Now that Healthcare.gov seems to be working reasonably well (at least on the consumer end), Republicans are going to have to find something else they can focus on in their endless war against the Affordable Care Act. So get ready for the return of "death panels."
They never really went away. Those who aren't immersed in the fantasy world in which conservatives move were reminded of that last week, when chronicler of changed games Mark Halperin, the embodiment of most everything that's wrong with contemporary political journalism, did an interview with the conservative news organization Newsmax. When the interviewer mentioned "death panels, which will be coming," Halperin responded, "I agree, it's going to be a huge issue, and that's something else about which the President was not fully forthcoming and straightforward." Halperin didn't explain what lie he imagines Obama told about death panels (perhaps he thinks that when Obama said the government wouldn't declare your grandmother unfit to live and have her murdered, he wasn't telling the truth), but what matters isn't Halperin's own ignorance of the law (after all, understanding policy is for nerds, right?), but the fact that it came up in the first place. Which, if you pay attention to places like Newsmax, it still does. A lot.
But wait, you say. Wasn't this all debunked years ago? Yes, it certainly was. But why should that matter?
It's important to remember the switcheroo conservatives pulled on the "death panel" issue. They started off complaining that one provision in the law constituted "death panels," then when their unequivocal lie was exposed and condemned roundly even by neutral observers, they switched to asserting that all along they had been talking about an entirely separate and unrelated provision, and when they say "death panels" they aren't talking about death, or panels for that matter, but about health care "rationing."
Here's how it happened. The ACA originally included a provision allowing doctors to get reimbursed by Medicare for sessions in which they counseled their patients about their end-of-life options and how to make sure their wishes were properly carried out. The problem is that most of the time, when a patient shows up in the hospital in crisis, the staff has no idea what the patient wants if they can't communicate. Do they want to be resuscitated, or intubated, or have every heroic measure taken until the moment they expire? All of us have different ideas about this, and it's important that we think about it beforehand. So the ACA said, if a doctor spends a half hour talking to a patient about it, they'll be paid for their time. It didn't say what they had to tell them, it just said they could get paid for doing it, because right now if they do that counseling, they're doing it for free, which makes it much less likely to occur, which is not only bad for the system but bad for individual patients.
So that part of the law said simply that doctors can bill Medicare for the time they spend doing that kind of counseling, just like they do for a physical exam or performing a procedure. To the people who supported it, the idea seemed commonsensical. Wouldn't you want doctors and patients to have those kinds of conversations? You'd think. But turning that into the "death panel" lie began, as a remarkable number of health care lies have in the last couple of decades, with policy fraudster Betsy McCaughey, who went on Fred Thompson's radio show in 2009 while the law was being debated and told his listeners, "Congress would make it mandatory-absolutely require-that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner." That would be terrible! It would also be terrible if our beloved elders were then hurled from hot air balloons hovering over volcanoes, but the law doesn't require that either.
Unlike most deceptions in politics, which can be justified by pleading that there was some misinterpretation of ambiguous language, or that what the speaker meant just got garbled in the articulation, this was a clear and specific lie-or two lies, in truth-that McCaughey simply made up in her attempt to subvert the law and then repeated multiple times. There was nothing mandatory or required about counseling, every five years or ever, for any patient, and the counseling was not about "how to end their life sooner."
To continue our story, then Sarah Palin took things the next step, turning a blatant lie (but at least one with some connection to what the law was about) and spinning it out into an extravagant fantasy one can only imagine came from some obscure 1970's dystopian sci-fi movie she saw at four in the afternoon one day while the snow fell gently in Wasilla. "The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel,'" she wrote on her Facebook page, "so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care. Such a system is downright evil." 11 The quotation marks were a nice touch, since we in the English-speaking world use them to denote actual quotes from a specific person or document, not just something you make up. For instance, I could write, "I wouldn't like to go to Sarah Palin's house, where 'heroin is given to children' and 'homeless men are hunted for sport.'" But that would be extremely misleading, since as far as I know, no one has said those things about Sarah Palin's house, least of all Palin herself. And thus "death panels" were born.
