Health Care for Older Persons in England and the United States: A ...

Health Care for Older Persons in England and the United States: A Contrast of Systems and Values Michael Gusmano Hastings Center and Columbia University Sara Allin University of Toronto

Abstract This article extends previous comparisons of access to health care for older persons in England and the United States by comparing rates of avoidable hospital conditions as a proxy for primary care access and by examining the distribution of care within these older populations. Drawing on hospital data from the two countries, we find that older persons in the United States, particularly those over the age of seventy-five, receive far more revascularizations than do older persons in England. Differences in the use of lower-joint replacement are not as great, but we are unable to assess differences in the need for these procedures. Although older persons have greater access to specialty care in the United States, there appears to be much better access to primary care in England. We are unable to draw comparisons on the extent of inequalities in access to health care, although in the United States there is evidence of inequalities in access by race, and in England we confirm earlier studies that find inequalities by level of deprivation. These findings are discussed in the context of the political debates over access to care and rationing in the two countries.

Introduction

Previous comparisons of access to health care for older persons in England and the United States focused on the differences in the use of expensive medical technology. The U.K. National Health Service (NHS) offers a “painful prescription” that is particularly painful for older persons who have limited access to potentially life-saving and quality-enhancing medical technology. Sometimes age rationing in the English system is the result of explicit debate, but often it is a consequence of a limited health care budget, the judgments of medical professionals, and the expectations Journal of Health Politics, Policy and Law, Vol. 36, No. 1, February 2011 DOI 10.1215/03616878-1191117 © 2011 by Duke University Press

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of patients. The United States, in contrast, “can’t say no” and places few limits on the health care technologies available to older persons, regardless of cost or evidence of effectiveness (Aaron, Schwartz, and Cox 2005; Callahan 2009). While nearly all U.S. policy makers claim that health care spending is “unsustainable,” few seem interested in limiting access to care for older persons (or anyone else), and calls for virtually any spending reduction are met with efforts by opponents to characterize such efforts as an “attack” on Medicare (Callahan 2009). During the recent health care reform debate, Republicans and some Democratic opponents claimed that the Obama administration was threatening access to care for older persons because it proposed to reduce Medicare reimbursement rates to providers and study the “comparative effectiveness” of medical technologies (Gusmano and Gray 2010; McCaughey 2009). Our article builds on this debate, and the previous work by Aaron, Schwartz, and Cox (2005), but extends it in three ways. First, because Aaron, Schwartz, and Cox were focused on how the NHS limits access to expensive health care services, they did not compare access to primary care among older persons. A more complete understanding of access to health care in the two systems requires comparing both primary and specialty care. We revisit their earlier comparisons of the use of revascularization and lower-joint replacement, but we also compare rates of avoidable hospital conditions (AHC), an indicator of access to timely and appropriate primary care. We also compare rates of hospitalizations for marker conditions, which are not related to primary care access because these allow us to assess whether differences in rates of AHC are due to differences in population health status or the use of hospitals. Second, comparisons of access to care for older persons in England and most of the United Kingdom and the United States have focused almost exclusively on aggregate measures of access, but the distribution of this care among older persons is another important consideration. Although concerns about health care inequalities are part of the health policy debate in both countries, inequalities among older persons are often ignored. In the United States, for example, policy makers often assume that access is no longer a major issue for older persons because Medicare is a nearuniversal program and they face fewer financial barriers to care than younger persons, particularly those without health insurance. To examine distribution, we use the national hospital administrative data for England to compare access to primary and specialty care among English counties and single-unit authorities. The U.S. National Hospital Discharge Survey (U.S. Centers for Disease Control and Prevention 2010b) does not allow

Gusmano and Allin ■ Health Care for Older Persons 91

for comparable analysis of geographic variation, but we are able to compare access among racial groups. Finally, we comment on differences in end-of-life care in the two countries. More is not always better when it comes to the use of health care services, and this is particularly true when it comes to care at the end of life. In both countries, advocates for older persons argue that there is inadequate use of palliative care and people spend too many days in the hospital during the last two years of life. Recent studies suggest that the use of intensive care at the end of life is particularly high in the United States. These studies are unable to conclude whether intensive care is overused in the United States or underused in the United Kingdom, but they point to distinctive patterns that seem to reflect significant differences in health care budgets, infrastructure, and values. The next section presents a brief overview of the two health systems to provide context for the comparisons of access to care. Then, we summarize briefly the literature on aging and health spending. Most studies suggest that the use of health care technology, not population aging itself, is the major contributor to health spending. It is useful, therefore, to better understand how these two systems influence access to health care technology among older persons. Finally, we present our empirical findings and discuss their policy implications. A Brief Overview of Two Health Systems

The United States relies on a mix of public and private financing with multiple payers and spends more on health care than any other nation. Despite enormous expenditure on health care, about 47 million Americans are uninsured and millions more are underinsured.1 The Patient Protection and Affordable Care Act (Pub. L. 111 – 141), adopted in 2010, would reduce the number of uninsured through various mechanisms but would leave millions without health insurance coverage. The majority of Americans under the age of sixty-five with health insurance have employer-sponsored private health insurance, but since 2000, the percentage of employers who offer health insurance, and the percentage of employees who accept these offers, has declined. A small portion 1. The Patient Protection and Affordable Care Act, signed into law on March 23, 2010, would cover about 94 percent of the population. Among other changes, the new law (1) requires individuals to purchase health insurance (or pay a fine); (2) imposes new regulations on small group and individual insurance plans designed to make such plans more affordable; and (3) expands the Medicaid and State Children’s Health Insurance programs.


of this decline is due to the expansion of public health insurance coverage, particularly the State Children’s Health Insurance Program (SCHIP), but most of the decline is due to increases in health insurance premiums (Reschovsky, Strunk, and Ginsburg 2006). In addition to this decline among current workers, several employers have reduced or eliminated retiree health benefits (Gottschaulk 2007). Although the majority of working-age adults and their families receive health insurance through their employers, this publicly subsidized private system does not address the health insurance needs of those who are not in the workforce, particularly the unemployed and older persons (Starr 1982: 333). The adoption of Medicare and Medicaid in 1965 attempted to fill these gaps. The Social Security Amendments of 1965 (the Medicare and Medicaid legislation) included three distinct layers. The first was Medicare Part A, a hospital insurance program based on the Social Security contributory model. The second was Medicare Part B, a voluntary supplementary medical insurance program funded through beneficiary premiums and federal general revenues. The third, the Medicaid program, broadened the protections offered to the poor under medical vendor payments and to the medically indigent under Kerr-Mills. The Kerr-Mills means test was also changed to cover additional older citizens, and eligibility among the indigent was broadened to include the blind, the permanently disabled, and adults in (largely) single-headed families and their dependent children (Gusmano, Rodwin, and Weisz 2010; Grogan and Gusmano 2007). While there is nearly universal coverage for U.S. residents aged sixtyfive and over under Medicare, in areas of the country with large numbers of immigrants (e.g., California, Florida, New York, and Texas), many older persons are not eligible for Medicare Part A coverage because they are recent immigrants or have not met the minimum periods of legal employment. For example, in the Bronx, Brooklyn, and Queens, recent immigrants and people who have worked in the “cash economy” make up a much larger percentage of the older population. In these boroughs, 20 – 25 percent of the older population does not have Part A coverage — and these estimates do not include older undocumented immigrants.2 What is more, there are significant gaps in benefits. Older New Yorkers ineligible for Medicare or unable to obtain sufficient supplementary insurance coverage confront many of the same financial barriers to access faced by Medicaid beneficiaries and the uninsured (Gusmano 2009). The recent health care 2. We do not know how many of these individuals qualify for Medicaid.


