On former Sen. Fred Thompson’s radio show, former lieutenant governor of New York Betsy McCaughey said that the House’s proposed health care bill contained a provision that would institute mandatory counseling sessions telling seniors how "to do what’s in society’s best interest … and cut your life short." House Minority Leader John Boehner made a slightly more measured statement, warning that the same provision "may start us down a treacherous path toward government-encouraged euthanasia if enacted into law."

In truth, that section of the bill would require Medicare to pay for voluntary counseling sessions helping seniors to plan for end-of-life medical care, including designating a health care proxy, choosing a hospice and making decisions about life-sustaining treatment. It would not require doctors to counsel that their patients refuse medical intervention.

Analysis

Our inboxes have exploded recently with worried queries from readers who have heard that the House’s proposed health care bill, H.R. 3200, contains a provision that would require that ailing seniors be pressed to consider suicide in order to save the taxpayers money on Medicare. Most messages mention that this clause appears on page 425 of the legislation. A sample e-mail forward:

Chain e-mail: On Page 425 of Obama’s health care bill, the Federal Government will require EVERYONE who is on Social Security to undergo a counseling session every 5 years with the objective being that they will explain to them just how to end their own life earlier. Yes…They are going to push SUICIDE to cut medicare spending!!!

Page 425 does deal with counseling sessions for seniors, but it is far from recommending a "Logan’s Run" approach to Medicare spending. In fact, it requires Medicare to cover counseling sessions for seniors who want to consider their end-of-life choices – including whether they want to refuse or, conversely, require certain types of care. The claim that the bill would "push suicide" is a falsehood.

McCaughey’s Scare Tactics

Many of the e-mails cite former Republican lieutenant governor of New York Betsy McCaughey’s interview on former senator and Republican presidential candidate Fred Thompson’s radio show. On July 16, McCaughey, who founded a group called the Committee to Reduce Infection Deaths in 2004, appeared on Thompson’s program to discuss health care. Citing page 425 of the bill, McCaughey claimed that “the Congress would make it mandatory … that every five years, people in Medicare have a required counseling session that will tell them how to end their life sooner, how to decline nutrition, how to decline being hydrated, how to go into hospice care … all to do what’s in society’s best interest … and cut your life short.” Thompson chuckled at this and said, “I’ve seen bits and parts of [the bill], Betsy, but I didn’t know that.” He hasn’t seen that bit, of course, because it doesn’t exist.

McCaughey misrepresents the content of page 425 of the bill. That section would require Medicare to pay for some end-of-life planning counseling sessions with a health care practitioner. Here’s part of the section in question.

H.R. 3200, page 425: Subject to paragraphs (3) and (4), the term ‘advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning … .

(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders … .

The accepted definition of end-of-life planning means thinking ahead about the care you would like to receive at the end of your life – which may include the choice to reject extraordinary measures of life support, or the choice to embrace them. For instance, the National Library of Medicine describes end-of-life services as "services [that] are available to help patients and their families deal with issues surrounding death." This can include making decisions about treatment, designating a health care proxy, choosing a hospice program and putting together a living will, all of which the bill mentions explicitly as being part of an advance care planning consultation. In a 2003 study, the Agency for Healthcare Research and Quality found that "

atients who talked with their families or physicians about their preferences for end-of-life care had less fear and anxiety, felt they had more ability to influence and direct their medical care, believed that their physicians had a better understanding of their wishes, and indicated a greater understanding and comfort level than they had before the discussion."

Furthermore, the bill would not make these sessions mandatory. It modifies section 1861(s)(2) of the Social Security Act, defining what services Medicare will pay for – if these definitions made treatments mandatory, seniors would all be required to get artificial legs and midwife services, too. In other words, this section of H.R. 3200 would require Medicare to pay doctors when they counsel their patients about such things as living wills, but no more frequently than once every five years, unless there’s a significant change in health status. "Both myself and our outside counsel have reviewed section 1233 of the House bill, and neither one of us can reach the conclusion that it is a mandatory consultation for Medicare and Medicaid beneficiaries," Jon Keyserling, vice president of public policy at the National Hospice and Palliative Care Organization, told us. "The opportunity for the consultation is not only voluntary but patient-initiated."

