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Age-based
health care rationing By Ellen Beck WASHINGTON
- America's struggle to pay for rising health care costs leads people to
consider the idea of rationing based on age -- a discussion topic many
consider ethically and morally taboo, yet necessary. For
a decade or more health care providers, ethicists, geriatricians, the
young and the old have danced around the subject of how much health care
is enough, how much is too much -- if that even is possible -- how should
it be paid for and who is entitled to it. Daniel
Callahan, director of International Programs at the Hastings Center in New
York City, told a panel discussion held by the Alliance for Aging Research
in Washington, D.C., this week, "We have to find some way to
integrate age as a standard or criterion for the allocation of
resources" in health care. Many
issues come into play, ranging from the cold, hard facts on health care
spending and society's desire for all the technological whistles and bells
and miracle cures to the philosophy of medicine, an American fascination
with the underdog and religious convictions about when life should end. The
bottom line is people are living longer. Ancient Greeks lived only to
their 30s, but in the past 100 years life expectancy has soared past 65
and now more people are living well into their 80s, 90s and beyond. It is
also a fact that older people consume more health care services. Callahan
is well respected in the bioethics field and has pushed the discussion
toward the taboo. "We
now have on our hands what I call the infinity model of medicine," he
said. It is the idea that we simply want more -- treatments, drugs,
procedures, technology -- without a guarantee of success in curing disease
or extending lifespan and without a limit on cost. "I
think that is increasingly unsustainable," he added. The
cold hard facts bolster that position. The Department of Health and Human
Services reported health care spending in the United States rose to $1.4
trillion in 2001, an 8.7 percent increase over 2000. Health insurance
premiums, as well as the costs of prescription medicine -- fueled by
utilization and advances in technology -- are increasing by double-digit
percentages. Of
that $1.4 trillion, some $277 billion was spent on Medicare, the health
care program for seniors. Congress is now finalizing a $400 billion bill
to add a prescription drug benefit to Medicare. The Democrats have floated
proposals that could take the program to $1 trillion as the baby boomers
retire in the upcoming two decades and double Medicare's beneficiaries to
an expected 79 million. The
numbers are mind boggling for younger workers, who through payroll taxes
pay for a large chunk of Medicare expenditures. This brings up the issue,
Callahan says, of what the young owe to the old and vice versa. He
said the young owe the elderly the possibility of a decent old age, Social
Security, respect and an appropriate level of health care. "The
old at least owe the young not to take away what they need for their own
living conditions," he said. Health care should help young people
live to old age but "not to have old people become infinitely
older." "The
notion of a lifespan, a life cycle, seems to make sense to me," he
added. "Beyond a point it is not a human tragedy that people die. ...
It's good for the species." In
reality, American society has dealt with rationing health care for some
time. When managed care was at its high-water mark in the mid-1990s,
health maintenance organizations became the villains of the industry for
restricting access to specialists, emergency room care and expensive
diagnostics. Even Hollywood movies picked up on the theme of the heartless
HMO denying treatment to a sick child or a cancer patient whose last hope
was bone marrow transplant. It played to the American psyche of cheering
the underdog to beat the odds with a medical miracle. Society
did not want to acknowledge, however, that such denials often were made
based on scientific evidence showing the treatments were hugely expensive
and had only a slim chance of working. Society won that battle, managed
care restrictions eased considerably -- and health care spending began
soaring again at the turn of the 21st century. Dr.
Roger Levy, a clinical professor of orthopedic surgery at Mount Sinai
School of Medicine in New York, who often writes about these issues, said
rationing health care based on age is "something that might not
literally get discussed because of the political implications," but
will be part of the general discussion of allocating resources. He
said efforts to rein in costs largely have focused on the supply side and
have not worked, whereas little has been done to curtail the demand side
of the equation. Levy
said there should be a definition of what constitutes futile treatment and
positive treatment based on categorical criteria -- including, though not
exclusively, age. The problem with "evidence based" health care,
he added, is it is subjective. Physicians
and other health care experts can consider a wide body of literature on
the efficacy of various treatments, but they might or might not include it
all in the decision-making process. The
culture of professional medicine also is at odds with age-based health
care. Levy said it has been the mark of success for a physician to pull
the rabbit out of the hat, so to speak, and come up with a diagnosis no
one else could find or a treatment that no one considered. Other
countries -- Britain, Canada, Australia, New Zealand -- have tried, with
varying degrees of success, to ration health care at least partly by age. There
was a backlash in Australia and New Zealand, said Devon Herrick, a
research manager and health economist for the National Center for Policy
Analysis in Washington. It created a situation in which there was
"more of an implicit rationing" -- older people were not treated
as aggressively as younger patients. Levy
said Britain and Australia have ended up with a two-tiered system of
government-paid, universal health care layered with an option of private
care. Canada
watches more closely what procedures are successful and which physicians
perform them most effectively. There
is concern rising costs will force families to contribute not only to
their own health care expenses but also to care for their parents or
grandparents. It brings up the potential of having to decide if Grandma
gets a hip replacement or Johnny goes to college. Dr.
Christine Cassel, president and chief executive officer of the American
Board of Internal Medicine, said seniors are making rationing choices for
themselves. "I
don't believe that most older people are clamoring for artificial hearts
at age 95 ... What I see is a movement toward more palliative care,
hospice. There is a very strong basis for exactly the kind of democratic
social movement Dan (Callahan) is talking about," she said. "At
a certain point those patients themselves say it's time to stop." Cassel
said America spends a lot of money on health care treatments that do not
produce better quality and, as Levy does, supports rationing based more on
evidence-based medicine. Herrick
agreed an evidence-based system for rationing care was a better basis than
age. There is no indication, he said, that "something costly and
wasteful" is involved in the current health care system in the last
six months of an elderly person's life, when costs tend to be highest. "Age
itself is simply not a good indicator" for allocating health care
resources, he added. The
religious perspective also will color this issue. Excluding any group,
including the elderly, from health care treatments could be seen as
playing God -- setting limits to that group's life expectancy. Christian
and Jewish doctrines are founded on the premise that all people are
created in the image of God and no one has the right to relegate anyone
else to a lower status that would shorten his or her lifespan. Callahan said despite the public's perception at the moment, "age is not a bad standard." He noted, however, that Congress would be unlikely to tackle any legislation in this arena that does not receive huge public support. But eventually, he said, people will come around and see "this is the only way to go." Copyright
© 2002 Global Action on Aging
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