No anti-health care reform argument has generated more profound puzzlement on my part than the related claims that the legislation will require "rationing" of health care and will create and empower "death panels" to make end-of-life decisions, or to force patients into such decisions against their wishes and better judgment. Often, when these subjects come up, I have found myself unable to get beyond any point other than the observation that "There's nothing like that in the bill, so what are we talking about it for?"
Today, an op-ed piece by Danielle Allen, published in the Washington Post, discussed these and related issues in a way that let me better see where the folks making these arguments are coming from.
I thought it would be worthwhile to share Ms. Allen's op-ed piece (mentioned in BarbinMD's "Abbreviated Pundit Round-Up" today, although in connection with a separate point) with others and perhaps generate some discussion of what appear to be the implications.
First, a word about Danielle Allen. She is a Professor in the School of Social Science at the Institute for Advanced Studies in Princeton, N.J. More bio information here. Although I was unfamiliar with her work before reading her op-ed today, she has written some interesting things which I intend to look into.
The thrust of Ms. Allen's piece is concerned not with the loonies nor the Palinesque demagogues, but with people who sincerely advance contentions about rationing and death panels as topics meriting serious consideration. Unlike the shouters and the wingnuts, these people do not make the claim that "it's in the bill," and if only you will "Read the bill! Read the bill!" you'll see it. They know it's not in any specific words in the bill, so there is no point to arguing semantics about the meaning of particular provisions of the various drafts. Instead,
Their claim is that, whatever the stated goals of policymakers, the concrete outcomes that will flow from the policies on the table will include experiences that feel like rationing and conversations that sound like "death panels."
In this claim, Ms. Allen believes, there resides a valid point. And it is a point that only feeds on what we have all seen with respect to the evolution of the health care debate. She points out, for example, that during his campaign, in his debates with Hillary Clinton, President Obama "denied that his approach to reforming health care would require an individual mandate requiring everyone to buy health insurance." The voters nominated and then elected Obama, who maintained this position throughout. In actuality, it now seems clear that every bill, and Obama himself as well, now accepts that such individual mandates will be required to make reform work. To critics of the bills, there appear to be two possibilities: either Obama lied during the debates, or he didn't know what he was talking about. Either is discomforting.
Specifically, when people see changes of this magnitude occurring, and when no sufficient explanation for the change is forthcoming, it generates suspicions as to what might be in the drafted legislation that, in practice, will not work out as it has been explained, and perhaps even as it was honestly intended by the drafters and proponents.
In asking lawmakers to consider not merely the goals of their policies but also the experiential meaning of concrete realities that those policies may bring, they have a point. One can't answer them by saying: "These policies won't ration; there will be no death panels." If these reforms do either of these things, they will do so as a matter of unintended consequences.
As to how to convince voters that these potential "unintended consequences" will, in fact, not come into being, Ms. Allen's presciption is a bit less convincing than her diagnosis, but that only confirms for me the fact that these concerns are sincere, and not the product of addled brains or the politics of no. In essence, her recommendation is "to explain the institutional checks that will prevent" the unintended consequences. As to the discussion of rationing, she says, we should point out that "under the new regime one will always be able to pay out of pocket for any procedure one desires," subject only to normal triage practices. This argument seems unlikely to calm anyone's fears. For most of us, if we are to be provided an expensive operation, or a costly drug, we must obtain it, if at all, under the terms of our policies, whether we have private coverage, Medicare or the "public option" that may, and hopefully will, result from the current legislative efforts. It is cold comfort to all but a relative handful to be told, "You can get it if you can pay the going market price."
Ms. Allen's prescription regarding end-of-life matters seems more on target, but still depressingly difficult to achieve. She advocates "demystifying" the process of addressing end-of-life issues, and ultimately making it more of a universal practice to memorialize our wishes earlier in life, say in our 40s or 50s, rather than deferring until the need to do so is upon us. That is certainly a meritorious long-term goal; it seems more dubious that proceeding in that direction can do much to alleviate immediately the end-of-life concerns that have arisen about the pending bills.
Nevertheless, the first step in dealing with any problem is understanding it. Ms. Allen's thoughtful contribution took me a good ways down the road to understanding the insistence of those citizens who continue to assert fears of rationing and end-of-life issues, even though there is nothing specific or concrete in the bills upon which to base such concerns. Unless you are prepared to believe simply that looniness has overtaken a good portion of the citizenry at this particular time, and to write such folks off as not worth any of our time, I recommend trying to come to grips with the concerns.
Certainly, we can start by admitting that the process by which we have arrived at the point we find ourselves has not been ideal; campaign positions and rhetoric segueing into actual legislative sausage-making is bound to leave something to be desired. Certainly, it would have been preferable to have a series of separate discussions about the problems we face: how to reform and regulate the existing health insurance market; how to provide insurance for the one-sixth of the nation that is currently uninsured; how to pay for both the short and long-term effects of any changes we make; and, of course, how to spend less for the care we get, or at least moderate the growth in the total amount of resources spent in this country on health care. And clearly, the necessity of taking up all these issues at one time in one set of legislative proposals, with no guidance as to the overall plan coming from the White House (or anywhere else), out of a desire to allow Congress to operate in its proper sphere (or whatever), has all led to a high degree of confusion and anxiety.
The answer may be that that's where we are and there's nothing to be done but to push through whatever we can push through, by whatever means we need to employ to push it through. I firmly believe, however, that the result will be better to the extent we can still engage those who can still be engaged in honest, if laborious, discussion of real issues. That requires, of course, first acknowledging that "rationing" and fear of "death panels" are, in fact, real issues.