Controversy 4

1. Controversy 4 Should We Ration Health Care for Older People?

2. Should We Ration Health Care for Older People? • Americans over age 65 account for one-third of all national health care expenditures • More than $200 billion is spent on Medicare alone each year • But rationing health care on the basis of age alone is troubling to most Americans • How are we to justify spending large amounts of money prolonging the lives of the elderly? Who will get access to expensive health care resources? • These questions don’t have easy answers

3. Precedents for Health Care Rationing • Has rationing health care ever been done before? Is it likely to be introduced in America? • Denial of kidney dialysis in Britain – kidney dialysis has been routinely withheld from people over age 55 • Waiting lines in Canada – for some procedures (like non-life saving surgery) it may be necessary to wait long periods • Life-and-death decisions in Seattle – hospitals used to have special committees which decided who would have access to dialysis • A rationing plan in Oregon – for health care problems covered by the state’s Medicaid program, funding is available and services are rationed not according to individual cases, but according to a consensus reached by democratic means and a computer-based ranking of severity

4. The Justification for Age-Based Rationing • There are many ways to ration health care besides age: • Ability to pay • Anticipated clinical effectiveness • Waiting lists • First-come first-served • Productivity to society or social worth • But rationing based on age might be better because: • It would be efficient to administer • Older people are less productive in the economy • All people are members of every age group at some time

5. Rationing as a Cost-Saving Plan • Difficult to determine how much money would be saved • The majority of money spent on health care goes to prescription drugs, nursing home care, and home health services • The rapid rise in heath care costs is not solely due to longevity; also: • Increases in intensity and rates of utilization • Introduction of new medical technologies • Rise in real wages of health care personnel • General price inflation • Fraud, waste, abuse, and futile medical treatment

6. The Impetus for Rationing • A big part in the rationing debate is economics – the science of scarcity • Only when scarcity is at hand is rationing seriously considered • The “oldest-old” – those over age 85 – have the greatest number of health problems and cost the most in terms of health care • If expensive health care resources were rationed on the grounds of age, as philosopher Daniel Callahan (1987), then this group would be the denied group

7. Cost Versus Age • We often end up spending more and more money to achieve small gains, usually with a remaining poor quality of life, while other social needs go unmet • Callahan believes that society owes the elderly a decent minimum of health care – at least up to a certain age • Critics of Callahan argue that age-based rationing actually affects only those who depend on government-run health care programs – that is, older people who can’t afford private care • Callahan believes we already have an “invisible” form of rationing in place, and it would be better to make it overt and public, rather than hidden and invisible

8. Alternative Approaches to Rationing • Possible alternative approaches to rationing include: • Limit medical procedures based on effectiveness as measured by health outcomes research • Cost-benefit analysis – asks how much a treatment costs in comparison with the total benefit that will be created if the patient lives • Cost-effectiveness analysis – looks at which treatment provides the desired outcome for the least cost • Quality-adjusted life years (QALY) – the commonsense view that 10 years of life with disability may not have the same value as 10 years of good health