End-of-Life Care

As initially proposed, the ACA aimed to reduce these conflicts by reimbursing doctors for time spent discussing end-of-life care with patients and families. This plan was dropped from the ACA after opponents labeled such discussions “death panels.” However, since 2016 Medicare has reimburse doctors for providing end-of-life counseling.

Debate over which procedures should be made available first came to the fore in 1989 with passage of legislation establishing the Oregon Health Plan (OHP), which offered free care to all Oregonians who were too poor to purchase insur- ance but not poor enough to get Medicaid (Saha, Coffman, and Smits, 2010). To keep costs affordable, each year the OHP first lists all possible health care services in order of priority based on effectiveness and costs as well as public priorities and values. It then contracts with managed care organizations to purchase services for OHP members, beginning at the top of its priority list and working its way down until it reached its budget limit. Thus, based on the budget available in any given year, expensive lower-priority services (such as heart transplants) might be eliminated, but low-cost and highly effective services (such as vaccinations) would be funded, and no individuals would be dropped from the program.

The OHP legislation marked the first time that a U.S. governmental body explicitly rationed health care—deciding in advance that some procedures simply cost too much to provide. The explicit use of rationing resulted in an outcry across the country, both from those who considered it discrimination against persons with disabilities and those who believed it was unethical to ration care only for the poor. Tellingly, the ACA did not adopt this approach.