For those of us who had hoped that American attitudes toward death were shifting in ways that would promote a wider reconstruction of the health care system, there's discouraging news from Health Affairs, the pre-eminent journal of health policy. It devotes its latest issue to "end-of-life" care and finds that — at least so far — the power to make health care more compassionate and cost-effective is limited.
That was the vision. Americans would become more realistic about death. Through "living wills," they'd reject heroic — often futile — treatment to keep them alive. Health spending would be lower (by one estimate, a quarter of Medicare spending occurs in the last year of life). People would die with dignity. They'd be spared needless suffering.
Superficially, the vision seems to be triumphing, according to the 17 studies in Health Affairs. By one study, a third of American adults — and nearly half those 65 and over — have some sort of living will. From 1999 to 2015, the share of Americans who died in hospitals dropped from more than half to 37 percent. Over the same period, the number dying at home or in a hospice rose from less than a quarter to 38 percent. Moreover, at 8.5 percent of health costs, spending in the last year of life is lower in the United States than in some other countries.