Cite this article as: C K Cassel, M A Rudberg and S J Olshansky The price of success: health care in an aging society Health Affairs 11, no.2 (1992):87-99 doi: 10.1377/hlthaff.11.2.87
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At the Intersection of Health, Health Care and Policy
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by Christine K. Cassel, Mark A. Rudberg, and S. Jay Olshansky Prologue: Americans are growing older, in part us a consequence of dramatic advances in the treatment of acute and chronic illness. Paradoxically, these achievements are making the task of providing health care to every citizen more formidable. Not only does death occur later in life, but the causes of death have shifted dramatically over the course of the twentieth century. While impressive gains have been made in postponing deaths from heart disease, cancer, and stroke, us Christine Cassel and her colleagues point out in this paper, fur less progress is evident-in preventing, postponing, and treating the nonfatal diseases of old age. Much more emphasis should be placed on controlling disability and chronic disease and providing effective long-term care. Cassel, a member of the Institute of Medicine, National Academy of Sciences, and her colleagues have sought to develop more effective approaches to forecasting future health care needs by combining what they characterize as medical demography with biological factors. Cassel holds a medical degree from the University of Massachusetts. She trained in internal medicine at the University of California, San Francisco, and has completed fellowships in bioethics and geriatrics. Cassel chairs the Section of General Internal Medicine at the University of Chicago and is director of the Center for Health Policy at the university’s Harris School of Public Policy Studies. During 1991-1992, she was a Henry J. Kaiser Family Foundation Fellow at the Center for Advanced Study in the Behavioral Sciences in Stanford, California. Mark Rudberg trained in medicine at the Medical College of Wisconsin and holds a master’s degree in public health from Boston University. Jay Olshansky has a doctorate in sociology from the University of Chicago and is a scientist at Argonne National Laboratories. He is on the faculty of medicine at the University of Chicago.
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THE PRICE OF SUCCESS: HEALTH CARE IN AN AGING SOCIETY
88 HE ALTH AFF AIRS | Su mmer 1992
D
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uring the past several decades, life expectancy has made unprecedented gains in our society, as well as in other developed nations. This is a curious, two-sided, almost Faustian phenomenon. The aging of our society and the progressive increase in life expectancy are marks of a successful civilization. Yet, from the perspective of public health care policy, these “successes” are awesome burdens that threaten the well-being of the very society that brought them forth. To forecast health care needs in the coming two decades, and to understand the effects of societal aging on those forecasts, we must look carefully at both aspects of this persistent paradox– success and its price. Life expectancy is defined as the average expected years of life remaining for an individual at a certain age-for example, at birth or at age sixty-five-and is based on observed death rates for a population in any given year. Since the turn of the century, life expectancy in the United States has increased by twenty-eight years. Today, life expectancy for 1 women is 78.5 years and for men, 71.8 years. Until the 1960s, most of the increase in life expectancy was the result of improved social conditions-specifically, sanitation, hygiene, nutrition, and working conditions. Deaths from infectious diseases declined steadily from 1900 on2 ward, even though antibiotics were not introduced until 1945. The impressive decline in mortality that occurred from 1900 to the mid-1960s appeared to plateau from 1965 to around 1968. Policymakers assumed that the genetically endowed limit to life expectancy (at birth) had reached its peak at around seventy years. But mortality began unexpectedly to decline again. This trend alarmed the Social Security and Medicare agencies, because these declines occurred most dramatically for the population age sixty-five and older. For example, from 1960 to 1988, life expectancy for American women increased by 17.7 percent at age sixty-five, 33.8 percent at age eighty-five, but only 6.9 percent at birth. This is the opposite of what happened earlier in the century, when gains in life expectancy for children and young adults exceeded those for 3 older people. Since 1968, old-age mortality has declined steadily; this likely will continue into the next century. Not only does death occur later in life, but the causes of death have shifted dramatically. In the first half of the twentieth century, deaths were caused primarily by infectious and parasitic diseases. By the late 1960s, the major causes of death were heart disease, cancer, and stroke (which together accounted for 75 percent of all deaths). Even though life expectancy is increasing, the major causes of death remain largely the same today. We have not succeeded in preventing the major killers, especially heart disease and stroke, but we have succeeded in postponing the time of life at which these diseases kill. Because of competing causes
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Life Expectancy And Numbers Of Elderly Americans Some scientists believe that the basic biological aspects of aging can be changed and, therefore, that life expectancy can increase. These changes may occur, for example, through manipulating the environ6 ment, changing nutritional status, or manipulating “aging” genes. However, they are theoretical and have not yet been demonstrated to be of value in prolonging human life. Another way to predict maximum achievable life expectancy is to analyze present epidemiologic and demographic data. Scientists who use this approach believe there is a biologic limit to life expectancy but differ on how best to determine it and, indeed, on what exactly is the correct measure. Some demographers, urging caution because of mistakes that have been made in past forecasts, believe that it is possible through risk-factor modification to achieve an average life expectancy of 7 over ninety-five years. However, estimates that use assumptions about the practical lower limits of mortality rates indicate that average life 8 expectancy at birth is not likely to exceed eighty-five years.
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of death, declines in heart disease mortality are related to an increase in cancer deaths. As a result, elimination of all coronary heart disease 4 deaths would only add about three years to life expectancy at birth. Present declines in old-age mortality have contributed to accelerated population aging and improved survival. Among babies born fifty years ago, only 30 percent would have survived to their sixty-fifth birthday, while almost 80 percent of babies born today will live past their sixtyfifth birthday. In fact, for every year of increased life expectancy for American women, the proportion of the population of women that will survive to age eighty-five increases an average 2.5 percent, a truly 5 remarkable increase. If the size of the aging population is combined with the lower fertility rates characteristic of developed countries, the “population pyramid” becomes more of a “population rectangle,” with roughly equal numbers of survivors in each age stratum until age seventy-five. This reshaping of the age composition leads to concern about a shrinking work force supporting a growing retired population. As a result of past and continuing declines in old-age mortality, several fundamental questions are before us. First, how much more will life expectancy increase? Is there a biological limit to the life span? Second, what is the relationship between increased life expectancy and health status? To what degree is increasing life expectancy, particularly in recent decades, associated with more years of disability? And finally, what kinds of health care needs will dominate for future elderly cohorts?
