Health care reform: The uncivil war dividing America

The following is part of a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

The unfettered debate about ideas that characterizes the democratic process in the United States operates best when there is a truthful presentation of the issues, and when the process is civil and respectful. Unfortunately, the debate about health care reform has evolved to the point that it fulfills neither of those criteria. It is legitimate for concerned parties to disagree when considering the costs of health care reform and the potential paths for financing any reform initiatives. But when facts about reform proposals are distorted beyond recognition in an attempt to fuel civil unrest, and when that unrest translates to unruly disruption of town hall meetings, then reasoned debate has transformed itself into an uncivil war.

The idea that the House bill, HR 3200, is proposing “death panels” is perhaps the most egregious misrepresentation of the reform proposal, but it is certainly not the only one. Fortunately, the media are now presenting more coverage to reveal the truth – that the bill proposes payment to health care providers for the voluntary discussion of advance directives and end-of-life issues. Sadly, however, just as the gross distortion of this proposal has become better known, the uncivil war that erupted around it may ultimately result in its elimination. This would be most unfortunate, as it is a rational proposal that is specifically intended to put an informed decision-making process about their care directly in the hands of patients, exactly where it belongs.

As someone who has practiced Pulmonary and Critical Care Medicine for many years, I have repeatedly seen from more than one perspective the importance of physicians and patients dealing with such issues. For my outpatients who are not yet critically ill but who have or are likely to develop end-stage lung disease, it is important that they understand the management options in the event of deterioration or an acute event. Advance planning allows physicians and other healthcare providers to act upon patients’ wishes at a time when they may not be able to participate in the decision-making process.

On the other hand, for my inpatients in the critical care unit who are not previously known to me and who are too ill to participate in the decision-making process, I have worked with families to best develop an understanding of what the patient would likely have expressed if he or she could have participated in these life-altering medical decisions. Trying to guess a patient’s desires, even with family input, can never compare favorably with an advance discussion between physician and patient that facilitates a reciprocal understanding of the medical issues and the patient’s wishes.

Might such discussions lead to a patient’s choosing in advance to forgo some treatment options? Indeed they might. But patients should be the ones to make these decisions – not their physicians, not even their families, and certainly not insurers or the federal government. Encouraging physicians and patients to discuss such sensitive issues encourages rather than compromises patient autonomy. This is the laudable goal that HR 3200 proposes.

If legislators decide to remove this proposal from HR 3200, the American public will have experienced an unfortunate and unnecessary casualty from this uncivil war. Just as patients need to be informed and educated with truthful facts about end-of-life care and decisions they may ultimately face, the American public deserves to be informed and educated about provisions such as the one discussed here before condemning those provisions to a premature, unnecessary, and avoidable death.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • American Medical Association

    As Dr.Weinberger recognizes, confusion and misinformation have taken hold recently in the health-reform debate. We need to focus on the facts, remembering what’s at stake – a better health system for every American. While we still have a long way to go, we have already seen physicians, patients and policymakers find common ground on ideas that offer real health system improvements. The stage is now set for meaningful reform and we must seize it. Our nation cannot afford to squander this opportunity.

    J. James Rohack, M.D.
    President, American Medical Association

  • melcos

    With an issue as important as finding ways to improve access and rein in unsustainable health care costs, I totally agree that current tactics of exaggerations and outright lies by both sides of the debate, compounded by representatives and senators who readily admit that they don’t even bother to read the bills before them, is a total disgrace to the democratic process. That said, I believe that this “death panel” thing is not a repudiation of end-of-life decision making, but rather it epitomizes the frustration that many Americans have with the approach congress is taking.

    Dr. Weinberger decries the possible removal of the end-of-life planning section of H.R. 3200 because Congressmen don’t have the backbone to defend what they believe are valuable elements of the legislation. But I would ask Dr. Weinberger why he, as a physician, needs a provision specifically written into law to have these discussions with his patients? Doesn’t he already have these discussions with his patients, and if not, why not? Do we need legislation to tell doctors to do the right thing? If so, we are in a sadder place than I thought – God help us all!

