The Trump administration is facing fresh criticism after proposing a Medicare policy that would encourage hospitals to document patients' end-of-life care preferences, a move that critics say closely resembles the advance care planning provision Republicans fiercely opposed during the battle over the Affordable Care Act more than a decade ago.
The proposal has reignited one of the most contentious healthcare debates in modern American politics. Conservative commentator Jonathan Cohn and several health policy experts argue that the new regulation mirrors a policy once denounced by prominent Republicans as creating so-called "death panels," raising questions about how attitudes toward advance care planning have shifted under a Republican administration.
The latest proposal, developed within the administration's healthcare policy framework, would require hospitals to incorporate advance care planning discussions into patients' electronic medical records. Compliance with those requirements could eventually become one factor used in calculating Medicare's value-based reimbursement payments to hospitals.
According to the proposal, the objective is to "establish advance care planning as a normalised, routine part of care regardless of health status and age."
Under the proposal:
- Medicare would reimburse physicians for advance care planning discussions.
- Patients would generally be eligible for one counseling session every five years.
- Additional consultations could be covered if a patient's health condition significantly changed.
- Participation would remain voluntary for patients.
- Discussions could include advance directives, healthcare proxies, living wills and durable powers of attorney.
The proposal links advance care planning to Medicare's quality-of-care initiatives rather than making treatment decisions on behalf of patients.
Jonathan Cohn argued that the underlying policy has long been supported by many healthcare professionals regardless of political affiliation. Writing about the proposal, he cited Pew Research showing that only about one-third of Americans younger than 60 have completed formal advance care directives, despite surveys indicating many people prefer making end-of-life decisions before facing a medical crisis.
The renewed controversy inevitably recalls one of the defining political battles surrounding President Barack Obama's healthcare overhaul.
During congressional debate over the Affordable Care Act in 2009, a House provision would have allowed Medicare to reimburse physicians for voluntary conversations about end-of-life planning. Those discussions were intended to help patients document their healthcare preferences before becoming unable to communicate their wishes.
The proposal quickly became politically explosive after conservative commentator Elizabeth McCaughey claimed it would require seniors to participate in counseling sessions designed to encourage them to limit medical treatment.
Appearing on conservative media outlets, McCaughey argued the legislation would "absolutely require" Medicare beneficiaries to undergo counseling every five years and suggested patients would be encouraged to "end their life sooner."
Healthcare policy specialists repeatedly disputed those interpretations, noting that the counseling provision was entirely voluntary and simply authorized Medicare reimbursement for physicians conducting advance care planning discussions.
Despite those clarifications, criticism intensified after former Republican vice-presidential nominee Sarah Palin popularized the phrase "death panels," alleging that government bureaucrats would effectively determine who should receive medical treatment.
The political backlash proved so intense that Democratic lawmakers ultimately removed the provision from the Affordable Care Act before final passage, even though organizations including AARP and the National Hospice and Palliative Care Organization had supported it as a way to help patients and families prepare for difficult medical decisions.
The earlier debate also placed bioethicist Dr. Ezekiel Emanuel at the center of political attacks.
Because Emanuel advocated incorporating advance care planning into routine healthcare, some conservative critics labeled him "Doctor Death" and accused him of promoting healthcare rationing for elderly and disabled Americans.
Reflecting on the Trump administration's proposal, Cohn asked Emanuel whether similar accusations should now be directed at Dr. Mehmet Oz, who serves as administrator of the Centers for Medicare & Medicaid Services under President Donald Trump.
Rather than criticizing Oz, Emanuel expressed support for the proposal.
He said he respected Oz's effort to "facilitate and incentivise these conversations" and described the initiative as "pretty bold."
That response stood in sharp contrast to the criticism Emanuel himself received during the Obama administration, when similar proposals became one of the most polarizing issues in the healthcare debate.