reform law does nothing to address problems in access faced by these immigrants. In contrast to the United States, England has minimal direct financial barriers to health care, which reflects a strong commitment to ensuring equitable access to care. The NHS was introduced in 1948 with the objective of creating equitable access to health care by making health services free at the point of use. This objective was restated in the NHS constitution of 2008 including, among other things, the right for citizens to access health care free of charge except for certain limited exceptions agreed on by Parliament (these are in the form of user charges for private treatment, prescription medications, and dental care) and not to be unlawfully discriminated against on grounds of gender, race, religion, sexual orientation, or disability (Department of Health 2010b). England provides universal coverage of health services, financed mainly through general taxation and national insurance contributions. Total spending on health care remains considerably lower than in the United States, despite significant growth in recent years. From 1997 to 2007, total spending on health as a share of gross domestic product (GDP) increased from 6.6 percent to 8.4 percent (compared with 16 percent in the United States), corresponding to a doubling of expenditure in real terms (Office for National Statistics 2008). This rise in spending led to significant increases in the supply of physicians: in 2007 there were more practicing physicians in the United Kingdom (2.48 per 1,000 population) than in the United States (2.43) (OECD 2010).3 During this period there were notable changes to the way physicians and hospitals were paid, and new regulatory agencies were introduced to uphold nationally set standards such as for maximum waiting times. In 2003 – 2004, the payment of hospitals changed from a system of annual block contracts to an activity-based payment system (called payment by results) with standard prices for the same treatment regardless of the provider. General practitioners (GPs) are most often the patient’s first point of contact with the systems, and they serve as gatekeepers to more specialized care. A new GP contract was introduced in 2004 with the majority of England’s GPs to improve patient access to care and to more closely link payments to performance. To improve access, the new contract included a budget for a core set of essential services with allocations to GP practices on the basis of the Carr-H ill formula to account for variations in 3. We have data for physicians in the United Kingdom only.


patient needs (including sex, age, morbidity, and mortality); to improve performance, a new quality and outcomes framework provided extra payments for services linked to achieving quality standards by the GP practice (Boyle 2011). The new contract also emphasizes equitable access to primary care, stating that the practice “can only refuse an applicant to join its list if it has reasonable grounds for doing so which do not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition” (cited in Boyle 2011). The new contract does place new limits on access, however, by removing the twenty-four-hour duty of care from GPs. Despite the removal of direct financial barriers and other explicit efforts to ensure equitable access to health care in England, there is evidence of inequity in the case of specialist care (Allin, Masseria, and Mossialos 2010; Cookson, Dusheiko, and Hardman 2007; Dixon et al. 2007; Morris, Sutton, and Gravelle 2005). Inequity may arise if higher socioeconomic groups have a louder “voice” allowing them better to navigate the health care system than those with less socioeconomic advantage; they may be better able to acknowledge their needs, identify the services available, and make demands on their GPs such as for specialist referrals (Dixon et al. 2007). The option of private health care may also contribute to inequity whereby individuals with private insurance coverage (held by about 10 percent of the population), who are wealthier on average than the general population, may have shorter waits for specialty and surgical interventions. This access advantage has decreased, however, as NHS waiting lists have shrunk considerably in recent years. Among older populations, inequity in specialist care could be due to differences in individuals’ knowledge of services, expectations of the benefits of treatments, likelihood of delaying seeking treatment, confidence interacting with health care professionals, and transportation-related barriers to access (Fernandez et al. 2008). In comparison with the United States, however, the extent of inequity in England is modest (van Doorslaer, Masseria, and OECD 2004; Schoen and Doty 2004). Population Aging and Health Care Spending: Summary of the Evidence

By the year 2050, every third person on the planet will be over sixty years old. Population aging often provokes fears of impending social security deficits and uncontrollable medical expenditures. A common assumption of this literature is that the pressures from population aging and globalization render existing welfare state commitments “unsustainable.”


Despite these concerns, studies conclude that population age is not correlated with health care spending. Indeed, there is no correlation between the percentage of the population sixty-five years and older and health expenditures as a percentage of GDP. Analysis of cross-national health care data shows that, after controlling for income, age has little effect on national health expenditures (Propper 2001; Moon 1996; Zweifel, Felder, and Meiers 1999). Price, volume, and the spread of technology, not population age, are the most important factors that drive health care costs (Anderson et al. 2003; Glied 1997: 91). In England and the rest of the European Union, high prices are less of a concern than they are in the United States. Volume and the spread of technology, however, are significant concerns in terms of increasing cost pressures. While population aging may not represent a significant cause of health inflation, health care costs are a legitimate concern for most countries. Like public pensions, revenue for most health care systems is affected by the fraction of the population in the labor force. In the absence of policy reforms that eliminate incentives for early retirement and make it possible for older persons to remain in the workforce, health care costs will put a growing strain on the budgets of all nations in the Organisation for Economic Co-operation and Development (OECD). If Technology Is the “Problem,” Can We Control Its Growth?

Aaron and Schwartz compared access to specialty care in Great Britain and the United States in their 1984 study to explore the implications of introducing budgetary limits on health care costs. Their work has been influential in shaping perceptions, and fears, of the NHS and the potential for life-extending or improving care to be denied because of budgetary constraints; these perceptions continue to this day in the debates about expanding the public role in health care in the United States. In their 2005 update of this “painful prescription” study, Aaron, Schwartz, and Cox (2005) compared rates of life-saving, quality-improving, and diagnostic procedures in Great Britain and the United States. Among the life-saving treatments, there was more evidence of rationing when associated costs were high. High-cost but relatively low-prevalence services such as bone marrow transplantation and hemophilia treatments were provided at similar levels in both countries. However, they found significantly lower rates of dialysis and kidney transplantation for severe kidney failure in Great Britain than in the United States, and fewer intensive


care beds as a proportion of total hospital beds in Great Britain than in the United States, which led the authors to conclude that rationing in Great Britain is “severe and persistent” (Aaron, Schwartz, and Cox 2005: 58). Comparing the rates of two quality-of-life-improving procedures — hip replacements and coronary revascularization — they found no notable difference in hip replacement rates, but found the rate of revascularization in Great Britain was about one-quarter that of the United States. The United States also had a greater supply of diagnostic equipment than Great Britain, with about one-quarter of the number of CT scanners per capita and about one-third of the number of MRIs in Great Britain compared with the United States. The authors note the differences in medical cultures between the two countries, in addition to service availability, that play an important role in explaining the differences in delivery. They also recognize that the U.S. levels of care may in fact be too high. In addition to these limitations, however, by concentrating on a number of specialized procedures, their comparison gives only a partial and, we would argue, a distorted picture of access to care in the two health systems. The English NHS places limits on the use of certain technologies, but it provides more comprehensive primary and preventive services than the United States. It also has made considerable efforts to distribute primary and specialized services equitably. Nevertheless, advocates in England are correct to guard against ageism and the assumption that providing life-saving technologies to older people is always a “waste of money.” In both countries, calls for more explicit criteria and public debate are probably the most sensible course of action. How Can We Assess Access to Health Care?