90 HE ALTH AF FAIRS | Su mmer 1992
Morbidity, Disability, And Mortality Most people are less interested in the number of years of life lived in old age than in the quality and healthfulness of those years. Gains in life expectancy have resulted from our ability to postpone deaths from heart disease, cancer, and stroke. But we have made far less progress in preventing, postponing, and treating the nonfatal, disabling diseases of old age. These are predominantly chronic musculoskeletal diseases such as osteoarthritis and osteoporosis, degenerative neurological diseases such as Alzheimer’s and Parkinson’s diseases, and sensory impairments such as hearing loss and blindness. Data are now inadequate to precisely describe the relationship between morbidity, disability, and mortality. But there is no evidence to indicate that the onset of nonfatal, disabling diseases occurs later in life. Also, there is no evidence that the causes of declining death rates from fatal diseases have any beneficial effect on many of the nonfatal diseases of aging. Until more progress is made in understanding the causes and potential prevention of the disabilities of old age, increasing longevity will bring greater years of disability. Morbidity. One measure of the healthfulness of the older population is to determine the diseases and conditions that affect the population.
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Even if the present trend of increasing life expectancy stops at about age eighty-five, our society will include markedly increased numbers of older people. With an average life expectancy of seventy-five years, as we have now, half of the population will survive past age seventy-eight. As with any statistical average, the variance around that average is equally important. It appears that if average life expectancy is eighty-five years, the number of persons over age eighty-five will inevitably increase from the present three million to between seven and eight million by the year 2010; and for those over age 100, the numbers will increase from 9 30,000 to 200,000-more than a sixfold increase. From a policy perspective, projections of the number of older individuals in a given age group are much more informative than is average life expectancy. Studies have demonstrated that life expectancy is not a sensitive metric in an aging society, because small changes in life expectancy can result in large increases in the number of people who survive 10 past age seventy-five or even eighty-five. Implications for chronic care services, housing, transportation, and other needs can best be estimated based on numbers of people in various age strata (sixty-five to seventyfour, seventy-five to eighty-four, or eighty-five and older), because research on disability generally uses these age categories, and because disability is a more sensitive indicator of service need than is diagnosis.
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Exhibit 1 Leading Self-Reported Chronic Conditions For Noninstitutionalized Adults, 1990 Age 75 and older
Age 65-74 Condition
Men
Women
Men
Women
Arthritis Hypertension Hearing impairment
337.1 (1) 317.6 (2)
517.6 (1) 437.0 (2) 183.8 (4)
496.7 (1) 294.7 (4) 402.1 (2)
588.5 (1) 423.1 (2) 335.8 (4)
Heart disease Chronic sinusitis Deformity”
259.7 (4) 150.9 (5) 139.9 (6)
209.0 (3) 152.4 (5) 142.5 (6)
371.0 (3) 99.1 (9) 130.5 (6)
342.5 (3) 189.1 (7) 204.4 (6)
Tinnitus Cataracts Visual impairment
84.8 (7) 76.0 (8) 74.9 (9)
135.4 (7)
182.7 (5) 124.8 (7)
264.5 (5) -
Diabetes Varicose veins Hemorrhoids
74.0 (10)
Diseases of the prostate Frequent constipation Emphysema
-
102.5 (8) 89.3 (9) 78.1 (10)
92.6 (10) 107.8 (9)
99.3 (8) 80.6
(10)
114.6 (8) -
Source: P.F. Adams and V. Benson, “Current Estimates from the National Health Interview Survey, 1989,” Vital and Health Statistics 10, no. 176 (National Center for Health Statistics, 1990). Note: Races per thousand civilian noninstitutionalized population. Rankings for each age/ sex category are in parentheses. a Deformity or orthopedic impairment; permanent stiffness so that the affected joint does not move.
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This information, however, is difficult to obtain because of the inadequacy of existing population-based morbidity data. The largest database for which ongoing samples of the U.S. population are obtained is the National Health and Nutrition Examination Survey (NHANES), but, until very recently, this survey has included almost no elderly people. Even now, this survey contains relatively small numbers of older people and none of the very disabled and institutionalized population. The current National Health Interview Survey (NHIS) includes a larger number of elderly people and asks more questions about functional status, but it also relies on self-reported medical conditions. Changes in this questionnaire throughout its history have caused some discontinuities. Two new surveys– the Longitudinal Study on Aging and the National Long-Term Care Survey–should add considerably to the understanding of many of these factors in the oldest old. However, both of these surveys do not yet provide the kind of longitudinal data needed to answer the fundamental questions of changing health status. Exhibit 1 lists the conditions most commonly affecting older persons, as obtained in a nationally representative sample of communitydwelling persons. These data show that among older individuals, these potentially disabling diseases of aging have prevalence rates as high as 50
92 HE ALTH AFF AIRS | Su mmer 1992
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percent (for arthritis) and that prevalence increases rapidly with age. Many of these disorders are not usually considered fatal; persons often live with these conditions and die from another cause. Dementia, confusion, and depression are not present on this list, although they affect older persons. The NHIS was not designed to capture these conditions and does not include institutionalized persons, among whom disabling conditions are more prevalent. This suggests that these numbers underestimate overall chronic illness in the population over age sixty-five. Two additional points warrant mention. First, evidence shows that 11 morbidity has also increased for diseases that are ultimately fatal. Persons who now suffer from heart disease, cancer, and stroke may not die rapidly from these diseases but may live on with a related infirmity for several years. In effect, the successful treatment of fatal diseases has transformed them into chronic diseases. Second, the aggregate burden of these conditions is often more than the data in Exhibit 1 imply. For many older persons, multiple disabling conditions are the rule, and their 12 effects combine to increase disability. These chronic disabling conditions have major social implications. For example, hip fractures currently cost $1.6 billion and immeasurable pain and suffering at the level of 250,000 cases per year in the United 13 States. Twenty percent of people who fracture a hip do not survive another year, and another 20 percent are never able to walk again without assistance. Furthermore, 50 percent of hip fracture patients are discharged from the hospital to a nursing home. A conservative projection of hip fractures in the year 2010 is 350,000 at a cost of $2.5 billion 14 (in 1987 dollars) for acute care alone. Dementia, caused primarily by Alzheimer’s disease and by strokes, is another age-associated disorder that in itself is not fatal but that causes severe dependency and disability. Hard data on dementia are difficult to find. Jacob Brody found that the prevalence rate for dementia increases from 2.8 percent at ages sixty-five to seventy-four to 9 percent at ages seventy-five to eighty-four, and to 28 percent at age eighty-five and 15 older. However, the Established Population for Epidemiologic Studies of the Elderly for East Boston shows a rate of 47 percent over age 16 eighty-five for those who have Alzheimer’s disease. Current costs for care of patients with moderate to severe dementia are estimated to be $35.8 billion per year, including long-term care expenses. Conservative projections of five million cases of dementia in 2010 would result in 17 annual costs of at least $80 billion (in 1985 dollars). In the future, without major scientific breakthroughs, these chronic conditions as well as the others listed in Exhibit 1 will continue to occur at the same high age-specific rates.18 If the present prevalence rates of
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Exhibit 2 Prevalence Rates Of Three Common Chronic Conditions Among The Elderly, By Sex And Age, 1990 And 2010
Source: A.W. Wade, “United States Population Projections for OASDI Cost Estimates, 1989,” Actuarial Study 105 (U.S. Social Security Administration, Office of the Actuary, 1989); and J.E. Fitti and M.G. Kovar, “The Supplement on Aging to the 1984 National Health Interview Survey,” Vital and Health Statistics 1, no. 21, DHHS Pub. no. PHS 87–1323 (1987).
