Rationing Health Care on the Basis of Age: Is This the Future of American Health Care?

by Thomas Halper

The British experience has implications f o r health care policy in the United States and other industrialized

countries trying to meet growing demands with limited resources.

A mericans of a certain age may well remember ration booklets from World War II. The war so dominated the nation's productive

capacity that little remained for ordinary consumer goods, which in consequence were quite scarce. If price had been left to the normal play of supply and demand, many of these goods could have been afforded only by the well-to-do. The political leadership considered this unjus tnand, in a democracy where the non-well-to-do vote, politically explosivenso prices were kept moderate, and the right to purchase was allocated by the government in the form of the familiar ration booklets.

Rationing is a means of allocating goods and services at below market prices, and the World War II experience conforms closely to the classic rationing situation: a widely demanded good or service in severe shortage as a result of a temporary crisis; a central rationing agency implementing a consistent policy on a society-wide basis; and a public knowledgeable about the rationing system and broadly supportive of its imposition. The spur was not the desire for justice--but the more mundane and potent sense of injustice: ordinary citizens would feel themselves at such an unfair disadvantage in bidding for scarce goods in the wartime free market that government felt compelled to create a more defensible allocation system.

Yet, rationing need not follow the World War II model, and, indeed, may take a thousand forms. Goods and services may be allocated according to criteria of need, merit, or virtue--or on such unsavory bases as bribery, threat of physical violence, or racial and ethnic prejudice. And allocations may go to named individuals, classes of persons, or to the society at large.

The United States allocates a considerable portion of its health services at below market prices, mainly through Medicare and Medicaid, the chief government

programs for funding health care for the aged and the poor, respectively. Millions of patients, as a result, obtain medical care at a fraction of its true cost. But at the same time that government devises and implements general rationing policies, individual physicians make individual treatment decisions. Different physicians, however, may treat similar patients in different ways, reflecting differences in training, temperament, interests, and a number of other medical and nonmedical factors--and these differences are likely to persist so long as physicians retain their autonomy and distinctive individuality. Often, the society level and physician level decisions harmonize, as when a Medicare regulation stops hospital reimbursement in the case of a patient whose physician agrees is ready to go home. Sometimes, however, the sound is dissonant, as a regulation--dictated by government's conception of good medical practice or a desire to save money-- conflicts with a physician's judgment--dictated by his conception of good medical practice or a desire to make money. A considerable degree of such tension is probably unavoidable (and perhaps useful, too). But there is no question that the overall consistency of the system is compromised as a result.

Rationing of health care for the aged, in any case, is vastly different from the wartime rationing of, say, automobile tires. For one thing, wartime rationing was acknowledged and its rationale and workings exposed to public view. It could, therefore, be analyzed and criticized, and officials responsible for its creation and implementation could be held accountable for their actions. And accountability is the very hallmark of democracy.

But since the war, the United States has been slow to rediscover the rhetoric of rationing. Seduced by fantasies of ever-rising economic graph lines and mesmerized by advertising images of luxury and abundance, many Americans resist talk of scarcity as a

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patient does bad news. All this has staved off comprehension of what has really been happening, but the days of staving off may be about to run out. And then what? A truer, surer grasp of reality, of the inescapable fact of scarcity? Perhaps. Surely, after over a decade and a half of struggle for tens of millions of lower-income Americans, scarcity will hardly be news to everybody. Yet, even now there remain many for whom an appreciation of scarcity has been bred out, as seeds have been almost eliminated from certain fruits. And so rationing of health care for the aged is nearly always met with official denial, though the media have lately begun to warn that rationing "may not be far o f f " or "may become necessary."

Medically, the aged are the most heterogeneous stratum of the

population.

Looking for candor from the more visible health officials, however, is frequently like expecting a diamond as the prize in a breakfast cereal box. For, of course, the access of the American elderly to medical goods and services at below market prices is already

�9 subject to a long list of limitations: "diagnosis related groups" determine Medicare reimbursement to hospitals and routinely trigger discharges; Medicare- supported home health care is narrowly confined; and so on and so on. Nor is this rationing a temporary tide- me-over answer to a passing emergency, like the wartime tire shortage. Rather, it is a general response to a problem so long-term that no serious observer can today see its end. Those straining to keep rationing distant, therefore, strive to maintain a world that does not exist, except in daydreams or idealogy.

Notwithstanding all the tedious rhetorical evasions, the question remains: ought health care to be rationed on the basis of age? A first reaction might be " O f course not. Health care should be allocated on the basis of medical need. Age is irrelevant, and should be no more determinative than hair color or astrological sign." Reinforcing this is the fact that the aged, medically, are the most heterogeneous stratum of population, particularly the aged between 65 and 74. Geriatricians, in fact, often speak of "biological" and "chronological" ages because the two are synchronized so poorly.