There are many ways to assess access to health care. An adequate health care delivery system is a necessary condition for access, so studies often examine the density of medical professionals, hospital beds, medical equipment, and other “inputs” as indicators of access. For example, the Department of Health in the United Kingdom uses the number of full-time equivalent GPs per 10,000 as an indicator of access to care.4 While the supply of such inputs may be necessary, they are not sufficient to ensure access to care. Financial, cultural, and other barriers to access may exist in areas with a rich supply of medical resources. To better understand the use of available resources, researchers often 4. The Department of Health weights this indicator to account for cross-boundary flows, temporary residents, as well as the age and needs of the population (Evandrou 2006).


turn to surveys of patients and providers. For example, the National Survey of NHS Patients is a useful source of information about the actual use of health care services in England. Among other indicators, the survey asks patients how long they had to wait to see a GP (Evandrou 2006). Similarly, the U.S. Medical Expenditure Panel Survey asks a sample of patients whether they have a “usual source of care” and were unable or delayed in receiving medical care, dental care, or prescriptions. This survey also provides information on additional measures of access and quality including the percentage of people who reported going to a doctor’s office or clinic within the past twelve months and the percentage who received all recommended screening and preventive care (MEPS 2009). Unfortunately, national surveys differ greatly from country to country and make international comparisons difficult. To overcome this problem, there have been some notable efforts by international agencies and private foundations to field comparably worded questions in several countries, including the EU’s EuroBarometer Survey of fifteen EU countries. Most recently, the Commonwealth Fund in New York launched a “commission on a high performance health system.” The Commonwealth Fund’s project supplements are a range of existing data sources with original surveys of patients and primary care providers, designed and fielded by Harris Interactive, in Australia, Canada, Germany, New Zealand, the Netherlands, the United Kingdom, the United States, and, more recently, France. The Commonwealth Fund survey is an impressive effort and provides important information about access, cost, and quality in these countries, but original international surveys are expensive. The sample sizes, while sufficient to make reasonable claims about national aggregates, do not allow researchers to capture variations within each country. Furthermore, the Commonwealth Fund surveys, because they are not conducted annually, do not allow for examining trends across or within countries. Another method for comparing access to care cross-nationally, which we employ here, is to use routinely collected mortality and hospital administrative data and examine well-established indicators of primary and specialty care from the literature on health services research. England, the United States, and most other OECD countries code mortality and hospital administrative statistics by using the World Health Organization’s International Classification of Disease (ICD) codes. This allows us to compare indicators with nearly identical definitions.5 Furthermore, 5. Weissman’s original definition of AHC relies on ICD-9 (Weissman, Gatsonis, and Epstein 1992). Of the twelve conditions included, ten translate directly to ICD-10. Only two, neither of which are large contributors to the rate of AHC, pyelonephritis and gangrene, require


because these data are collected routinely for administrative purposes, it is easier and less expensive to examine several years of data. Since we do not have access to comparable clinical or administrative “encounter” data that would allow us to make direct comparisons of primary care use in England and the United States, we rely on a more indirect measure. AHCs are inpatient hospitalizations for a host of conditions that, in theory, can be “avoided” through timely access to effective primary health care. These include hospitalizations for bacterial pneumonia, cellulitis, and several chronic conditions, such as congestive heart failure, asthma, and diabetes. It is not possible to eliminate all hospitalizations for most of these conditions, but access to primary care for their effective management should significantly reduce the number of acute episodes leading to hospitalization. AHC is widely accepted as a valid measure of access to primary care. In its 1993 report Access to Health Care in America (Millman 1993), the Institute of Medicine recommended that AHC rates be used to monitor access to health care services at the national level and that these rates be tracked to determine whether conditions for obtaining care were improving or deteriorating, especially for vulnerable populations. Since then, the Agency for Healthcare Research and Quality (AHRQ) has used AHCs to monitor access to safety-net services across large metropolitan areas of the nation (Billings and Weinick 2003), and the Commonwealth Fund is publishing annual statewide comparisons based on Medicare data. Because many of these hospitalizations are for chronic conditions, comparing AHC rates also provides important information about how well health care systems are coping with the growing challenge of chronic disease (Ettelt et al. 2006; Olshansky et al. 2005). As the populations in these countries grow older, an increasing number of adults have multiple chronic conditions. If their care is not well coordinated, they are at risk for avoidable hospitalizations and other adverse events (Davis 2007). AHCs are often contrasted to so-called marker conditions, which are not influenced by access to ambulatory care. Marker conditions are for hospitalizations hip fractures, GI obstruction, or appendicitis. For each of these conditions, timely and appropriate primary care is not likely to lower interpretation. To capture pyelonephritis (ICD-9 590.0, .1, .8), we use codes ICD-10 N10 – 12, 13.6, 15, which include pyelonephritis and acute and chronic tubulo-interstitial nephritis and pyonephrosis. To capture all cases of gangrene included in ICD-9 785.4, we use R0.2 (gangrene unspecified), supplemented with I73.9 (unspecified peripheral vascular disease) and I74.3 (embolus and thrombosis of arteries of the lower extremity). These minor differences in coding have a negligible impact.


the probability of a hospitalization. In addition, admission to a hospital is an appropriate course of action. Revascularization procedures — percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery (CABG) — are an example of specialty services known to be effective for treating severe medical conditions. Although revascularizations are expensive procedures, there is evidence that the benefits of these interventions far exceed the costs (Cutler and McClellan 2001). Cutler and McClellan estimated that the “net benefit” associated with each revascularization is about $60,000. Nevertheless, when Glied and Little compared the use of revascularization among persons aged fifty-five to sixty-four in the United States, they con cluded that persons without health insurance were far less likely to receive the procedure, resulting in enormous welfare losses to society (Glied and Little 2003). The index does not assume that every person who has an acute myocardial infarction (AMI) receives one of these procedures. Nor does it assume that this is the only diagnosis for which these procedures are an appropriate intervention. The examination of the ratio of revascularization rates to AMI mortality rates is merely an index that attempts to adjust for the prevalence of heart disease (Gusmano et al. 2007).6 Access to Primary Care

We found that for all age groups, the average discharge rate for AHCs in the English NHS was between 30 and 50 percent lower than that of the United States (fig. 1). In contrast, the average discharge rate for marker conditions was between 14 and 28 percent lower in England for the two youngest age groups, but rates were identical for the oldest age groups. These results suggest that older people in England receive better access to primary care than their American counterparts, consistent with comparisons of London and New York (Gusmano, Rodwin, and Weisz 2010). An 6. For the United States, we obtained hospital discharge data for calculating AHCs and revascularizations from the National Hospital Discharge Survey, National Center for Health Statistics, for the years 2004 – 2006. Mortality data are from the National Vital Statistics Reports published by the National Center for Health Statistics Division of the Centers for Disease Control and Prevention (U.S. Centers for Disease Control and Prevention 2010a, 2010b). For England, we obtained hospital discharge data for calculating AHCs and revascularizations from the Department of Health’s Hospital Episode Statistics (HES) database, which includes information for all residents of England on all hospitalizations (in NHS and private hospitals) paid for by the NHS, for the years 2004 – 2006 (Department of Health 2010a). Mortality data are from the Office for National Statistics (2008).


