1. Should We Ration Health Care for Older People?
Controversy 4
Should We Ration Health Care
for Older People?
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2. Should We Ration Health Care for Older People?
Americans over age 65 account for one-third of all national health care expenditures
In 2009, ,ore than $500 billion was spent on Medicare and this figure is expected to increase
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 older adults? Who will get access to expensive health care resources?
These questions don’t have easy answers
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3. Precedents for Health Care Rationing
Has rationing health care ever been done before? Is it likely to be introduced in the United States?
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 that 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
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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:
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
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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 due to the following:
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
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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) recommends, then this age group would be denied health care
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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 older adults 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
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8. Alternative Approaches to Rationing
Possible alternative approaches to rationing include the following:
Limit medical procedures based on effectiveness as measured by health outcomes research
Cost-benefit analysis—determine 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
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9. Reading 16: Why We Must Set Limits
When Callahan’s book Setting Limits was first published, it was considered quite controversial. What are the main points of his argument and what would society look like if his recommendations were implemented?
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10. Reading 17: Why It’s Time for Health Care Rationing
Ubel claims that the need to ration health care created managed care in the United States but that managed care alone is not a sufficient solution to scarce resources.  What alternative approaches to rationing does Ubel suggest?
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11. Reading 18: The Pied Piper Returns for the Old Folks
Hentoff argues that Callahan’s proposal is class biased—that is, it discriminates against the poor.  Is this argument convincing? Does Hentoff’s point, if valid, destroy Callahan’s argument?
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12. Reading 19: Letting Individuals Decide
Wetle and Besdine also challenge Callahan’s ideas. What are their main arguments? Which side of the debate do you come down on?
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13. Reading 20: Aim Not Just for Longer Life, But Expanded “Health Span”
The concept of “health span” provides a different way of thinking about longevity than does increased life expectancy or compression of morbidity. What do Perry and Butler mean by “health span”?
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