AARP Hawai`i Urges State to Remove Age Bias From Crisis Health Plan

AARP Hawai`i sent a letter to Health Director Dr. Libby Char and Gov. David Ige urging the state to change Hawai`i’s Crisis Standards of Care Triage Allocation Framework to remove age discrimination.

The Crisis Standards of Care framework is an emergency plan to ration health care in a disaster when demand for medical care exceeds the supply. In the COVID-19 pandemic, the Crisis Standards of Care could be invoked if there is not enough oxygen, intensive care beds or ventilators to give to everyone who needs it. But the plan can also be used in a tsunami, hurricane or other disaster if the need for health care exceeds the ability of hospitals, doctors and nurses to provide it.

The plan as currently written tells hospitals and medical personnel that race, national origin, ethnicity, gender, sexual orientation, disability status, limited English proficiency, perceptions of societal worth, immigration status, religion, insurance status, and socio-economic and housing status cannot be considered in health care decisions. But it allows age to be considered in a “tiebreaker” situation.

The plan states that “life cycle considerations” should be part of the decision on who gets health care if all other medical factors are equal and younger people should be given health care over older people. In COVID-19 cases, people 64 and younger should be prioritized over those 65 and older in a tiebreaker.

At AARP Hawai`i, we believe that no one should be categorically excluded from accessing treatment because of their age. Period. It violates the laws and guidance of the federal government. But more importantly, it’s just wrong.

Below is the letter that we sent to the Health Department and Governor’s office.

September 21, 2021

Elizabeth Char, M.D., Director
Hawaii State Department of Health
Honolulu, Hawaii

Dear Dr. Char,

On behalf of AARP Hawai`i’s 145,000 members and all Hawai`i kūpuna, we are writing to raise concerns about the Hawai`i State Crisis Standards of Care Triage Allocation Framework revised this month and posted on the Hawai`i Department of Health website.

We are grateful for the extraordinary efforts of the Health Department, the Hawai`i Emergency Management Agency, the Healthcare Association of Hawai`i and of the entire health care community in keeping us out of a crisis situation where we have to ration health care and use the guidelines. We are also mindful of the difficult decisions that must be made in coming up with the crisis standard of care.

However, AARP Hawai`i is disappointed that the revised Crisis Standards of Care Triage Framework posted on the Department of Health website last week did not include age in the list of ethical considerations to ensure all cases are treated alike and that age discrimination does not occur. Age is still a tiebreaker when deciding how to ration health care within the plan, which allows for discrimination against patients age 65 and older. 

We understand that the standards are “a living document, intended to be updated and revised to reflect timely advances.”  We also understand that the document being released publicly increases transparency and to helps build public understanding of the guidelines. However, not specifying age as a factor that should not be considered in health care triage decisions (page 6 section C) and not removing age bias and discrimination from the crisis standards may violate the federal Age Discrimination Act of 1975.

A March 28, 2020 Bulletin from the U.S. Department of Health and Human Services’ Office of Civil Rights (OCR) also makes clear that care should not be denied on the basis of stereotypes, quality of life assessments, or judgments about a patient’s relative worth based on disability or age. The bulletin calls for providers to make decisions about treatment based on “an individualized assessment of the patient based on the best available objective medical evidence.”

The OCR has followed up on this guidance and worked with North Carolina, the North Texas Mass Critical Care Guidelines Task Force, the Southwest Texas Regional Advisory Council, the Indian Health Service, and other agencies and states, to revise their guidelines to remove age and disability discrimination. Notably, the revised crisis standards contain a specific prohibition on the use of a patient's long-term life expectancy as a factor in the allocation and re-allocation of scarce medical resources; and a prohibition on the use of categorical exclusion criteria. Instead, they require an individualized assessment based on the best available objective medical evidence.

Age discrimination in the standards is also against current thinking in medical ethics, even if the guidance is specific to the COVID pandemic. An August 30, 2021 article in the American Academy of Medicine Journal that reviewed Crisis Standards of Care across the country recommended that states continue to review their standards for bias and that states remove age bias from their health care rationing plans. Specifically, the authors suggest, “The triage process should specifically exclude consideration of age, race, gender, disability, and other inappropriate discriminators, and those conducting triage should be trained on implicit bias with the aim of mitigating the inadvertent exacerbation of disparities.”

Like you, we hope the number of cases continues to decline, and that hospitals and health care professionals are not placed in a position to utilize the crisis standards of care. We have continually stressed that the public plays a significant role in keeping each other safe by getting vaccinated, wearing masks, social distancing and avoiding large gatherings. Whether the crisis standards of care need to be implemented or not, age should not be a determining factor, even in a tiebreaker.

We ask that as you continue to update and revise the crisis standards and that you ensure Hawai’i’s kūpuna will not be subject to discrimination and age biases. Thank you for all your efforts to keep us safe and your consideration of our suggestions to ensure age bias is not part of the Hawai`i Crisis Standards of Care Triage Allocation Framework.

Sincerely,

Keali`i Lopez
AARP Hawai`i State Director