Clift: Time for an Honest Healthcare Conversation

So many people are working to bring down health-care reform because it has a negative impact on their little corner of the world, or they've got a partisan interest in hampering President Obama's agenda. The various special interests may want cost control, but they don't want systemic change. And most are pretty heartless about the more than 40 million uninsured, thinking that those people should do something for themselves and not drain resources from the rest of the system.

This is what Obama is up against. These are the attitudes driving the debate, and the corporate interests and conservative activists who want to kill reform smell blood. Obama's approval ratings have suffered major declines, according to the latest Pew Research Center survey, down from 61 percent in mid-June to 54 percent. For the first time since Obama took office, about as many say the government is on the wrong track (48 percent) as on the right track (46 percent).

Rising unemployment numbers and a relentless assault on Obama for wading into the controversy over the arrest of Henry Louis Gates Jr. have taken a big toll. Voters are more skeptical than they might otherwise be about the health-care proposals advanced by the president, and more receptive to the misrepresentations and outright lies stoked by the opposition, leaving Obama with a credibility problem.

We've just come through six years of a war we didn't have the means to pay for, and assuring voters that major health reform will raise costs only for a small percentage of people—families earning more than $1 million—doesn't ring true. State-of-the-art technology and new drugs are expensive, and as a society we have serious cultural issues around the beginning of life and the end of life.

Those issues caught up with Obama this week at a town-hall meeting sponsored by AARP. A woman named Mary stood up to say she had been told there is a clause in the health-care plan that everyone of Medicare age will be visited and told to decide how they wish to die. Obama at first tried to lighten her concern with a quip, saying there aren't enough government workers to undertake such a task. Then he explained that the provision was about making it easier for people to fill out a living will, which makes sense whatever age you are in order to make your wishes clear should you become incapacitated. He noted that he and Michelle have one. If the provision becomes law, Medicare would cover a consultation about end-of-life care every five years.

Obama went on to explain that the intent of the provision is to give people more information about their options, including hospice care, and that Medicare would pay for that. Jon Keyserling, vice president for public policy at the National Hospice and Palliative Care Organization (NHPCO), says all the provision does is cover consultations about advance care planning. It does not order seniors to do anything, and the discussion is not with some faceless government bureaucrat, as critics claim, but with the family physician or specialist treating the patient. Keyserling has been doing legislative work for 35 years and says he doesn't mind debating facts. "But when folks intentionally skew legislation, it is particularly galling. I should be used to it, but it still irks me."

That's what happened when critics glommed onto one seemingly benign provision on page 425 of the 1,000-page House health package and blew it up into an Obama-inspired effort to force people to prematurely end their lives. In the spirit of full disclosure, I joined the board of NHPCO four years ago, after my husband died at home with hospice care. The experience made me a believer in what I came to see as the closest thing to a good death when death is inevitable and imminent. Most people do not want to die in a hospital hooked up to tubes, and if given the information might choose to forgo expensive and heroic medical interventions that lower the quality of life and do little to extend it.

Everybody likes to talk about "bending the cost curve," but doing it means taking on some sacred cows. "What people in Congress need right now is courage," says Len Nichols, a health-care economist with the New America Foundation, "because it's hard to go out and say 'bend the cost curve' when it leads to accusations of rationing." Nichols spoke at a recent event in Washington that brought together 10 communities across the country that had achieved high-quality care at low cost. Moderator Mark McClellan, administrator of the Centers for Medicare & Medicaid Services under George W. Bush, challenged the participants, wanting to know if they discussed rationing care with patients. A representative from St. Petersburg, Fla., a community with a high number of elderly citizens, said rationing was not the word that was used, it's radioactive, but that patients welcome an honest discussion about the medical choices before them. "Seniors don't look at it as taking things away, but as somebody listening to what they want," he said, adding that 95 percent have advance directives. There's a lesson here for Obama. He has mastered every element of health-care reform but one, and that's the longing for the truth, even when it hurts.