Distributive Justice and Racial Health Equity: What COVID-19 Teaches About Medicare's Blanket Priority for Americans of Advanced Age

Abstract

Not a single COVID-19 crisis standard of care allocation plan suggests that life-saving critical care resources should go first to those able to pay or to the oldest in need. Yet, every day we ration healthcare in the United States, and with limited exceptions, care is rationed based on ability to pay, with special assistance provided to Americans of advanced age. This blanket preference for older adults lacks normative basis, squanders resources, and perpetuates significant racial disparity in access to care, structurally reinforcing centuries of disadvantage.

This article applies lessons from COVID-19 crisis standard of care allocation to propose a more ethical and efficient framework for Medicare eligibility that will reduce racial health inequity. Section I describes how the current health care system, and Medicare in particular, disproportionately leaves historically marginalized racial minorities without access to care. Section II explains how COVID-19 highlighted racial health disparities and forced states to develop frameworks for rationing healthcare. It outlines the distributive justice principles underpinning most critical care crisis allocation plans, including such plans’ approach to age. Section III applies these principles to demonstrate why the United States should abandon its blanket preference for older Americans and instead utilize evidence of likely benefit with some adjustment for equity to determine priority. Citing philosophical arguments and empirical evidence, this Section shows how benefit-driven allocation would improve health equity by helping more people and shifting resources towards traditionally marginalized groups. Section IV advocates gradual reallocation of age-based Medicare funds to expand coverage for cost-effective care to low-income Americans of any age. It is past time for America to adopt a more just distribution of government healthcare spending.

Note: Funding: None to declare.

Declaration of Interests: None to declare.

Keywords: Health Inequity, Medicare, Rationing, COVID, Crisis Standard of Care, Medical Ethics, Distributive Justice, Health Policy

JEL Classification: I14, I13, I18