The Challenge of an Aging Society: The Future of U.S. Health Care Must Involve Some Form of Rationing, Argue a Former Governor and a Medical-Policy Scholar. the Problem Is Not Simply How to Control Costs, but How to Achieve Social Justice

Article excerpt

One of the great challenges in America's future is to retire the baby boomers without bankrupting the country or unduly burdening future generations. This crisis could soon overwhelm American public policy, as yesterday's baby boom becomes tomorrow's grandparent boom.

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This demographic revolution raises some awesome challenges:

* How can we continue to fund present programs for the elderly and also expand those programs for the aging baby boomers?

* How can we fund retirement as well as general health-care programs in an America with ever more older citizens and ever fewer children?

* How do we provide the social infrastructure for an aging society?

* And finally, how can we do politically what needs to be done while being fair to both the present generation and the future generations who will fund these programs?

If we act soon, we can answer these questions rationally, prepare for our future, and avoid steep economic decline. But if we wait, the decisions we will be forced to make will be truly draconian. Age could well be as divisive in the next 40 years as race and sex have been for the last.

There are basically two ways to provide health care and retirement benefits for the elderly: Society can prefund these programs, much as most private-sector retirement programs are funded today, or it can develop a social-insurance scheme. The United States chose social insurance, and it has worked well so far, but how long can it continue?

The U.S. retirement system is now actuarially unsustainable, and health-care expenditures in the nation have grown over the past 40 years at about two and one-half times the rate of inflation, now consuming more than 15% of GDP. Thoughtful people are coming to realize that, given science's seemingly endless production of new miracle treatments, the efforts expended to maintain our own aging bodies can bankrupt our children and our grandchildren.

Today's elderly account for approximately 13% of the U.S. population, yet they get more than 60% of all federal social spending. Americans spend about three times more taxpayer funds on the elderly than on children; the federal government's spending is even more disproportionate. It is not a workable nation-building strategy to spend significantly more on the last generation than we do on the next generation. We must rethink many of our basic public-policy assumptions, because the status quo in health care and retirement spending is no longer an option. The only question is how much and what type of reform we need.

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The Next New Deal

To admit that the current system of funding health care is unsustainable requires us to give up a cherished dream: the dream of total, universal care for any ailment freely available on demand. Like the "take backs" some employers now demand from union members, many Americans find it unacceptable to even consider renouncing benefits they have enjoyed, or expected to enjoy, no matter what the reason.

Reform will thus require leader-ship--strong bipartisan leadership, which so far has been lacking. The public already distrusts the political process, and individual citizens are wrapped up in their own needs and lives. With the nation now politically split almost down the middle on many issues, it will be hard to prepare the public for the type and magnitude of change necessary.

The dominant issue in American medicine for the immediate future will be how we adjust to the demographic realities of an aging society. It will be politically and professionally painful. It will cause much agony in a medical profession trained to assume that there are virtually unlimited resources available and that cost is never a consideration. It will be a seminal issue, causing as much unsettling change as did the reform of medical education early in the twentieth century. …