Consider, in this regard, the British experience with end-stage renal disease, a chronic kidney condition that

is nearly always fatal. Though matters have changed considerably in recent years, practice for a long time was simply not to offer treatment to older patients (defined variously as over ages 50, 55, 60, or 65), who as a result died. The rationing was implicit and unacknowledged, usually calling for deception from the doctor and passivity from the patient and his family. There was no national policy document to point to, and significant variations in treatment patterns could be found from district to district. In short, the rationing was far removed from the practice of classic wartime rationing: it was neither explicit nor temporary, consistent nor widely supported.

Older patients in Great Britain were denied care because of a complex of mutually reinforcing beliefs: they were seen as more expensive to treat, their prognosis was usually poorer, their economically productive years were thought to be behind them, and they had already lived a relatively long life. It was not that older patients were deemed unworthy to live, but rather that in a context of serious scarcity they were graded as less worthy than their younger competitors.

For many years, regardless of the political party in power, treatment rates grew only by small increments, as Great Britain lagged behind comparable Western European countries by ever increasing margins. In the mid-1980s, however, the Thatcher government proposed major changes in the National Health Service for which it was widely attacked as heartless and insensitive. Given the enormous public support for the health service and the government's obvious vulnerability to these attacks, it found it useful to target a few afflictions for special attention, as symbols of its compassion and commitment to the NHS. End-stage renal disease had by this time gained considerable public visibility--largely as the result of the efforts of the indomitable leader of the principal patients' organization--so it became one of the afflictions selected to receive more resources. In all this, British age-based organizations played no role.

One question provoked by the British experience is whether age should properly be considered a medical criterion. There is no question that, in general, advancing age has important negative implications for kidneys, and that treatment for older patients is more complicated, expensive, and problematic. It makes sense, therefore, for physicians to use age in a " s o f t " fashion that alerts them to a congeries of difficulties. Too often, however, Britain's general practitioners and internists used age in a "ha rd" fashion as a more or less rigid boundary that settled questions of treatment.

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The clearest advantage to doctors of relying on age in this hard way was that it obviated the need to agonize over specific decisions. Instead of having to confront their own imperfect knowledge and impartiality on a patient-by-patient basis, physicians simply categorized patients on the basis of an easily understood and applied general rule. In place of uncertainty and subjectivity were certainty and objectivity, and the expenditure of time and error was minimized as well. Moreover, the blame for selection errors and the pain of rejecting some patients for treatment could be laid on the general rule, not the physician. However flawed a medical criterion chronological age may have been, it was plainly of immense value to decision makers seeking to avoid stress, guilt and discomfort, and to save time and effort by trading their discretion for the automatic implementation of a principle. And best of all, it saved money, too.

But age was used not only as a medical proxy variable, a convenient shorthand term for a set of afflictions that were assumed to appear at certain advanced points in the life cycle. Age also was used as a normative proxy variable, reflecting a value judgment that older persons had weaker claims on the public purse than did younger persons. The medical and normative factors, of course, reinforced each other, with fatal consequences for thousands of older Britons suffering from end-stage renal disease.

The British experience provides a harrowing illustration of the effects of rationing health care on the basis of age. And because we all look forward to a long life--because we are all either the aged or the not-yet aged--we all can identify with the older patient in Great Britain turned away with a few words of medical mumbo-jumbo and a sympathetic handshake as sincere as Judas' kiss. It is a jarring shock or recognition.

Yet, having said this, two other facts must also be acknowledged. The first is that in all economically advanced societies the aged consume a share of health care resources vastly disproportionate to their numbers, much of this for the treatment of diseases and injuries that, while not unique to the aged, are much more common in this group: cancer, diabetes, heart disease, kidney failure, arthritis, cataracts, and so forth. Once upon a time, these afflictions were considered a natural part of aging; today, they are considered diseases to which the aged are especially prone. But in either case,

there is no denying that the aged constitute by far the most medically vulnerable--and costly--chronological stratum of the population. (Conversely, of course, the

aged consume a disproportionately small share of resources devoted to such purposes as education and criminal justice.)

The British experience provides a harrowing illustration of the effects

of rationing health care on the basis of age.

Second, in the U.S. the aged (and their political allies) have been relentless in their efforts to legitimize age as a basis for conferring benefits. Medicare, an endless list of discounts at stores, restaurants, and

theaters , publicly financed senior centers, and so on-- in all these, advocates of the elderly have proclaimed age an appropriate criterion for categorizing people, a criterion so powerful that it often eliminates the necessity to inquire as to need.

