Executive Summary 

• Quality-adjusted Life Years (QALYs) are commonly computed as outcomes for health policy analysis and cost-effectiveness analysis to facilitate treatment and value comparisons across diseases and populations, attempting to balance treatment investment with quality of life. 
• As employed by single-payer systems to ration care, however, QALYs reduce the benefit of a medical intervention to how many years of “quality” life it delivers for the cost, and thus raise a host of ethical questions, including how “quality of life” is measured. 
• While the United States has explicitly rejected the use of QALYs, other countries regularly use them as key decision points in their health care systems; yet by reducing human experience to numbers and prioritizing population averages over individual needs, QALYs risk entrenching systemic bias, denying care, and eroding trust in public health systems. 

Introduction  

The cost, value, and efficacy of medical interventions are key components of evaluating health care outcomes across the world. In the United States, access and choice are equally important, as well. In countries that embrace single-payer health care systems, however, the cost, value, and efficacy variables are considered the more important aspects of care. This is because – with a finite budget – care must be rationed in single-payer systems (as previously documented) to balance the demand for services with limited supply. Quality-adjusted Life Years (QALY), a metric developed in the 1970s, attempts to integrate quantity of life and quality of life into a single factor. QALYs are commonly computed as outcomes for health policy analysis and cost-effectiveness analysis to facilitate treatment and value comparisons across diseases and populations.  

If desired, QALYs can then be used for decisions about the allocation of health care resources. One year in perfect health is worth 1.0 QALY. Years lived with an illness or disability are given lower values (less than one – such as 0.5 or 0.3), depending on the severity of the ailment. These scores are then used to assess the “value for money” of treatments, often through cost-per-QALY thresholds. 

Issues With QALYs 

QALYs attempt to balance treatment investment with quality of life, but they reduce the benefit of a medical intervention to how many years of “quality” life it delivers for the cost. They raise a host of ethical questions, including how “quality of life” is measured. Because of the subjectivity in this type of model, there is inherent discrimination against older people, as any intervention will necessarily deliver fewer additional “life years,” and against those with disabilities or chronic conditions, as their “quality of life” is certain to be judged lower. This means treatments that offer more QALYs per dollar spent are more likely to be covered, while those that fall below a set threshold may be rejected – even if they benefit individual patients. 

A core problem with QALYs is that they reflect population-based averages and values, not individual experiences or needs. This creates multiple challenges: 

• Discrimination Against People With Disabilities and Chronic Illnesses: Because QALYs necessarily assign lower values to health states associated with disability or chronic disease, treatments for these groups often appear less “cost-effective.” This can lead to systematic underfunding of interventions for populations that already face barriers to care. 
• Age and End-of-life Bias: Older adults may benefit less in QALY terms simply because they have fewer expected years of life remaining. As a result, life-extending treatments for seniors may be de-prioritized, raising troubling questions about age discrimination in public health policy. 
• Neglect of Non-health Benefits: QALYs focus narrowly on physical health, omitting broader social, emotional, and economic effects of illness and treatment. Interventions that improve a caregiver’s ability to work, reduce a family’s stress, or enhance community participation are often undervalued or ignored in QALY-based evaluations. 
• One-size-fits-all Measurement: Health preferences vary by culture, context, and individual experience – but QALY valuations often rely on standardized surveys or utility scores that do not reflect this diversity. The result can be an approach that oversimplifies complex medical and ethical trade-offs. 

By reducing human experience to numbers and prioritizing population averages over individual needs, QALYs risk entrenching systemic bias, denying care, and eroding trust in public health systems.  

U.S. Rejection of QALYs 

The United States has explicitly rejected the use of QALYs to ensure patients have care available to them, and that such decisions are made by a care provider and not limited by an administrative authority. Freedom to determine acceptable value and quality-of-life trade-offs of treatments is one of the crown jewels of the U.S. health care system. In the U.S. commercial market, patients have substantially faster access to new innovations than in other countries – often several years sooner. The United States leads in global access to medicines in every therapeutic area, particularly dominating in the areas of cancer, rare disease, and cardiovascular medicines. 

Federal law prohibits the establishment of a QALY threshold to limit payment for medical care by Medicare. Last February, the House passed the Protecting Health Care for All Patients Act, with lead sponsor Representative Cathy McMorris Rodgers (R-WA) saying “it’s unconscionable that a health care bureaucracy would so callously determine that someone’s life is worth less. They deserve every chance to have hope and reach their full potential.” 

Even with the United States actively discouraging the use of QALYs, other countries regularly use them as key decision points in their health care systems. Two prominent examples include the United Kingdom and Canada. 

Single-payer Countries Using QALYs 

United Kingdom 

In the United Kingdom (UK), the National Institute for Health and Clinical Excellence (NICE) – the body that ensures that the National Health Service (NHS) “uses its finite budget effectively” – generally will not pay for a medicine that exceeds £20,000 and £30,000 ($26,347–$39,521 USD) per additional QALY gained. Some advocate to further reduce this threshold to £15,000 ($19,760 USD). 

Take Kisunla, for example – an innovative drug approved by the U.S. Food and Drug Administration in July 2024 for its effectiveness in slowing the progression of Alzheimer’s in patients in the early stages of the disease. Despite its promise, NICE declined to cover Kisunla, stating that there was “not enough benefit to justify the additional cost to the NHS [and the] taxpayer.” The data showed that Kisunla would help 70,000 patients battling dementia in the UK. Similarly, NICE also rejected Leqembi for the second time, another drug aimed at treating early Alzheimer’s.   

Canada 

Similar to the UK, Canada uses QALYs to determine the drugs patients can access. The Canadian Agency for Drugs and Technologies in Health’s (CAD) arbitrary threshold of $50,000 CAD per QALY has led to a delay in access to innovative therapies and inherently discriminates against older populations as well as those battling chronic illnesses.  

A 2024 Consensus Forum of 18 leading Canadian oncologists found that all strongly agreed that, for cancer drugs, the $50,000 CAD per QALY threshold is unreasonable, unacceptable to clinicians and patients, and “out of touch with reality.” Without an increase in the threshold or a formal exception for specific conditions, “Canadian patients will continue to die due to a lack of timely access.”   

In 2024, pancreatic cancer was the third leading cause of cancer-related death in Canada. Pancreatic cancer primarily impacts men and women over the age of 50, and statistics show that the net five-year survival rate for those diagnosed with pancreatic cancer is 10 percent. Initially approved by the FDA in 2015, Onivyde is an innovative treatment that can extend a patient’s overall survival by 45 percent. Yet regulators rejected Onivyde in Canada, claiming that the drug was not “cost-effective at the submitted price.” While Onivyde received regulatory approval in Canada in 2017, the drug has still not been approved for reimbursement. 

The UK and Canada are not the only countries in the world that use QALYs. Below is a table that lists some of the countries that use QALYs and summarizes how they use them. As shown below, QALY use is both prevalent and varied.