Should Rationing Health Care Favor The Young, Or The Old?

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Should Rationing Health Care Favor the Young, or the Old?

How do we resolve divisive issues in an increasingly aged society? Population expert Kenneth Howse has some ideas. 

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When it comes to older populations, Kenneth Howse is a foremost expert. Since the 1980s, his work has investigated health policy, intergenerational equity, and ethical questions surrounding aging, among other topics. He is currently a Senior Research Fellow at the Oxford Institute of Population Ageing and Director of the Centre for Policy Challenges of Population Ageing.

Do you agree with Arthur Caplan that aging is not an intrinsic part of human nature and that “there is no reason why it is intrinsically wrong to try to reverse or cure aging”?

We're the only species apart from the ones we domesticate that actually survives quite a long time after reproduction. For many other creatures, the survival pressures are such that they don't live long enough to show signs of aging. On the whole, we tend to regard that as a very good thing. It's a human achievement that people live long enough to find that their knees stop working well. The next human achievement is to find out ways that you can deal with the knee problems. I think one would have to think of it as a social experiment and try to think through the costs, risks, and benefits of that experiment, but the idea that there's something intrinsically wrong with it is one I'd be reluctant to accept.

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Scientists disagree over whether there is a distinction between aging and disease. Does that make talking about aging and forming policy recommendations difficult?

The distinction between aging and disease may matter to some people if they want to use the distinction in order to try to dictate what is a legitimate use of health care resources. You might want to say you'll only use health care when people have a disease but to me that doesn't seem terribly useful. There are so many age-related health problems and it might be moot whether we think of them as disease or not, but we may still think we should do something about them. It doesn't really matter how we describe them because we know they're quite important for quality of life.

Is it wrong to spend money on studying anti-aging research in a world where many people in poor and developing countries already have a much lower life expectancy?

We do live a lot longer than people in developing countries and a lot of that's actually not to do with anti-aging research. It's to do with basic social conditions that affect mortality quite early in life. You can think of gains in life expectancy in the rich world in the 20th century as really being divided into two parts: In the first half of the century, up to the 1950s and 1960s, most of the gains came from improvements in infant, child, and early adult mortality. After that, you start getting the improvements in later life mortality and now in the rich world nearly all the gains come from improvements in later life mortality. We may eventually benefit from anti-aging research. People in the poorer world still have quite a way to go with infant, child, and early adult mortality. They still have a lot to do in dealing with infectious disease and parasites. If you ask me whether I think that's fair or unfair I would say the rich world does have something of an obligation to help reduce that kind of mortality.

What benefits does extending life expectancy have for society?

If you think about the reductions in what we might think of roughly as premature mortality it's very easy to see gains for society, not just for individuals. Individuals gain because they don't die but if they're workers they can continue working. If we’re talking about households, families, parents, it means that the child doesn't lose a parent, which is good for the child. If the older population is active and contributory it's pretty straightforward to see what gains are there. But you need quite a few policies in place to ensure that happens. There are gains to be made but I think aging societies have to work in order to realize them. The gains for individuals are a different and more subjective matter for individuals to consider.

Do you think there's unnecessary anxiety among younger generations about how older generations will act politically? I’m thinking of the possibility that they’ll vote for things that benefit them at the expense of younger, working generations.

I don't know how much anxiety there is, actually. It may be there's more anxiety in the United States than there is in Europe. If there were anxiety, I would think it's reasonable to have a certain level of it. In other words, it's possible given the way the voting structure is set up – which is that older people vote more and there's more and more older people in society – that they're quite likely to vote to protect their own benefits. It seems not unreasonable to work out some standards of fairness that would allow younger and older people to decide on how to handle the costs older people are incurring. That's how I would approach it.

What questions do health care systems have to face when it comes to aging populations?

Things look pretty different from where you are depending on which country you're in, but one challenge is to do with the fact that most health care systems in the rich world are centered around an acute hospital-based model of care. They have to change that, I think, to a more community-based primary care model. That's a big organizational challenge, for sure. Some countries would be better at doing that than others – health care systems with socialized medicine, like Denmark and the U.K. would probably find that easier to turn around than very complex mixed systems like the U.S. where it's very different to actually legislate the change across the board.

How about when it comes to spending?

