Opponents of the various Democratic health-reform proposals spend a lot of time talking about how people should be free to purchase whatever kind of insurance they want. Except, it turns out, if those people are women.

Going into Saturday's debate on the House health-care bill, the measure included provisions designed to maintain the status quo against federal funding for most abortions. It took steps to ensure that federal subsidies to purchase insurance wouldn't be used to pay for abortion coverage. It required that every exchange include one plan that did not cover abortions, so that no one would be forced to subscribe to a plan that violated anti-abortion beliefs. That wasn't enough for the anti-abortion crowd, including the Catholic bishops. So House Speaker Nancy Pelosi (D-Calif.) was backed into a corner, facing the loss of anti-abortion Democrats unless she acceded to an amendment offered by Rep. Bart Stupak (D-Mich.) that effectively prevents insurance companies participating in the new insurance exchanges from covering abortions. It passed, 240 to 197, with 64 Democrats voting in favor.

Under the Stupak amendment, no plan that accepts people eligible for federal subsidies is permitted to cover abortions. It's hard to imagine a plan participating in the exchange that refuses to accept people with subsidies, since the vast majority of people in the exchanges will receive subsidies. Therefore, no abortion coverage in the exchange -- except to save the life of the mother or in cases of rape or incest. If you are a woman whose health is endangered by a pregnancy, you'll have to pay for an abortion out of pocket. Same if you are carrying a fetus with severe birth defects.

Stupak supporters argue that women will still be able to obtain abortion coverage by purchasing a separate rider to the policies. As if people plan ahead to have abortions. As if insurance companies will go to the trouble -- and risk the controversy -- of providing such riders.

It wasn't worth torpedoing health reform over this issue, so I understand Pelosi's choice. It's outrageous, though, that she had to make it.

Originally published on the opinion blog Post Partisan, updated daily at washingtonpost.com/postpartisan.

If the 35 percent tax is going to be passed on to consumers, I am definitely against that. However, it is clear that there are efficiencies built into other versions of health-care reform legislation with electronic medical records and meaningful use of health information technology. And it is clear that the ultimate benefit of electronic records will go mostly to the insurance companies; therefore, I think the tax on them is appropriate.

As a matter of fact, since the insurance companies will benefit the most with the added resources of health information technology, they should be paying largely for the set up, education and maintenance of electronic health records in physicians offices. That way, physicians can more efficiently provide services to the increased numbers of patients in the most need of medical help.

As a chronically ill patient and a former nurse of many years, I see malpractice as an ever-growing circle in the pond of medical care. The threat of lawsuit eats at the judgment of good, well-trained physicians.

Our wildly litigious society is ever ready to "collect." I've seen friends collect from stores when they trip over their own feet. The person or institution should pay the costs of injuries if they are truly at fault. Doctors are not the only ones who are liable -- we all are. We have to worry about cracks in the sidewalk in front of our house, don't we?

We have to educate the public to realize it is not their God-given right to collect for every incident in their lives. Why does blame always have to be placed? Many of our fellow citizens see all insurance companies, both medical and others, as banks to be visited when the opportunities arise: make a withdrawal.

Doctors are a much-needed part of our society but they are, after all, only well-trained, well-paid, very well educated technicians. They are also human beings who often work long hours, have bad days. Sometimes, they screw up. There's a big difference between a doctor who makes a medical mistake and one who is irresponsible and careless. All doctors, even the best ones, make mistakes. One of the best OB men I ever knew cut a baby's ear during a C-section. Errors occur. That's a far cry from the doctor who is poorly educated, drinks too much or callously schedules too many surgeries so he can take his vacation a day early.

This week's topic, how the proposed overhaul will impact senior citizens, is very dear to my heart. I am a family physician with substantial experience in geriatric medical practice; I have always tried to be an advocate for my elderly patients. I wish to focus my comments on the issue that seems to have hijacked the reform debate from the senior perspective: advanced directives and end-of-life care.