This strategy has paid enormous dividends. The resources devoted to the aged have soared, so that today, for example, per capita health care expenditures for Americans over age 65 exceed those for Americans under age 18 by a multiple of six. Yet the strategy is not without its problems. One is that by clamoring for more and more resources, the advocates of the aged undercut their claims to autonomy and dignity. To say that the aged require assistance, after all, may appear the equivalent of calling them dependent and impaired. Images of the neglected frail elderly used to generate support for age-oriented public policies and charities do battle with images of the vigorous elderly used to enhance popular respect and overcome ageism. The three-quarters of the elderly without disabilities may be stigmatized by the one-quarter who are suffering.

Another problem with the strategy is that those who utilize age to justify benefits are not well positioned to complain when others use age to deny them, for both agree on the primacy of the age variable. It may be arbitrary, and therefore discriminatory, to lump all older persons together and deny them, say, the opportunity to benefit from certain kinds of major surgery; it would make more sense to make the decision on an individual, patient-by-patient basis. But is it equally arbitrary, and therefore discriminatory against the non-aged, to lump all older persons together and pay most of their medical expenses? Can age be used only when it helps, and never when it hurts?

Arguments ostensibly on principle cannot evade the charge of self-interest, and it is not to be wondered that

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intergenerational conflict--and, in particular, economic resentment toward the elderly--has become a topic of concern. Indeed, certain observations are by now so commonplace as to be cliches: younger generations believe that they face narrower economic opportunities and lower living standards than their predecessors; older generations are seen as the chief beneficiaries of the vast entitlement programs to which younger generations are compelled to contribute; younger generations are dubious that equivalent entitlements will be available when they will reach the appropriate beneficiary age; and so forth.

Can age be used only when it helps and never when it hurts?

No major intergenerational backlash has yet emerged, and the beneficiaries of age-based benefits are so numerous and well organized that no one imagines that the age criterion will go away. Yet, as the aged's benefits have grown so too have the burdens on the

non-aged, and clearly now the pendulum has begun to swing back in their direction. Portions of Social Security pensions have become taxable, Medicare copayments are increasing, and more discussion is taking place about making it easier for persons to provide for their own old age rather than relying on others.

Some observers find hope in the Western European experience, where even higher proportions of the elderly have failed to provoke much intergenerational conflict. These societies, however, are less individualistic than the United States, and more favorably disposed to all sorts of social programs. Yet, even they are hardly immune to resentment and hostility toward groups seen to be winning unfair privileges, as the innumerable outrages, often violent, against foreigners or their descendents have revealed.

Will hard age standards begin to be employed against the American elderly as they were against kidney patients in Britain? Certainly, there will be a temptation to do so, for the financial savings may seem too big to be dismissed. Already, the state of Oregon has obtained federal approval to embark on a five-year experiment to ration care for the poor under Medicaid. Can the elderly be far behind? Medicare, for example, spends nearly 30% of its budget to treat people in the final year of life, 40% of this for the last month of life.

Though this percentage has not changed since the 1960s, the phenomenal growth of Medicare has meant that $180 billion was devoted to that purpose in 1991--a sum that exceeds annual total national health expenditures until the mid 1970s. To some observers, current spending seems profligate, futile, and impossible to justify. In this and other areas, calls for Medicare rationing are beginning to be heard.

All this is merely a specific example of a more general phenomenon: America's bottomless appetite for health care. The "can do" activist tradition, the sunny conviction that for every problem there is a solution, the notorious love affair with technology and the widespread inability to accept the inevitability of death have each contributed to this gluttonous hunger. So, too, has the health care industry, which for generations has appealed for public and private funds with shameless rhetoric of "miracles" and "wonders ." And the ubiquity of third payers--Medicare and Medicaid (i.e., mostly, other taxpayers) plus private insurers (i.e., mostly, other policy holders)--provides a powerful incentive for patients to demand more: other people, they know, will foot all or most of the bill.

But as the number of elderly persons increase and the elderly themselves live longer, the aggregate cost of treating their aliments becomes greater, and eventually large numbers of the younger strata of society may come to feel resentful, used and overburdened. America has by no means reached the stage where a major reaction is imminent. There is still a vast reservoir of sympathy for the aged in whom the younger strata recognize not only their parents but also their future selves. And in contrast to Europe, America's elderly are far more politically astute and aggressive and America far more imbued with the language and mythology of rights and abundance. But even in America, advocates for the elderly have learned that they cannot increase their share of the pie without limit, for good health may be priceless but health care is far from free.

Thomas Halper is professor of political science and chairman of the department of Baruch College (City University of New York). He has written extensively on health care in the United States and Britain, and is best known for his book, The Misfortunes of Others: End Stage- Renal Disease in the United Kingdom (Cambridge University Press, 1989).

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