There are now 125 million people aged 80 years and over worldwide, projected by the United Nations to grow threefold by 2050. While increases in life expectancy and rapid increases in the older-age population are considered positive developments, the consequential future health care burden represents a leading concern for health services. We revisit Williams’ ‘fair innings’ argument from 1997, in light of technological and demographic changes, and challenge the notion that greater longevity may impose an unfair burden on younger generations. We discuss perspectives on the equity-efficiency trade-off in terms of their implications for the growing over-80 population, as well as society in general. This includes questioning the comparison of treatment cost-effectiveness in younger vs. older populations when using quality-adjusted life years and the transience of life expectancies over generations. While recognising that there will never be a clear consensus regarding societal value judgements, we present empirical evidence on the very elderly that lends support to a stronger anti-ageist stance given current increases in longevity.