On the face of it, it would seem preposterous to argue that the over 65 population should support health care rationing. After all, both Democrats and Republicans regularly pledge to protect Medicare from any changes and attack the other party for threatening the program. And in a 2012 Pew Foundation poll, over 65ers by a 3:1 ratio said that government policies should favor older people over younger.
I believe, however, that there are four strong considerations that would point us over 65ers towards at least considering the possibility of supporting the concept of rationing:
1. Improved health. Health care rationing, done right, can improve our health. By reallocating funds from quixotic pursuit of cure when cure is not to be had to targeted infrastructure investments like income support, housing, social services, and transportation, we can improve the overall health of the over 65 population. It’s well known that factors like these have more of a bearing on health status than medical care. Shifting some of our present investments in medical care to health promoting infrastructure could, paradoxically, improve our health.
2. Improved access. Health care rationing, done right, will improve the health of less well off elderly. By “done right” I mean increasing access to primary care and the kind of geriatric care Leslie Kernisan described last month. Here I’m imagining reallocation within the sphere of medical care, whereas in the paragraph above I’m arguing for reallocation from the medical care sector to the broadly understood public health sector.
3. Improved medical treatment. Without the specter of health care rationing – a vision that has been anathema to the body politic – we’re not likely to get a grip on the segment of medical cost seen as “waste.” From the perspective of elderly patients, a significant component of “waste” is better understood as “overtreatment” – interventions that should not be done because the harm they cause outweighs any benefit. Overtreatment, as I posted about last month, is, alas, a common occurrence in treatment of the elderly. As a small example, elimination of routine PSA examinations will reduce unneeded prostate biopsies, and in the aftermath of those biopsies, treatment of some for prostate cancer when the negative outcomes of treatment (most notably, incontinence and impotence) outweigh any benefit from treating a cancer that would not have caused harm before death came from other causes.
4. Improved intergenerational equity. Health care rationing, done right, makes us over 65ers better members of society. Here “better” refers to aligning us with the continued well-being of our nation and our planet. Many years ago, an elderly neighbor came to my door, canvassing on behalf of a town initiative called “SOS” (“save our schools”). When I asked him why he was doing this, since he had no children or grandchildren in the schools, he said – “it’s the right thing to do.” My neighbor’s attitude was consistent with another finding in the Pew Foundation poll – that support for policies favoring the elderly over the young dropped from 4:1 among 50 – 64 year olds to 3:1 among over 65ers, a finding consistent with the hypothesis that as we age our attitudes about intergenerational equity shift. Although 51% of the over 65ers said “no” when asked if current levels of Medicare and Social Security funding will put too much of a burden on the younger generation, a substantial minority – 35% – said “yes.”
Some of the physicians I respect most, including Arnold Relman and Donald Berwick, believe that improving quality and eliminating waste will obviate the need for rationing. I hope they’re right, but with the continued growth of the over 65 population and development of new and costly treatments, I fear they’re too optimistic. But either way, the crucial point is that unless it’s clear to health professionals and the public that there’s no chance whatsoever of avoiding rationing if we don’t improve quality and reduce waste, we won’t accomplish those laudable goals.
The weakest part of my argument is my vision of rationing “done right.” Shifting expenditure from low benefit medical treatment to improved access and stronger health-promoting infrastructure is a long shot. But without support from among us over 65ers, the kinds of public health and future oriented changes I envision can’t possibly occur.
James Sabin, M.D., 74, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.