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Figure 1 Avoidable Hospital Condition and Marker Condition Rates per 1,000 by Age, England and the United States, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b

especially high rate of AHC can be seen among the oldest individuals in both countries. This is not surprising given the increased severity of illness in this age group that would also increase their risk of hospitalization for otherwise treatable conditions, but, perhaps more importantly, it suggests that the effective coordination of ambulatory care for older people with complex care needs remains a significant challenge in both countries. In an effort to shift resources away from institutional and hospital-based care toward community-based care by preventing or delaying the need for higher intensity or institutional care, the U.K. Department of Health funded a number of pilot projects. These “Partnerships for Older People” projects have shown some success in reducing emergency hospital beddays use (PSSRU 2008). Access to Specialty Care

The rate of revascularization among persons aged fifty to sixty-four is twice as high in the United States as in England. Among persons over sixty-five, the difference is even greater (fig. 2). Among those over eightyfive, the rate of revascularization in the United States is six times higher than in England. Although the use of revascularization in England remains low in comparison with the United States, these rates have increased dramatically


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Figure 2 Revascularization Rates per 1,000 by Age, England and the United States, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b

during the past few years. Between 2000 and 2006, the average rate of revascularization among persons increased from about 3.6 per 1,000 to just over 5 per 1,000 (Gusmano, Rodwin, and Weisz 2010). After adjusting for differences in heart disease, the national differences in the use of revascularization among the fifty-to-sixty-four- and sixtyfive-to-seventy-four-year-old cohorts are comparable with the difference in rates of revascularization per 1,000 (fig. 3). Among those seventy-five and older, however, the ratio of revascularization rates to AMI death rates appears to be even greater than previously reported. This measure highlights the degree to which the English NHS places severe limits on the use of revascularization among the so-called older old. The HES data do not include revascularization funded by private payments. Estimates of the number of private revascularizations not included in the HES dataset varies from 7 to 30 percent (Black, Langham, and Petticrew 1995; Williams et al. 2000), and 12.5 percent in London (Mindell et al. 2008), so the national differences in the use of revascularization may not be as large as these data suggest. As we discuss below, however, counting privately financed revascularization may point to even greater inequalities in access among older persons. The rates of lower-joint replacement appear to be lower in England than in the United States for all age groups (fig. 4). The greatest difference is seen in the youngest age group, with rates in England less than half of those in the United States, and the smallest difference is among those aged eighty-five years and older. It is likely that the English rates


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Figure 3 Ratio of Revascularizations per 1,000 to Acute Myocardial Infarction Mortality Rates per 1,000 by Age, England and the United States, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b

are underestimated because of the exclusion of those surgeries that are paid for privately. This could amount to 25 percent of the total surgeries performed (Williams et al. 2000). The proportion of private surgeries is likely to be highest among the youngest age groups because, unlike in the United States, in England private insurance coverage is highest among those aged fifty-five to sixty-four because it is usually an employment benefit (Foubister et al. 2006). Inequalities in Access to Health Care among Older Persons

In the United States we were able to compare the rates of AHCs and marker conditions across three broad ethnic groups as a preliminary assessment of inequity in access to primary care (fig. 5). A strong age effect on hospitalization can be seen across all three groups, with significantly higher rates for those aged sixty-five and older than those aged fifty to sixty-four. However, there is also a noticeably higher rate of AHCs, on average, for blacks than for both whites and Asians. These differences are more pronounced among the younger than the older age group: among those aged fifty to sixty-four, the average rate of AHCs for blacks was almost three times that of whites, and six times the rate of Asians. This racial difference in AHCs could be related to a multitude of factors, including comorbidities and socioeconomic status; some studies of the sixty-five-year and older population have found similar patterns even after controlling for these and


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Figure 4 Rates of Lower Joint Replacement per 1,000 by Age, England and the United States, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b

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Figure 5 Avoidable Hospital Condition and Marker Condition Rates per 1,000 by Race and Age, United States, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b

other observable characteristics (Laditka, Laditka, and Mastanduno 2003; Laditka and Laditka 2006), while others did not (Blustein, Hanson, and Shea 1998; Pappas et al. 1997). Because racial differences in the rates of marker conditions are much smaller than differences in the rates of AHC, our evidence suggests that differences in health status are insufficient to explain the differences in rates of AHC.


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Figure 6 Avoidable Hospital Condition and Marker Condition Rates per 1,000 by Deprivation Quartile of Neighborhood and Age, England, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b

In England, we compare rates of AHC and marker conditions by county or single-unit authority. In figure 6, we group our results by county and single-unit authority by deprivation index quartile. Among persons fifty to sixty-four, the rate of AHC is nearly twice as high in the most deprived areas of England than in the least deprived. Among persons sixty-five and over, the differences are not as great, but the rate of AHC is nearly 30 percent higher in the most deprived areas of England than in the least deprived. In contrast, rates of marker conditions do not vary as greatly among either age cohort. We find inequalities in access to specialty services as well, but interpreting these differences is more complex. In the United States, the rate of revascularization is lowest among Asians (fig. 7). This is not surprising, because the incidence of heart disease is much lower among Asians than other racial groups. The rate of revascularization is about 20 percent lower among blacks than whites even though the incidence of acute myocardial infarction is about 30 percent higher among the former (CDC 2008). We see an even larger racial difference in rates of lower-joint replacement, but since we do not have an adequate measure of need for these procedures, it is difficult to assess whether these differences reflect differences in need or differences in access. In England, differences in rates of revascularization by deprivation quartile of residence are not large (fig. 8), but the incidence of heart dis-

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Figure 7 Revascularization and Lower-Joint Replacement Rates per 1,000 by Race and Age, United States, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b

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Least deprived

Figure 8 Revascularization and Lower-Joint Replacement Rates per 1,000 by Deprivation Quartile of Neighborhood, England, 2004–2006 Averages Sources: Department of Health 2010a; U.S. Centers for Disease Control and Prevention 2010b


ease is at least 30 percent higher among residents of the most deprived neighborhoods in England (Lawlor et al. 2005; Morris et al. 2008). Geographical differences in lower-joint replacement are larger, particularly among older persons. Among those sixty-five and over the rate of lowerjoint replacement is 20 percent higher in the least deprived counties and single-unit authorities than it is in the most deprived areas. End-of-Life Care

Studies in Europe and the United States conclude that proximity to death, not age, leads to an increase in health spending (Moon 1996; Zweifel, Felder, and Meiers 1999). An analysis using microdata to examine health spending on older persons in Switzerland found that health care spending is concentrated “in the last few months of life” (Propper 2001: 166). “The impact of ageing will thus be to push the high levels of health care expenditure to later in individual’s lives rather than to increase per capita expenditure” (ibid.). As several have noted, claims about the relationship between population aging and health care spending “confuse the cost of living with the cost of dying” (Seshamani and Gray 2004; Stearns and Norton 2004; White 2004, 2007; Zweifel, Felder, and Meiers 1999). In the United States, Medicare beneficiaries spend more days in the hospital during their last two years of life (23.6 v. 21), but there are even larger differences between the two countries when it comes to the use of intensive medical services that neither extend life nor improve its quality than their counterparts in England (Dixon et al. 2004; Dartmouth Atlas of Health Care 2008). Using data from 2001, Wunsch and colleagues (2009) found that more deaths occur in the hospital (50.3 percent) in England than in the United States (36.6 percent), but while only about 5 percent of all deaths in England involved intensive care, more than 17 percent of deaths involved intensive care in the United States. Among all age groups, about 10 percent of hospital deaths in England involve the use of intensive care versus about 47 percent in the United States (Wunsch et al. 2009). The use of intensive care was much greater in the United States than England among deaths because of medical conditions, including solid neoplasms, hematologic neoplasms, cerebrovascular disease, and pneumonia. It was also higher among patients who died after receiving hip replacements and lung surgery — but the use of intensive care was comparable in the two countries among persons who had received a CABG. This makes sense “because patients are likely to receive intensive care after CABG surgery no matter where the surgery is done” (Wunsch et al. 2009: 878).


