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 dont 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 states 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 cant 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