Access to the best care

is what is at stake in allowing end of life preferences and planning discussions to be covered in annual wellness exams for Medicare beneficiaries. When I teach my class in health policy, and give lectures about health reform and health policy, I typically start with the first of two basic laws that govern any health system:

• Everyone dies, it is only a matter of when and from what.

When I say this in lectures, there is always a nervous laughter. Of course everyone knows this to be true, but I think the laughs are saying why start there? I start there because it is the only thing I know to be absolutely certain about health policy and our health care system.

Allowing physicians to be paid to discuss the options that Medicare beneficiaries have as they move inexorably toward death (we are all one day closer than yesterday, right?) is a matter of ensuring access to high quality care. I have written about the benefits of palliative care (care designed to improve quality of life regardless of age or prognosis) including ways in which I think the hospice benefit in Medicare should be opened up and expanded to allow persons to access many of the services offered even if they wish to continue aggressive medical treatments.

As a culture, we really need to grow up and learn to talk about the inevitability of death, both with family members, our health care providers, and more broadly. In the same talks with community groups that I mention above, after the nervous shifting is done, later people insist that we have to control out of control health care spending. Then as I walk through ways we might do this, the audience doesn't like any of them. I conclude that we are a profoundly delusional people when it comes to facing death and the amount of money we spend to forestall it. The root of this delusion is that we don't know how to talk about hard things in health care.

We have come a long way in talking about choices that people have as they approach death in the past 30 years or so since the Medicare program started covering hospice care (in 1983) and when there began to be books and dialogue around the concept of a good death, and amplifying patient choices. We still have a ways to go, and expanding access to discussions of this sort between doctors and patients if they want them is a good step.