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these common conditions and the projections of the Health Care Financing Administration (HCFA) Office of the Actuary for the numbers of elderly in the year 2010 are applied, the prevalence rates of these conditions increase dramatically (Exhibit 2). The challenges for research are to understand the etiology and to prevent or delay the onset of these chronic disabling conditions. More immediately, we must develop devices, medications, and environments to allow optimal quality of life for the millions of elderly people who are thus afflicted. Disability. Although data are available on diseases affecting older persons, functional abilities are a better predictor of medical and service needs, from a health and social service perspective. Information on functional abilities is only beginning to be systematically collected. Analysis of data from the Longitudinal Study on Aging, a nationally representative study of the noninstitutionalized older population, reveals many important points about functioning (Exhibit 3). First, despite the fact that some people remain independent throughout life, rates of dependence increase rapidly with age. For example, while 22.6 percent of the population ages sixty-five to seventy-four experience difficulty with activities of daily living (ADLs), this increases to 44.5 percent at age eighty-five and older. Second, activities such as shopping, paying bills, and cleaning house are more difficult to do than basic self-care activities. When one applies rates of disability from the Longitudinal Study on Aging to the projected size of the future population,
94 HE ALTH AFF AIRS | Su mmer 1992 Exhibit 3 Number Of Elderly Persons With Difficulty In Activities Of Daily Living, By Age Group, 1990 And 2010
one sees a marked increase in the number of disabled individuals in the United States in the coming decades-measured in millions-who will need medical and social services.19 Assuming there are no changes in the age-specific risk of disability, the number of people age sixty-five and older experiencing difficulty with ADLs will therefore increase from 8.7 million in 1990 to 11.5 million in 2010-a 30.7 percent increase in just twenty years. This will result in higher medical spending. According to a recent Institute of Medicine (IOM) report, medical spending per capita for those limited in activity because of two or more chronic 20 conditions is five times that of persons not limited in activity. The disabilities of older persons are not static, and functional status 21 can change as often as daily. Although it is not possible to generalize from such descriptions to national statistics, these kinds of data show that individual variations are important in planning for residential and supportive care. One study found that in certain subpopulations nationwide, up to 18 percent of disabled persons were less disabled two years 22 later. However, the likelihood of returning from disability to functional ability decreases with age. In health policy and planning, restorative and rehabilitative care will be as important as custodial and palliative care. Active life expectancy. To study changes in disability, it is helpful to partition life expectancy into independent and dependent periods. This
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Source: A.W. Wade, “United States Population Projections for OASDI Cost Estimates. 1989.” Actuarial Study 105 (U.S. Social Security Administration, Office of the Actuary, 1989); and J.E. Fitti and M.G. Kovar, “The Supplement on Aging to the 1984 National Health Interview Survey,” Vital and Health Statistics 1, no. 21, DHHS Pub. no. PHS 87–1323 (1987). Note: ADL is activities of daily living. IADL is instrumental activities of daily living.
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Medical Technology Now And In The Future In the past, we have often viewed progress in health care as scientific and technical advances that could save lives. There have also been what Lewis Thomas has presciently referred to as “halfway technologies.” While these did not care or prevent disability, they did keep people alive, although at great cost–both human and financial. One example of a halfway technology is the iron lung for people with polio, now mercifully obsolete because of the dramatic effect of the polio vaccine. A current example of halfway technology is renal dialysis, which helps people survive, albeit with significant dependency. Many life–sustaining technologies– organ transplantation, cardiac revascularization, cancer surgery, and combination chemotherapy and radiation therapy-have shown success in extending life, although all are costly. The use of new life-sustaining medical technologies in the very old has become a highly controversial issue among medical policymakers and ethicists. Some have proposed an arbitrary, age-based limit to use of life-extending medical technology, based on the idea that the person has already had a chance to lead a good and full life, and, as data have
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concept has led to research to predict active life expectancy– that portion of life expectancy during which one will not be disabled and will not need help with activities necessary for independent living. An assessment of present and future trends in active life expectancy requires assumptions about life expectancy trends overall and trends for the burden of chronic diseases and disability-most importantly, time of onset of chronic illness and degree of disability that it causes. Active life expectancy measures differ from health status measures in that independence, or active life, can occur even in the presence of some chronic diseases. Indeed, treatments aimed at improving functioning become increasingly important as age progresses. If length of life continues to increase and yet the onset of disabling diseases such as osteoarthritis or Alzheimer’s disease is the same as in previous decades, the population inevitably will experience longer durations of disability. Some experts suggest that 80 percent (9.6 months) of each twelve 23 months of increased life expectancy is spent in a state of disability. Also, as people advance in age, the percentage of remaining life that can be expected to be active and independent decreases. In general, other studies in which active and disabled life expectancy is measured by 24 various methods show that disability in the population is increasing. Thus, with inevitable increases in the population age eighty-five and older, there will be a dramatic increase in the need for long-term care.
