To the extent that health care is registering at all in this election campaign, one focus (driven, interesting, by the CMA) has been to press an incoming federal government to think more clearly and strategically about seniors’ health care. This is a very beneficial and timely policy focus, and there is certainly much room for improvement. Some provinces are especially fearful of this « silver tsunami, » as they worry it may strain their health care system beyond sustainability. In Nova Scotia, for example, 16.6% of the population was over 65 in 2011. In 2031, this figure is projected to be 28.4%. And, if old people cost the system the most, the health care costs will be cataclysmic, will they not?
In fact, demographic factors are a very minor variable when it comes to health care cost drivers. A CIHI report on cost drivers noted that population aging contributed an annual average growth of only 0.8% to the cost of health care between 1998 to 2008 (compare this to physician spending, which increased at an annual rate of 6.8% per year over the same period).1 What we do know is that the last six months of life are generally the most expensive. We just don’t know when anyone’s last six months will be, except after the fact. Indeed, there is intriguing evidence that « the link between age and health care expenditure is not linear » – Dixon et al (2004), for example, found that « the average number of bed days spent in hospital in the period before death does not go up by increasing age ».2 A WHO study on ageing and health released last week cited a UK study showing that, while health expenditure peaked between the ages of 65 and 74, it actually decreased after that.3 In other words, the older the age at which people die, the lower the health care costs may be. (Not to put too fine a point on it, but past a certain point, the older you are, the quicker you die). So, rather beguilingly, as our population is actually living longer, this may mean that the costs associated with the advanced elderly may actually decrease.
Moreover, if health care costs are closely determined by age, then we should see all states with rising age cohorts exhibit similar increases. But we don’t. To the contrary, age-related increases in health care costs vary enormously across developed states, with costs much higher in Canada than in, say, Sweden. Remember the old ParticipAction commercial that told us that the average 30 year old Canadian was as fit as a 60 year old Swede? Well, now those 60 year old Swedes are 80 or 90, and they’re costing Swedish society a lot less than those Canadians who used to be unfit 30 year olds. There are, of course, also structural and institutional factors at play here, like a better home care system. But again, the point is that these are the results of social and political choices made at both the individual and the collective level. There is no « silver tsunami » bearing inexorably down on us, and the social costs of an aging population are much more firmly within our collective control than we may think.
One might reply, ah, but we do know that cancer rates are rising, especially amongst the elderly, and that the costs of cancer care are climbing rapidly. CTV news recently reported that « the number of new cases of cancer diagnosed in Canada is expected to rise by about 40 per cent in the next 15 years, in large part because Canadians are simply growing older ».4 Yes; but, in fact, this is a success story. The cancer rate is indeed rising; but a major reason for this is that we have been so successful in preventing, curing, or mitigating all kinds of other illnesses. We have to accept that we will all die of something: and the more successfully we have evaded all kinds of other pernicious deaths, the more likely we will probably die of cancer in the end.
So it’s not age per se that is the real cost driver here. A small number of very ill people cost the system a huge amount of money before they die. Yet little is being done about this, for a number of reasons. It’s a highly emotive issue that people often have to address when they are least disposed to look at things objectively and analytically. It’s difficult to raise this issue without coming across as a cold, callous bean-counter with little empathy for the suffering of others. We essentially leave it to doctors to « do something » about this problem; we as a society are sadly unwilling to support them in such an impossible task. It is the Subject that Cannot be Discussed. Politicians do not want to touch this issue – hardly surprisingly, perhaps, given that any attempt to do so allows opportunistic opponents to accuse them of « setting up death panels for granny. » So, politically, it’s a hugely difficult issue. But that’s exactly the point. It’s a political issue; it’s not some imminent force bearing down on us over which we have no control.
So don’t fear the silver tsunami. It is heartening that the issue of a « seniors’ health care strategy » is being raised during the election campaign; but it is useful more clearly to identify what the issues surrounding seniors’ health care really are. Some of them are issues that make politicians squirm while in office. But don’t let them forget that we elect them precisely to address the hard questions.
- http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Spending%20on%20health%20…%2050%20years%20low%20res%20for%20web.pdf, 8