Setting Generational Priorities

In the mid-1980s, just as I was becoming interested in health care for the elderly and the future of Medicare, Samuel Preston, a distinguished social scientist at the University of Pennsylvania, give a 1984 presidential address to the Population Association of America. His topic was the growing disparity between health and other resources for children and for the elderly. In 1970, he said, poverty among children under 14 was 37 percent less than poverty among the elderly. But by 1982 the incidence of  poverty among children was 56 percent greater than among the elderly. And, he added, “let’s be clear that the transfers from the working-age generation are also transfers away from children, since the working ages bear far more responsibility for child rearing than do the elderly.”

Preston’s address and the position he took set off a great debate, leading to the quick formation of a group called Americans for Generational Equity and statements by the Gerontological Society of America against such a position. Someone influenced by that backlash once said to me “90 minutes old or 90 years old, both deserve equal resources.” Since that time the gap in resources to the young and to the old for resources has increased, with far more children than the elderly in families below the poverty line.

I was one of the few at the time who did not believe that generational equity justified that kind of gap, much less that the 90-minute-old child should have to compete with a 90-year-old person on a level playing field. It seemed to me then and seems to me now that children have the greatest claim on health care, the adult working population responsible for running society and raising the children should come next, and the elderly last. That kind of ranking has little public support. The 2012 Pew Foundation poll, cited by Jim Sabin in his recent post, found by a 3:1 margin that government policies should favor older people over younger.

I was astonished by that poll result, which seems to fly in the face of the common good of the generations living together. A symptom of that bias is that still, despite all the talk about the need to control Medicare costs and reduce the deficit, only some 20% of the public, and few politicians, are in favor of reducing its benefits – but are quite ready to do so for children’s programs such as Head Start. But children are the future and those of us over 65 are the past. Most of us in that age group resist being put in that category: don’t we count also?

We do indeed count, but not so much that our needs trump those of children. They are the future and we are not. We have had a chance at a full life, which they have not and need to get where we are now. More than 60% of the entire health care spending in this country goes to less than 20% of the population, mainly those older people needing expensive chronic care medicine. We are very good in this country in expensively keeping very sick old people alive in ICUs, but not nearly so good in making sure our children, all of them, grow up healthy and have the support of good schools and other welfare related benefits.

I join my colleague Jim Sabin in saying we need to ration health care for the elderly, and expensive treatment of chronic illness near the end of life is a place to start. At the same time we need programs to strengthen health care at lower levels, and to shore up the coming shortfalls in retirement money for many elderly. The aim will be to find a good balance between economic and health care needs.

Daniel Callahan, Daniel Callahan, 82, is President Emeritus of The Hastings Center and the author of two new books, a memoir, In Search of the Good: A Life in Bioethics (MIT Press), and a collection of essays and papers, The Roots of Bioethics (Oxford University Press).