a particular medical procedure. it reflects the quality and the quantity of life added by incurring a particular medical expense. the measure has been used for over 30 years in the country's universal single-payer healthcare system and has been implemented in several other countries to help with rationing decisions. australia applies qaly measures to control costs and ration care and allows private supplemental insurance for those who can afford it. by comparative effectiveness research medicare spending per person varied significantly across states in 2006 several treatment alternatives may be available for a given medical condition, with significantly different costs but no statistical difference in outcome. such scenarios offer the opportunity to maintain or improve the quality of care while significantly reducing costs through comparative effectiveness research. writing in the new york times, david leonhardt described how the cost of treating the most common form of early-stage, slow-growing prostate cancer ranges from an average of $2,400 (watchful waiting to see if the condition deteriorates) to as high as $100,000 (radiation beam therapy): some doctors swear by one treatment, others by another. but no one really knows which is best. rigorous research has been scant. above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. most die of something else before prostate cancer becomes a problem. according to economist peter a. diamond and research cited by the congressional budget office (cbo), the cost of healthcare per person in the us also varies significantly by geography and medical center, with little or no statistical difference in outcome: although the mayo clinic scores above the other two , its cost per beneficiary for medicare clients in the last six months of life ($26,330) is nearly half that at the ucla medical center ($50,522) and significantly lower than the cost at massachusetts general hospital ($40,181)...the american taxpayer is financing these large differences in costs, but we have little evidence of what benefit we receive in exchange. comparative effectiveness research has shown that significant cost reductions are possible. office of management and budget (omb) director peter orszag stated: "nearly thirty percent of medicare's costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas." president obama has provided more than $1 billion in the 2009 stimulus package to jumpstart comparative effectiveness research (cer) and to finance a federal cer advisory council to implement that idea. economist martin feldstein wrote in the wall street journal, "comparative effectiveness could become the vehicle for deciding whether each method of treatment provides enough of an improvement in health care to justify its cost." by government former republican secretary of commerce peter george peterson indicated that some form of rationing is inevitable and desirable considering the state of us finances and the trillions of dollars of unfunded medicare liabilities. he estimated that 25 to 33% of healthcare services are provided to those in the last months or year of life and advocated restrictions if quality of life cannot be improved. he also recommended for a budget to be established for government healthcare expenses by establishing spending caps and pay-as-you-go rules that require tax increases for any incremental spending. he has indicated that a combination of tax increases and spending cuts will be required. he advocated addressing those issues under the aegis of a fiscal reform commission. arizona modified its medicaid coverage rules because of a budget problem that included denying care for expensive treatments such as organ transplants to medicaid recipients, including those who had previously been promised funding. msnbc's keith olbermann and others have dubbed governor jan brewer and the state legislatures as a real life death panel because many of those poor people who are now being denied funding will die or have health because of the political decision. by age in the us, the discussion on rationing healthcare for the elderly began to be noticed widely in 1983 when economist alan greenspan asked "whether it is worth it" in referring to the use of 30% of the medicare budget on 5–6% of those eligible who then die within a year of receiving treatment. in 1984, the democratic governor of colorado, richard lamm, was widely quoted but claimed to have been misquoted as saying that the elderly "have a duty to die and get out of the way." medical ethicist daniel callahan's 1987 setting limits: medical goals in an aging society discusses whether healthcare should be rationed by age. he calls the elderly "a new social threat" and selfish and for age to be used as a criterion in limiting healthcare. callahan's book has been widely discussed in the america media, including the new york times, the washington post, the wall street journal, and "just about every relevant professional and scholarly journal and newsletter." one of the major arguments against such age-based rationing is the fact that chronological age, by itself, is a poor indicator of health. another major argument against callahan's proposal is that it inverts the western tradition by making death a possible good and life a possible evil. amherst college jurisprudence professor robert laurence barry called callahan's view "medical totalitarianism." one book-length rebuttal to callahan from half-a-dozen professors who held a conference at the university of illinois college of law in october 1989 was in 1991's set no limits: a rebuttal to daniel callahan's proposal to limit health, edited by robert laurence barry and gerard v. bradley, a visiting professor of religious studies at the university of illinois at urbana–champaign. arguments in favor australian philosopher peter singer argued for rationing processes: "rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. if we ration we won't be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. when public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. the debate over health care reform in the united states should start from the premise that some form of health care rationing is both inescapable and desirable. then we can ask, what is the best way to do it?" medicare and medicaid spending as a percentage of gdp the congressional budget office reported in june 2008: "future growth in spending per beneficiary for medicare and medicaid—the federal government's major health care programs—will be the most important determinant of long-term trends in federal spending. changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation's central long-term challenge in setting federal fiscal policy... total federal medicare and medicaid outlays will rise from 4 percent of gdp in 2007 to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. the bulk of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of beneficiaries associated with an aging population." in other words, all other federal spending categories (such as social security, defense, education, and transportation) would require borrowing to be funded, which is not feasible. president obama stated in may 2009, "but we know that our families, our economy, and our nation itself will not succeed in the 21st century if we continue to be held down by the weight of rapidly rising health care costs and a broken health care system.... our businesses will not be able to compete; our families will not be able to save or spend; our budgets will remain unsustainable unless we get health care costs under control." healthcare rationing remained a political topic into 2017, with bernie sanders and ted cruz debating on cnn whether a single-payer system would lead to healthcare rationing.