What I refer to as "Good Daughter Syndrome" is a scenario that I have seen play out innumerable times in my career, and it breaks my heart every time I see it. Too many elderly have little or no family support. But oftentimes, there is one attentive family member, most often the good daughter (or son, or niece -- you catch my drift) who has stayed close to Mom and has heard many times from her, "I don't want to die in pain / un-dignified / a burden." There may or may not be an advanced directive. Regardless, as the terminal stage clearly develops, the less-attentive family members seem to come out of the woodwork, their guilt at having ignored their loved one kicking in and now everybody adds their voice to the cacophonous din. The good daughter's voice is drowned out by a chorus of, "But you gotta keep Mom alive at all costs." Then, despite Mom's well-known prior wishes to the contrary, all the stops come out and two weeks of painful, expensive and ultimately futile hospital care ensues.

Let me be clear: I am no proponent of euthanasia, which I find to be morally repugnant. And that is not what the advanced directive provision in HR 3200 proposes. There is a huge difference between euthanasia and compassionate palliative care. At some point in every chronic, terminal condition, it becomes clear that effecting a cure is not possible. However, attempting to relieve pain and anxiety at the end of life is always possible. You have to know when to say when. Regardless of whether this activity is mandated by legislation, it is critical that we embrace the spirit of advanced directives and keep faith with our loved ones by supporting all the good daughters out there: enforcing Mom's wishes when the time comes. It is not merely an economic imperative, it is a moral imperative.

As I view the heated debate over health-care reform legislation taking place at various town hall meetings across the country, it feels to me that the frustration spilling over is a lot like the angst I see family members grappling with at the time of the impending demise of their loved one. Emotions strained. Statements curt. Manners often in short supply. And then the end comes... And the family dynamic re-casts itself. Some folks reconcile; others retreat to their respective corners.

I suspect that health-care reform legislation is ultimately going to play out in much the same fashion. As the heat of August burns away, we'll all become resigned to the fact that a dramatic transition is coming. Hopefully, cooler, more moderate voices will hold sway in September. And we'll pass meaningful, fiscally responsible, morally upright health-care reform legislation.

It's what Mom would've wanted us to do.

It astonishes me that current and future Medicare beneficiaries are raising concerns about future legislation: in the absence of reform, these programs will fail!

The Medicare Part A program (the hospital insurance program) runs out of money in just a few years. There is no statutory authority to fund this program without new legislation: it is entirely unclear how the program functions once the trust fund is exhausted.

The Medicare Part B program (outpatient and physician services, primarily) is not going to run out of money (it is funded via beneficiary premiums and federal tax revenues). But, written into statute are draconian cuts to physician reimbursements. If allowed to occur, many physicians will opt out of the program, leading to dramatically reduced access. Thus, the program will begin failing our Medicare beneficiaries unless there is legislative change.

Only the Medicare Part D program (the prescription drug benefit) faces no immediate challenge.

Medicare is at great risk in the absence of reform. It is beyond the scope of this posting to offer real solutions, but clearly we need to communicate with the public about how the reform effort will make Medicare more secure, not less.

The old saying that "the devil is in the details" certainly applies to this question. For the elderly, what matters most in health care reform is what lawmakers do about how doctors and hospitals are paid. The Medicare system pays them for activity, not quality of care, so the elderly get a great deal of care, but, like the rest of the population, they get the right care only about half the time, according to a RAND Corporation study. If health care reform drives better quality care, the elderly, as the highest-volume health care consumers, will benefit most.

A courageous part of the legislation attempts to get everyone to document end-of-life preferences. We spend a lot on keeping people alive while they are in extreme pain and discomfort with no hope of recovery, or while they are in comas, without knowing what they would have wanted. My dad lapsed into a coma in July 2001 on a Friday and died two days later. On the day before he died, a nurse attempted to administer a $2,300 injection for prostate cancer therapy. Since he had a living will and my sister and I had powers of attorney, we were able to refuse the treatment. In too many cases, unnecessary care is provided simply because the patient has not taken the steps my dad did.

