Age-Based Rationing of Health Care

Proponents of old-age–based rationing have set forth both economic and philosophical rationales for their views. Their economic argument is essentially that the costs of health care for older people will become an unsustainable economic burden for the United States during the next few decades because of population aging, thereby posing grave problems for the economy and making it very difficult for government to spend funds on other worthy social causes.

The number of older Americans will grow sharply during the first half of the twenty-first century as the baby boom—a cohort of seventysix million persons born between 1946 and 1964—reaches old age. At the turn of the century, persons age sixty-five and older were about 13 percent of the U.S. population and accounted for one-third of the nation's public and private health care expenditures (about $400 billion out of a total $1.2 trillion in 2000). Per capita spending on persons in this age range is four times greater than on younger persons, largely because older people are far more likely to need health care than younger ones. The total number of older Americans, which was thirty-six million in 2000, will be seventy-six million by 2030 and will constitute 20 percent of the population. Consequently, the aggregate health care needs of the older population will be even greater in the future than they are now. For example, the proportion of national wealth (gross domestic product) spent on Medicare in 1998 was 2.5 percent; it is projected to more than double, to 5.3 percent, in 2025.

Moreover, the number of persons of advanced old age—in their late seventies and older—will increase markedly, and in this older age range the rates of illnesses and disabilities requiring health care are much higher than among the rest of the population. Even if important advances are made in treatments, illness prevention, and health promotion, they are unlikely to have a major impact in terms of eliminating the overall extent of illnesses and disabilities in advanced old age, and on the costs of caring for older persons in the next several decades. Indeed, the implementation of such advances will probably lead to more intensive use of medical care.

The philosophical arguments for old-age– based rationing are more varied than the economic arguments. The philosopher Norman Daniels (1988), for instance, poses an abstract problem of justice by depicting a society in which each individual has available a fixed sum of money for his or her lifelong health care. Without our knowing our particular individual positions in such a society, Daniels asks: How would we allocate, in advance, the availability of funds for care at various stages of life? His answer is that we would choose to make sure that we had enough for health care in our early and middle years, and allocate very little for our old age.

In contrast, Callahan propounds a communalist philosophy. He argues that it is inappropriate for older people to pursue their individualistic needs and aspirations. As he sees it, the meaning and significance of life for the elderly is best founded on a sense of limits to health care, and recognition that life cannot go on for long and death is on the way. This meaning of aging envisioned by Callahan requires older persons to adhere to a value of serving the young through politics, and more directly in one-onone relationships. As he sees it, limiting lifesaving care for older persons would affirmatively promote the welfare of the elderly and of younger generations.