And of course, the charge was picked up by Fox News, and Rush Limbaugh, and all the other far-flung outlets of the conservative media universe. But then the existence of any such panel was debunked and debunked and debunked again. The fact that the evocative phrase originated with Palin probably made it more difficult for conservatives to make it stick beyond their own self-contained world, since Palin is widely understood to be one of America's most celebrated nincompoops. In addition, cowardly Democrats removed the provision on end-of-life counseling from the bill (to their unending shame) so even the entirely worthy provision of the law was gone. In response, conservatives cast about, and decided that the "death panels" they so feverishly warned of never referred to end-of-life counseling, but to the Independent Payment Advisory Board (IPAB), which did end up in the final bill and which has the benefit of resembling an actual panel.
In brief: the IPAB is a group of 15 health-care experts appointed by the president and confirmed by the Senate who will make recommendations on how Medicare could save money. Those recommendations are due at the beginning of each year, and Congress has until August to overrule them. If Congress doesn't, the Secretary of Health and Human Services will implement the recommendations. But the IPAB only makes the recommendations if Medicare's growth exceeds certain target rates.
Now listen to this part carefully: the text of the ACA prohibits the IPAB from recommending that care be rationed. It also prohibits them from recommending other things, like increasing premiums or cutting benefits. And perhaps most importantly, if Medicare's growth is modest, IPAB won't make any recommendations at all. And if things go the way they've been going and the way they will if many of the other reforms contained within the ACA succeed (including steps to transition from a purely fee-for-service model in which sicker patients means more revenue for providers to one in which they have incentives to keep people healthy), the IPAB might never have to make cost-cutting recommendations. Although things could change of course, the Congressional Budget Office believes that for the next decade Medicare's growth is unlikely to be large enough to trigger any IPAB recommendations.
You may wonder why conservatives, who are constantly saying we need to control the cost of Medicare, are so vehemently opposed to the existence of a panel of experts whose job it is to come up with ways to control the cost of Medicare. That just shows how little you understand. IPAB, they will tell you, will ration care, which will kill your grandmother, no matter what the law says. 22These kinds of claims, and a general feeling of hysteria around end-of-life issues, circulates relentlessly throughout the conservative world. You may remember that during the 2012 presidential primaries, Rick Santorum told an audience that in the Netherlands, which has a tightly regulated system of physician-assisted suicide, "people wear different bracelets if they are elderly. And the bracelet is: 'Do not euthanize me.' Because they have voluntary euthanasia in the Netherlands but half of the people who are euthanized-ten percent of all deaths in the Netherlands-half of those people are euthanized involuntarily at hospitals because they are older and sick." This was about as true as if he had said that all Portugese people have ESP or that Mongolia is ruled by a parliament made up of dogs and cats. But he didn't get his fantasy bracelets and fantasy statistics from nowhere-the idea surely arrived to him via the cretinous version of the "telephone" game that is the conservative information bubble, where such things circulate and mutate until they come out the mouths of candidates for president. Just as a for instance, go on over to National Review and search for IPAB, and you come up with articles with titles like, "AARP Betrays Seniors By Supporting IPAB," and "IPAB, Obama, and Socialism," and "New England Journal of Medicine Supports Unamerican Expansion of IPAB." As I said, once they can no longer complain about healthcare.gov, and once those people who had their junk insurance cancelled turn out to be getting much better insurance, conservatives are going to have to turn somewhere, and I'm guessing "rationing" will be on all their lips.
So what started as "Obama is forcing doctors to encourage their patients to die," then became "Obama's death panel will assess individuals one by one and withhold treatment from those they find unworthy, leaving people like Sarah Palin's kid to plead for their very lives," ends up as "Obama's IPAB death panel will force health-care rationing on us."
I do think that the chances that renewing the "death panel" scare will successfully undermine the ACA are slim. The fact that they don't exist does matter. If you're a reporter wanting to write a story about someone who lost their junk insurance and will have to buy real coverage, at least there are individuals you can focus on, even if you do a poor job of telling their stories. But there's no one you can interview who went before a death panel, or whose relative went before a death panel. Because, to repeat myself, they don't exist. So this whole discussion is likely to remain very abstract. Eventually, conservatives will find something else to cry wolf about. Did you know that under Obamacare, if you kiss a person with herpes, you could get herpes? That's right: Obamacare will give you herpes. Pass it on.
