Abstract

PIP: A critique is presented of a paper entitled "Death and Taxes: the Public Policy Impact of Living Longer", which was published in 1984 by the Population Reference Bureau (PRB). The 1st point at issued concerns the prospects and means of extending human life. The age group over 85 is the fastest growing segment of hospitial and nursing costs peak at these ages. The rapid aging of the population reflects recent significant declines in death rates from chronic degenerative diseases whose mortality rates at all but extreme ages are very low and death occurs very late in life without disease. The findings on which this forecast is based are controversial and are discounted by many demographers, actuaries, and research biologists. The PRB scenario is based on 3 questionable hypotheses: 1) that the life span is biologically fixed and programmed, 2) that we are rapidly approaching the predetermined limit of life, and 3) that research on the "underlying causes of aging", as distinct from disease processes, may extend quantity and quality of life. For at least the foreseeable future, the chronic degenerative diseases will pose the greatest threat to quality of life of the elderly. Even if "natural" death were theoretically possible in the far future, support for disease-specific research would be required over the next 40 to 50 years to meet the needs of the elderly. Since the end of World War II, there has been impressive progress in extending the average length of life, but the prevalence of the major life-threatening chronic diseases has increased or decreased only slightly, raising the possibility of a population living longer but in a less health condition. Reconceptualizing health as a process with multiple outcomes of morbidity, diability, and death suggests a perspective in which slowing the rate of disease progress emerges as an important clinical goal, research focus, and health policy objective. The direction and mignitude of public expenditure will largely shape the health of the future older population; in that context, the PRB estimates of the "costs" to the federal budget from saving individual lives are troublesome, since they deal only in financial terms. Balancing the actual dollar costs against more qualitative aspects of population aging is the true challenge to public policy. The greatest objection to the paper is that it discounts societal, value-based commitment to the elderly in favor of a purely financial reckoning.