WASHINGTON — For those who hoped that American attitudes regarding death changed so as to promote broader health care system reconstruction, news of Health Affairs, the prominent publication of health policy, are discouraging. The publication devotes its latest issue to the care of “end of life” and concludes that — at least so far — the power to make health care becomes a more compassionate and profitable practice is limited.

That was the vision. Americans would become more realistic about death. By “living wills” they refuse heroic treatments — often in vain — to keep them alive. Health costs decrease (by one estimate, a quarter of Medicare costs occur in the last year of life). People die with dignity. It would save unnecessary suffering.

Superficially, that vision seems to be triumphing, according to 17 studies in Health Affairs. According to one study, one-third of American adults — and nearly half of those 65 and older – have some kind of living will. From 1999 to 2015, the share of Americans who died in hospital fell by more than half, to 37 percent. In the same period, the number who died at home or in hospice facilities increased from less than a quarter to 38 percent. In addition, representing 8.5 percent of health expenditures, expenditures last year of life are lower in the US than in some other countries.

But with further examination, advances seem less noticeable. The portion of individuals living wills not changed in six years. Another study in Health Affairs, the increase in palliative care is not replacing expensive hospital care but adding to them. According to the study of Melisa Aldridge, Mount Sinai Hospital in New York, and Elizabeth Bradley, Vassar College:

“What emerged [is] a relatively new pattern of use of palliative care. … Enrollment in palliative care [became] an ‘aggregate’ medical care after extensive use of other health care services and a few days of death. “

Expenses last year of life, although substantial, still represent a small portion of total expenditures, which refutes the argument that the high cost of death explains why health care in America is so cotosa.

“We found that health care costs in the United States [during the last year of life] represented less than a tenth of total health care costs in the United States [8.5 percent] and therefore can not be the primary cause of the high cost of medical care in the United States compared with other countries, “was the conclusion of another study in health Affairs, headed by Eric French, of University College London.

(The fact that the effect is much greater in Medicare reflects a simple arithmetic: As Medicare represents only about one-fifth of total health spending US spending last year with a smaller base compared.)

None of this means that you can ignore the end of life. Indeed, the problems will almost certainly worsen, because much of care are provided by family and friends. Already, 29 percent of the adult population — two thirds of whom are women —  are considered caregivers.

As the population ages, loads grow. In 2010, the ratio of potential caregivers (individuals between 45 and 64 years) individuals aged 80 years was 7-to-1; 2030 is projected to be 4-to-1. Alzheimer’s cases increase. Pressures on Medicare and Medicaid spending will intensify.

It is unclear whether the persistence of expensive care reflects good medical practice, a deep human need to cling to life or both things. But the rhetoric about the “end of life” changed more than reality. To the question —  Can we die in peace and with dignity? —  the answer is “not yet”.