Rates of intensive care use among children and younger adults are comparable in the two countries, but diverge among persons forty-five years and older. The differences between the countries are particularly striking among the “older old.” Only 1.3 percent of persons eighty-five and older who died in the hospital received intensive care in England, but 11 percent did so in the United States. Yet the use of intensive care declines with age in both countries (Wunsch et al. 2009: 877), and the assumption that reducing the use of intensive care among older persons would reduce health care expenditure in the United States is not supported by the data. In contrast to claims about the cost of dying frequently repeated in the press, expenditure on acute care at the end of life falls as the age at death increases, and end-of-life care represents only about 1 percent of the U.S. Medicare program’s budget (International Longevity Center 2007; Roos, Montgomery, and Roos 1987; Scitovsky 1994; Spillman and Lubitz 2000). Limiting the use of intensive care at the end of life and focusing instead on the availability of palliative care may represent better, more responsive care, but it is not likely to reduce health care expenditures. Variation in the use of intensive care within the United States is just as great as the differences between the countries. Even after limiting the analysis to hospitals “that appeared on the 2001 U.S. News and World Report list of ‘America’s best hospitals’ for geriatric care and for the treatment of three common chronic illnesses: heart disease, cancer, and pulmonary disease,” Wennberg and colleagues found that “the percentage of deaths associated with a stay in intensive care ranged from 8.4% to 36.8%” (Wennberg et al. 2004: 607). Furthermore, they found that this variation was not associated with patient need or patient preference but could be attributed, primarily, to differences in the supply of intensive care beds (ibid.). Differences in supply also help explain the differences between England and the United States. The United States has six times as many intensive care beds per capita basis. Although this may reflect differences in the definition of intensive care beds, it is more likely to reflect differences in clinical practice styles reinforced by differences in resource constraints. Faced with greater resource limitations, health care providers in England limit the use of intensive care among older persons, but maintain access for children and younger adults. Limiting the use of intensive care, however, is not the only focus of end-of-life care in England. In recent years, policy makers have placed an emphasis on keeping people out of the hospital and have ramped up


intermediate care and home care strategies to provide an alternative to expensive inpatient hospital care. Nevertheless, the percentage of deaths that take place in the hospital and other institutions has been rising steadily in England as well. Between 1974 and 2008, “home death proportions fell from 31% to 18% overall, and at an even higher rate for people aged 65 and over, women and noncancer deaths” (Gomes and Higginson 2008: 33). In 2000 the National Council for Palliative Care (2000: 1) in England argued that “only a small proportion of those who wish to die at home or in a hospice are currently able to do so,” and the record of health authorities in making plans for palliative care was described as “patchy” (Seymour, Clark, and Marples 2002: 6). In July 2008 the Department of Health published End of Life Care Strategy for the United Kingdom, which describes a plan for improving access to palliative care and recognizes the importance of patient choice at the end of life (Department of Health 2008). The question of how to address end-of-life care is complex, and a simple comparison of place of death or the use of intensive care are inadequate to make normative judgments about which system is “better” or more responsive. Advocates suggest that the treatment of older people at the end of life is far from perfect in either country, but the NHS is clearly more likely to set limits on the use of intensive care than the United States. As Murray and Jennings (2005: S54) described the situation in the United States, “Virtually everything is oriented toward using life-sustaining equipment and techniques, not toward forgoing them. The informal culture of specialty medicine, the reward system, the institutional pressures faced by family members, the range of choices people in extremis are being asked to make — each of these factors and more make up a system that is remarkably resistant to change.” In both countries, calls for more explicit criteria and public debate are probably the most sensible course of action. Political Debates over Access to Care for Older Persons in England and the United States

In England, policy debates, particularly since the 1980s, have focused on the inappropriate denial of care for older persons. Led by groups like Age Concern, there have been regular discussions of age-based rationing and charges of “ageism” (Macnicol 2006). Responding to the Aaron and Schwartz suggestion that NHS-style rationing might be an appropriate


model for the United States, Francis and Francis (1987) argued that this type of rationing is “neither just nor ethical.” One of the primary concerns about age-based rationing within the English NHS was the lack of public deliberation. For example, in 2000 Age Concern advocated for changes in the use of “do not resuscitate” orders when they found that such orders had been issued for a number of older persons in NHS hospitals without their consent. These appeared to be “purely age-related decision[s], unconnected to prognosis or baseline health” (Ashcroft 2005: 212). Francis and Smeeding (1987: 8) argued that the sort of age-based rationing that occurs in the NHS is justified only if: “1. it is made with the participation of those whose interests are at stake; 2. it is made with explicit awareness that rationing was at issue; and 3. alternatives are available should those whose interests are at stake disagree with the social consensus.” They argued that the NHS did not meet these conditions. Physicians rationed care on the basis of age without a public debate. In recent years, however, there has been more public deliberation about the merits of agebased rationing. The first national plan with the explicit aim to end age discrimination in the NHS and to improve quality of care for older people was introduced in 2001 by the Department of Health. The 2001 National Service Framework for Older People had “rooting out age discrimination” as its first standard, with the aim “to ensure that older people are never unfairly discriminated against in accessing NHS or social care services as a result of their age” (Department of Health 2001). Since that time, the Department of Health has consistently reported on the progress toward achieving the framework’s goals; for instance, there were significant increases in the number of specialists in old-age medicine and in the rates of elective surgeries to improve quality of life such as cataracts and hip and knee replacements (Department of Health 2004). These changes led to positive statements of progress, for example, by senior managers in the NHS: “Since the NSF for Older People was published, older people have moved from the margin to the mainstream in access to NHS treatment and services” (ibid.: 20). Despite this progress, a recent review of age equality in health and social care found that age discrimination remains an important issue that both national and local organizations should address (Department of Health 2009). Well-publicized limits to specialty care services led to calls for rooting out age discrimination, but others within England have defended agebased rationing of care as a sensible response to finite resources and have characterized the alternative as socially undesirable: “This attempt to


wring the last drop of medical benefit out of the system, no matter what the human and material costs, is not the hallmark of a humane society. In each of our lives there has to come a time when we accept the inevitability of death, and when we also accept that a reasonable limit has to be set on the demands we can properly make on our fellow citizens in order to keep us going a bit longer” (Williams 1997: 820). In the United States, policy makers have been concerned about health care costs for decades. In 1969 President Nixon declared that the U.S. health care system was facing a “massive crisis in this area” (Morone 1990: 266). Health care inflation was not a new problem in the United States — there had been a continual increase in health care spending as a percentage of gross national product for years prior to the discovery of a “cost crisis,” but after the adoption of Medicare and Medicaid in 1965, the federal government began paying a much larger share of the nation’s health care bill. Between 1960 and 1970 federal government health spending as a percentage of total government spending nearly tripled. Once the federal government was responsible for financing over 40 percent of the nation’s health care bill, health care inflation became a serious problem. Moreover, the perception that Medicare contributed to this problem also transformed the image of older people (Oberlander 2003). Architects of the Medicare program viewed it as a first step toward universal coverage. They started with the older persons because they had a clear need and were viewed, even by the program’s opponents, as a “deserving” group. In contrast, contemporary debates about the Medicare program and its beneficiaries are often marked by claims that older persons receive “unfair” levels of support and, at the extreme, that health and long-term care spending on older persons is the cause of growing child poverty. Yet, despite the handwringing about intergenerational equity and concerns that Medicare will become “bankrupt,” most elected officials run away from discussions about how to set limits. As Callahan (2008: 1) put it, the issue is “unpopular, or, perhaps more precisely put, it is dodged and evaded as if it were a nasty political virus to be avoided.” Policy makers are more likely to claim that there is a magic solution that allows us to provide unlimited access while limiting spending. The Right and the Left are equally guilty and merely differ with regard to the magic solutions of choice. Republicans focus on the need for market-based solutions (Brown and Jacobs 2008), while Democrats are more likely to focus on planning, or health services research to eliminate “wasteful” spending and small area variations that cannot be explained easily by differences in need or