    In a nutshell, the issue really is the nit-picking details packed into a 1000+ page bill filled with obscure language written by special interests that are not clear until we start implementing the bill, especially the unintended consequences that always seems to arise whenever billions of dollars is at stake in any federal program. There are countless examples where good intentions are codified into law, have terrible unintended consequences but then require an Act of Congress to fix.

  • Classof65

    I wish they had never started calling it “health reform” — what they are proposing, and what we want is “insurance reform.” The Federal government has already shown that it has the capability to run a huge program providing health care to millions — Medicare! Just extend Medicare to all of us, that’s all we want. No denials of care due to pre-existing conditions, no caps on care, and coverage for all Americans. It can be easily funded by pulling out of Iraq and Afghanistan and using the money we’re wasting over there (and giving to Halliburton) to fully fund Medicare-For-All. Quit making up lies about what the proposals are in the legislation.

  • Pingback: The matter of distortion, distorted « Whispers

  • Dr. Mary Johnson

    Perhaps if I believed those who wanted healthcare reform were genuine . . . and that reform was real reform, carefully planned and thought-out, mindful of the failures of the past, and fiscally responsible?

    I don’t.

  • drmonte

    Read Paul Krugman’s editorial in the NYTimes from today (August 31, 2009). The health insurance industry pours $1.4 million per day into lobbying our congress. That works out to around $2500.00 per congressman and senator per day!

    Health care reform will never happen, at least not in a meaningful way.

    What we really need is to convince the mainstream media to cover the real issues. The unbelievably stupid comments by politicians (mostly the Republicans, but some of the Democrats too) are irrelevant. I’d like to see the media really cover the efforts by industries who don’t want the status quo to change.

    Most of the people screaming at town hall meetings are the very people who need health care reform that includes a public option. They have been so distracted by lies that they can’t understand they’re working against their own interests.

    An interesting book along these lines is Thomas Frank’s “What’s the Matter with Kansas.”

    Monte Ladner, M.D.

  • John Ryan

    Dr. Weinberger, you make a good point, but distortions of the truth aren’t limited to bogus “death panels”. Our President has announced at “town hall meetings” (easily viewed on YouTube) that our profession chooses tonsillectomies for sore throats and amputates diabetic feet in order to maximize fees. If the lead policy-maker is so misinformed, what can we hope for?

  • drmonte

    I might not agree with some of the things politicians have said on YouTube, but I do think there is a need for doctors to put ourselves under the microscope.

    I was trained in Anesthesiology with a fellowship in pain medicine. I was appalled at what I saw happening in the world of chronic pain with regard to unnecessary, expensive, and potentially harmful procedures being done with little scientific data to support many of the procedures. Patients with back pain would get a presumptive diagnosis that would then be “tested” by performing a series of injections under fluoroscopy. If the patient “got better” the diagnosis was “confirmed” by the treatment. If the patient didn’t get better a new diagnosis was assigned and it in turn was tested by a treatment of different injections. This could, and often did, go on for a very long time and was very profitable for the doctor. Patients rarely got long-term benefit.

    I would get patients like this referred to my office for second opinions. I was always shocked that the insurance companies had paid for the treatment and that the patient had allowed it to happen. People trust us. That puts a big burden of responsibility on our shoulders.

    When my own father herniated a lumbar disc I had to take him to four different spine surgeons in different cities before finding one who would agree to a simple microdiscectomy. The others wanted to perform procedures involving cages and fusions. My father was in and out of surgery in a day and fully recovered with no complications within a few months. That was four years ago and he remains in excellent condition. Yes, some patients would have needed the more extensive and more expensive fusion surgery – but my experience in pain medicine was that the threshold for picking the most invasive and most expensive treatment option is often set very low.

    We have a lot of expensive surgical interventions that are helpful when applied to the “right” patients. However, for physicians to turn a blind eye to misbehavior among their own is a poor reflection on our profession and another reason health care reform will be difficult.

    My experience in medicine is that it is not a good thing for physicians to be tempted between invasive expensive treatment options and noninvasive, less expensive options.

