Bioethics Cost Considerations

Age-based healthcare rationing is a concept that limits the allocation of medical resources based on the age of the patient population. This concept is rooted in the belief that the cost of care for older adults and the elderly is unsustainable due to the complexities of their prevalent medical conditions combined with the treatments and resources required to treat them. Preventative care is often perceived as less costly and more beneficial, whereas life-extending technology is significantly more expensive and provides less improvements to the quality of life for aging patients. 

Although age-based healthcare rationing has been a topic of discussion for decades, concerns about its use became increasingly prominent during the COVID-19 pandemic. Many hospitals were directly affected by reductions in staff, resources, and intensive care beds, leading healthcare professionals to prioritize patient care according to the odds of survival. Since older adults and elderly patients are often exposed to ageism in healthcare, they may also have had limited access to some medical procedures due to the biases of their physicians. This led some patients to worry that they will not receive adequate care compared to younger patients. 

Moreover, there have been ongoing concerns about society’s ability to maintain and support future healthcare needs, especially as the baby boomer generation continues to age. Some projections suggest that by 2030, there will be around 74 million people over the age of 65. Others have indicated that by 2034, older adults will outnumber children under the age of 18. As the healthcare system continues to struggle in the aftermath of the pandemic, there is renewed interest in age-based healthcare rationing concerning the costs associated with the general provision of care, lifesaving treatments, and emerging life-extending treatments. 

While age-based healthcare rationing may have the potential to reduce costs attributed to these resources and extend the reach of preventative care to younger patient populations, it’s important to acknowledge that it’s a model that can create and exacerbate inequalities between age groups and sexes. Age-based healthcare rationing favors younger patients over the elderly, suggesting that access to resources should be based on age rather than each patient’s individual needs. Chronic conditions and wellness can vary greatly within age groups, so patients within older and elderly populations have their unique concerns. Similarly, since women live longer than men, they may be disproportionately affected by age-based healthcare rationing that would limit their access to life-extending care and other vital medical treatments. Therefore, careful considerations should be taken when implementing age-related policies to ensure that it does not perpetuate these disparities and potentially compromise the principles of ethical healthcare.

Sources

“How Elderly People Are Left Behind During Medical Care Rationing”. WBUR. https://www.wbur.org/hereandnow/2020/07/10/elderly-covid-19-health-care-rationing 

“Is ageism creeping into your care of older adults?”. American Medical Association. https://www.ama-assn.org/delivering-care/population-care/ageism-creeping-your-care-older-adults 

“Aging population to hit U.S. economy like a ‘ton of bricks’ -U.S. commerce secretary”. Reuters. https://www.reuters.com/world/us/aging-population-hit-us-economy-like-ton-bricks-us-commerce-secretary-2021-07-12/ 

“By 2030, All Baby Boomers Will Be Age 65 or Older”. United States Census Bureau. https://www.census.gov/library/stories/2019/12/by-2030-all-baby-boomers-will-be-age-65-or-older.html 

“Why do women live longer than men?”. Our World in Data. https://ourworldindata.org/why-do-women-live-longer-than-men 

Although Americans are loath to discuss rationing of healthcare, the cost of intensive medical interventions at the end of life is an issue that’s hard to avoid. According to Kaiser Health News, in 2020, Medicare spending was $689 billion, which represented 12% of the federal budget and  20% of the nation’s total healthcare expenditures that year. What’s more, a large percentage of that money was spent during patients’ last six months of life. 

There are several factors that are currently impacting Medicare spending, and unfortunately, they will continue to do so for many years to come. Most importantly, the American population is aging, so the number of Medicare beneficiaries is growing each year. According to Kaiser Health News, there were 63 million people enrolled in the program in 2020 (a number that includes younger people with a qualifying disability), and that number is expected to increase to 93 million over the next 40 years. Further, older Americans are living longer, albeit not necessarily healthier lives. In 2020, the percentage of people over 65 who were in their 80s and 90s was about 25%; that number is expected to increase to one-third over the next 40 years. Not surprisingly, health care spending increases exponentially as people age. 

Another factor that is hugely impacting healthcare spending is the soaring cost of prescription drugs. According to the Congressional Budget Office, nationwide spending on prescription drugs increased from $30 billion in 1980 to $335 billion in 2018. Per capita spending increased from $140 to $1,073. And while that spending reflects a wider availability of many extremely beneficial drugs that have improved many lives, some experts believe these increases are unsustainable over the long term. 

As of this writing, Medicare is legally barred from refusing to pay for a medically necessary treatment due to cost. However, the definition of “medically necessary” is open to interpretation by both private insurers and Medicare and Medicaid. One example: Medicare recently made the controversial decision not to pay for the very expensive and questionably effective Alzheimer’s treatment Aduhelm, which was approved by the FDA under fraught and highly questionable circumstances in June 2021. This was a highly unusual move; Medicare has paid for at least 80% of all FDA-approved drugs and devices in recent years. But as the cost of care continues to rise, it may become more and more common for insurers, including Medicare, to limit the treatments and drugs they will pay for, especially at the end of life.   

Sources

“The Facts About Medicare Spending”. KFF. https://www.kff.org/interactive/the-facts-about-medicare-spending/ 

“Prescription Drugs: Spending, Use, and Prices”. Congressional Budget Office. https://www.cbo.gov/publication/57772