Sick To Death > Chapter 2 > Life Span Perspective
A remarkable proportion of overall health-care needs and costs is now concentrated in the last few years of the life span. Most of the costs - and the burdens - of bad health arise with serious chronic illness in the last tenth of life. Figure 3 illustrates how experienced physicians and managers estimate the distribution of total health-care costs over the typical American's lifetime. Since no database records these expenses directly, expert estimates are our only source. Existing data strongly support the estimate for the last year of life. During that year, a Medicare beneficiary ordinarily uses more than $25,000 in health-care costs and the preceding two years add up to about the same total (Hogan et al. 2000; Shugarman et al. 2004). But we must double the sum of these last three years because Medicare covers only about half the costs (for example, Medicare does not cover nursing-home costs or prescription drugs) (Maxwell, Moon, and Segal 2001). Assuming an eighty-year life span, each tenth of the life span would be eight years. The costs of the last three years of life add up to around $100,000, and another $5,000 per year (close to average Medicare expenses) is a reasonable figure for the five years before. Thus, the last tenth of life incurs roughly $125,000 in health-care costs, probably nearly half of the costs over the person's lifetime. More reliable estimates would be well worth having, but the concentration of costs in the last part of life will be striking, even though neither the patients nor the clinicians may see those services as having anything to do with the end of life at the time they are provided (Alemayehu and Warner 2004).
A similar curve for the U.S. population in 1900 would have been much flatter, both because serious illnesses were more common throughout life and because death often occurred suddenly in the course of a generally healthy life. Moving the bulk of serious illness into old age is a laudable achievement. Even so, having a few years of serious disability at the close of life has become both commonplace and costly.