President Barack Obama’s healthcare reform initiative is predicated on eight basic guiding principles that are, on their face, essentially impossible to argue against.
The argument is over the translation of those principles into substantive policy provisions both general (a public insurance option?) and specific (increase utilization factor for calculating advanced imaging payment rates?). One proposal demands our attention because of the strange controversy it has engendered and what it will tell us about the balance between policy commitment and the politics of fear in the Congressional process: The proposal to provide Medicare payment to physicians for end-of-life counseling sessions with patients and family members.
This is a straightforward coverage and payment provision. Many doctors already provide such counseling to their elderly and/or terminally ill patients. But they simply don’t get paid for it, because Medicare, like most private insurers, only pays for reasonable and necessary medical care — a category that excludes conversations that do not focus on specific therapeutic choices.
If doctors could get paid for EOL counseling, at the same rate as for any intermediate or extended medical consultation, they would do more of it and care decisions at the end of life would accurately reflect patient wants far more frequently than is currently the case.
The quality and patient-responsiveness of care would thereby be improved and patients would be spared the indignity of extreme measures that cannot help them get better and that they don’t want. The system would be spared the substantial cost of those unwanted and largely ineffective measures. The EOL consultations would be strictly voluntary; no one would be told what they want or could have, but choices at the end of life would be better informed choices. Everyone wins.
This extraordinarily constructive and benign proposal (well, now you know where I stand!) has somehow been construed by opponents of the President’s reform initiative as the gateway to government-administered euthanasia. It’s the source of the posters and YouTube clips likening Obama to Adolph Hitler, complete with iconic mustache. It is a prime element in the angry health reform town hall meeting protests garnering enthusiastic coverage from media both mainstream and marginal.
Don’t get me wrong. I can imagine legitimate opposition to Medicare coverage of EOL counseling, just as I can understand, without agreeing with, principled opposition to sex education in the schools. But we’re not talking about that kind of opposition. We’re hearing arguments that are either cynical and fear-mongering (take a bow, Rush!) or around-the-bend crazy.
But it’s all just a sideshow, right? Congress can’t possibly be taking any of this nonsense seriously, can it? Democrats will go home during the August recess and clarify the proposal’s limits to their constituents; responsible Republicans will go home and turn the discussion to real and serious policy concerns. No responsible political figures are buying any of this nonsense. Right?
So imagine my surprise when the Wall Street Journal reported that members of Congress are backing away from the EOL proposal as fast as they can; that the Senate bill, in deference to the Blue Dogs and Republican opposition, will have no EOL provision; and that its increasingly unlikely that such a provision will survive in any House legislative proposal. The reason: Too much heat from the ignorant and the off-center (my characterization, not the Journal’s).
If Congress can’t cut through the noise, consider the legitimate policy arguments for and against the EOL coverage proposal and come to a decision on the merits, how can it possibly constructively address the real and far more significant policy decisions that will make the difference between meaningful and constructive health reform and an ultimately futile exercise?
In a small way, the apparent abandonment of the EOL proposal (perhaps the WSJ — no friend to Obama’s proposals — overstates the case) is a Congressional portrait in political cowardice.
Our elected representatives are supposed to reflect their constituents’ wants. They are also supposed to lead, to educate those constituents by explaining complex issues and correcting misperceptions.
And when significant principles are at stake, they are supposed to vote their conscience and their beliefs. If EOL counseling goes down without a fight, it is clear testimony that many in Congress, from both parties, have neither.