We should not fall into the trap of denying care to the elderly based on some formulaic approach to the value of an additional year of a person's life. At the same time, we cannot provide any care anyone wants, whether or not it is effective. I do not believe in micromanaging individual patient-doctor decisions, but overall regional incentive payments given to an integrated health-care system will drive doctors to discuss difficult issues in advance with their patients.

This week's question is outside of my own expertise, so I am only weighing in as an optimist. While I respect the need to maintain momentum and prevent ourselves from being distracted from this important domestic agenda item, I can not help but wonder whether a brief delay could be a good thing. Our elected officials have made health care reform (in its full meaning) a major priority; and there is little doubt that thousands of hours of real work has been incorporated, thus far; But getting the details right and building a true bipartisan base of support should be equally important.

If this bill cannot be bipartisan as it stands now, then the extra time will still have been useful in demonstrating that the opposition is obstructive rather than merely looking out for our nation's best long-term interests. There is such strong consensus that health care delivery and insurance-coverage is broken and headed in the wrong direction: it just seems impossible that we can not generate full support for positive change, once we get the details right.

The current, seemingly permanent, extraordinary growth in domestic health-care spending is a predictable result of our tax policies and the many federal rules forced upon Medicare. If we are going to be serious about making health care more responsible and effective, we need to address these issues first.

Our tax system provides ever larger federal subsidies for ever-more-generous insurance policies. Thus, it is not surprising that we buy the most insurance we can afford -- or get our employers to pay for. As predictable, we then allow insurance design and coverage to dictate what health care we need. In the absence of evidence about the effectiveness of new technologies, we find ourselves willing to "buy" the latest and greatest tools, irrespective of known value, confident that someone else will pay.

As important, our federal Medicare program, though less than 20 percent of national health expenditures, affects a disproportionately large amount of health-care delivery. Hospitals, physicians and numerous other providers receive reimbursement that is variably influenced by Medicare policy. Health plans mostly follow Medicare coverage decisions even when there is little evidence that it will be a true improvement in health for their members. Physicians, in an almost vicious circle, chase the latest technology, as long as it is covered by Medicare; then proceed to apply it to ever broader populations, even when evidence for positive effect is lacking.

However difficult it may be to transition to outcome- and health-based reimbursement, we must make that effort. However challenging it may seem to revise our tax code, in order to reduce the distorting effects, we must make that stride. Through these and other reforms, we can curtail cost growth and bend the curve back!

Our health-care workforce includes a dynamic group of individuals willing to go above and beyond the call of duty for the sake of another, a testament to the notion that health care ought to be a right, not a privilege.

I know. You have read the reports on workforce overspending that underestimates the human and financial cost of questionable practices. True. But, what often goes unnoticed is the tireless devotion and innovation that health-care providers employ to fill the system's gaps.

Imagine the 7-year-old cancer patient whose last round of chemotherapy failed. Recognizing that an experimental treatment is his last hope, a benevolent group of oncologists, nurses and social workers spend long hours convincing an insurance company to cover the cost of therapy. He is treated and shows improvement. Or the diverse group of physicians who collectively understand that youth violence is not the mantra of delinquent hoodlums, but rather a public health problem that is modifiable and preventable. Against tradition, they collaborate with local youth to address the issue. Community members start talking to each other and take steps to address youth violence.

Examples like this occur across the U.S and with them, the emergence of a new generation of health-care leaders who possess an incredible array of talents and gifts that will facilitate the path toward a healthier society. Medical students are being educated to look beyond diseases to understand how social influences affect well-being. Promising health-care leaders are being trained to not only ask the tough health-care questions in our country but to answer them with clarity and forethought. Providers across the country are volunteering their skills and time in the service of others, sometimes without compensation; and, that is cause for hope.

A system is only as good as what is put into it. By extension, an unsupported workforce compromises the system. To ensure that the workforce is not weakened, we must create new paradigms in medical education that cultivate the manifold gifts our future workforce currently possesses, generate incentives that keep talented health-care providers in the system and support innovative approaches that ensure the health of society. In short, we must dare to think outside the box.