Heterogeneity in US pandemic allocation policies: state-to-state variation, stakeholder insights and implications for older Americans

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ABSTRACT Even before 2020, older Americans made up the majority of ICU admissions and deaths. In 2020, as a pandemic infiltrates every corner of the globe, older adults are disproportionately impacted, facing greater morbidity and mortality from COVID-19 than any other segment of the population. As a society we are tackling unsettled questions about how best to deploy limited resources as we confront mass critical illness on a scale not seen for generations. These questions strike at the core of our ethos as a nation, challenging us to craft policies to sort through waves of patients, knowing that if crisis standards of care are enacted those policies will determine who is allocated intensive care resources – and who is not. In Aim 1 we propose to analyze states’ scarce resource allocation policies through an anti- discrimination lens, seeking to characterize the ways in which policies explicitly or implicitly disadvantage older or disabled persons. These may include consideration of advanced age or disability as an initial exclusion or deprioritization criterion, or as a tiebreaker among patients presenting with similar severity of illness. We then seek in Aim 2 to measure the size of the American population at highest risk to suffer from such criteria, Medicare beneficiaries with two or more comorbid conditions living in jurisdictions that factor age and disability into allocation decisions. In Aim 3 we will contextualize our findings with in-depth interviews with policy authors from states with varied approaches to age and disability in triage. This pilot research will lay evidentiary groundwork for future policy reform, characterizing the permutations and pervasiveness of discriminatory policies against older adults and persons living with disability. During the award period the principal investigator, who is a critical care physician, will acquire skills in qualitative methods and layer policy findings over summary claims data, a methodology she intends to further explore in future career development mechanisms. The proposed projects will serve as a first step in the candidate’s trajectory toward an independent research career at the intersection of bioethics, critical care, health policy and aging research.