outcome (Baker, Fisher, and Wennberg 2008; Fisher, Bynum, and Skinner 2009; Morone 1990). As Fleck (2009: 1) explained, there is “nothing more than a tempting ‘moral’ mirage,” but most analysts dismiss these solutions as inadequate (Aaron, Schwartz, and Cox 2005; Jena and Philipson 2007). Rather than promote a public debate about whether to limit the use of expensive technology, U.S. policy makers continually focus on clever ways to avoid difficult choices. Conclusion

In 1984, when Aaron and Schwartz published Painful Prescription, there were explicit age-based treatment cutoffs in England that no longer exist (Ashcroft 2005). Nevertheless, in terms of specialty care access, we find that access to coronary bypass surgery and angioplasty is significantly lower among older persons in England. Once we account for differences in heart disease, the differences among the “older old” are even greater than previously reported. Access to lower-joint replacements is only slightly lower among older persons in England than the United States, but we do not have a reliable measure of the need for lower-joint replacement surgery in either country. Thus we are unable to assess whether access to these procedures for older persons are comparable in the two countries. Access to primary care appears to be significantly better among older residents of England. They are far less likely to be hospitalized for conditions that can be managed by primary care providers than are older persons in the United States. In contrast, similar hospitalization rates for marker conditions suggest that the country-level differences we observe are unlikely to be explained by differences in population health status or the use of hospitals. Our analysis of health care inequalities among older persons at the national level does not allow for direct comparisons, but in both countries, there are troubling inequalities in access to primary care and some forms of specialty care services. In England, older residents of the most deprived counties had rates of AHC that were about 25 percent higher than residents of the least deprived counties. Inequalities in access to revascularization are not as large as those we found for rates of AHC, but since the HES database on which we rely for our analysis does not include procedures in private hospitals paid for with private funds, our data probably under estimate inequalities in access because residents of the least deprived counties in England are more likely to go outside the English NHS to receive these services. Furthermore, since residents of the more deprived


counties in England suffer from poorer health, our finding that these surgery rates are comparable in the most and least deprived neighborhoods suggests that access to these services does not reflect need. These findings are consistent with previous studies of inequalities in access within Great Britain. For example, a study of 1998 – 2001 data from the General Household Survey found that older people from the top four income quintiles were more likely to consult a GP and receive hospital inpatient and outpatient services than were those from the poorest quintile, even after taking health status into account (Evandrou 2006). We also find considerably higher rates of lower-joint replacements in the least deprived counties than the more deprived, which is consistent with previous findings using HES data from 2001 (Cookson, Dusheiko, and Hardman 2007). In the United States we find large differences in rates of AHC, revascularization, and lower-joint replacement by race among older persons. Nevert heless, racial differences for AHC are smaller among the over sixty-five cohort than they are among persons fifty to sixty-four years of age, so it appears that Medicare has succeeded in reducing well-k nown racial inequalities in access to primary care. This finding is consistent with previous studies that examine the effects of Medicare on service use (Decker 2002; Card, Dobkin, and Maestas 2008). Without Medicare, racial and ethnic disparities among older persons in the United States would almost certainly be greater. Political debates in the two countries regarding access to care among older persons differ greatly as well. In the United States, the policy debate tends to focus on the extent to which spending on older persons limits the availability of resources for younger persons, but there are few debates about access limitations faced by some older persons. Although some academics have discussed difference in access among Medicare beneficiaries, this issue is not high on the policy agenda. Policy discussions about how to limit health care spending and improve health policy require “vivid ethical self-consciousness and public deliberation” (Fleck 2009: 1). In the 1980s and 1990s the NHS was accused of implicit, and inappropriate, age-based rationing. In more recent years, U.K. policy makers have engaged in far more explicit public debate about the issue (Klein 2007). Because they operate within the context of a budget, policy makers and health professionals in the United Kingdom are more willing than those in the United States to engage in an explicit debate about setting limits on access to care, including care at the end of life. In the United States, policy makers often raise concerns about the sustainability of the Medicare pro-


gram and the impact of health care spending on the economy, but not only do the major parties seem unwilling to accept the need for limits, they also seem loathe to discuss them. Democrats and Republicans have very different policy goals for the health care system, but both focus on “painless prescriptions” that would limit health care spending without reducing access to “necessary” care. Our comparison of access to care among older people in England and the United States highlights the difficulty of drawing simple conclusions about the performance of health care systems. Older people in England have more limited access to some specialty care services than do older people in the United States. Nevertheless, by providing much better access to primary care than the U.S. Medicare program, the English NHS does a better job of managing chronic illness and reducing rates of avoidable hospitalizations. England may offer a different “prescription” than the United States, but it seems unfair and inaccurate to characterize it as more painful. Decisions about how best to meet health care needs involve complex value choices that require public deliberation informed by the best available evidence. We hope our article contributes to this discussion.

References Aaron, H. J., and W. B. Schwartz. 1984. Painful Prescription: Rationing Hospital Care. Washington, DC: Brookings Institution Press. Aaron, H. J., W. B. Schwartz, and M. Cox. 2005. Can We Say No? The Challenge of Rationing Health Care. Washington, DC: Brookings Institution Press. Allin, S., C. Masseria, and E. Mossialos. 2010. Equity in Health Care Use among Older People in the United Kingdom: An Analysis of Panel Data. Applied Economics. First published on April 21, 2010 (iFirst). Anderson, G. F., U. E. Reinhardt, P. S. Hussey, and V. Petrosyan. 2003. It’s the Prices, Stupid: Why the United States Is So Different from Other Countries. Health Affairs 22 (3): 89 – 105. Ashcroft, R. 2005. Death Policy in the United Kingdom. In End-of-Life Decision Making: A Cross National Study, ed. R. H. Blank and J. C. Merrick, 197 – 218. Cambridge, MA: MIT Press. Baker, L. C., E. S. Fisher, and J. E. Wennberg. 2008. Variations in Hospital Resource Use for Medicare and Privately Insured Populations in California. Health Affairs 27:w123 – 134. Billings, J. D., and R. M. Weinick. 2003. Monitoring the Health Care Safety Net, Book I: A Data Book for Metropolitan Areas. Rockville, MD: Agency for Healthcare Research and Quality.


