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Can Safety, Freedom And Rationing Co-Exist For The Elderly?

Do you recall when Dr. Ezekiel Emanuel, the chief architect of the Affordable Care Act, made a chilling announcement that he does not wish to live beyond the age of 75 because his productive life will be over?

As explicit rationing of medical care becomes inevitable, a champion of the elderly must be among those at the policy-making table. We are all destined to some level of dependence. But, this dependence does not diminish the societal role of elders who guide us, whose minds are full of family history and knowledge, and who are keen at identifying the joys in our lives. The ability to accept mortality’s pains and impediments requires a measure of courage and dignity with which few of us are blessed in our prime.

Those 65 and older are expected to make up 20 percent of the total population by the year 2030, up from 13 percent today. The population of the “old-old” (85 and older) will quadruple as the large Baby Boom cohort reaches advanced age. Seniors with five or more chronic conditions account for less than a quarter of Medicare’s beneficiaries but more than two-thirds of spending. They are the fastest- growing segment of the Medicare population. If nothing is done to alter current patterns of health care, per capita health expenditures will rise by one-fifth due to population aging alone.

We will each spend an estimated $388,000 on our health throughout the course of a lifetime. Sixty percent of that cost will be spent after age 65, while 30 percent will be spent after 85. Medicare cost the nation $583 billion in 2013 and covered 54 million people ages 65 and older along with those with permanent disabilities.

Nursing home care is one slice of the elderly’s cost pie, predominantly paid by taxpayer dollars. In 2011, it weighed in at $150 billion for more than a million Americans. In 2000, that number was only $85 billion.

How much of this expense is due to the search of safety of our loved ones? How much is a result of real medical care? Have we warehoused our elderly, relegating them to institutional lives for medical reasons? Or, have we diminished their abilities to re-engage in life, make decisions and be treated as vital beings in the name of “safety”? Certainly, safety is essential. However, safety alone is an empty goal.

In a just society where scarce resources must be fairly allocated across the full spectrum of life and conditions, where do the elderly fit? If a respected thought-leader like Emanuel were setting policy, would those 75 and older need to defend their claim for medical resources? His proclamation that productive life has finished can be dangerous. Fortunately, we are only beginning to unwrap the discussion on rationing. Even though it is long overdue, we are not taking such pronouncements as a call to action.

Dr. Atul Gawande’s recent Being Mortal: Medicine and What Matters in the End posits that modernization did not demote the elderly; it demoted the family. “It gave people, the young and the old, a way of life with more liberty and control, including the liberty to be less beholden to other generations,” Gawande writes. “The veneration of elders may be gone but not because it has been replaced by veneration of youth. It has been replaced by veneration of the independent self.” This veneration is reflected in the burgeoning elderly population and attendant cost of nursing homes and assisted living facilities.

Autonomy is jeopardized when safety becomes the primary goal. The institutional setting confines choices and challenges the freedom to shape one’s life- the very marrow of one’s being. The battle to avoid being diminished and the struggle to be the master of one’s own destiny is misinterpreted as non-compliance in institutional settings. This non-compliance sets into motion a diminution of more freedoms.

Harvard psychologist Ellen Langer observed in various experiments that mental acuity and general health improved in old people when they were re-engaged in life, made decisions for themselves and were treated as the vital people they were in their prime. The rekindling of their egos was “central to the reclamation of their bodies.” Prolonging life in the name of safety does not translate into reclaiming a vital self. It is not the goal of people who have a serious illness or who are losing their independence.

Apolitical and rational discussions about unsustainable costs can generate creative solutions. When we start by defining our society as “just,” the old will not be cast aside. They will have equal standing with all other members of our community. Our responsibility is not to allow an arbitrary age of 75 to define the end of productive contribution. Rather, we should be seeing solutions that first address the expansiveness of life versus the restrictiveness of safety. If we commissioned a study regarding what the costs of safety have been in institutional settings versus the investment in Aging in Place or the Green House Project – both proven to reduce costs, we may agree that more independence results in a double effect of promoting mastery of individual destiny and reduced cost.

Rationing is real, but there are ways to prevent it from being punitive. It is not helped when a red line is drawn upon someone’s whiteboard, declaring that the entire usefulness of a population is over. Is our goal to strip the individual joy of shaping whatever remains of life by expending scarce resources for the objective of safety? I believe we can have a safe and engaged elderly while balancing the resource demands of an aging society. It takes more time, creativity and enlightened decision-makers who understand what is important as we age. It does not take a proclamation by one individual who fears irrelevance.

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