96 HE ALTH AFF AIRS | Su mmer 1992
Health Policy Implications Community-based care. Most of those who support the idea of agebased rationing are not against any and all treatment for older persons. On the contrary, they argue for more resources for long-term care, where the goal is comfort rather than life extension. Health care utilization data support the importance of this emphasis. There are currently an estimated 1.5 million nursing home beds in the United States at any given time and somewhat fewer than a million hospital beds. Today, many hospital beds are going empty, and many hospitals are closing. Two major reasons for this decline in acute care capacity are inadequate funding for the poor and uninsured, and the move to community-based care. Many disorders that previously required inpatient care can now be handled on an outpatient basis. This phenomenon suggests that the hospital will become a center for intensive care and major surgery. Meanwhile, the need for community-based care for people of all ages 27 with chronic illness will increase. The number of people who will need nursing homes over the next thirty years has been predicted to rise to 28 between three and five million. In addition, roughly two to three times as many people of equal levels of disability will be cared for at home with 29 some combination of formal and informal services. This represents, then, as many as fifteen million individuals who will require long-term care for chronic and progressive disabilities in the year 2010. High technology versus supportive care. Further research is needed into the impact of increased life expectancy on morbidity in the elderly. However, there is no doubt from a clinical standpoint that many nonfatal diseases of old age will not disappear quickly, if at all, given how little we currently know about their pathogenesis, prevention, amelioration, or treatment. A major challenge for the United States is deciding how to handle the growing prevalence of chronic illness. Health insurance, both public and private, covers expensive life-sustaining technology, even for patients who are permanently unconscious, while ignoring the more labor-intensive, supportive care that could keep a fairly functional ninety-year-old out of a nursing home. In the coming decade, budget constraints may finally force us to confront this paradox.
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shown, chances of an extended survival with declining functioning are high.25 Others argue that given the tremendous diversity of health status among older people, we must make these decisions on an individual 26 basis to avoid discrimination against one segment of the population. While these moral arguments against age-based rationing are strong, they point to difficult decisions ahead for U.S. policymakers.
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We emphasize here that many millions of older people will live independent and active lives well into advanced age. We also emphasize that many elderly people who live with chronic illnesses still find life worth living and can contribute to society. There is also, however, a third group for whom brain disease has eradicated the ability to participate in life or for whom physical disabilities have become so onerous that life no longer seems worthwhile. The policy debate rages about their right to die and about the ethical standards that should guide the use of life-supporting treatment, including even food and water, for the most severely disabled patients. This debate will have an enormous impact on the life expectancy of the most extremely dependent in our society and increasingly for those who reside in nursing homes. Quality of life. Another major question is how health policy can be focused to improve quality of life. There is enormous need for research and development in this area: basic research on the cau ses of osteoarthritis, Alzheimer’s disease, and other degenerative age-related diseases; and research on which strategies and health services organizations can most effectively provide long-term care. Long-term care financing. Finally, we must confront the financing of long-term care. This is more than a matter of economics; it also involves our society’s culture and values. Almost all other developed countries have confronted these needs more effectively and directly than the United States has. Two examples illustrate the range of policy choices. In Sweden, it is the norm that a frail elderly person will move to one of a large network of high-quality long-term care institutions, which are financed through the government and supported by taxation- A majority of Swedish women are in the work force and contribute taxes that support this long-term care network. At the other extreme is Japan, which has recently overtaken Sweden in worldwide life expectancy comparisons. Japan has a long tradition of caring for elderly people at home. There are few nursing homes, although that number is beginning to grow, and much long-term care is delivered in Japanese hospitals. It is still not the social norm for Japanese women to work outside the home; thus, a built-in caregiver is at home for elderly persons in need. Clearly, circumstances in the United States are different from those of Japan and Sweden, both culturally and economically. Nonetheless, our society still must face the task of caring for its elderly citizens. The answer to long-term care financing in this country must, in some way, be consistent with our diverse yet uniquely American values. Policy priorities. Several policy priorities emerge from our review of the changing health care needs of an aging society. First, we need access to better-quality institutional care and better funding for home care of
98 HE ALTH AFF AIRS | Su mmer 1992
We thank Jeff Goldsmith, Dorothy Rice, and Jacob Brody for their helpful suggestions, and Sylvia Furner for her assistance in obtaining the Longitudinal Study on Aging data. This work was supported by The Pew Charitable Trusts (Health of the Public Project) and National Institute on Aging (NIA) Grant no. K07 AG06188-02. NOTES 1. National Center for Health Statistics, Health, United States, 1990 (Washington, D.C.: NCHS, 1990) 67. 2. J.B. McKinlay and S.M. McKinlay, “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century,” Milbank Memorial Fund Quarterly 55, no. 3 (1977): 405–428. 3. L.M. Verbrugge, “Recent, Present, and Future Health of American Adults,” Annual Review of Public Health 10 (1989): 333–361. 4. J. Tsevat et al., “Expected Gains in Life Expectancy from Various Coronary Heart Disease Risk Factor Modification,” Circulation (April 1991): 1194–1201. 5. S.J. Olshansky et al., “Trading Off Longer Life for Worsening Health: The Expansion of Morbidity Hypothesis," Journal of Aging and Health (May 1991): 194–216. 6. S.K. Nishimoto, S.M. Padilla, and D.L. Snyder, “The Effect of Food Restriction and Germ-Free Environment on Age-related Changes in Bone Matrix," Journal of Gerontology 45 (1990): B164–168; D.K. Ingram et al., “Dietary Restriction and Aging: The Initiation of a Primate Study,” Journal of Gerontology 45 (1990): B148–163; S. Goldstein, “Replicative Senescence: The Human Fibroblast Comes of Age,” Science (September 1990): 1129–1133; and R.A. Lockshin and Z.F. Zakeri, “Programmed Cell Death: New Thoughts and Relevance to Aging,” Journal of Gerontology 45 (1990): B135–140. 7. K. Manton, E. Stallard, and H. Tolley, “Limits to Human Life Expectancy: Evidence,
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severely disabled persons. The major barrier to both of these is not lack of knowledge or skill, but inadequate financing mechanisms. In addition, we must develop effective and efficient care for the less severely disabled. With millions of people expected to live many years of life with chronic conditions, new residential arrangements that maximize independence will be required. To enhance a vital aging society, flexible and creative approaches to housing, work, transportation, and education are needed. Changes are also needed in the way health care providers are trained. Since many of the health problems of the elderly require “hightouch,” not “high-tech” care, health professions training and reimbursement policies should encourage the use of nurses, nurse aides, rehabilitation therapists, and social workers as well as physicians. Finally, the study of amelioration and prevention of the nonfatal diseases of aging should become a major medical research priority. These challenges to our health care system are diverse. That we face them at all is the price of our success at surviving. We need not look ahead to 2010, however, to know the importance and difficulty of these challenges, because they are upon us today.
