Health Care Reform and the Euthanasia Hoax

Health care reform is complicated. Constraining the cost of medical care in the face of an aging population, new technologies, and increased health care expectations is hard. Providing health care coverage to the millions of Americans who cannot afford it or feel they don’t need it is challenging. And the list goes on.

Given this reality, one might hope the focus of the nation would be on the many legitimate public policy differences worthy of debate. Are current proposals for a public plan creating fair competition with private carriers or unfair competition? What is the appropriate role (if any) for an exchange? How can comparative effectiveness research restrain medical costs without shackling doctors to menu medicine?

Unfortunately attention is being diverted from these substantive issues to those which generate fear and conflict, but do nothing to illuminate or resolve tough issues.

Take euthanasia, or what former Governor Sarah Palin refers to as the “death panels.” Section 1233 of "America’s Affordable Health Choices Act" (HR 3200) is the source of this controversy. Section 1233 makes consultations between patients and doctors concerning end-of-life discussions a covered expense under Medicare. It does not require these discussions. Nor does it require patients to consult with a government panel nor is the patient obliged to take any action as a result of the discussion. All this section does is reimburse doctors for taking the time to talk about what services (such as palliative care and hospice) Medicare will cover and how powers of attorney, living wills, and the like work. That’s it. And it only covers these consultations once every five years, when there is “a significant change in the health condition of the individual,” or when the patient enters a skilled-nursing facility, nursing home or hospice. In other words: twice a decade or when the individual needs to talk about these matters.

Section 1233 is written in legislative language which is, admittedly, difficult to follow (but then, it is legislation). Take the time to read it, however (it starts on page 424), and it clearly does not encourage euthanasia. It takes a substantial twisting of common sense and logic to make it even seem so. Apparently it’s all about “context.” Here’s Governor Palin convoluted reasoning as presented on her Facebook page:

1. President Barack Obama has said that one purpose of health care reform is to “bend the curve” on medical costs. Authorizing payments for end of life consultations is, consequently, a cost cutting move. Costs will be reduced not by informing patients of lower cost options (hospice versus nursing home versus hospital care versus home care), but by encouraging the patient to commit suicide.
2. Because HR 3200 calls for paying doctors to have these consultations physicians will have an incentive to initiate these talks. Due to the fact that doctors are authority figures in white coats, unwilling seniors will be pressured to have them. In order to reduce overall medical care spending in the country, doctors will use their influence to coerce patients into “’formulation’ of a plug-pulling order right then and there. Apparently doctors are so greedy a fee for spending time with a patient is enough to turn Dr. Welby into Dr. Kevorkian. Yet they are so patriotic they will kill off their patients in order to reduce health care costs. They also must be dumb. Because if they initiate these discussions only to make a few bucks, you’d think they’d be smart and  greedy enough to figure out that dead patients pay no bills. If Governor Palin was being consistent, wouldn’t she assume the doctors would be encouraging people to hang in there and consume as much health care services as possible?
3. Dr. Ezekiel Emanuel, an advisor to President Obama on health care and the brother of White House Chief of Staff Rahm Emanuel has written that medical spending needs to take into account the patients age, condition and chances of recovery. While I haven’t seen Dr Emanuel’s statements in context, what do they have to do with the legislation? The language of a bill is the language of a bill. What someone wants it to say does not trump what it does say. You’d think a governor might know that.
4. So, as mentioned, it all comes down to context. Health care reform is about cutting medical costs, doctors are greedy, patriotic and stupid, and what a presidential advisor says trumps the clear meaning of the legislative language.  Given this context, Section 1233 can only be read as a cost cutting measure that will encourage doctors to talk their patients into committing suicide. (I still don’t see where the death panels come into this. They must be in the fine print only real Americans can see).

Maybe it’s me, but this doesn’t strike me as logic. But it does look like fear mongering. Or ignorance. Or maybe it’s just evidence of a world view that sees Democrats as elder-killers, doctors as untrustworthy, and older Americans as incapable of comprehending that that suicide is not only illegal, it’s optional.

Nah. It’s fear mongering.