    Part of health care reform should be doctors policing ourselves better. How do we do that?

    Monte Ladner, M.D.

  • newsdoc

    It will either be change that we help make or change will come. If no bill is passed Medicare is due go bankrupt in 2012, the SGR will continue to squeeze payment to doctors Small changes will never get tort reform since as an individual concept it won’t pass through Congress or indiviually. I hope that when the government must pick up the bill like VA clinics the option to sue (the government) will go. Insurance companies and lawyers have a long history of codependence.
    The argument that no one has read the bill is false. There are at least 3 versions out there. They are different in the Senate than in the House. They will need to be made into one if passed and then riders will be attached. That is how it is for all bills. The health insurance industry is large so it is not surprising the bill is big but it is still puny next to the budget.
    The socialism argument is false. If it is Medicare, I must charge within certain guidelines. For other entities I can charge what I like but what I am paid is determined by the company. I cannot even bargain with the insurance companies except as an individual which is like David bargaining with Goliath.
    Finally it is going to be expensive no matter what we do. By extending coverage to all those young people who don’t buy it now and others that think it is too expensive or that they are too healthy the monies coming in (the pool which the insurance company wants) will increase. Then hopefully through a reduction in insurance companies overhead (CPT-10) and tort reform the monetary pain may be bearable.

  • John Ryan

    The issue that I bring up isn’t that there aren’t badly motivated doctors (there are, as Dr. Ladner describes), but that our President is implying that we are subject to the same motivations (follow the money) that the Paul Krugman NY Times article reveals is guiding the actions of our legislators.
    The chilling feeling I get from these statements is that the next step will be rationing expensive care under the guise of curbing physicians evil nature.
    I don’t share the common view that we physicians don’t police ourselves. After 25 years doing primary care, I know exactly who to refer my patients to, and who not to. In the hospital environment, it is much more difficult, since the medical staff system is under the thumb of administration and its lawyers. But if you are not on your hospital credentials committee, you should be. It is very evident and quite easy who gets passed, and who needs a “performance agreement”.

  • Outrider


    Thank you. I’m a DVM, not an MD, but members of my profession wrestle with the issue of recommending tests and treatments every day. The difference is that our clients pay out of pocket, so we have a clear motivation to openly discuss cost vs. potential benefit.

    That has not been my experience with human medicine, unfortunately. But I don’t have a good answer for how MDs should police themselves, though becoming hospital employees on flat salaries might be one solution upon which the government may ultimately decide.

    As for myself, as an occasional patient, I prefer less intervention. More is not always better. I suspect that I am in the majority here.

  • radphys

    DrMonte and Outrider:

    I couldn’t agree more. The conflicts of interest are glaring. One of the best things that could happen to health care is for physicians to once again become practitioners of medicine rather than entrepreneurs.

  • Robert Ricketson

    I have not read the entire 1018 pages of HR 3200 yet but what I did discover in the first 32 pages was this. It appears that in Sections 123 and 124 there is a discussion regarding the Standards Benefits. It expressly states that the Standard Benefits package does not have to be decided until 18 months AFTER the Act has been passed. This is obviously a concern. Why would you endorse a product that does not present what it will cover? At this point, one can only assume. That is a dangerous position. And if the final package is unacceptable, what recourse is there? There needs to be some clarification to this before we offer a blanket endorsement.

  • newsdoc

    The final bill, whatever it is, will only be a skeleton. It seems long to the lay person at one thousand pages but the Medicare manuel is much larger and gets larger by the year, same with the Medicaid manuels. Check with your biller and that is only about billing.The best thing would be (and most likely will be) a panel of doctors and others will be appointed to determine the benefits. Please remember the present array of service is vast and so are the conditions and the types of physicians and types of clinics and exceptions and on and on. Try to get specific payment levels from insurance companies or their “rules”. They are just now being obligated to tell us what they pay for more than a few CPT codes. The new ICD 10 program has over 10,000 diagnosis codes. Change is coming one way or the other. Not choosing is choosing.
    Politically it is now more important that the bill be less specific with ridiculous criticism like death panels being used to scuttle the whole thing.

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