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8. 9. 10. 11. 12. 13.
14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
25. 26. 27. 28.
29.
Prospects, and Implications,” Population and Development Review (December 1991): 603–637. S.J. Olshansky, B.A. Cames, and C.K. Cassel, “In Search of Methuselah: Estimating the Upper Limits to Human Longevity,” Science 250 (1990): 634–640. U.S. Bureau of the Census, The Centenarians (Washington, D.C., 1988). Olshansky et al., “In Search of Methuselah;” and N. Keyfitz, “What Difference Would It Make If Cancer Were Eliminated? An Examination of the Taeuber Paradox,” Demography 14, no. 4 (1977): 411–418. Verbrugge, “Recent, Present, and Future Health of American Adults.” J.M. Guralnik, Aging in the Eighties: The Prevalence of Comorbidity and Its Association with Disability, Advance Data from Vital and Health Statistics (26 May 1989). S.E. Kellie and J.A. Brody, “Sex-Specific and Race-Specific Hip Fracture Rates,” American Journal of Public Health (March 1990): 326–328; and E.L. Schneider and J.M. Guralnik, “The Aging of America: Impact on Health Care Costs,” Journal of the American Medical Association (2 May 1990): 235–240. Schneider and Guralnik, “The Aging of America.” J.A. Brody, “Prospects for an Aging Society,” Nature (June 1985): 463–466. D.A. Evans et al., “Prevalence of Alzheimer’s Disease in a Community Population of Older Persons,” Journal of the American Medical Association (10 November 1989): 2551–2556. Schneider and Guralnik, “The Aging of America.” M.A. Rudberg and C.K. Cassel, “Prevention of the Common Conditions of Old Age: Implications for Active Life Expectancy” (unpublished). Data were generated by the HCFA Office of the Actuary. A.M. Pope and A.R. Tarlov, eds., Disability in America: Toward a National Agenda for Prevention of Disabilities (Washington, D.C.: National Academy Press, 1991), 67-73. L.M. Verbrugge and D.J. Balaban, “Patterns of Change in Disability and Well-Being,” Medical Care (March 1989): S128–S147. K.G. Manton, “A Longitudinal Study of Functional Change and Mortality in the United States,” Journal of Gerontology 13 (1988): S153–161. S. Katz et al., “Active Life Expectancy,” The New England Journal of Medicine (17 November 1983): 1218–1224. AC. Bebbington, “The Expectation of Life without Disability in England and Wales,” Social Science and Medicine 26 (1988): 321–326; A. Colvet and M. Blanchet, “Disability Trends in the United States Population, 1966-76: Analysis of Reported Causes,” American journal of Public Health 71 (1981): 464–471; A. Colvez and M. Blanchet, “Potential Gains in Life Expectancy Free of Disability: A Tool for Health Planning,” International Journal of Epidemiolog? 2 (1983): 224–229; Verbrugge, “Recent, Present, and Future Health of American Adults;” and R. Wilkins and O.B. Adams, “Health Expectancy in Canada, Late 1970s: Demographic Regional and Social Dimensions,” American Journal of Public Health 73 (1983): 1073–1080. D. Callahan, Setting Limits (Briarcliff Manor, N.Y.: The Hastings Center, 1988). C.K. Cassel and B. Neugarten, “The Goals of Medicine in an Aging Society,” in Too Old for Health Care?, ed. R. Binstock and S. Post (Baltimore: The Johns Hopkins University Press, 1991). Schneider and Guralnik, “The Aging of America.” K.G. Manton and K. Liu, “The Future Growth of the Long-Term Care Population” (Projection based on the 1977 National Nursing Home Survey and the 1982 LongTerm Care Survey, as cited in Senate Special Committee on Aging, Developments in Aging, 1984, 188). R.M. Ball, “Public-Private Solution to Protection against the Cost of Long-Term Care,” Journal of the American Geriatrics Society 38 (1990): 156–163.
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At the Intersection of Health, Health Care and Policy
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by Christine K. Cassel, Mark A. Rudberg, and S. Jay Olshansky Prologue: Americans are growing older, in part us a consequence of dramatic advances in the treatment of acute and chronic illness. Paradoxically, these achievements are making the task of providing health care to every citizen more formidable. Not only does death occur later in life, but the causes of death have shifted dramatically over the course of the twentieth century. While impressive gains have been made in postponing deaths from heart disease, cancer, and stroke, us Christine Cassel and her colleagues point out in this paper, fur less progress is evident-in preventing, postponing, and treating the nonfatal diseases of old age. Much more emphasis should be placed on controlling disability and chronic disease and providing effective long-term care. Cassel, a member of the Institute of Medicine, National Academy of Sciences, and her colleagues have sought to develop more effective approaches to forecasting future health care needs by combining what they characterize as medical demography with biological factors. Cassel holds a medical degree from the University of Massachusetts. She trained in internal medicine at the University of California, San Francisco, and has completed fellowships in bioethics and geriatrics. Cassel chairs the Section of General Internal Medicine at the University of Chicago and is director of the Center for Health Policy at the university’s Harris School of Public Policy Studies. During 1991-1992, she was a Henry J. Kaiser Family Foundation Fellow at the Center for Advanced Study in the Behavioral Sciences in Stanford, California. Mark Rudberg trained in medicine at the Medical College of Wisconsin and holds a master’s degree in public health from Boston University. Jay Olshansky has a doctorate in sociology from the University of Chicago and is a scientist at Argonne National Laboratories. He is on the faculty of medicine at the University of Chicago.
