Can Medicare Afford the Perpetual Human?

Medscape

25-07-2025

The year is 2055, and Bella Gilbert is headed to the hospital for her second synthetic heart replacement. Gilbert, age 117 and going strong, has been on Medicare for the past 52 years, during which time she has received three sets of three-dimensional (3D) printed corneas and more new joints and gene therapies than she can remember.
If such a scenario seems unlikely, think again. Bioengineers inside university labs and billionaire-backed start-ups around the world are working on technologies to fight aging and the diseases associated with it. Bone marrow banks, brain tissue regeneration, and cryopreservation for organs-on-demand are among the interventions underway.
But Gilbert is lucky. She has the financial resources to access these medical advancements. Most other Americans do not — Medicare will not pay for them.
Through the years, Medicare has tended to cover new technologies that help people live longer. But a wave of new innovations could push the system to a breaking point.
'I don't think anyone's quite prepared [for] a world where everyone's living to 110, but people are still retiring at age 65,' said Loren Adler, MS, a fellow and associate director at the Brookings Institution's Center on Health Policy. 'If you're paying into Social Security and Medicare for 30 years and then taking out of it for 50 years, the math is going to be very difficult to make work.'
Medicare already is struggling to meet demands by physicians for higher reimbursements and open access to sought-after GLP-1 agonists. The recently passed federal budget reconciliation bill, which includes about $500 billion in cuts to the program between 2026 and 2034, could compound those challenges.
The mounting fiscal pressures on the program, which currently provides coverage for 66 million Americans, may foreshadow a future where only some are granted access to perpetual life.
'Medicare is going to face a real challenge,' said Norman Ornstein, PhD, an emeritus scholar at the American Enterprise Institute. 'That challenge is not just what to do with expensive drugs that can save lives for lengthy periods, but the pressure to provide access to drugs that cost huge sums but may be extend life for 4 months or 6 months.'
Life Extension…for Some
A movement to extend lifespan and reimagine — or do away with — how the human body ages is hurtling forward, fueled by scientists and their patrons. Many efforts are moving toward the clinic and the market. Within a few decades, patients could be lining up for drugs that target pathologic senescent cells and replacement organs for ailing human bodies.
The national waiting list for organ transplants is 103,000 people long. More than 13 people per day die waiting, and many more who could benefit from transplants are deemed ineligible because of health conditions or age.
People of all ages need new kidneys, hearts, and lungs, but most people on the waiting list are past middle age: About 42% are aged 50 years or older, while 26% are at least 65. An unlimited supply of replacement organs could transform aging, potentially eliminating the need for expensive drugs — such as medicines for chronic heart failure and chronic kidney disease — and therapies like dialysis that keep people alive while they wait for an organ.
United Therapeutics, a biotechnology company founded by entrepreneur Martine Rothblatt, has led the charge for on-demand organs.
'I believe that every person in the world should have the right to live as long as they want to do it, and my religion is about making science serve that faith,' Rothblatt said in a 2015 interview with New York Magazine .
The company expects to reach clinical trials on its 3D printed lung — with 2000 miles of capillaries — this decade. And this year, it will start a clinical trial of pig kidneys genetically engineered to prevent organ rejection.
Recent one-off studies (using the FDA's Expanded Access Protocol program) transplanting animal organs into humans have resulted in patients most often dying shortly after. But life was extended by 2 months in one case, while another patient resumed dialysis because her body rejected the pig kidney.
Other efforts are underway to eliminate the need for gene edits to the donor and antirejection drugs after organ transplantation, said Doris Taylor, PhD, founder and CEO of the biotechnology company Organamet Bio, Inc., in Manchester, New Hampshire.
Doris Taylor, PhD
'Our hearts become a person's own,' Taylor told Medscape Medical News . 'That's our whole deal — personalized human hearts on demand.'
Taylor is investigating a method to strip pig hearts of everything except its four chambers and valves. She uses a patient's own stem cells to grow blood vessels and heart cells. Then, the blood vessel cells are injected into the pig heart by hand and fed with a protein-rich solution until they nearly cover the vasculature.
The heart cells are added next, along with artificial blood and an electrical signal using a pacemaker. Over time, more blood is added, voltage is gradually increased, and the heart learns to pump — something Taylor has done successfully.
Robots being developed by biofabrication company Advanced Solutions would inject the cells and guide the organs to maturity. Her team is also perfecting the hearts' orientation as they grow, mimicking their positioning inside the human body as closely as possible. All of this work is vulnerable to delays and expensive — Taylor estimates needing up to $500 million to reach the clinical trial stage.