Black, N., S. Langham, and M. Petticrew. 1995. Coronary Revascularisation: Why Do Rates Vary Geographically in the UK? Journal of Epidemiology and Community Health 49:408 – 412. Blustein, J., K. Hanson, and S. Shea. 1998. Preventable Hospitalizations and Socio economic Status. Health Affairs 17 (2): 177 – 189. Boyle, S. 2011. England: Health System Review. Health Systems in Transition, forthcoming. Brown, L. D., and L. Jacobs. 2008. The Private Abuse of the Public Interest: Market Myths and Policy Muddles. Chicago: University of Chicago Press. Callahan, D. 2008. Curbing Medical Costs. National Catholic Weekly. www.america magazine.org/content/article.cfm?article_id=10669 (accessed October 17, 2009). ———. 2009. Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System. Princeton, NJ: Princeton University Press. Card, D., C. Dobkin, and N. Maestas. 2008. Does Medicare Save Lives? National Bureau of Economic Research Working Paper No. 13668. Cambridge, MA: NBER. Centers for Disease Control and Prevention (CDC). 2008. Men and Heart Disease Fact Sheet. Atlanta: Division for Heart Disease and Stroke Prevention, CDC. Cookson, R., M. Dusheiko, and G. Hardman. 2007. Socioeconomic Inequality in Small Area Use of Elective Total Hip Replacement in the English National Health Service in 1991 and 2001. Journal of Health Services Research and Policy 12 (suppl. 1): 10 – 17. Cutler, D. M., and M. McClellan. 2001. Is Technological Change in Medicine Worth It? Health Affairs 20 (5): 11 – 29. Dartmouth Atlas of Health Care. 2008. www.dartmouthatlas.org/data/topic/topic .aspx?cat=19 (accessed January 10, 2010). Davis, K. 2007. Learning from High-Performance Health Care Systems around the Globe. Testimony before U.S. Senate Health, Education, Labor, and Pensions Committee, Health Care Coverage and Access: Challenges and Opportunities hearing, January 10, 2007; 110th Congress, First Session. Commonwealth Fund Publication No. 996. New York: Commonwealth Fund. Decker, S. 2002. Disparities in Access to Health Care for Older Americans before and after Medicare. New York: International Longevity Center – USA. Department of Health. 2001. National Service Framework for Older People. London: Department of Health. ———. 2004. Better Health in Old Age. London: Department of Health. ———. 2008. End of Life Care Strategy — Promoting High Quality Care for All Adults at the End of Life. London: Department of Health. ———. 2009. Achieving Age Equality in Health and Social Care: A Report to the Secretary of State for Health by Sir Ian Carruthers OBE and Jan Ormondroyd. London: Department of Health. ———. 2010a. Hospital Episode Statistics, 2006. www.hesonline.nhs.uk/Ease/servlet/ ContentServer?siteID=1937 (accessed November 24, 2010). ———. 2010b. The NHS Constitution for England. London: Department of Health.


Dixon, A., J. Le Grand, J. Henderson, R. Murray, and E. Poteliakhoff. 2007. Is the British National Health Service Equitable? The Evidence on Socio-economic Differences in Utilisation. Journal of Health Services Research and Policy 12:104 – 109. Dixon, T., M. Shaw, S. Frankel, and S. Ebrahim. 2004. Hospital Admissions, Age, and Death: Retrospective Cohort Study. BMJ 328:1288. Ettelt, S., E. Nolte, N. Mays, S. Thomson, M. McKee, and International Healthcare Comparisons Network. 2006. Health Care Outside Hospital Accessing Generalist and Specialist Care in Eight Countries. Copenhagen: WHO on Behalf of the European Observatory on Health Systems and Policies. Evandrou, M. 2006. Inequalities amongst Older People in London: The Challenge of Diversity. In Growing Older in World Cities, ed. V. Rodwin and M. Gusmano, 173 – 199. Nashville, TN: Vanderbilt University Press. Fernandez, J.-L., D. McDaid, J. Kite, A. Schmidt, A. Park, and M. Knapp. 2008. Inequalities in the Use of Services among Older People in England: A Rapid Review of the Literature for Age Concern. In PSSRU Discussion paper DP2610, 1 – 169. Canterbury, U.K.: PSSRU. Fisher, E. S., J. Bynum, and J. S. Skinner. 2009. Slowing the Growth of Health Care Costs — Lessons from Regional Variation. New England Journal of Medicine 260:849 – 852. Fleck, L. 2009. Can Rationing Be Painless? Hastings Center Cost Monitor blog. September 8. http://healthcarecostmonitor.thehastingscenter.org/leonardfleck/ can-rationing-be-painless/. Foubister, T., S. Thomson, E. Mossialos, and A. McGuire. 2006. Private Medical Insurance in the United Kingdom. Copenhagen: WHO Regional Office for Europe, on Behalf of the European Observatory on Health Systems and Policies. Francis, J. G., and L. P. Francis. 1987. Rationing of Health Care in Britain: An Ethical Critique of Public Policy-making. In Should Medical Care Be Rationed by Age? ed. T. Smeeding, 125 – 126. New York: Rowman and Littlefield. Francis, L. P., and T. Smeeding. 1987. Introduction. In Should Medical Care Be Rationed by Age? ed. T. Smeeding, 1 – 10. New York: Rowman and Littlefield. Glied, S. 1997. Chronic Condition: Why Health Reform Fails. Cambridge, MA: Harvard University Press. Glied, S., and S. E. Little. 2003. The Uninsured and the Benefits of Medical Progress. Health Affairs 22 (4): 210 – 219. Gomes B., and I. J. Higginson. 2008. Where People Die (1974 – 2030): Past Trends, Future Projections, and Implications for Care. Palliative Medicine 22:33 – 41. Gottschaulk, M. 2007. Back to the Future? Health Benefits, Organized Labor, and Universal Health Care. Journal of Health Politics, Policy and Law 32:923 – 970. Grogan, C. M., and M. K. Gusmano. 2007. Healthy Voices, Unhealthy Silence. Washington, DC: Georgetown University Press. Gusmano, M. K. 2009. Growing Older in World Cities: Benefits and Burdens. In Cultural Competence of Aging, ed. J. Sokolovsky, 395 – 417. 4th ed. Santa Barbara, CA: Greenwood. Gusmano, M. K., and B. H. Gray. 2010. Evidence and Fear: Navigating the Politics of


