Transcript Controversy 4

IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
IDSP 465/565: Issues in Gerontology
Controversy 4: Should We Ration Health Care for Older People?
IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
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
IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
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
IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
The Justification for
Age-Based Rationing
• There are many ways to ration health care besides age:
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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
IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
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:
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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
IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
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
IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
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 governmentrun 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
IDSP-465 Issues in Gerontology: A Life Course Perspective on Aging
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