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THE PRICE OF SUCCESS: HEALTH CARE IN AN AGING SOCIETY
88 HE ALTH AFF AIRS | Su mmer 1992
D
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uring the past several decades, life expectancy has made unprecedented gains in our society, as well as in other developed nations. This is a curious, two-sided, almost Faustian phenomenon. The aging of our society and the progressive increase in life expectancy are marks of a successful civilization. Yet, from the perspective of public health care policy, these “successes” are awesome burdens that threaten the well-being of the very society that brought them forth. To forecast health care needs in the coming two decades, and to understand the effects of societal aging on those forecasts, we must look carefully at both aspects of this persistent paradox– success and its price. Life expectancy is defined as the average expected years of life remaining for an individual at a certain age-for example, at birth or at age sixty-five-and is based on observed death rates for a population in any given year. Since the turn of the century, life expectancy in the United States has increased by twenty-eight years. Today, life expectancy for 1 women is 78.5 years and for men, 71.8 years. Until the 1960s, most of the increase in life expectancy was the result of improved social conditions-specifically, sanitation, hygiene, nutrition, and working conditions. Deaths from infectious diseases declined steadily from 1900 on2 ward, even though antibiotics were not introduced until 1945. The impressive decline in mortality that occurred from 1900 to the mid-1960s appeared to plateau from 1965 to around 1968. Policymakers assumed that the genetically endowed limit to life expectancy (at birth) had reached its peak at around seventy years. But mortality began unexpectedly to decline again. This trend alarmed the Social Security and Medicare agencies, because these declines occurred most dramatically for the population age sixty-five and older. For example, from 1960 to 1988, life expectancy for American women increased by 17.7 percent at age sixty-five, 33.8 percent at age eighty-five, but only 6.9 percent at birth. This is the opposite of what happened earlier in the century, when gains in life expectancy for children and young adults exceeded those for 3 older people. Since 1968, old-age mortality has declined steadily; this likely will continue into the next century. Not only does death occur later in life, but the causes of death have shifted dramatically. In the first half of the twentieth century, deaths were caused primarily by infectious and parasitic diseases. By the late 1960s, the major causes of death were heart disease, cancer, and stroke (which together accounted for 75 percent of all deaths). Even though life expectancy is increasing, the major causes of death remain largely the same today. We have not succeeded in preventing the major killers, especially heart disease and stroke, but we have succeeded in postponing the time of life at which these diseases kill. Because of competing causes
AGING SO CIE TY 89
Life Expectancy And Numbers Of Elderly Americans Some scientists believe that the basic biological aspects of aging can be changed and, therefore, that life expectancy can increase. These changes may occur, for example, through manipulating the environ6 ment, changing nutritional status, or manipulating “aging” genes. However, they are theoretical and have not yet been demonstrated to be of value in prolonging human life. Another way to predict maximum achievable life expectancy is to analyze present epidemiologic and demographic data. Scientists who use this approach believe there is a biologic limit to life expectancy but differ on how best to determine it and, indeed, on what exactly is the correct measure. Some demographers, urging caution because of mistakes that have been made in past forecasts, believe that it is possible through risk-factor modification to achieve an average life expectancy of 7 over ninety-five years. However, estimates that use assumptions about the practical lower limits of mortality rates indicate that average life 8 expectancy at birth is not likely to exceed eighty-five years.
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of death, declines in heart disease mortality are related to an increase in cancer deaths. As a result, elimination of all coronary heart disease 4 deaths would only add about three years to life expectancy at birth. Present declines in old-age mortality have contributed to accelerated population aging and improved survival. Among babies born fifty years ago, only 30 percent would have survived to their sixty-fifth birthday, while almost 80 percent of babies born today will live past their sixtyfifth birthday. In fact, for every year of increased life expectancy for American women, the proportion of the population of women that will survive to age eighty-five increases an average 2.5 percent, a truly 5 remarkable increase. If the size of the aging population is combined with the lower fertility rates characteristic of developed countries, the “population pyramid” becomes more of a “population rectangle,” with roughly equal numbers of survivors in each age stratum until age seventy-five. This reshaping of the age composition leads to concern about a shrinking work force supporting a growing retired population. As a result of past and continuing declines in old-age mortality, several fundamental questions are before us. First, how much more will life expectancy increase? Is there a biological limit to the life span? Second, what is the relationship between increased life expectancy and health status? To what degree is increasing life expectancy, particularly in recent decades, associated with more years of disability? And finally, what kinds of health care needs will dominate for future elderly cohorts?
90 HE ALTH AF FAIRS | Su mmer 1992
Morbidity, Disability, And Mortality Most people are less interested in the number of years of life lived in old age than in the quality and healthfulness of those years. Gains in life expectancy have resulted from our ability to postpone deaths from heart disease, cancer, and stroke. But we have made far less progress in preventing, postponing, and treating the nonfatal, disabling diseases of old age. These are predominantly chronic musculoskeletal diseases such as osteoarthritis and osteoporosis, degenerative neurological diseases such as Alzheimer’s and Parkinson’s diseases, and sensory impairments such as hearing loss and blindness. Data are now inadequate to precisely describe the relationship between morbidity, disability, and mortality. But there is no evidence to indicate that the onset of nonfatal, disabling diseases occurs later in life. Also, there is no evidence that the causes of declining death rates from fatal diseases have any beneficial effect on many of the nonfatal diseases of aging. Until more progress is made in understanding the causes and potential prevention of the disabilities of old age, increasing longevity will bring greater years of disability. Morbidity. One measure of the healthfulness of the older population is to determine the diseases and conditions that affect the population.
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Even if the present trend of increasing life expectancy stops at about age eighty-five, our society will include markedly increased numbers of older people. With an average life expectancy of seventy-five years, as we have now, half of the population will survive past age seventy-eight. As with any statistical average, the variance around that average is equally important. It appears that if average life expectancy is eighty-five years, the number of persons over age eighty-five will inevitably increase from the present three million to between seven and eight million by the year 2010; and for those over age 100, the numbers will increase from 9 30,000 to 200,000-more than a sixfold increase. From a policy perspective, projections of the number of older individuals in a given age group are much more informative than is average life expectancy. Studies have demonstrated that life expectancy is not a sensitive metric in an aging society, because small changes in life expectancy can result in large increases in the number of people who survive 10 past age seventy-five or even eighty-five. Implications for chronic care services, housing, transportation, and other needs can best be estimated based on numbers of people in various age strata (sixty-five to seventyfour, seventy-five to eighty-four, or eighty-five and older), because research on disability generally uses these age categories, and because disability is a more sensitive indicator of service need than is diagnosis.
