What will it take to remove end-of-life counseling from its current role as a political football in the scrum over health care reform?
Match Sarah Palin's "death panel" attack with claims that she wants old people to die slowly and in pain? Meet Newt Gingrich's assertion that health care reform is wrong because the government cannot be trusted with accusations that he hates our (government!) soldiers and wants to kill the VA and Medicare?
Nah. Let's try facts.
Palin's crazy Facebook posting (and did you ever expect the phrase "Facebook posting" to turn up as a primary source in a serious political discussion?) is far from the most dangerous recent commentary in this context. I'd give that nod today to the Washington Post's Chuck Lane. He offered a column on the subject this week that carries the patina of reason -- as Palin's screed does not.
I admit that I'm not "objective" on this topic. As I've written here earlier, I've watched my wife during her career in long-term health care, in nursing homes and in hospice work. And I've faced what could have been a couple of end-of-life episodes with my own dad . Plus I've actually read both the relevant section in the House bill (search for 1233) and the relevant section in the Medicare code.
So let me lay my high card on the table: Posturing that is calculated to score political points but is likely to make some people afraid of counseling, hospice, and their own doctors is nothing less than evil.
In reading Lane's column, I was reminded of a Peter, Paul and Mary concert I attended many years ago. They were about to sing "Puff the Magic Dragon." And they alluded to an accusation from years before that the song was actually about smoking pot. They "confessed" that was true. And in the national interest, they were going to expose another song with drug-promotion hidden in the lyrics:
"Oh, say can you see. 'C' as in cocaine . . ." And so on. The point being that words can be twisted into a meaning that may not actually be there.
So let's turn to Lane's column. In it he attacks a provision in one of the current health care reform bills that would authorize Medicare to pay a doctor for a consultation with a patient about end-of-life issues.
He starts with a nod toward reason, acknowledging that there is no basis for claims that this is tantamount to legalizing euthanasia. (As Patricia Murphy has pointed out here at PD, an amendment already accepted would make it illegal for counselors to promote or even list suicide or assisted suicide as an option.)
Lane goes on:
I was not reassured to read in an Aug. 1 Post article that "Democratic strategists" are "hesitant to give extra attention to the issue by refuting the inaccuracies, but they worry that it will further agitate already-skeptical seniors."
If Section 1233 is innocuous, why would "strategists" want to tip-toe around the subject?
Perhaps because, at least as I read it, Section 1233 is not totally innocuous. . . .
Section 1233, however, addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they're just trying to facilitate choice -- even if patients opt for expensive life-prolonging care. I think they protest too much: If it's all about obviating suffering, emotional or physical, what's it doing in a measure to "bend the curve" on health-care costs?
As with Puff, sometimes things may simply mean what they appear to mean: End-of-life is a politically fraught issue because merely talking about it makes people afraid. Try it. Sit down with your friends or family -- particularly if you include folks past, say, 65. Strike up a chat about dying and see how far you get. Search for an easy political upside to that conversation.
Why would this issue be addressed in a bill that is, in part, about reducing health care costs? Because most responsible medical authorities believe that patients and their families who are better informed about what medicine can and cannot do for the dying are more likely to choose alternatives that are, on average, less expensive than what happens today. Emphasis on the phrase "more likely to choose."
Back to Lane, and we need a large chunk here to be fair to him:
Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren't quite "purely voluntary," as Rep. Sander M. Levin (D-Mich.) asserts. To me, "purely voluntary" means "not unless the patient requests one." Section 1233, however, lets doctors initiate the chat and gives them an incentive -- money -- to do so. Indeed, that's an incentive to insist.
Patients may refuse without penalty, but many will bow to white-coated authority. Once they're in the meeting, the bill does permit "formulation" of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would "place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign," I don't think he's being realistic.
What's more, Section 1233 dictates, at some length, the content of the consultation. The doctor "shall" discuss "advanced care planning, including key questions and considerations, important steps, and suggested people to talk to, an explanation of . . . living wills and durable powers of attorney, and their uses" (even though these are legal, not medical, instruments); and "a list of national and State-specific resources to assist consumers and their families." The doctor "shall" explain that Medicare pays for hospice care (hint, hint).
"Hint, hint"? I'm pretty sure that's the point I could literally feel my blood pressure elevate. He is suggesting nothing less than that your doctor will be inclined to push you into a premature death, only because he could bill Medicare for the cost of an hour or so of conversation.
Perhaps Lane himself is seeing the wrong doctor.
But let's be civil. We need to trace what the bill and current law actually say. The bill, which is a long way from becoming law, would add to Section 1861 of the Social Security Act, subsection (s)(2). It's a section that includes a long list of things that Medicare will currently pay for.
Here are a few: home dialysis supplies and equipment, prescription drugs used in immunosuppressive therapy, qualified psychologist services, prostate cancer screening tests, colorectal cancer screening tests, screening for glaucoma, ultrasound screening for abdominal aortic aneurysm, kidney disease education services, leg, arm, back, and neck braces, and artificial legs, arms, and eyes.
And so on and so on. Does Lane believe that doctors have an unwarranted incentive to push patients into installing a fake eye or taking dialysis or getting their colon scoped because current law pays for it? Seriously?
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