There are plenty of reasons to oppose the health care reform put forward in Congress thus far and to fight for a better reform package. Let’s stick to the rational ones.

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Health Care Reform 2009: More Required Reading

There’s a lot of moving pieces to the health care reform process currently underway in Washington, D.C. Politics, policy, and personal interest are all colliding as lawmakers and President Barack Obama Administration try to fix what everyone is calling America’s broken health care system. To put the debate in context it helps to know what the participants are thinking. To understand what they’re thinking it helps to know what their reading and writing.

Earlier this year I put forward a list of required reading for understanding the health care reform debate. Here’s the second installment of what will be a series of such posts. (Note: a third list of required health care reform reading was added August 2, 2009).

1. The Senate Finance Committee, chaired by Senator Max Baucus, will play a major role in determining the health care reform legislation that is likely to arrive on President Barack Obama’s desk this Autumn. And they are taking this role very seriously. The Committee has produced three policy option documents to facilitate their deliberations. The policy papers don’t describe what the Finance Committee will decide upon, but it does provide insight concerning what they will be deciding upon. The option papers are:

• Transforming the Health Care Delivery System
• Expanding Health Care Coverage (which covers market reforms of special interest to brokers)
• Financing Comprehensive Health Care Reform

2. The Senate Finance Committee isn’t the only one in the upper house with jurisdiction over health care reform. The Senate Health, Education, Labor and Pensions Committee and its chair, Edward Kennedy, will have a great deal to say about the final legislative package as well. The Committee released an outline of its reform plan yesterday. I have yet to get my hands on that document, although I did find a Senate HELP Committee Briefing Paper dated May 21, 2009.  (When I get a copy of the most current outline I’ll post it here). In addition, as I’ve posted previously, Senator Kennedy recently described his vision for health care reform in some detail. The HELP Committee’s plan stakes out the most liberal, yet still politically realistic, proposals (meaning it doesn’t call for a single payer system). Whether Senator Kennedy expects to get much of what’s laid out in the outline into legislation is unknown. At the very least, by providing an anchor on the left his plan will help him keep the final product from moving what he would consider too far to the middle.

3. As members of Congress begin drafting legislation they will be paying close attention to the impact health care reform will have on the federal budget. The analysts they will turn to for answers work in the Congressional Budget Office.  The CBO recently published guidelines explaining how they will evaluate the budget impact of various proposals in the Budgetary Treatment of Proposals to Change the Nation’s Health Insurance System. An added bonus: the director of the CBO, Douglas Elmendorf, posts frequently to the Congressional Budget Office Director’s Blog, providing additional insight into the agency’s thinking.

4. The Emanuel family has hit the trifecta. Their youngest son is a major Hollywood agent. The middle son is a former Congressman and currently the White House Chief of Staff. Their oldest son is a doctor. Not just any doctor. He is the Chair of the Deparment of Bioethics at the Clinical Center of the National Institutes of Health (that must be one huge business card he’s got). But wait, there’s more. Earlier this year, Dr. Ezekiel Emanuel was named a special adviser to the director of the White House Office of Management and Budget for health policy. In other words, he’s pretty close to health care reform’s ground zero in the Obama White House.  (No slight intended of the Director of the White House Office on Health Reform, Nancy-Ann DeParle, who gets to sit on the actual bulls eye — see #5).  How Dr. Emanuel views reform, consequently, matters. He’s thought long and hard on the subject and, fortunately for inquiring minds, he’s written extensively on the topic, including the book Healthcare, Guaranteed: A Simple, Secure Solution for America. Other writings by Dr. Emanuel include a posting he made to The Huffington Post and another he co-wrote for the New America Foundation.

