of us would choose to live more fully in the time we have left, rather than to chase every possible medical treatment, we may well turn down enough treatments to create some cost-savings. But there is nothing in advance-care planning that prevents us from choosing expensive care if it helps us live the life we want. And there is nothing about advance-care planning that prevents us from changing our minds, and choosing more aggressive care.

Life is a series of choices and becomes ever more precious when the end nears. We will all need honest information and supportive counseling when we find ourselves in this unfamiliar situation. The latest rumor-mongering about end-of-life care has forced politicians to pull back from a simple amendment to Medicare that would have enabled better choices about how to live with serious illnesses.

Most of us will live with such conditions at some point. Because Medicare covers more than three-quarters of us at the time we die, we should demand to track the quality of care during that period. One of the key measures would be the degree to which the plan of care reflects the patient’s priorities.

It has been said that “man is condemned to be free … we are our choices.” None of us – not the rich, not the politicians – can evade the kinds of choices we are talking about forever. Nor can we evade the consequences of not having thought about them. No matter what our views on healthcare reform, we should all lament that funding advance-care planning ended up as collateral damage in the attacks on the healthcare legislation. We’re all in this one together.

Editor's Note: Steven M. Asch and Karl Lorenz are researchers and physicians at the RAND Corporation. Diane Meier, recipient of a MacArthur Fellowship in 2008, is a geriatrician at the Mount Sinai School of Medicine in New York City.


Filed under: Health Care • Raw Politics
soundoff (16 Responses)
  1. keisha

    it's not about the gov. taking care of people it's about these insurance companies getting rich! we need a choice! i work hard for my money and i shouldn't have to pay and arm and a leg for health care he's not taking away what we already have he's giving us another option thats all

    September 16, 2009 at 3:28 am |
  2. Vivian

    I would still like to know what all this health care reform means to me and others like me. Democrats want to dictate to Republicans and Republicans want to dictate back. What is actually happening is Congress is dictating to the people what is best for all based on their petty needs. I can see a wholesale change in Congress in the next election. We can't seem to put one together that will just do their jobs while working for us.

    September 15, 2009 at 10:32 pm |
  3. maron

    I have been a nurse for forty years with most of that time in intensive care nursing.It is true that the most healthcare dollars are spent in the last few days of life.Never in that time was anyone denied care regardless of their income,gender or ethnicity, It is not only the responsibility of the doctorsand nurses to discuss care and outcome of diseases or treatment it is the patients responsibily to have a living will, healthcare POA and a frank discussion with their family. It is very sad to see someone without those papers in place and have family members bicker over their end of life care.Their would never be a death panel due to a mountain of litigation against it!

    September 15, 2009 at 9:39 pm |
  4. Kendal Fuller

    It is real sad to know that you are in a hospital bed and that you don’t have much longer to live. The doctors are trained professional but it should be family’s decision for the family member’s medical treatment. Money is a big issue when it comes to health care. Medicare does not pay for everything unless they are blended with other services. People have the right to voice their opinion.

    September 15, 2009 at 9:11 pm |
  5. Rachelle C. San Francisco, CA

    The problem here is not the Government taking care of America. It is the fact that, Insurance companies have gotten away with taking advance of the American people for a long time now.

    The Health Care Reform Bill does not take away from your choices. The problem is, that for so long, Insurance Companies were able to make the rules, make a profit, and allow coverage to selective individuals.

    We really need to understand the facts before we start getting hysterial, about the government controlling us.

    September 15, 2009 at 7:49 pm |
  6. Alice, AR

    Mr. Conserve for USA. I promise you that I do work, own my own business and make great money. But, I understand that we will all come to a place in our lives where we have to use the Health Care System. This means that Health Care should be a right and not a priviledge.

    There are a lot of people WORKING for small businesses that do not get Health Care coverage through their employer. They need access to affordable Health Care and the Insurance Companies are not providing that. 50% of all bankruptsies are due to medical bills. We need to fix this. I just hope you are not the next victim of this broken Health Care system.