Daniel Callahan has written quite a lot on this. Basically the thinking is that if expenditure on health care as a proportion of GDP keeps going up, at some point or another society's going to have to face questions regarding rationing. If that does occur, then the secondary question is whether we should ration health care on the basis of age. From the U.K. point of view, it's quite interesting that that question has actually ceased to be important because we've legislated against it. In other words, the doctors in the National Health Service (NHS) are not meant to discriminate on the basis of age when they allocate health care resources to different individuals. This all has to do with what you think is actually driving health care expenditure. Do you think what's driving increasing health care expenditure is mainly the demography – more older people in the population? But then there's probably quite a strong consensus that the main driver of increasing expenditure on health care is actually technology. That doesn't actually put the whole thing to rest because presumably more and more of that technology is used to help older people. So it's a complex issue, but these questions are fairly important. How do you want to allocate your health care resources between extending life and improving quality of life?

Are these questions of allocating resources always going to be ethical questions or can they be solved by research?

Research can help in certain ways. We have something in the U.K. called the National Institute for Health and Care Excellence (NICE). When a new technology becomes available to be purchased by the NHS and it needs to be considered, it goes to NICE and NICE does a cost effectiveness assessment. Basically what they determine is the price per QALY (quality-adjusted life year). They actually have a threshold and when anything falls below the threshold NICE advises against its purchase. Anything above the threshold is agreed upon as worthwhile. So if you have an agency like that, that's certainly one way of doing it, but you still have to agree on where you should set the threshold.

Could the setting of that threshold be a reflection of a country's attitudes about old people?

It might be. In a sense these questions become very arcane very quickly. What I found interesting when I noticed some of these recommendations and judgments is that if they are drawn to public attention, they can become political hot potatoes very quickly. This happened quite a bit 10 years or so ago with proposed dementia treatments. In other words, NICE says this particular medication is not worth it because the gains are just too small and then a pressure group comes in and says we should have it anyway. My own view would be that it would be a mistake to think that NICE's judgments mean they don't value older people.

Are these questions best answered by something more objective such as NICE or should they be decided in the public sphere?

I think there does need to be public debate on it. NICE's procedures can be transparent so everyone can follow what they're doing and understand exactly why a decision is being made, but you still may wonder whether it's the right one. I think NICE tries to be flexible in this respect. It isn't purely technical, so they will get the results through the cost-effectiveness assessment but then probably argue about it in a committee. The people there will be more than just economists to check the figures. There will be other considerations. It's not a great idea that every new technology comes up for debate in the public domain. I'm not saying they should be suppressed but it seems quite reasonable to build a system that doesn’t rely on public opinion. It can still accommodate public debate about the criteria or principles that are used to make decisions.

To switch gears to a related topic, how do you think aging populations impact the environment? How do changes in the environment impact aging populations?

The second question is probably easier than the first because you can identify older populations in certain parts of the world as being especially vulnerable to environmental changes, especially climate change. The question of whether aging populations do actually make a difference to environmental impact is trickier. The standard way of looking at the interaction between population and environmental pressure is through population growth.

Quite recently, there has been an attempt to see whether other kinds of demographic change would matter at all in that regard. One of the factors to get at is changing age structure in the population. I don't know of many clear estimates of this. My guess would be you'd have to try to ask whether consumption patterns were in some way significantly different for older people than for younger people. It's certainly easy to think of ways in which they might. Older people are much less likely to want to drive cars with higher levels of petrol consumption. Those are younger peoples' toys. But maybe older people are changing – maybe those cars will become older peoples' toys as well. As a general rule, though, older people spend less on those everyday consumption items and more on health care. If you look at consumption over age, there's a shift in the balance of expenditure. People do different things with their money at different ages.

Is there an argument in saying every year a person lives on the earth they are consuming resources, so therefore the longer they live the more impact they're going to have?

I don't' think so. Every extra person on earth is also a pair of hands and a brain so they are producing more as well. Carbon footprint isn't the only thing to think about. They may have been producing things that could reduce carbon footprints – alternatives to carbon, for instance. So I wouldn't buy the argument that more longevity is simply bad for the planet. The main thing to say is that fertility levels matter more for population growth than longevity. Most high and middle income countries are very likely to have zero or negative population growth by the end of this century and increasing longevity is not going to change this very much at all.  It is quite likely, in fact, that the world's population will have stopped growing by the end of the century. For what it's worth I think that this is a good thing. 

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