Correspondence
Costs of Health Care for the Elderly
N Engl J Med 1997; 336:663-664February 27, 1997
- Article
To the Editor:
Callahan (Sept. 5 issue)1 has again urged us to confront openly the challenge of providing decent health care to the elderly in a manner that is socially affordable. What his essay does not note is that we must also confront the fact that a medical insurance scheme such as Medicare that covers only the elderly will always face financial crisis. How could it be otherwise? This population is more likely to be ill and to need very expensive care, either in hospitals or nursing homes. Only by expanding the pool of insured people to include the young and more typically healthy segments of the population will it be possible to create the conditions for an equitable sharing of the financial burden across the generations. Only when there is universal health insurance will it be possible to have the kind of dialogue urged by Callahan — one that does not blame the elderly for breaking the bank because they have so thoughtlessly survived into old age.
1 ReferencesRonald Bayer, Ph.D.
Columbia University School of Public Health, New York, NY 100321
Callahan D . Controlling the costs of health care for the elderly -- fair means and foul. N Engl J Med 1996;335:744-746
Full Text | Web of Science | Medline
To the Editor:
Callahan suggests that we should open the debate, agree that providing less health care for the elderly is necessary, and define an age cutoff. Unfortunately, the reason current methods of creating the necessary inequity between young and old are not working is not because they are poor methods, but because when we see what providing poorer care to the elderly means on an individual basis — to our own parents or grandparents — we find it repugnant and, given the choice, reject it. At heart, most of us consider human lives equal regardless of age. Our common humanist values admit that suffering is equal in intensity in any decade.
Other nations are not in such parlous circumstances. Realizing that expenditures for health care must be reduced, we can reduce them equally for all people, regardless of age or income. If we want to be content, we will moderate our expectations appropriately, and if we manage to avoid the gross inequity of the American system and the sense it engenders that others have better, then we stand a good chance of being able to do so. The only solution to soaring health care spending in the United States is an appalling one, but we have the luxury of not having to adopt that solution. We have learned much from the success of America; let us learn also from its failures.
Mark Sudlow, B.M., B.Ch.
University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, United KingdomTo the Editor:
Perhaps it was always clearer to practicing physicians than to ethicists that to deny care because of age or under the presumption of the end of life (as if that were possible to determine with certainty in a meaningful number of instances) was next to impossible. That is, it could not be done explicitly without countervailing the autonomy of most people. The same difference between ethicists and physicians has also always applied to advance directives, or assisted suicide, as a means of solving the problem of the increased costs of medical care for the aged.
Callahan also recognizes, as has been repeatedly reported, that the elderly respond as well to treatment as do younger people and therefore that the presumption that much medical care for the aged is futile cannot be used to deny it to them. In view of all these realities, as much as it distresses Dr. Callahan, he now acknowledges that rationing, if it is to be used to control the cost of medical care for the elderly, will need to be done implicitly.
Rationing has always been a most difficult business, and the implicit–explicit dichotomy (or “open” and “covert,” as Callahan puts it) is only one of many distinctions that need to be made.1
1 ReferencesHenry A. Shenkin, M.D.
3300 Darby Rd., Haverford, PA 19041-1069To the Editor:
Callahan's arguments are based on the hypothesis that additional government funding for health care for the elderly will never be forthcoming. Yet it is not quixotic to see the “Medicare crisis” as an opportunity to expand the debate to re-explore economic possibilities that have been largely ignored in recent years.
After the dissolution of the Soviet Union there was discussion of major reductions of military expenses in the United States, which presumably would result in enhancing other federal services or reducing taxes. Reductions in military spending have actually been small and have plateaued. If the issues are well defined and clearly presented, will the elderly (and even the young) feel better protected by a huge military force or by a Medicare program that provides them the full benefits of modern medicine and long-term care?
Gerson T. Lesser, M.D.
200 East End Ave., New York, NY 10128Author/Editor Response
Dr. Callahan replies:
To the Editor: Dr. Bayer is right to think that universal health care in the United States could make it easier to distribute resources equitably between young and old. Even so, we would still face a nasty situation. The European countries and Canada, all with universal care systems, also worry about the growing number and proportion of the elderly. It is becoming a problem everywhere, regardless of the way health care is provided. Contrary to Dr. Sudlow's view, I believe that whatever “luxury” other countries may now have in comparison with the United States will soon disappear.
It is nowhere appropriate to blame the elderly for this demographic situation. It is hardly their fault that public health advances and medical progress have extended life expectancies or that the ratio between young and old is shifting. It is not anyone's fault but the result of medical success.
The important question before us is, What counts as an equitable distribution of resources between young and old? Sudlow thinks that if we must reduce health care expenditures, “we can reduce them equally for all people, regardless of age or income.” What's equitable about that? Are children just beginning life to be forced to make sacrifices equal to those who have had a full life? And the poor forced to give up as much as the rich? Since I am over 65, I would like to have what Dr. Lesser calls the “full benefits” of modern medicine. But it is precisely the effort to provide such benefits that will become all but impossible with the graying of the baby-boomers.
Dr. Shenkin rightly implies that the Hippocratic tradition, with its singular focus on benefiting individual patients, has run up against limited resources. As nice as it would be to treat patients with an eye blind to age, those limitations will increasingly not allow us to do so without generating inequity between young and old. For policy purposes, age-group differentials must be taken into account.
I am less disturbed about this than others are, and for one reason: nothing in my experience or reading indicates that the key to a happy and decent old age is access to unlimited medical resources, much less unlimited medical progress. Have I missed something here?
Daniel Callahan, Ph.D.
Hastings Center, Briarcliff Manor, NY 10510