5. As noted in #4, Nancy-Ann Deparle’s is charged with coordinating President Obama’s health care reform efforts. It’s her job to keep the various players and issues in the debate from spinning out-of-control. Like a traffic cop, it’s up to her to keep things moving toward eventual passage of comprehensive legislation. It’s hard to find much on her personal health care reform positions (if anyone out there has links to her writings on the topic, please let me know).  In an April 2009 briefing for reporters sponsored by the Kaiser Family Foundation, Families USA and the National Federation of Independent Businesses, she did define what she means by a “public health plan.”  You can read a transcript or view a video of her presentation to the press on the Kaiser Family Foundation site

6. Everyone knows the key to health care reform is controlling medical costs. You can have all the market reforms Congress can dream up, but if medical inflation continues to outpace general inflation and wage growth at the rate it has been, it will cripple the economy. Even entrenched stakeholders recongize this reality, which is  how the Advanced Medical Technology Association (AdvaMed), America’s Health Insurance Plans (AHIP), American Hospital Association (AHA), American Medical Association (AMA) , the Pharaceutical Research and Manufacturers of America (PhRMA) , and the Service Employees International Union (SEIU) came to publish their medical cost reduction proposals. The document contains cost cutting committments the organizations have made to President Obama.

7. Perhaps the most talked about article on cost containment making the rounds today is a New Yorker article by Dr. Atul Gawande. It is a terrific read that recounts his investigation into why McAllen, Texas is “the most expensive town in the most expensive country for health care in the world.”  It seems MediCare pays twice as much per person in McAllen than it does 800 miles away in El Paso. Dr. Gawande investigates why, offering insights into the health care system that are too rarely considered.

8. It is generally accepted that 30% of health care spending in the united states is unnecessary. That’s $700 billion we’re talking about that could be spent insuring the uninsured, among other uses. Folks like Peter Orszag, the former director of the CBO and currently director of the White House Office of Management and Budget (which makes him Dr. Emanuel’s boss, for those keeping track) often sites this statistic — and its source: Dartmouth University’s  “Atlas of Health Care.”  They have done numerous and extensive studies on the connection (or lack thereof) between medical spending and health outcomes. Their most recent findings, published February 27, 2009, are described in Health Care Spending, Quality, and Outcomes. It’s subtitle: “More Isn’t Always Better,” pretty well sums up the results.

9. A bonus item: For a 3 minute summary of the health care reform debate, presented in a surprisingly entertaining, clear, and balanced way, take a look at the video at myhealthreform.org.  The video is not an in-depth dive into the issue, but rather an informative overview of the topic. If you’ve got friends, clients or colleagues who are looking for a simple explanation of what the debate is all about, it’s a great place to start. (Full disclosure: the site is run by Humana who clearly has a stake in the outcome of health care reform).

There will be more required reading coming soon. For example, we should hear very soon from the  three House Committees with jurisdiction on health care reform with details on their proposals for change. In the meantime, if you come across any articles, books, postings or the like you think belongs on a list of required health care reform reading for 2009, please send them my way.

Obama Health Care Reform: Early Tea Leaves

As President-elect Barack Obama’s administration takes shape some hints as to the direction health care reform will play out are beginning to drop. While the clues are preliminary and a lot can change in the 47 days before the inauguration. But it’s never too early to read tea leaves. Who knows, some of these predictions might actually be right. Among those tea leaves:

Health care reform will be addressed sooner rather than later. The issue was too central to the President-elect Obama’s campaign to be put off for long. And there’s too much pent up demand for change to delay. Plus there’s a host of reform proposals already, or soon to be, in play. Some are plans bi-partisan, some are being offered by Congressional heavyweights like Senators Max Baucus and Ted Kennedy. All of these proposals have a lot in common, which means health care reform 2009-style will be off to a much better start than the Clinton Administration effort (fiasco?) in 1993.

Former Senator Tom Daschle will play a major role in fashioning health care reform. Although his nomination to be Secretary of Health and Human Services isn’t yet official, it’s received the controlled leak treatment that has presaged every other nomination. Senator Daschle has spent much of his time since losing his Senate seat in 2004 thinking and writing about health care reform.  That thinking has led him to argue, according to Time magazine, that health care reform is essential to dealing with the nation’s financial woes and that delay in implementing reforms is unacceptable.