"As I understand it, the intent of the provision is to have patients be provided an opportunity to discuss with their own health care professional, probably the one they have been seeing for the past many years, what their treatment wishes might be as they approach the end of life," said Keyserling, who stressed that consultations like this are treatment-neutral. Comparing this to forced euthanasia is like saying that a bill making retirement planning easier would force Americans to quit their jobs.

A press release from the AARP describes McCaughey’s description of the health care bill as “rife with gross – and even cruel – distortions.”

AARP press release, July 24: Ms. McCaughey’s criticism misinterprets legislation that would actually help empower individuals and doctors to make their own choices on end-of-life care.

This measure would allow Medicare to pay doctors for taking the time to talk with individuals about difficult end-of-life care decisions. It would help provide people with better information on the positives and negatives—both physical and financial—that different treatments can mean for them and their families.

Facing a terminal disease or debilitating accident, some people will choose to take every possible life-saving measure in the hopes that treatment or even a cure will allow them more time with their families. Others will decide that additional treatment would impose too great a burden—emotional, physical and otherwise—on themselves and their families, declining extraordinary measures and instead choosing care to manage their discomfort. Either way, it should be their choice.

This measure would not only help people make the best decisions for themselves, but also better ensure that their wishes are followed.

Incidentally, we’ve rebutted other claims by McCaughey. In February, she claimed, based on the bill’s promotion of comparative effectiveness research, that the stimulus bill would enact a health care rationing board that would deny care to seniors.

Boehner’s Baseless Claim

At least two Republican leaders have echoed this end-of-life distortion. On July 23, Republican Rep. John Boehner of Ohio, the House minority leader, released a statement, along with Republican Policy Committee Chairman Thaddeus McCotter of Michigan, saying that the bill would encourage euthanasia:

Boehner/McCotter statement, July 23: Section 1233 of the House-drafted legislation encourages health care providers to provide their Medicare patients with counseling on “the use of artificially administered nutrition and hydration” and other end of life treatments, and may place seniors in situations where they feel pressured to sign end of life directives they would not otherwise sign. This provision may start us down a treacherous path toward government-encouraged euthanasia if enacted into law.

We can’t argue with Boehner’s claim that counseling “may” cause more seniors to refuse treatment such as artificial nutrition and hydration, but we see no evidence that it will. There’s certainly no requirement in the bill that seniors decline life support or extraordinary measures of medical treatment.

Furthermore, seniors have had control over the end-of-life issues the Republicans are concerned about for a long time. California first legally ratified the use of advance directives like living wills in 1976, and the 1990 Patient Self-Determination Act mandated patients’ rights to decide what degree of intervention they prefer. Though there are still controversies over what care patients should be allowed to refuse and under what circumstances, the fact is that the right to refuse care is nothing new.

As for the argument claiming that this is the first step on a slippery slope leading to government-encouraged euthanasia, that’s a stretch. The right to draw up an advance directive is federally guaranteed, but doctor-assisted suicide is legal in only three states. It would take a lot more than Medicare-funded counseling for voluntary euthanasia to become a standard government recommendation.

The original author of this part of the legislation responded to Boehner’s and McCotter’s statement on the House floor, saying that "nothing could be further from the truth." The section under question was based on a stand-alone piece of legislation sponsored by Democratic Rep. Earl Blumenauer of Oregon and Republican Rep. Charles Boustany of Louisiana. Three more Democrats and another Republican cosponsored the legislation. On July 24, Blumenauer expressed his "disappointment" in Boehner’s misinterpretation of the bipartisan bill:

Rep. Blumenauer, July 24: In a statement from the minority leader … there is an allegation that somehow there is legislation in the health care draft that may place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign that may start us down a "treacherous path towards government-encouraged euthanasia if enacted into law."

