Blog | Monday, July 2, 2012

Health care reform and informed opinions in democracy: A pipe dream goes up in smoke


The Patient Protection and Affordable Care Act (PPACA) was just upheld by the SCOTUS. This verdict has split the entire country down the middle as shown by a recent Gallup Poll.

The law is complex and difficult to interpret. The law will be implemented in stages over several years, which makes it even more confusing. The fact that even independents are split so evenly makes it more than just a political bias. There are some places to find summaries of the law.
Reddit summary of law with citations
Reddit some doctors' concerns
Official site

Looking at the discussion at some of these sites also gives one an idea of the very strong and diverging opinions. People struggle to separate the issue of whether this is the "right thing to do" vs. whether it is constitutional vs. the right way to do it. Thus most would agree that folks should not have to worry about getting health care when they need it and they should not have barriers to getting preventive care to keep them healthy. How to achieve this and how to finance this seem to be questions causing the arguments. The complexity of the law makes having intelligent informed discussions difficult. The emotions around the issue make it difficult to keep personal bias out of the discussion.

It is a fascinating time to see democracy "working."

I personally have not read the text of the original law or the entire text of the SCOTUS opinion. Why not? One reason is the difficulty in making sense of the legalese and staying awake while doing so. I have spent quite some time trying to understand it, probably more than the average citizen. I have read the Cliff notes versions, the statements issued by various organizations for their members and public and participated in discussion in social media to get a better understanding from various perspectives. During these discussions I have noticed many incorrectly informed opinions expressed from both sides.

To try and get a better handle at the level of complexity of this law, I tried to read up about a "simple" law that I describe below.

Recently I went to an event that raised a number of questions in my mind requiring me to go to the original law.

First let me describe the setting.

This was a concert at a huge facility - with a covered pavilion near the stage and a larger lawn seating area around it. There is no wall or other physical barrier between the lawn and the pavilion. On summer evenings, it makes for a beautiful setting to listen to live music. My previous experience of this facility was listening to Beethoven and Bach or the Boston Pops playing John Williams tunes, sitting under the stars on a blanket with a picnic basket. This was clearly going to be different experience and I thought I was prepared for it, and I was except for one thing.

Smoking was allowed in the lawn portion of the facility! And almost half the people were smoking, to the extent that a pall of smoke hung over the entire area. The facility is in a bowl shaped valley which probably contributes to this situation.

In Ohio smoking is not allowed in a public place, even in bars and restaurants, even at the Cleveland Browns Stadium, which is not a covered roof stadium. A facility this big could not be willfully breaking the law so I had to look this up when I got home. The law can be found here. The key provisions/definitions it seems were:
"Public place" means an enclosed area to which the public is invited or in which the public is permitted and that is not a private residence
"Enclosed Area" means an area with a roof or other overhead covering of any kind and walls or side coverings of any kind, regardless of the presence of openings for ingress and egress, on all sides or on all sides but one.
"Outdoor patio" means an area that is either: enclosed by a roof or other overhead covering and walls or side coverings on not more than two sides; or has no roof or other overhead covering regardless of the number of walls or other side coverings.


Apparently the law provides an exception to outdoor patios to allow smoking. Based on my non-legal interpretation the setting of this facility does not fall under the smoking ban law because it is completely uncovered and is thus an outdoor patio. The pavilion has an overhead roof and is somewhat circular so difficult to "count" how many sides it has. My guess is that it is not an enclosed area as the majority of the perimeter does not have walls.

So the questions that came to mind were:
--The point of the law is to protect people from the dangers of second hand smoke. Why would the law fail to provide protection to people who go to this facility? A few minutes there and I felt my lungs filling up with fumes. So clearly there was second-hand smoke exposure
--How do we balance the freedom of a person to smoke with the right of a person not to be injured by another person? Adults should have the right to smoke if they want to and understand the risks (will not debate who pays for their smoking related health conditions). People come to this facility to enjoy and smoking is possibly a part of that experience for them. What about the enjoyment of the other paying audience? Even if one could debate the long term risks of 2 hours of second hand smoke exposure, what if they had migraine or asthma triggered by this?
--What would it take for a facility like this to set up some non-smoking zones with a big no-mans-land around it to at least diminish the exposure? The Cleveland Browns set up a family zone where even alcohol is not permitted, even though that is not a legal requirement (I think).
--I saw several young kids brought in by their parents. Do the kids have a choice and the ability to make an informed choice? I overheard a very angry comment made by the parent of one of these kids about the situation.
--The facility does mention on their web site that "light smoking" is permitted in the lawn area. Whatever does that mean?
--Would the facility reimburse people who find the smoking more than "Light"?
--What are the options for those folks who want to attend a live event like this but cannot bear the second hand smoke or want to take kids?

You can see how what seems like a simple issue can be so complicated and difficult to interpret. The health care law is complex and polarizing. Democracy depends on people making informed decisions and voting accordingly. When people depend only on others to tell them what a law means, there is serious risk of bias. When people involved in healthcare don't have time to read and digest all the details of the law, what can we expect from the whole population? Informed consent in medicine is supposed to mean that patients understand the various risk benefits and alternatives of a procedure before agreeing to it. In order to do this we need to use language that can be understood by our patients. There are of course laws describing how to provide informed consent (e.g. link to informed consent for human subject research).

This fall, people will be voting partly influenced by the PPACA. Can we hope that these will truly be informed opinions? On an issue of such importance how can we ensure that the answer is yes? Do we need a law requiring voters to pass a quiz before voting?

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.