Why the Elderly Should Support Health Care Rationing

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.

4 Responses to “Why the Elderly Should Support Health Care Rationing”

  1. Bob Fenton

    If you are considering house calls in this, then this would be something worth support. Too often, patients have travel difficulties and bypass care when they need it. Especially after a hospital discharge or when they live in doctor sparse rural areas. Even some that live in doctor dense areas find it too dangerous to venture away from their homes.

  2. James Sabin

    Dear Bob –
    Thank you for your comment. House calls for over65ers in the circumstances you describe represent (a) good care and (b) potential satisfaction for doctors and nurses as long as (c) they are compensated fairly for the activity. House calls are the kind of “high value intervention” that could be subsidized if we restricted benefits for “low value interventions.” When I did research in London in the 1990s I spent three days shadowing excellent GPs – in their offices and with them on house calls to patients who were not mobile enough to come into the office, and I saw how useful house calls could be. And I’m old enough to remember my own pediatrician making a house call when I had what turned out to be mumps encephalitis but was feared as being polio. He did a lumbar puncture with me lying on the kitchen table! Leslie Kernisan’s post on April 25 gives a vision of geriatric care consistent with your comment.

  3. mary dicerni

    I cannot think that you have any knowledge of what is being done. Ask those people with ruptured abdominal area, and have no way of knowing why they are suffering so much. We are talking about the healthy ones who are being neglected after 45 yrs old. This is not old age, and they should be repaired, in oder to prevent the next stage where we are all in a nursing home, and then you will start to look at the quality of life…That is much too late.. While healthy, we should be hanging on to that quality. Instead, we are ignoring those ruptures, allowing the whole core and then the body to disintegrate.. and goes into a nursing home…Why? Those ruptures should be repaired as early as we can… and now we have all these 75 year olds , ruptured, with difficulty walking, and bent forward, blaming the BACK?? It is the abs that are supposed to hold that back up strong. .. how can they ? they are all undone.. with other ruptures as well… How can we allow this to go on, and say it is good? Does anyone know about these ruptured people? I am 82, and have suffered for 7 years after a colonoscopy that tore down previous bladder surgery, and added some ruptures as well. How will anyone do the repairs when there is such horrid rationing. making a healthy person that was landscaping, go into a HOME??. There may be some other definitions we might use, other than age?? i am very angry with all doctors and especially the young ones who have not known anyone over 40. Seniors are the smart people in the crowd. Ask them anything. I know you will not . If any of you can add up the 40 years of suffering, and millions of visits, futile, and expensive. the many joint and back surgeries, and the many filling the HOMES… compare it to them not spending all this money, and being great volunteers still, with the grandparents still helping their children, well into their nineties. How much would it cost to repair the young in day surgery? Before it all falls apart and need a cane and more? Train surgeons to do these quick repairs before age 50. Each patient should have abdominal exam along with the complete physical, and have them repaired as soon as they show signs of great separation and ruptures. Hernias of any kind will only get much larger as we now live to 100. Are these the people you thought we might save money on? Where have we lost our logic and caring? Cheaper to not repair those suffering for 30 years, with millions of visits and frustration from neglect and ignorance? And still paying for their medicare ?? What country is this? nazi? Mary D.

    • James Sabin

      Dear Mary

      Your comment dramatizes the challenge people like myself who advocate for well thought out rationing policies must deal with. It sounds like you are describing abdominal or “ventral” hernia. When these hernias cause symptoms, surgical repair is what’s called for. In a country as wealthy as the US, with the medical resources we have, no rationing program would eliminate this kind of surgical repair. Repair of abdominal hernia is well above the cut-off line in the Oregon health priority list, and there is no age restriction on the coverage.

      What you have encountered may be caused by inadequate local funding, which itself is a symptom of the tremendous waste in our health care system. The reason we over 65ers should support “rational rationing” is that reducing waste and costly treatments that produce – at best – tiny benefits, will allow our health system to allocate its resources where they’re more needed. What you describe should not be happening in the US. It’s a symptom of stupidity in our health system, which is the opposite of thoughtful rationing.

      Thank you for your comment!