AGING SOCIETY 91
Exhibit 1 Leading Self-Reported Chronic Conditions For Noninstitutionalized Adults, 1990 Age 75 and older
Age 65-74 Condition
Men
Women
Men
Women
Arthritis Hypertension Hearing impairment
337.1 (1) 317.6 (2)
517.6 (1) 437.0 (2) 183.8 (4)
496.7 (1) 294.7 (4) 402.1 (2)
588.5 (1) 423.1 (2) 335.8 (4)
Heart disease Chronic sinusitis Deformity”
259.7 (4) 150.9 (5) 139.9 (6)
209.0 (3) 152.4 (5) 142.5 (6)
371.0 (3) 99.1 (9) 130.5 (6)
342.5 (3) 189.1 (7) 204.4 (6)
Tinnitus Cataracts Visual impairment
84.8 (7) 76.0 (8) 74.9 (9)
135.4 (7)
182.7 (5) 124.8 (7)
264.5 (5) -
Diabetes Varicose veins Hemorrhoids
74.0 (10)
Diseases of the prostate Frequent constipation Emphysema
-
102.5 (8) 89.3 (9) 78.1 (10)
92.6 (10) 107.8 (9)
99.3 (8) 80.6
(10)
114.6 (8) -
Source: P.F. Adams and V. Benson, “Current Estimates from the National Health Interview Survey, 1989,” Vital and Health Statistics 10, no. 176 (National Center for Health Statistics, 1990). Note: Races per thousand civilian noninstitutionalized population. Rankings for each age/ sex category are in parentheses. a Deformity or orthopedic impairment; permanent stiffness so that the affected joint does not move.
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This information, however, is difficult to obtain because of the inadequacy of existing population-based morbidity data. The largest database for which ongoing samples of the U.S. population are obtained is the National Health and Nutrition Examination Survey (NHANES), but, until very recently, this survey has included almost no elderly people. Even now, this survey contains relatively small numbers of older people and none of the very disabled and institutionalized population. The current National Health Interview Survey (NHIS) includes a larger number of elderly people and asks more questions about functional status, but it also relies on self-reported medical conditions. Changes in this questionnaire throughout its history have caused some discontinuities. Two new surveys– the Longitudinal Study on Aging and the National Long-Term Care Survey–should add considerably to the understanding of many of these factors in the oldest old. However, both of these surveys do not yet provide the kind of longitudinal data needed to answer the fundamental questions of changing health status. Exhibit 1 lists the conditions most commonly affecting older persons, as obtained in a nationally representative sample of communitydwelling persons. These data show that among older individuals, these potentially disabling diseases of aging have prevalence rates as high as 50
92 HE ALTH AFF AIRS | Su mmer 1992
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percent (for arthritis) and that prevalence increases rapidly with age. Many of these disorders are not usually considered fatal; persons often live with these conditions and die from another cause. Dementia, confusion, and depression are not present on this list, although they affect older persons. The NHIS was not designed to capture these conditions and does not include institutionalized persons, among whom disabling conditions are more prevalent. This suggests that these numbers underestimate overall chronic illness in the population over age sixty-five. Two additional points warrant mention. First, evidence shows that 11 morbidity has also increased for diseases that are ultimately fatal. Persons who now suffer from heart disease, cancer, and stroke may not die rapidly from these diseases but may live on with a related infirmity for several years. In effect, the successful treatment of fatal diseases has transformed them into chronic diseases. Second, the aggregate burden of these conditions is often more than the data in Exhibit 1 imply. For many older persons, multiple disabling conditions are the rule, and their 12 effects combine to increase disability. These chronic disabling conditions have major social implications. For example, hip fractures currently cost $1.6 billion and immeasurable pain and suffering at the level of 250,000 cases per year in the United 13 States. Twenty percent of people who fracture a hip do not survive another year, and another 20 percent are never able to walk again without assistance. Furthermore, 50 percent of hip fracture patients are discharged from the hospital to a nursing home. A conservative projection of hip fractures in the year 2010 is 350,000 at a cost of $2.5 billion 14 (in 1987 dollars) for acute care alone. Dementia, caused primarily by Alzheimer’s disease and by strokes, is another age-associated disorder that in itself is not fatal but that causes severe dependency and disability. Hard data on dementia are difficult to find. Jacob Brody found that the prevalence rate for dementia increases from 2.8 percent at ages sixty-five to seventy-four to 9 percent at ages seventy-five to eighty-four, and to 28 percent at age eighty-five and 15 older. However, the Established Population for Epidemiologic Studies of the Elderly for East Boston shows a rate of 47 percent over age 16 eighty-five for those who have Alzheimer’s disease. Current costs for care of patients with moderate to severe dementia are estimated to be $35.8 billion per year, including long-term care expenses. Conservative projections of five million cases of dementia in 2010 would result in 17 annual costs of at least $80 billion (in 1985 dollars). In the future, without major scientific breakthroughs, these chronic conditions as well as the others listed in Exhibit 1 will continue to occur at the same high age-specific rates.18 If the present prevalence rates of
AGING SOCIE TY 93
Exhibit 2 Prevalence Rates Of Three Common Chronic Conditions Among The Elderly, By Sex And Age, 1990 And 2010
Source: A.W. Wade, “United States Population Projections for OASDI Cost Estimates, 1989,” Actuarial Study 105 (U.S. Social Security Administration, Office of the Actuary, 1989); and J.E. Fitti and M.G. Kovar, “The Supplement on Aging to the 1984 National Health Interview Survey,” Vital and Health Statistics 1, no. 21, DHHS Pub. no. PHS 87–1323 (1987).