Like Taylor, Mark A. Skylar-Scott, PhD, an assistant professor of bioengineering at Stanford University, Stanford, California, will need to get around financial and logistical roadblocks to create 3D printed hearts. For example, the process he is testing to grow this heart relies on a $6000/d cocktail of biologic proteins — which is beyond the means of an academic lab.
Mark A. Skylar-Scott, Ph
Skylar-Scott hopes to cut costs by gene-editing stem cells that do not require an expensive protein-rich medium to produce heart cells.
But other hurdles exist. No one has created a 3D printed heart yet. The entire biofabrication field is struggling to create necessary parts and orchestrate their maturation into a self-sustaining organ. Skylar-Scott said clinical trials could be about a decade away. But even if these trials are successful, gaining FDA approval and setting up a manufacturing process 'is a long road,' he said.
'The Most Valuable Medical Intervention in History'
What will likely come available sooner is a drug that targets the aging process, also known as a gerotherapeutic, said Steven Austad, PhD, a professor of biology at the University of Alabama at Birmingham and scientific director of the American Federation for Aging Research.
Steven Austad, PhD
On that front, numerous well-funded efforts are underway, from cell rejuvenation therapies being developed at Jeff Bezos-backed Altos Labs to therapies targeting cellular stress in progress at Google's biotech company Calico Labs. This year, the Buck Institute for Research on Aging demonstrated in a clinical trial of 42 people how plasma exchange can improve markers of biologic aging in healthy adults aged over 50 years.
Investigations into gene therapies targeting aging and aging-related diseases have also taken off. Researchers are exploring gene therapy to treat Alzheimer's disease. And California recently awarded $4 million toward the study of a gene therapy for cardiomyopathy and potentially other aging-related chronic diseases.
The federal government has supported research on senescent cells, which increase with age and which drive disease. Researchers have reversed aging in mice using drugs that target these cells. A handful of clinical trials in humans have demonstrated benefits for those with advanced diabetic macular edema, lung disease, and bone loss. But more conclusive research is needed.
Drugs that could target aging are already being used for other indications. Eight years ago, Austad helped design a clinical trial to investigate whether metformin, an approved drug for type 2 diabetes, could prevent age-related chronic diseases like heart disease and cancer. But that trial, which he is no longer involved with, has been stymied for years by a lack of funding.
Bleak Outlook for Health Equity
'In the field, I hear a lot of talk about equity,' Austad said. 'If you look at the stuff that actually is under development, it's all expensive stuff. The rich people will be able to afford it. Most people will not.'
That future is also playing out with GLP-1 receptor agonists, which are on the radar of aging researchers. While approved to treat obesity and type 2 diabetes, GLP-1s are shown to help prevent cardiovascular, neurodegenerative, and chronic kidney diseases. They may stem chronic inflammation and oxidative stress.
'The moment someone develops a verified gerotherapeutic, it becomes the most valuable medical intervention in history,' said S. Jay Olshansky, PhD, a professor of epidemiology and biostatistics at the University of Illinois Chicago. 'It is not likely to be equitably distributed to begin with. If it's GLP-1s, well, those are not equitably distributed today.'
S. Jay Olshansky, PhD
Medicare limits coverage of GLP-1s to prescriptions for diabetes and sleep apnea, despite the estimated 3.6 million beneficiaries who have both cardiovascular disease and are obese or overweight and could benefit from the drugs.
Researchers at the University of Chicago, Chicago, recently projected that expanding Medicare coverage of GLP-1s for obesity would save about $18 billion in reduced hospitalizations and chronic disease care. But doing so would result in $48 billion in new Medicare spending over 10 years. Prices would need to plummet by 80% to be cost-effective, the researchers found.
While prices are likely to drop eventually, such as when the drugs go off-patent, 'in the meantime, it's going to probably exacerbate [an] already huge problem with health disparities,' Austad said. 'Already, if you're rich, you live 10 years longer.'
To encourage equitable access to aging interventions in the future, efforts to set up an 'ethics infrastructure' should get underway now, said Arthur L. Caplan, PhD, professor of bioethics at NYU Grossman School of Medicine, New York City. This approach would mean devoting more money and research to GLP-1s than gene therapies, for instance.
'You have to commit right now to funding the technologies that look like they're the cheapest and the easiest to apply, not just that they work. We have technologies now that work that no one can afford,' said Caplan, a frequent contributor to Medscape Medical News .
Can Medicare Afford to Keep Aging at Bay for All?
In 2022, 57.8 million Americans were aged 65 years or older, representing 17.3% of the population. By 2040, the figure will grow to 78.3 million and make up 22% of the population. Already, about 93% of older Americans have at least one chronic condition, while nearly 79% have two or more. And nothing causes more death and disability or drives up healthcare costs more than chronic disease.
