Medical care in the United States presents a paradox. At its best, U.S. medicine is a marvel, featuring state-of-the-art diagnostic and surgical technology augmented by sophisticated pharmaceutical agents. Most citizens report that they are happy with their medical care. Yet, at the same time our health care system merits serious criticism: it is by far the most expensive in the world, consuming almost 12 percent of the nation’s gross national product; its health status, as measured by such standard indices as life expectancy from birth or infant mortality rates, lags that of most developed countries; its organization and distribution of health care resources are unbalanced, with a serious skew toward technology-intensive services, sometimes at the expense of primary care, preventive services (especially for the poor), home care, and long term care; and more than 30 million persons lack any form of health insurance, thereby posing severe problems of access and equity.

By contrast, the elderly enjoy comprehensive coverage and usually excellent access to hospital and acute care facilities under the Medicare program. Coverage for ambulatory care is also good, although benefits for home and long term care are limited. By international standards, the U.S. elderly enjoy excellent health status. As judged by life expectancy from age 65, and especially from age 75, the U.S. ranks among the countries with the best longevity in the world.

Driven largely by concerns about relentlessly rising expenditures for medical care, many health policy analysts now believe that explicit rationing of health services is the appropriate strategy for medical cost containment. The prospect of rationing, however, must be viewed in the context that, for the elderly in the United States, utilization of services such as coronary artery bypass surgery, prosthetic replacements of diseased hips,