    September 15, 2009 at 7:16 pm |
  7. JudiB

    Thank you for adding this voice of sanity to the topic!!! How is it that the media seems so hell bent on AMPLIFYING the misleading, inflammatory, and downright IGNORANT comments about such a serious subject as providing information to the public about the realities of what lies ahead of them and the choices that would be available for their treatment.

    Seems than can't handle an honest, FACTUAL, dialogue on the pros and cons of the facets of health care, so they're stooping to lies and scare tactics. Didn't work in the election....let's hope their track record remains intact!

    September 15, 2009 at 6:07 pm |
  8. Susan, Calif

    I find it hard to believe that in this day an age, people are unaware of living trusts, health care directives and hospice. I do not need a babysitter! As soon as I was an adult, I took responsibility for myself and my actions. Why should I expect the other citizens of this country to pay for making sure I have this information?

    Everyone I know has handled this by themselves. What has happened to the people of this country that they need someone else to take care of them. A whole lot of people need to learn that you make your choices and you live with the consequences. I don't want Big Brother taking care of me....there are many other uses the government could make of the funds that would be used for this.

    September 15, 2009 at 5:58 pm |
  9. janet

    People obviously haven't been hospitalized lately. Currently, when hospitalized, every patient is required to give the hospital, their physician or the hospitalists that information in order to make appropriate medical decisions. I have that discussion with patients and family members on a daily basis. It would be so much easier on all the parties involved if they had had that discussion around the dining room table prior to having to make that decision under duress when their family member becomes critically ill.

    September 15, 2009 at 5:48 pm |
  10. Conserve' for USA

    The Canadians have free health care, but the average Canadian also pays 48% of their income to taxes. Now, this might not bother those of you that don’t work and want the government to take care of you, but for those of us that do work, government keep your free health care and I will buy my own!

    September 15, 2009 at 4:49 pm |
  11. Patty Byrd

    Re: Tea Party I think this party should go home, they are not protesting against healthcare, they are protesting our Presidents Race and some of there signs they are holding up confirms it..plus if they want to make a believer out of me, they need to add some color to there little tea party, & remove those name calling signs......

    September 15, 2009 at 4:41 pm |
  12. Patty Byrd

    I don't think our President is wanting to take over Heath care I think President Obama is wanting to give the people of America choices. I'm sorry but President Obama is the only President that ever came out of the White House to here what the little people have to say.

    September 15, 2009 at 4:33 pm |
  13. Patty Byrd

    I'm sorry did I miss something? I thought people of america wanted Health care revised, by our Goverment that was why it was part of our Debate Quistions.

    September 15, 2009 at 4:24 pm |
  14. Patty Byrd

    Maybe Joe Wilson should go find the want 2 be politician Joe the plumber

    September 15, 2009 at 4:18 pm |
  15. Alice, AR

    Thank you!! I have been amazed and outraged by Sarah Palin's statement that the government wants to set up Death Panels. She has done such an injustice to this provision. This is desperately needed and to come up with such outrageous statements makes me thank God that she is not our Vice President. I voted for Mr. McCain, but after watching the outrageous statements and fear tactics of the extreme right wing groups, I am so glad that the majority of the people saw her for what she was. Thank God, we have President Obama leading this country. We need Health Care Reform and we need counseling for families during these difficult times. How do we make the best decisions for our loved ones at the end of their life? We need someone that understands what we are going through and how to best leave this world with dignity.

    September 15, 2009 at 4:06 pm |
  16. Patty Byrd

    It is real sad that we are acting like uncivilized people. It's one thing to disagree with the president and his policy, But all this name calling of our President & outburst of our politicions is going to far. We are starting to act like a 3rd world country, next we will be bringing out our guns and shoot people who doesn't agree with us. Some people are letting there evil side of us all take over.
    I say lets give our elected President more time to make change, after all we gave our last elected President 8 years for improvement, & now we want to give President Obama only 8 months, there is no fareness in that.
    Where was this Tea Party when Bush was screwing things up?????

    September 15, 2009 at 4:03 pm |