But slowing aging even a little could delay the onset of fatal and disabling diseases, which can affect the economy, said Andrew J. Scott, PhD, a global macroeconomist and director of Economics at the Ellison Institute of Technology, funded by Oracle co-founder Larry Ellison.
Andrew J. Scott, PhD
Scott found that adding just 1 year of good health to life expectancy among Americans would boost economic welfare — defined as the overall level of prosperity and standard of living — by $38 trillion annually, yielding a 3.5% increase in gross domestic product each year. A study he published in June 2025 projected that reducing the incidence of six key chronic diseases in the UK would also drive economic growth there by 0.99% after five years and 1.51% after 10 years — mostly because people could continue working for longer.
'The challenge we've got at the moment is that a lot of the funding for geroscience is coming from very, very wealthy people,' Scott said.
Many of those people already have access to the most nutritious foods, exercise regimens, healthy living conditions, and effective medicines and interventions. With all of that already in place, they are more likely to seek out expensive treatments that extend life to 110 or 120, Scott said.
'I think what we really need is cheaper stuff that operates across lots of people, focusing first on keeping people healthy for longer, rather than just making them live longer,' he said. GLP-1s, for instance, could help prevent heart disease, the leading cause of people leaving the workforce in the UK, particularly among those over the age of 50 years. 'GLP-1s, from an economic point of view, even though they're expensive, still represent pretty good value for the government,' he said.
Given the money and interests behind the longevity movement, progress on expensive interventions is unlikely to abate. If life-extending technologies go on to earn FDA approval, Medicare will likely face pressure on multiple fronts — from professional groups, Congress, patients, and technology companies — to cover them, said Rita Redberg, MD, MS, a cardiologist and professor of medicine at the University of California, San Francisco.
Rita Redberg, MD, MS
In 2014, Redberg chaired the Medicare Evidence Development and Coverage Advisory Committee, which provides expert guidance to the Centers for Medicare and Medicaid Services (CMS) on advanced medical technologies eligible for coverage. After reviewing evidence for lung cancer screening, the body found a lack of benefit and potential for 'significant harms' in Medicare beneficiaries, Redberg said.
Medicare decided to pay for the tests anyway. More recently, the program announced it will cover transcatheter tricuspid valve replacement, despite the procedure failing to significantly reduce mortality in a clinical trial.
'You have to first establish that these technologies are lifesaving before committing Medicare resources. And that is still not happening,' Redberg said.
Officially, Medicare does not consider costs when making coverage decisions or setting prices, according to Sean Tunis, MD, MSc, a senior fellow at Tufts Medical Center for the Evaluation of Value and Risk in Health and a former chief medical officer for CMS.
The program tends to justify coverage restrictions by citing safety and efficacy uncertainties, Tunis said. In recent years, it has used those reasons to limit access to new Alzheimer's drugs before expanding access later. However, 'the motivations are really more about affordability, and do they think it's worth the money?' Tunis said.
That approach differs from the UK, where the National Institute for Health and Care Excellence can perform cost-benefit analysis of new technologies and drugs and use the results to negotiate prices.
'I've thought for a long time that the US really needs something like that, and it's a shame we can't get it,' said Richard S. Foster, who served as chief actuary for CMS from 1995 to 2005.
Previous efforts to amend how Medicare determines coverage and sets prices haven't always panned out. For instance, a provision in the Affordable Care Act to let Medicare reimburse doctors for end-of-life consultations with patients led to outcry over which patients might be considered ineligible for continued care.
'Many times, when the idea of considering costs as one of the factors in setting prices or coverage of technologies in this country is raised, immediately, the R-word gets mentioned. We're rationing healthcare services,' Tunis said. 'In this country, we don't support the idea of rationing based on the value of a technology; we ration based on people's income.'
Case in point: the recently passed Trump administration budget bill, which is expected to gut Medicaid, with more than 11 million Americans losing health insurance. The Biden administration's Inflation Reduction Act granted Medicare the ability to negotiate prices on select high-cost, widely used drugs — including GLP-1s starting in 2027. 'That's probably gone now,' Ornstein said.
Without more ways to control costs, Medicare's hands are tied. As the system approaches a future teeming with life-extending technology options, it also faces reduced government spending for healthcare.
Americans already spend more on their care than they do on groceries or even housing, and healthcare costs have long been growing faster than the economy.
'Eventually, that's got to give,' Foster said. 'General economic forces are going to cause hard decisions, and something will be done such that either we don't adopt all of these new improvements, or we pay for them in more limited circumstances because you basically can't have healthcare crowding out everything else.'
Austad is a scientific advisor to XPRIZE Healthspan and WNDRHLTH, neither of which has any stake in the development of a polypill. Olshansky, Ornstein, Redberg, Scott, Skylar-Scott, Taylor, and Tunis reported having no relevant financial conflicts of interest.