[peterbecich]

Speaking only of the financial aspect, not any other ethical issues:

Those end-of-life patients paid into the system, earlier in their lives, financing the cost of earlier generations of end-of-life patients. It would be unfair to change the social contract now.

In my opinion, it is no different from how adult taxpayers finance public education for children. It is a rolling responsibility from generation to generation.

You may be able to alleviate this financial issue (and not any other ethical issues) by phasing-in this policy change with the youngest generation of Medicare taxpayers, somehow.

[mgh95]

> Those end-of-life patients were paying into the system, earlier in their lives, financing of the cost of earlier generations of end-of-life patients. It would be unfair to change the social contract now.

> In my opinion, it is no different from how adult taxpayers finance public education for children. It is a rolling responsibility from generation to generation.

This hits upon the core issue: the next generation is substantially smaller than the last and relative costs have ballooned due to greater availability of therapies. The generational contract is that you pay your taxes a percentage of wages -- in effect, a PAYG mechanism. If wages do not rise sufficiently to cover increased costs, that does not imply that the generational contract was unfulfilled; the taxes were paid.

The demographic pyramid and weaker than necessary wage growth really renders the care demanded burdensome to the point where we have already provided elderly cost advantages in insurance in the form of cost premium multiple maximums and medicare from payroll taxes while beggaring the rest of the population in the process.

> In my opinion, it is no different from how adult taxpayers finance public education for children. It is a rolling responsibility from generation to generation.

Fundamentally, children are an investment. They produce cash flow (taxes) from increased public health. The end-of-life are not; by definition, they will be dead soon. It's a horrible thing to say, but in the face of ever increasing elder care burdens and weak public debt/gdp ratios, what real choice is there?

[peterbecich]

> If wages do not rise sufficiently to cover increased costs, that does not imply that the generational contract was unfulfilled; the taxes were paid.

That's an interesting alternative view I had not considered. I think it is debatable. I believed the generational contract to be "healthcare for 65+ with 20% copay, etc., no gov. expense spared" whereas you argue the generational contract to be "Medicare payroll tax of X% is constant over all time; spend it wisely." I would argue the first option was the original intent of the Medicare law.

> Fundamentally, children are an investment. They produce cash flow (taxes) from increased public health. The end-of-life are not

You could argue the same for the end-of-life, in at least two ways: * the end-of-life patient has already produced cash flow to the government, just in reverse order from the student * Good education produces a higher taxpaying adult, the investment you refer to. I would argue the assurance of end-of-life healthcare also produces a higher taxpaying adult.

I acknowledge the costs have gone up faster than wages+population.

[_DeadFred_]

And productivity in society has gone up by huge amounts since the 1960s. Just since the 90s it's more than doubled, but going back to the 1960s it's much more than that. So you can't just say 'but population dropped'.

Fundamentally what is the purpose of society if the improvements it makes over time don't improve its's citizens lives? If even with tripling it's economic output it can't care for it's people (just because they are old doesn't make people not part of society)?