AMA Journal of Ethics^®

“Elderly people who are terminally ill have a duty to die and get out of the way.”
—Colorado Governor Richard D. Lamm in a 1984 address to the Colorado Health Lawyers Association

“Do not cast me off in old age; When my strength fails, do not forsake me!”
—Psalms 71:9

When the baby boomer generation reaches senior citizenship in 3 years, their growing appetite for the health care dollar and the increasing pressure it puts on the American economy will surface in an ever more dramatic form. The U.S., already strained by the world’s highest per capita spending for health care, is about to inherit a huge wave of elderly citizens who will need (and want) their share of the health care dollar. The explosion of this demographic time bomb, coupled with the cost of increasingly sophisticated and expensive medical technology, will result in an unsustainable economic burden that might not only bankrupt Medicare but also have a devastating impact on the American economy.

It is doubtful that any politician will have the temerity Governor Lamm had when he stated in 1984 that old, terminally ill Americans “have a duty to die and get out of the way.” But underlying Lamm’s heartless statement is a feeling probably held by many Americans: old folks who have lived their lives should not be allowed to place a huge economic burden on the young by using a disproportionate amount of limited financial resources for medical care.

There is an implied and fallacious assumption in this line of reasoning, which is that by spending less on the aged we will have more money for those who might put the funds to “better” use. Medicare money is not fungible, and a decrease in its budget will not result in more money being allocated elsewhere. This does not exclude the possibility, however, that the Medicare budget could be spent more wisely on the elderly, a point I will get to later.

Not too long ago, some societies actually treated their elders as second-class citizens when it came to health care. During a trip to the Soviet Union in 1986, I was told that elderly patients in Soviet hospitals were badly neglected because they were felt to be nonproductive elements of society. I was also told how, in an Eastern European communist country, people lied about their ages when calling an ambulance because emergency services were not dispatched to older patients.

These extreme and repugnant examples of ageism should serve as dramatic reminders that age should not be used as the sole criterion for allocating health care resources. Whereas age may play a role in selecting recipients for certain treatments, for example scarce organ transplants, it is difficult to think of instances where age by itself should play an exclusionary role.

Besides, how would such determinations be made (and by whom)? Should patients above a certain age be excluded from ICU care? Should octogenarians not be offered coronary bypass surgery? Should we withhold aggressive chemotherapy from patients above a certain age? The inhumanity of such suggestions is self-evident.

The reason elderly patients use a disproportionate share of medical resources is obvious—they are sicker and need the care. They are also entitled to the care, inasmuch as most have paid Medicare taxes all their working lives on the understanding that this program would provide for them when they needed it.

The real question isn’t whether our elderly are entitled to these resources, but how the money can be spent wisely, and whether there are reforms that, if carried out, would decrease expenditures that do not promote the health of Medicare recipients.

It is often stated that 27-30 percent of all annual Medicare expenditures are spent on caring for people in their last year of life [1], with the implication that this is too large a portion of the Medicare budget and that much of this money should be spent on health care for the non-dying. Firstly, this percentage has been remarkably stable over many years [2]. Secondly, the suggestion that this is excessive assumes that we can know ahead of time which patients will die so that less money would be “wasted” on their terminal care. This, of course, is incorrect. Many elderly patients, treated aggressively, survive for years with a good quality of life. And even if we could reasonably predict which of these patients were in their last year of life, we would still have to provide them with palliative care that is not inexpensive.

Medicare statistics do, however, point to glaring discrepancies that call for further investigation and corrective measures. A 2003 study found that per-capita Medicare expenditures in certain areas of the country were more than double those in others, without any appreciable difference in the quality of care. In fact, the data showed that “low-use [Medicare services] states tend to have higher quality services relative to high-use states” [3]. The reasons for such variability may lie in a complex mix of differences in beneficiaries’ propensities for seeking care, area-specific practice patterns, and the racial and ethnic mix of the over-65 population. Finding explanations for these data holds a promise of decreasing medical expenditures without sacrificing the health care of the elderly.

Another topic that should be mentioned is the medically responsible use of technology. For example, the finding that life expectancy of patients with severe heart failure can be prolonged with the placement of implantable cardiac defibrillators has resulted in thousands of elderly patients with CHF receiving these very expensive, sophisticated devices without corresponding evidence that people in this advanced age group benefit from them.

A third reform that might save Medicare funds without sacrificing the quality of health care is reversal of the trend towards specialization among medical school graduates. By closing the income gap between medical practices that are procedure-based and the so-called cognitive specialties, we might encourage more graduates to become general internists, whom geriatric patients depend upon most. Skilled geriatricians can not only prevent excess expenditures on the unnecessary tests and procedures favored by specialists, they might also provide better overall care for the elderly than the fractionated pattern of specialist-centered care that many senior citizens receive.

Finally, one promising statistic is that Medicare expenditures in the last year of life decreases for those aged 85 years or older [4], in large part because the aggressiveness of medical care decreases with advanced age. As a greater percentage of the elderly population reaches their mid-80s (and if they have not had expensive, life saving interventions up until then), Medicare expenditures may actually drop.

In short, the proper approach to an aging population that consumes ever more health care dollars is not to cut their access to care arbitrarily but to develop a multifaceted approach that emphasizes patient and physician education about what medical care is helpful and what is not; promotes research into which procedures help the elderly and which do not; and endeavors to revive the increasingly neglected practice of general internal medicine with a focus on the geriatric population.