Olympia Estate Planning

Can We Have a Fact-Based Conversation About End-of-Life Planning?

By Brendan Nyhan 

Dealing with health care needs at the end of life is a difficult but unavoidable issue in an aging society with rising health care costs like ours. After a failed attempt to deal with the issue as part of the Affordable Care Act, it may again be returning to the policy agenda. Can we avoid another catastrophic bout of misinformation?

The debate over end-of-life planning has largely been dormant since 2009, when the former Alaska governor Sarah Palin’s false claim that President Obama’s health care plan included a “death panel” spelled the end of a proposal for Medicare to reimburse doctors for voluntary end-of-life consultations with patients. The Obama administration briefly issued and then withdrew a regulation that would have added end-of-life consultation coverage to Medicare in early 2011, but is likely to revisit the issue after receiving a recommendation from an influential American Medical Association panel.

Unfortunately, the lesson from the “death panel” controversy is that this issue is vulnerable to demagoguery if it becomes linked to people’s partisanship or feelings about controversial political figures and issues. For example, after Ms. Palin’s comments became widely known, and other prominent Republicans began to echo her claims, the myth came to be deeply held among the public. People’s negative predispositions toward Mr. Obama or his plan overwhelmed their critical faculties.

A Myth That Refuses to Die

Although the claim has been repeatedly proved false, polls have consistently shown that more than a third of Americans believe the Affordable Care Act created a government panel to make decisions about end-of-life care for people on Medicare.

%

40

30

20

10

0

34%

Jul '10

Dec '10

Jun '11

Nov '11

Sep '12

Mar '13

Mar '14

Source: Kaiser Family Foundation polls

In an analysis of 2009 polling data, for instance, I found that Republicans who thought they were well informed about Mr. Obama’s plan were more likely to be misinformed than those who said they didn’t know very much about it — the same pattern observed in 1993 for the myth that President Clinton’s health care plan would take away your choice of doctor.

The same biased reasoning processes make it difficult to undo these mistaken beliefs once they are entrenched. In a 2011 experiment, Jason Reifler, Peter Ubel and I found that corrective information about the “death panel” claim successfully reduced belief in the myth among people with neutral or warm feelings toward Ms. Palin who were less knowledgeable about politics.

Sarah Palin speaking in 2012. Her assertion that President Obama’s health care plan included a “death panel” helped derail a proposal for Medicare to reimburse doctors for voluntary end-of-life consultations with patients. CreditStephen Crowley/The New York Times

However, we found that misperceptions did not decrease significantly among people with mixed or positive feelings toward Ms. Palin who were more knowledgeable about politics — the individuals who are best equipped cognitively to resist unwelcome information. In fact, exposure to corrective information attributed to “nonpartisan health care experts” actually increased belief in the myth among respondents who feel very warmly toward her — a finding that is consistent with the “backfire effect” Mr. Reifler and I found in prior research.

The “death panel” belief has persisted in the years since Ms. Palin’s comments. Though the wording of the question is imperfect, polling datafrom the Kaiser Family Foundation shows that approximately one-third of Americans still believe in the myth — a proportion that has remained relatively stable since 2010. (Similarly, a 2012 academic survey using different wording found that one in two Americans endorsed the myth and only about one in six knew with high certainly that it was false.) This persistence may be the reason that the Obama administration has avoided the issue until now.

Will things turn out differently this time? Support for covering voluntary end-of-life planning is actually remarkably strong across the political spectrum. In addition to the American Medical Association panel’s recommendation, both private insurers and states such as Colorado and Oregon are now offering coverage for these consultations. Even critics of President Obama’s health care plan such as National Review’s Wesley J. Smith and Senator Johnny Isakson, Republican of Georgia, are in favor of advance planning.

Given the strength of this bipartisan consensus, adding coverage for end-of-life planning might seem unlikely to attract significant opposition or revive previous misconceptions. But a risk-averse administration may still elect to dodge the issue given Mr. Obama’s weak approval ratings and precarious political standing. A lesson of 2009, after all, is that it only takes one ambitious critic to spark a conflagration.