As a Senior Fellow at the liberal Center for American Progress has described the current health care system as seriously broken. Writing in an undated statement on the Center’s site, Senator Dashcle claims “Efforts to reform our health care system have been undercut by myths that hide the weaknesses of our current system and overstate the challenges of reform. One myth is that the United States has the best health care system in the world. There is no doubt that some Americans have access to the best care anywhere, but not all care is excellent.”

He continued, “We need to move beyond ideology and partisanship and meet our common health care system challenges with commonsense answers to provide affordable, quality health care to everyone in this great nation. This is not a weak alternative; it is the only one.”

These statements summarized the findings in a white paper on health care reform entitled, “Paying More but Getting Less: Myths and the Global Case for U.S. Health Reform.” The reforms called for in the white paper overlap those advocated by candidate Obama during the campaign. One encouraging note: Senator Daschle spends considerable time in his analysis on the need to control health care costs. This means he should find an ally with the new Director of Office of Management and Budget, Peter Orszag.

Controlling costs will be central to Obama’s health care reform plan.Although it got fewer headlines than the debate over whether his proposal would lead to universal coverage or not, candidate Obama focused more than most of his opponents on the need to restrain skyrocketing medical costs. As a candidate, President-elect Obama’s proposals were, to put it kindly, somewhat general in scope. Yet he’s bringing on board people who clearly get the importance of this task. As noted, Senator Daschle is one. Incoming Director of the Office of Management and Budget, Peter Orszag is another. In his current job as Director of the Congressional Budget Office, Director Orszag has long called for a focus on controlling medical costs. At the CBO Director Orszag pushed for evidence based assessments of new technologies and expansion of research into the effectiveness of treatment. He also called for new incentives in order to change provider and consumer behavior. His move down Pennsylvania Avenue from Congress to the White House is unlikely to change this emphasis. And given the impact health care reform will have on the economy (and thus the nation’s budget) his will be a loud and attended-to voice in the debate.

Emanuel may have a lot to say, too. Incoming White House Chief of Staff Rahm Emanuel will no doubt weigh in on health care reform, but he’s not the Emanuel I’m referring to. The one to keep an eye on is his brother, Ezekiel Emanuel, currently Director of the Clinical Bioethics Department at the National Institute of Health. Dr. Emanuel is a strong advocate of a voucher system. His proposal has gained significant attention, if not support. But with his brother holding the door open it’s highly likely the doctor will have a voice in shaping the Administration’s health care reform plan.

Reforming America’s health care system won’t be easy. The need for comprehensive health care reform is widely shared across the political spectrum. And as the Los Angeles Times, recently reported, there’s a growing consensus supporting universal coverage that includes business, unions, doctors, hospitals and insurance companies. Yet sharing a goal is a far cry from agreeing on solutions. As history has shown, once details emerge, so do objections. I believe health care reform is coming, but there will be vigorous debate and substantial compromises along the way.

A Single Payer system will be part of the debate, but not the solution. Supporters of a single payer system have a nearly religious zeal for their approach. They speak in terms of the morality of covering everyone and throwing those earning profits from the health care system. A government-run system accessible to all and paid through taxes is the salvation they preach. Advocates of a single payer system will not go away and they have many supporters in Congress. Yet, their chance of success has not been this bleak in years. The consensus building in Washington focuses on an employer-centric system. While expanding government health insurance programs is explicitly supported, all the major proposals currently gaining traction implicitly reject a single payer system. There will be sound and fury around this approach, but as a solution, it’s a virtual non-starter. This doesn’t mean that what emerges from the coming health care reform debate isn’t dangerous to health insurance agents and others important to the current system. It just means the truck heading our way is not being driven by Michael Moore.

Change is coming. Stay tuned. For those who care about America’s health care system, 2009 will be a watershed year. Something is coming. It’s broad outlines are becoming more clear as the new year draws closer. But the system won’t be changed by generalities. It’s the specifics that matter. And it’s time that is required to shape those details into reforms that make the system better, not worse, for the effort. The opportunity for meaningful, positive reform has never been greater. While there are risks to current stakeholders, there’s a good chance they may emerge stronger from the process. What’s clear is that the process will take months, maybe even years, before the coming change arrives. And make no mistake, change is coming. No tea leaves are required for that prediction.

