Comment by luckylion | Hacker News Reader

Comment by luckylion | Hacker News Reader

I'm not sure I follow the argument in general. Of course, I understand the idea that, as people live longer and the median age grows, and the elderly aren't working, the younger people in a society have to work more to also care for the elderly.

But that feels like it's mostly a theoretical/money-issue (at least in the industrialized nations), because as people age, their consumption also changes. I live in an area with plenty of old people who slowly die off and get replaced by young families. The old folks are low-activity, have at most one car, and even that seems mostly stationary except for the occasional grocery shopping.

At the same time, productivity has risen so sharply that it's absolutely not a problem to provide the basics (food, shelter, energy) because we're far away from 20% of the population working in agriculture. Healthcare and elderly care in general becomes an issue, but that feels like it's much more manageable, e.g. we could cut cost and not give hip replacements to 80year-olds.

So this feels less like a "omg this can't work, just look at the numbers"-issue and more like a renegotiation of the intergenerational contract. Granted, that's not an easy task either given that the elderly get a vote too, but it's no longer "how would we ever accomplish this" and instead becomes a political issue. Since many elderly are also at the wealthiest stage in their life, I feel like that's not an unsolvable riddle.

What am I missing?

You’re missing the bit where you can’t not give the 80 year old a hip replacement. Or look after them in their twilight years in a respectable standard of living. It’s easy to make hand wavy statements from where you are (maybe 20s?) - wait a little bit or see what happens as your parents age. You can’t not give the 80 year old the hip replacement because their quality of life will be significantly better for the next 10 (or -2, if they’re in the US)

My father has been dead for 10 years and my mother is in her late 70ies, I'm in my forties (and feel like 60, but that's besides the point).

I'm not sure we can't do that. I believe I read something about cuts in non-essential operations for the elderly in Germany's public healthcare system, but I can't find it any more because Google sucks. Still, I don't believe that's taboo if the other option is to have the system crash.

"You’re missing the bit where you can’t not give the 80 year old a hip replacement."

Why not? It happens a lot in 'Europe'. (yes I know that 'Europe' isn't one single thing)

What you're talking about is not some ideal state that we currently exist in where demographic trends aren't resulting in impairment of healthcare delivery (which is a fundamental human right). What you are talking about is the first part of the death by a thousand cuts which is demographic decline and failed service delivery which will only be exacerbated over the coming years as the impact of an ageing and reduced taxpayer, below-subsistence population replacement kicks in.

The fact is, and remains, that the 'right' thing to do is to ensure adequate service provision and that the 50 or 60 or 70 or 80 year old who needs a hip replacement, or aortic valve replacement, or high level care nursing home, actually receives it. But the powers that be, even now, are able to reduce the current impact to healthcare budgets (and thus government expenditure) by pushing waiting lists out to such an extent that people are rendered basically invalid by the wait times, and die on them.

It's not just europe, it's basically the rule in the US (unless you are independently wealthy or have a decent healthcare plan), and it will only get worse unless people unzip their trousers and make the beast that has two backs.

Or, we decide collectively that the attempt at death by a thousand cuts is not in any way acceptable. Which is hard because the insidious nature of death by a thousand cuts is (to absolutely mix metaphors) that you don't notice the temperature rising until you are parboiled.

What? No, that's not what I'm talking about at all. What I'm talking about is sensible healthcare provisioning, under the honest observation that just because some medical intervention is technically possible, it's necessarily a good idea (from both quality of life as well as financial points of view).

So no, just because it's technically possible to replace an 80 year old's hip, doesn't mean we should. There is nothing wrong with some cutoff where we say 'as a society, the maximum we want to pay for a daly is x' (or qaly or any other measure you want to take). There is nothing wrong with being honest about resources being finite, and that not every potentially possible medical intervention needs to be paid for by society. And this is what is happening in 'Europe' (although it isn't admitted as bluntly as I put it here...), and what I was referring to.

As the working population shrinks, so does the tax base. So you get an unsustainable equation of having fewer and fewer economically productive people needing to pay to support more and more retirees, and since the tax base is also shrinking in absolute numbers, it's increasingly difficult to fund other things like infrastructure.

Do the elderly have similar infrastructure requirements though? Like, generic infrastructure like highways or rail lines is a requirement and doesn't really change much as it's required for transporting of goods etc, but lots of local infrastructure seems to be something you're leaning on a lot when you're younger. It's an exaggeration of course, but if you keep the groceries coming and the TV program changing, the elderly will be somewhat content.

But even then, don't we have infrastructure productivity improvements, too? Building something these days requires more skilled workers, but much fewer.

Bridges, highways, sewers etc all still need maintenance even if there are less people using them. This is an increasingly large problem in Japan, which built lots of hugely unprofitable infrastructure during the Bubble years (bullet trains to the prime minister's rural home town etc) and is still addicted to grandiose projects as a form of rural subsidy/kickback.

Don't infrastructure projects scale well with regards to costs? I assumed that e.g. building a three lane highway isn't 50% more expensive than building two lanes, but maybe it even complicates things more as you run into more issues the more space you take up (can't squeeze through gaps, more attack surface for Godzilla and whatnot).

Isn't infrastructure profiting from automation as much? Health & elderly care has severe limits there until we get to very advanced robots in a few generations, but infrastructure feels easier.

Scaling only gets you so far. The maglev Chuo Shinkansen currently under construction between Tokyo and Nagoya involves around 250 km of tunnels punched through Japan's mountainous backbone and has a price tag of US$64 billion (and continually climbing).

Still, the real problem is not building new things, but maintaining old ones.

You're missing that some people are obsessed with 20th century ideas of boundless economic growth and existential anxiety over falling behind other countries, and genuinely can't fathom that down cycles are necessary and manageable part of any sustainable system.

Healthcare is proving hyperinflationary nearly everywhere in the long run. Revealed preference shows people love spending money on healthcare. People will allocate to healthcare over almost anything else. I don’t think a no hip replacements policy will be very popular.

It’s not whether or not they can be supported. It’s the overall economic productivity. You can support an elderly population and stagnate/decline.

Supporting your aging parents is easier when you have brothers and sisters, and harder when you are alone. This is the same effect, but on larger scale. The children of bigger families will now have to provide for those that could not or decided not to have kids. At least thats the way I look at it.

There is zero chance any extant Western society will cut costs by removing healthcare from the elderly.

Or to quote The Great Cuomo:

And we're not going to put a dollar figure on human life.

If your math doesn't account for the fact that we'll hamstring the youth to serve the old, it is simply incomplete.

By deliberately preventing or de-prioritising access, perhaps not. But at some point if you have more grandmothers needing hip replacements than they are health care workers able to perform the procedure and provide post-operative care, something's gotta give. Unless of course we find much cheaper/easier ways of or substitutes to performing such replacements, which isn't so unlikely (nanotech to rebuild existing weakened bones?).

We can slave the entire productive population to serving the old if necessary. We tried once in recent times.

What you're missing is understanding that our societies are currently run by rentier capitalists. The metrics they use to value their portfolio's. And that they're all leveraged.

The panic is that a falling population and lower consumption will wipe out their assets.

Reply on news.ycombinator.com