Older Americans and the rationing of health care.

• Author: Smith, Andrew H.
• Position: The Law and Policy of Health Care Rationing: Models and Accountability

OLDER AMERICANS AND THE RATIONING OF HEALTH CARE

Americans long ago dedicated themselves to the removal of social and economic barriers that unfairly burdened racial and ethnic minorities, women, and older people. Discrimination against individuals on the basis of their membership in artificially defined groups was rejected. The current crisis in health care expenditures, however, may be reviving some old prejudices and creating new ones, particularly against older people. Questions have been raised about older Americans, their place in society, and their rightful claim on resources such as health care. The way that society addresses these questions may well determine the character and quality of life in this country over the next few decades.

1. THE PROBLEM

   There is a broad consensus that cost containment efforts of the 1980s designed to stem the rising tide of health care expenditures were failures for the most part, and that the American economy cannot sustain the level of growth in expenditures that marked the decade. National expenditures for health care rose at an average annual rate of 10.4% between 1980 and 1990; as a share of the gross national product, these expenditures rose from 9.1% to 12.2% over that period.(1) Medicare expenditures increased at an even higher 11.8% average rate.(2) Health insurance costs to employers rose by 46.3% between 1988 and 1990.(3) Despite these enormous expenditures, there are today approximately thirty-four million people without even basic health insurance coverage,(4) and there is little evidence that Americans are healthier than citizens of other Western industrialized countries that spend far less on health care.(5)

   The failure of cost containment efforts instituted by governments and employers to control health care cost inflation(6) has propelled the discussion of explicit rationing of beneficial health care services from the halls of academe to the center of the health policy debate. Proponents of rationing believe that cost containment short of rationing is doomed to failure and see unbridled patient demand, the aging of society, and the onward rush in medical technology development as factors converging to produce an economic catastrophe.(7) They maintain that disaster may be averted only if policymakers face the painful truth that mandates the development and implementation of some form of explicit rationing of health care services.(8) Some maintain that there are both economic and moral imperatives to ration some health care services by age.(9) This makes the debate especially relevant to and poignant for older Americans.

2. MEDICAL CARE FOR THE ELDERLY AS AN ALLEGED SOURCE OF THE HEALTH CARE EXPENDITURE CRISIS

   Increasing patient demand for services has been identified by proponents of rationing as a major source of rising health care costs.(10) Available empirical evidence casts some doubt on this assertion. In a study of hospital usage patterns in Boston and New Haven, researchers found (after controlling for patient differences) that Bostonians used 4.5 beds per thousand population, while the citizens of New Haven used fewer than 3 beds per thousand.(11) Boston's per capita expenditures for hospitalization were found to be consistently twice those for New Haven.(12) Most of the difference in resource use was found to be associated with medical conditions for which there is a high variation in use rates and for which physicians' clinical decision thresholds for hospitalization depend on the supply of beds.(13) Of course, patients may be more demanding than in the past, but it is difficult to reconcile the view that patient demand is of primary importance in rising health care expenditures with the findings in the Boston-New Haven use pattern study. Are the citizens of New Haven less demanding than residents of Boston, or do physicians in Boston hospitalize more aggressively? What is apparent is that we really know very little about patient demand, and that it may thus be inappropriate to predicate policy changes upon such as assumption.(14)

   The aging of American society, with its associated increases in morbidity and health care costs,(15) is viewed by some as the most important component of a discouraging health care expenditure picture.(16) A number of commentators argue that the most appropriate place to ration care is with the elderly, and propose to restrict expensive, high technology, life-sustaining care for those who have reached a certain age.(17) It is assumed that this type of care represents an investment of scarce resources with few returns, frequently involving intensive and aggressive treatment that serves only to prolong the agony of dying.(18) It is also assumed that vast resources are being expended, and are destined to be spent, on such care for the dying elderly.(19) This perception is bolstered by a study that shows that a large amount of money is expended on Medicare beneficiaries in their last year of life.(20)

   Researchers examining data from 1978 found that the less than 6% of Medicare beneficiaries who died in that year accounted for approximately 28% of Medicare expenditures.(21) This proportion of expenditures may, intuitively, seem excessive. Intuition, however, is not a dependable guide. First, it is worth noting that the share of the Medicare budget devoted to elderly people in their last year of life has been nearly constant since the inception of the program.(22) Second, even if it were possible to predict with certainty which patients would die within twelve months (something which cannot be done), and all care were to be withheld from these beneficiaries, relatively small savings would be achieved; only 22.7 billion dollars, or 4.6% of health care expenditures, would have been saved in 1987.(23) Those who advocate age-based rationing do not generally propose to withhold all medical treatment from older persons, but rather, expensive, aggressive care. Researchers have found that only 3% of Medicare decedents incur "high costs."(24) Withholding all treatment for high-cost Medicare decedents would have produced savings of 2.8 billion dollars in 1987.(25) This is not a negligible amount of money, but saving this...