Obama Must Do Better on Health Care Reform

In his stump speech, during the presidential debates, highlighted in his 30 minute commercial, Senator Barack Obama has made clear that, were he elected president, health care reform will be near the top of his priorities. It’s viewed as a critical component in fixing the nation’s faltering economy, ranking alongside energy independence and a middle class tax cut at the top of his domestic agenda.

Senator Obama’s commitment to the issue is more than ideological, although he does see health care coverage as a right of all Americans. It is also highly personal. Senator Obama described the roots of his committment to health care reform in Sarasota, Florida yesterday this way: “And as somebody who watched his own mother lying on a hospital bed at the end of her life because they had cancer. The insurance companies were saying this was a pre-existing condition, maybe we don’t have to pay for your treatment, I know what it’s like to see a loved one suffer not just because they’re sick but because of a broken health care system.”

This combination of ideology, politics and the personal will assure that health care reform would be taken up early in an Obama Administration. Given his passion for the issue, the state of the economy and the real need to address serious problems in the current health care system, the odds are extremely high a comprehensive reform package will emerge sometime in his first term. Whether these reforms will be similar to what Senator Obama describes on the campaign trail, however, is, fortunately, both uncertain and unlikely.

One reason is because Senator Obama’s health care reform plan is seriously flawed. To cite just one example, a core attribute of his proposal is to require carriers to except all applicants for coverage without regard to their medical condition. As he put it in Sarasota, “… when I am president, we will end discrimination by insurance companies to the sick and those who need care the most.” This is a noble purpose, but if done wrong, it can lead to a health care reform surcharge that would increase the number of uninsured in the country while increasing costs in the system. The “wrong” way is require carriers to sell coverage without requiring consumers to purchase it. This, in essence, is how non-employer sponsored coverage works in New York and New Jersey. Average premiums in those states are more than twice what they are in California. 

The need for matching mandates, was integral to Senator Hillary Clinton’s health care reform plan. She perceived it more as a means to universal coverage, but also acknowledged that “adverse selection” is a real, proven phenomena. Imagine the premiums auto insurance companies would need to charge if drivers could wait until after an accident to buy automobile insurance. That is adverse selection and it is exactly what Senator Obama is proposing.

Another reason Senator Obama’s health care reform proposalis unlikely to survive the legislative process intact is it will need to compete with a host of other plans. Senator Ron Wyden (a Democrat) and Senator Bob Bennett (a Republican) have brought together a bipartisan coalition of Senators behind the “Healthy Americans Act.” Then there’s the proposal by Dr. Ezekiel Emanuel, Director of the Clinical Bioethics Department at the National Institute of Health, who proposes a voucher system financed by a Value Added Tax and shares some elements of the Wyden-Bennett proposal. Senator Ed Kennedy is talking to Senators and policy mavens from across the political spectrum to develop a reform package he hopes to introduce in January. Republicans, too, have a host of ideas for reforming the nation’s health care system. Some might even look similar to the health care reform package advocated by Senator John McCain during this presidential campaign.

In short, there will be no dirth of ideas when Washington begins to address health care reform in 2009. Hopefully a coherent, workable plan will arise from this stew of policies and concepts. Senator Obama speaks of being open to other approaches. As he put it when speaking at a Families USA forum in January 2007, “… affordable, universal health care for every single American must not be a question of whether, it must be a question of how. We have the ideas, we have the resources, and we will have universal health care in this country by the end of the next president’s first term.”

As president, Senator Obama would do well to remember these words. There will be pressure to pass something and pass something quickly. The “First 100 Days” nonsense will be pushed forward as his only window for pushing through comprehensive reform. This is silly. It’s far more important to get health care reform done right than according to an arbitrary timetable.

Instead of rushing reform, President Obama should demand that all the “hows” be on the table. He should require participants to leave their egos and pride of authorship at the door. He should demand an honest appraisal and accounting of both what’s working and what’s not working in the current system. He should set forth the principles he expects to achieve in the process. Then and only then should the hard work of building a new, better system, one that will provide “affordable, universal health care for every single American” begin.