Well, Mr. Speaker, nothing could be further from the truth. Had the minority leader, and his whip, and the conference Chair bothered to check how that legislation came to be enacted into our health care legislation, they would have found out that it was work of a bipartisan group of Ways and Means Committee members. There were Republicans cosponsoring it along with Democrats. …

We’re seeking … to be able to adjust Medicare so that it speaks to the needs of American seniors and their families, that they’re given the attention they need to prepare for this difficult period of time. There’s nothing in this legislation that would force people to have consultations. There’s nothing that would force them to sign advance directives. It’s not going to choose a health care professional by the government and force it on them. …

Mr. Speaker, I can’t tell you how disappointed I was to see this type of reaction to a carefully crafted piece of legislation that we’ve been working on for more than 6 months that is bipartisan and that speaks to the needs of American families.

Blumenauer also discussed the importance of advance planning on life-extension treatment. "[T]oo often senior citizens and their families are not given the information they need to be able to cope with the most serious situation any of us will ever face as we have a loved one move into the end of his or her life," he said. "We had … Republican committee members talk about how their loved ones didn’t get that type of help at the end of life and actually were subjected to things that they thought were not in the best interests of their loved one. If they had a choice, they wouldn’t have done it over again, and it didn’t prolong their life, it actually made them less comfortable."

Obama Responds

At an AARP town hall event on July 28, the president took on questions about these claims. A woman named Mary, from North Carolina, asked: “I have been told there is a clause in there that everyone that’s Medicare age will be visited and told to decide how they wish to die. This bothers me greatly and I’d like for you to promise me that this is not in this bill.” Obama responded:

Obama, July 28: I think that the only thing that may have been proposed in some of the bills – and I actually think this is a good thing – is that it makes it easier for people to fill out a living will. … And if you don’t want to fill out a living will, you don’t have to. But it’s actually a useful tool I think for a lot of families to make sure that if, heaven forbid, you contract a terminal illness, that you are somebody who is able to control this process in a dignified way that is true to your faith and true to how you think that end-of-life process should proceed. You don’t want somebody else making those decisions for you. … But, Mary, I just want to be clear: Nobody is going to be knocking on your door; nobody is going to be telling you you’ve got to fill one out. And certainly nobody is going to be forcing you to make a set of decisions on end-of-life care based on some bureaucratic law in Washington.

Moderator and AARP radio host Mike Cuthbert then told Obama: “As I read the bill, it’s saying that Medicare will, for the first time, cover consultation about end-of-life care, and that they will not pay for such a consultation more than once every five years. This is being read as saying every five years you’ll be told how you can die.” The president responded: “Well, that would be kind of morbid.”

He went on to explain: “The intent here is to simply make sure that you’ve got more information, and that Medicare will pay for it.” Exactly so.

– by Jess Henig, with Lori Robertson

Sources

U.S. House. "H.R. 3200." (as introduced 14 Jul 2009.)

Agency for Healthcare Research and Quality. "Advance Care Planning: Preferences for Care at the End of Life." Mar 2003.

Social Security Act. 42 USC 1395x. (accessed 29 Jul 2009.)

"AARP Responds to Health Reform Scare Tactics." Press release. AARP 24 Jul 2009.

Keyserling, Jon. Interview with FactCheck.org 29 Jul 2009.

House Republican Leader John Boehner. Statement by House GOP Leaders Boehner and McCotter on End-of-Life Treatment Counseling in Democrats’ Health Care Legislation. 23 Jul 2009.

Patient Self-Determination Act. 42 USC 1395cc. (accessed 29 Jul 2009.)

U.S. House. "H.R. 1898." (as introduced 2 Apr 2009.)

U.S. Congressional Record. 24 Jul 2009: H8796.

Remarks by the President in an AARP Tele-Town Hall on Health Care Reform, AARP Headquarters. WhiteHouse.gov 28 Jul 2009.

I am an Independent

This issue is clearly defined and some of you if you ripped out your insurance policy would  probably find  the same thing.