Evidence Based Medicine. In AcademyHealth Reports, vol. 38. Washington, DC: AcademyHealth. Gusmano, M. K., V. G. Rodwin, and D. Weisz. 2010. Health Care in World Cities. Baltimore, MD: Johns Hopkins University Press. Gusmano, M. K., V. G. Rodwin, D. Weisz, and D. Das. 2007. A New Approach to the Comparative Analysis of Health Systems: Invasive Treatment for Heart Disease in the U.S., France, and Their Two World Cities. Health Economics, Policy, and Law 2:73 – 92. International Longevity Center. 2007. Ageism in America. New York: International Longevity Center – USA. Jena, A. B., and T. Philipson. 2007. Cost-Effectiveness as a Price Control. Health Affairs 26:696 – 703. Klein, R. 2007. Review of Can We Say No? The Challenge of Rationing Health Care, by Henry J. Aaron and William B. Schwartz, with Melissa Cox. Journal of Health Politics, Policy and Law 32:539 – 542. Laditka, J. N., and S. B. Laditka. 2006. Race, Ethnicity, and Hospitalization for Six Chronic Ambulatory Care Sensitive Conditions in the USA. Ethnicity and Health 11:247 – 263. Laditka, J. N., S. B. Laditka, and M. P. Mastanduno. 2003. Hospital Utilization for Ambulatory Care Sensitive Conditions: Health Outcome Disparities Associated with Race and Ethnicity. Social Science and Medicine 57:1429 – 1441. Lawlor, D. A., G. Davey Smith, R. Patel, and S. Ebrahim. 2005. Life-Course Socioeconomic Position, Area Deprivation, and Coronary Heart Disease: Findings from the British Women’s Heart and Health Study. American Journal of Public Health 95:91 – 97. Macnicol, J. 2006. Age Discrimination: An Historical and Contemporary Analysis. Cambridge: Cambridge University Press. McCaughey, B. 2009. Ruin Your Health with the Obama Stimulus Plan. www .bloomberg.com/apps/news?pid=20601039&sid=aLzfDxfbwhzs (accessed March 3, 2010). Millman, M., ed. 1993. Access to Health Care in America. Washington, DC: National Academy Press. Mindell, J., E. Klodawski, J. Fitzpatrick, N. Malhotra, M. McKee, and C. Sanderson. 2008. The Impact of Private-Sector Provision on Equitable Utilisation of Coronary Revascularisation in London. Heart 94 (8): 1008 – 1011. Moon, M. 1996. Medicare Now and in the Future. 2nd ed. Washington, DC: Urban Institute Press. Morone, J. A. 1990. The Democratic Wish: Popular Participation and the Limits of American Government. New York: Basic Books. Morris, R. W., G. Wannamethee, L. T. Lennon, M. C. Thomas, and P. H. Whincup. 2008. Do Socioeconomic Characteristics of Neighbourhood of Residence Independently Influence Incidence of Coronary Heart Disease and All-Cause Mortality in Older British Men? European Journal of Cardiovascular Prevention and Rehabilitation 15:19 – 25. Morris, S., M. Sutton, and H. Gravelle. 2005. Inequity and Inequality in the Use of


Health Care in England: An Empirical Investigation. Social Science and Medicine 60:1251 – 1266. Murray, T. H., and B. Jennings. 2005. The Quest to Reform End of Life Care: Rethinking Assumptions and Setting New Directions. In Improving End of Life Care: Why Has It Been So Difficult?, ed. B. Jennings, G. E. Kaebnick, and T. H. Murray, S52 – S57. Garrison, NY: Hastings Center. National Council for Palliative Care. 2000. Palliative Care Manifesto. www.ncpc.org .uk/download/PalliativeCareManifesto.pdf (accessed November 19, 2010). Oberlander, J. 2003. The Political Life of Medicare. Chicago: University of Chicago Press. Office for National Statistics. 2008. Expenditure on Health Care in the UK. London: Office for National Statistics. Olshansky, S. J., D. J. Passaro, R. C. Hershow, J. Layden, B. A. Carnes, J. Brody, L. Hayflick, R. N. Butler, D. B. Allison, and D. S. Ludwig. 2005. A Potential Decline in Life Expectancy in the United States in the Twenty-first Century. New England Journal of Medicine 352:1138 – 1145. Organisation for Economic Co-operation and Development (OECD). 2010. OECD Health Data. Paris: OECD. Pappas, G., W. C. Hadden, L. J. Kozak, and G. F. Fisher. 1997. Potentially Avoidable Hospitalizations: Inequalities in Rates between US Socioeconomic Groups. American Journal of Public Health 87:811 – 816. Personal Social Services Research Unit (PSSRU). 2008. National Evaluation of Partnerships for Older People Projects: Interim Report of Progress. London: PSSRU. Propper, C. 2001. Expenditure on Healthcare in the UK: A Review of the Issues. Fiscal Studies 22:151 – 183. Reschovsky, J. D., B. C. Strunk, and P. Ginsburg. 2006. Why Employer-Sponsored Coverage Changed, 1997 – 2003. Health Affairs 25:774 – 782. Roos, N. P., P. Montgomery, and L. L. Roos. 1987. Health Care Utilization in the Years Prior to Death. Milbank Quarterly 65:231 – 254. Saunders, C. 2008. Where People Die (1974 – 2030): Past Trends, Future Projections and Implications for Care. Palliative Medicine 22:33 – 41. Schoen, C., and M. M. Doty. 2004. Inequities in Access to Medical Care in Five Countries: Findings from the 2001 Commonwealth Fund International Health Policy Survey. Health Policy 67:309 – 322. Scitovsky, A. A. 1994. “The High Cost of Dying” Revisited. Milbank Quarterly 72:561 – 591. Seshamani, M., and A. Gray. 2004. Time to Death and Health Expenditure: An Improved Model for the Impact of Demographic Change on Health Care Costs. Age and Ageing 33:556 – 561. Seymour, J., D. Clark, and R. Marples. 2002. Palliative Care and Policy in England: A Review of Health Improvement Plans for 1999 – 2003. Palliative Medicine 16:5 – 11. Spillman, B. C., and J. Lubitz. 2000. The Effect of Longevity on Spending for Acute and Long-Term Care. New England Journal of Medicine 342:1409 – 1415. Starr, P. 1982. The Social Transformation of American Medicine. New York: Basic Books.


Stearns, S. C., and E. C. Norton. 2004. Time to Include Time to Death? The Future of Health Care Expenditure Predictions. Health Economics 13:315 – 327. U.S. Centers for Disease Control and Prevention. 2010a. Mortality data from the National Vital Statistics System (NVSS), 2004 – 2006. www.cdc.gov/nchs/data _access/Vitalstatsonline.htm (accessed November 24, 2010). ———. 2010b. National Hospital Discharge Survey. 2006. www.cdc.gov/nchs/nhds .htm (accessed November 24, 2010). U.S. Medical Expenditure Panel Survey (MEPS). 2009. www.meps.ahrq.gov/ mepsweb/ (accessed September 30, 2009). van Doorslaer, E., C. Masseria, and the OECD Health Equity Research Group Members. 2004. Income-Related Inequality in the Use of Medical Care in Twenty-one OECD Countries. Paris: OECD. Wennberg, J. E., E. S. Fisher, T. A. Stukel, and S. M. Sharp. 2004. Use of Medicare Claims Data to Monitor Provider-Specific Performance among Patients with Severe Chronic Illness. Web exclusive, Health Affairs, October 5 – 18. http://content .healthaffairs.org/cgi/reprint/hlthaff.var.5v1. Weissman, J. S., C. Gatsonis, and A. M. Epstein. 1992. Rates of Avoidable Hospitalization by Insurance Status in Massachusetts and Maryland. JAMA 268:2388 – 2394. White, J. 2004. (How) Is Aging a Health Policy Problem? Yale Journal of Health Policy, Law and Ethics 4:47 – 68. ———. 2007. Protecting Medicare: The Best Defense Is a Good Offense. Journal of Health Politics, Policy and Law 32:221 – 246. Williams, A. 1997. The Rationing Debate: Rationing Health Care by Age: The Case For. BMJ 314:820. Williams, B., P. Whatmough, J. McGill, and L. Rushton. 2000. Private Funding of Elective Hospital Treatment in England and Wales, 1997 – 98: National Survey. BMJ 320:904 – 905. Wunsch, H., W. T. Linde-Zwirble, D. A. Harrison, A. E. Barnato, K. M. Rowan, and D. C. Angus. 2009. Use of Intensive Care Services during Terminal Hospitalizations in England and the United States. American Journal of Respiratory and Critical Care Medicine 180:875 – 880. Zweifel, P., S. Felder, and M. Meiers. 1999. Ageing of Population and Health Care Expenditure: A Red Herring? Health Economics 8:485 – 496.