The New York Times just posted David Leonhardt's latest interview with President Obama. It's full of fascinating material and well worth reading in full. But, naturally, it was the discussion on health policy that caught my attention.

The discussion--and it's really more a discussion than an interview, which is one of the reason's it's so revealing--doesn't dwell on expanding insurance coverage and access to care. Instead, it focuses on why health care is getting so expensive and what can be done about it. Along the way, Obama makes two crucial points.

First, he notes that it's physicians, not patients, who inevitably make most of the decisions about medical treatment. That's why simply increasing co-payments and encouraging consumers to shop around for medical care--i.e, the conservative solution to rising health costs--won't work and why it's critical the government develop guidelines on which treatments work best. 

OBAMA: ...we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.

And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.

The other striking passage is where Obama discusses end-of-life care. As a society, we spend a huge amount of money treating people during the final weeks and months of their lives. And, in the process, we expose many of these people to unnecessary pain and suffering.

But figuring out when to forgo further treatment is never easy--for the infirmed, their families, or their caregivers--partciularly since you can never be certain, in advance, when those last few weeks and months will be.

Resolving this dilemma will require a long, complicated conversation--one we have to have as a society and, then, as families and individuals. In the interview, Obama signals he grasps this. And he does so by recalling what happened a few months ago, when his grandmother passed away:

OBAMA: ...I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care--

LEONHARDT: Yes, where it’s $20,000 for an extra week of life.

OBAMA: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about--maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that--you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just--you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life--that would be pretty upsetting.

LEONHARDT: And it’s going to be hard for people who don’t have the option of paying for it.

OBAMA: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

LEONHARDT: So how do you — how do we deal with it?

OBAMA: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

I give Obama enormous credit for talking about this, and not just because he's obviously developed a very sophisticated sense of health care policy. The mere mention of treatment guidelines and end-of-life care invites demogoguery; rest assured, there will be right-wingers pouncing on the above statements as proof that Obama wants to pull the plug on every sick person over 65.

He doesn't, of course. He simply realizes this is a conversation we need to have. And it appears he's determined to start it, notwithstanding the political peril. 

--Jonathan Cohn