The Reality-Based Community

Robert Pear, in today’s New York Times, reports that Medicare will begin covering physician counseling for advance care planning—a variant of the dreaded “death panel” provision removed from health reform. As Pear summarizes things:

Congressional supporters of the new policy, though pleased, have kept quiet. They fear provoking another furor like the one in 2009 when Republicans seized on the idea of end-of-life counseling to argue that the Democrats’ bill would allow the government to cut off care for the critically ill.

The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.

While the new law does not mention advance care planning, the Obama administration has been able to achieve its policy goal through the regulation-writing process, a strategy that could become more prevalent in the next two years as the president deals with a strengthened Republican opposition in Congress.

This is a welcome development, for three separate reasons…..

This is a sound and humane policy, which helps patients, their families, and medical providers in difficult but inescapable situations.
Who among us would want to fall mortally ill without having had the chance to provide our families and our doctors with a clear plan? Who would want to be standing there exhausted and frightened at the bedside, trying to divine when our sedated parent or spouse would really want the withdrawal of a feeding tube or whether one’s unconscious parent suffering from metastatic cancer would want heavy doses of painkiller that provide comfort but that may hasten death by a week? Who among us wants to be the attending physician or young medical resident at that same bedside, trying to provide care without a proper roadmap of that patient’s preferences? For all kinds of reasons, discussing these difficult issues openly and calmly during one’s annual wellness visit is obviously a sensible thing to do.

It happens to be smart short-term politics for Democrats.
This issue is too intimate to our humanity for one’s view to be determined by partisan concerns. Still, it’s nice that good policy is also smart politics. Let’s implement this policy awhile, show that it is valuable, and see what Americans believe once they realize that the planet is still rotating with no actual sightings of bureaucratic goon squads. If Republicans then want to rescind this benign benefit, they’ll need to do so based on the actual merits, not on the basis of the most notorious verified literally “pants-on-fire” lie of the whole health reform debate.

It’s even better long-term politics for both Democrats and Republicans who actually want to govern.
The issues here are not about money or cost-effectiveness. I have no idea whether advanced care directives actually save money. That’s not the point, and it never was.

As Atul Gawande notes so well in the New Yorker, the real policy issues are different: to provide patients with the opportunity to speak frankly with a knowledgeable provider about one’s daily needs and goals when the possibility of cure is gone. It’s about alleviating some people’s all-too-realistic fears that they will needlessly suffer, and others’ equally plausible fears that those caring for them will give up too soon when they wish to fight on. When we think about the end of our own lives, it’s about providing our children, spouses, and friends with some comfort that we were treated in accordance with our wishes in our final days and hours.

End-of-life care and decision-making will still leave deep scars. How can it not, when what’s at issue is the manner of a loved person’s passing from this earth? It does not have to be the chaotic, undignified, needlessly painful mess it so often is today.

The political issues here are not really partisan, either. There’s nothing wrong with partisanship. I’m not a no-labels guy myself. One should be partisan about the proper size and role of American government, about progressive taxes, gay rights, and other basic matters. Health reform engaged serious ideological differences that had to be fought out. Debate about affordability credits, universal coverage, and the public option were bound to be heated, sometimes angry and loud.

That wasn’t what was going on here. The advance care directive provision, like so many of the pages in this huge bill, could have been written by either Republican or Democratic policy wonks, who actually agree about many delivery-system elements of health care reform. As it happened, the language appears to originate with a Georgia Republican. Unless one is so libertarian as to entirely reject Medicare, there are good conservative arguments for allowing individual patients to address these issues in advance, in the unhurried privacy of a doctor’s office, not on the fly in some crowded ICU, on the basis of frightened guesswork of an exhausted spouse or the personal practice philosophy of some random attending physician.

Maybe most important, getting this done would be a great victory for sane political debate. Forty years ago now, President Richard Nixon spoke of the silent majority, the non-shouters who watched American politics with dismay in a viciously divided time. His specific rhetoric was breathtaking in its dishonesty. As described in Rick Perlstein’s terrific and disturbing book Nixonland, the president himself was a cynical and vindictive exploiter of the very divisions he claimed he was trying to heal. That’s largely the politics Nixon left to us with Watergate and the endgame in Vietnam, hence the title of Perlstein’s book.

Still, there is a reason Nixon’s rhetoric was so appealing, appealing to me anyway. There is an often-silent majority in America of non-shouters and non-haters. Some of us are liberal. Some of us are conservative. Some are pro-life, some pro-choice. Wherever we reside ideologically and morally, we have a common stake in respectful serious politics based on reasoned, evidence-informed debate, in which people on each side actually listen to each other and honor the humanity of their counterparts across political divides.

Viewed in this light, the “death panel” screaming demagoguery was the low moment of the health reform debate. It was worse, though less determinative of the specific legislative outcome, than the ossified Senate rules or the accompanying sleazy side deals required to secure 60 Senate votes. It was a grotesque and calculated lie that exploited people’s primeval fears that cost-effectiveness analysis would be used to abandon the elderly and the disabled. In a particular orthogonian twist, Sarah Palin and others wildly and dishonestly trashed distinguished ethicist/oncologist Zeke Emanuel as part of this effort.

Such lies might momentarily serve Republican purposes. In the long-run, they don’t. Over the next half-century, America has a real mountain to climb to make Medicare a more effective, disciplined, and humane structure to finance medical care. You can bet that the next time Republicans win the presidency and advance their own complex and thus inherently forbidding plans, Democratic critics will be waiting with turnabout talk to seniors of death panels and the like. I hope both sides err on the side of civility within the reality-based community.

By not allowing last year’s demagoguery to derail this modest and sensible measure, this month’s Medicare regulations help us move ahead. We don’t have to live in Nixonland anymore.

Postscript: Jon Chait finds an essential link.

Posted: Monday, December 27th, 2010 at 8:20 am
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