At a recent forum in Manchester, NH, Jeb Bush discussed the topic of advance care planning — with rather unexpected results.

The subject came up in response to a question about his involvement in the Terri Schiavo case back in 2005. During his tenure as governor of Florida, Bush signed a law (subsequently deemed unconstitutional) that allowed him to assist Schiavo’s parents in their fight to keep her feeding tube in place.

At the Manchester forum, Bush explained that he has not had a change of heart about his actions during that time. Importantly, he also concluded that it would have been much better if Schiavo had completed an advance directive “where the family would have sorted all this out,” potentially avoiding the legal battle. (A good advance directive, at the very least, appoints a person as the surrogate health care decision-maker (an issue that was also contested in the Schiavo case); it will also provide guidance about the individual’s wishes for medical care and goals of care at the end of life and other situations, such as a persistent vegetative state, like Schiavo was in.)

But in Manchester Bush went even further. He suggested that Medicare beneficiaries be required to complete an advance directive in order to receive Medicare benefits. “I think if we’re going to mandate anything from government,” he stated, “it might be that if you’re going to take Medicare, you also sign up for an advance directive where you talk about this before you’re so disabled.”

The intellectual and policy shift that Bush’s proposal represents can hardly be overstated. With this statement, Bush has gone even further than the original advance care planning provision in the Affordable Care Act. That provision called only for Medicare to reimburse physicians for having voluntary conversations with their patients about end of life wishes. As you probably also recall, that provision was infamously and erroneously branded as the “death panels” provision, otherwise known as “pulling the plug on grandma.” The ensuing uproar not only killed the provision, but has also largely made advance care planning a proverbial third rail in our national politics ever since.

Let’s be clear: Bush is not calling for every Medicare beneficiary to sign a DNR. An advance directive communicates a person’s care wishes – whatever they are. This wish could be for hospitals to “do everything,” or to provide “comfort care only,” or for something in between.

That being said, Bush has opened a potentially exciting door here. He has broadened the debate about the appropriate role for our national government in advance care planning. It will be interesting to see whether his idea gets any traction in the primaries or in the general, as the presidential race picks up steam and the debate season draws ever closer.

Randi J. Siegel, MBA, is the President of DocuBank (docubank.com), which ensures that the emergency information and healthcare directives of its 200,000+ enrollees are available 24/7/365 through the largest advance directives registry in the U.S., as well as access to an online safe for storage of digital assets and other vital documents. Working with estate planning professionals since 1997, Randi frequently speaks at national estate planning conferences and has appeared on radio and television as an authority on registries. A member of the Philadelphia Estate Planning Council, the International Society of Advance Care Planning and the Coalition to Transform Advanced Care, Randi is active in health education and public engagement related to advance care planning/advance directives. She serves as Pennsylvania liaison to the National Healthcare Decisions Day initiative and as a board member of the Center for Advocacy for the Rights and Interests of the Elderly. Randi is an ongoing contributor to the Academy blog.

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