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these common conditions and the projections of the Health Care Financing Administration (HCFA) Office of the Actuary for the numbers of elderly in the year 2010 are applied, the prevalence rates of these conditions increase dramatically (Exhibit 2). The challenges for research are to understand the etiology and to prevent or delay the onset of these chronic disabling conditions. More immediately, we must develop devices, medications, and environments to allow optimal quality of life for the millions of elderly people who are thus afflicted. Disability. Although data are available on diseases affecting older persons, functional abilities are a better predictor of medical and service needs, from a health and social service perspective. Information on functional abilities is only beginning to be systematically collected. Analysis of data from the Longitudinal Study on Aging, a nationally representative study of the noninstitutionalized older population, reveals many important points about functioning (Exhibit 3). First, despite the fact that some people remain independent throughout life, rates of dependence increase rapidly with age. For example, while 22.6 percent of the population ages sixty-five to seventy-four experience difficulty with activities of daily living (ADLs), this increases to 44.5 percent at age eighty-five and older. Second, activities such as shopping, paying bills, and cleaning house are more difficult to do than basic self-care activities. When one applies rates of disability from the Longitudinal Study on Aging to the projected size of the future population,
94 HE ALTH AFF AIRS | Su mmer 1992 Exhibit 3 Number Of Elderly Persons With Difficulty In Activities Of Daily Living, By Age Group, 1990 And 2010
one sees a marked increase in the number of disabled individuals in the United States in the coming decades-measured in millions-who will need medical and social services.19 Assuming there are no changes in the age-specific risk of disability, the number of people age sixty-five and older experiencing difficulty with ADLs will therefore increase from 8.7 million in 1990 to 11.5 million in 2010-a 30.7 percent increase in just twenty years. This will result in higher medical spending. According to a recent Institute of Medicine (IOM) report, medical spending per capita for those limited in activity because of two or more chronic 20 conditions is five times that of persons not limited in activity. The disabilities of older persons are not static, and functional status 21 can change as often as daily. Although it is not possible to generalize from such descriptions to national statistics, these kinds of data show that individual variations are important in planning for residential and supportive care. One study found that in certain subpopulations nationwide, up to 18 percent of disabled persons were less disabled two years 22 later. However, the likelihood of returning from disability to functional ability decreases with age. In health policy and planning, restorative and rehabilitative care will be as important as custodial and palliative care. Active life expectancy. To study changes in disability, it is helpful to partition life expectancy into independent and dependent periods. This
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Source: A.W. Wade, “United States Population Projections for OASDI Cost Estimates. 1989.” Actuarial Study 105 (U.S. Social Security Administration, Office of the Actuary, 1989); and J.E. Fitti and M.G. Kovar, “The Supplement on Aging to the 1984 National Health Interview Survey,” Vital and Health Statistics 1, no. 21, DHHS Pub. no. PHS 87–1323 (1987). Note: ADL is activities of daily living. IADL is instrumental activities of daily living.
AGING SOCIE TY 95
Medical Technology Now And In The Future In the past, we have often viewed progress in health care as scientific and technical advances that could save lives. There have also been what Lewis Thomas has presciently referred to as “halfway technologies.” While these did not care or prevent disability, they did keep people alive, although at great cost–both human and financial. One example of a halfway technology is the iron lung for people with polio, now mercifully obsolete because of the dramatic effect of the polio vaccine. A current example of halfway technology is renal dialysis, which helps people survive, albeit with significant dependency. Many life–sustaining technologies– organ transplantation, cardiac revascularization, cancer surgery, and combination chemotherapy and radiation therapy-have shown success in extending life, although all are costly. The use of new life-sustaining medical technologies in the very old has become a highly controversial issue among medical policymakers and ethicists. Some have proposed an arbitrary, age-based limit to use of life-extending medical technology, based on the idea that the person has already had a chance to lead a good and full life, and, as data have
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concept has led to research to predict active life expectancy– that portion of life expectancy during which one will not be disabled and will not need help with activities necessary for independent living. An assessment of present and future trends in active life expectancy requires assumptions about life expectancy trends overall and trends for the burden of chronic diseases and disability-most importantly, time of onset of chronic illness and degree of disability that it causes. Active life expectancy measures differ from health status measures in that independence, or active life, can occur even in the presence of some chronic diseases. Indeed, treatments aimed at improving functioning become increasingly important as age progresses. If length of life continues to increase and yet the onset of disabling diseases such as osteoarthritis or Alzheimer’s disease is the same as in previous decades, the population inevitably will experience longer durations of disability. Some experts suggest that 80 percent (9.6 months) of each twelve 23 months of increased life expectancy is spent in a state of disability. Also, as people advance in age, the percentage of remaining life that can be expected to be active and independent decreases. In general, other studies in which active and disabled life expectancy is measured by 24 various methods show that disability in the population is increasing. Thus, with inevitable increases in the population age eighty-five and older, there will be a dramatic increase in the need for long-term care.
96 HE ALTH AFF AIRS | Su mmer 1992
Health Policy Implications Community-based care. Most of those who support the idea of agebased rationing are not against any and all treatment for older persons. On the contrary, they argue for more resources for long-term care, where the goal is comfort rather than life extension. Health care utilization data support the importance of this emphasis. There are currently an estimated 1.5 million nursing home beds in the United States at any given time and somewhat fewer than a million hospital beds. Today, many hospital beds are going empty, and many hospitals are closing. Two major reasons for this decline in acute care capacity are inadequate funding for the poor and uninsured, and the move to community-based care. Many disorders that previously required inpatient care can now be handled on an outpatient basis. This phenomenon suggests that the hospital will become a center for intensive care and major surgery. Meanwhile, the need for community-based care for people of all ages 27 with chronic illness will increase. The number of people who will need nursing homes over the next thirty years has been predicted to rise to 28 between three and five million. In addition, roughly two to three times as many people of equal levels of disability will be cared for at home with 29 some combination of formal and informal services. This represents, then, as many as fifteen million individuals who will require long-term care for chronic and progressive disabilities in the year 2010. High technology versus supportive care. Further research is needed into the impact of increased life expectancy on morbidity in the elderly. However, there is no doubt from a clinical standpoint that many nonfatal diseases of old age will not disappear quickly, if at all, given how little we currently know about their pathogenesis, prevention, amelioration, or treatment. A major challenge for the United States is deciding how to handle the growing prevalence of chronic illness. Health insurance, both public and private, covers expensive life-sustaining technology, even for patients who are permanently unconscious, while ignoring the more labor-intensive, supportive care that could keep a fairly functional ninety-year-old out of a nursing home. In the coming decade, budget constraints may finally force us to confront this paradox.
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shown, chances of an extended survival with declining functioning are high.25 Others argue that given the tremendous diversity of health status among older people, we must make these decisions on an individual 26 basis to avoid discrimination against one segment of the population. While these moral arguments against age-based rationing are strong, they point to difficult decisions ahead for U.S. policymakers.
AGING SOCIETY 97
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We emphasize here that many millions of older people will live independent and active lives well into advanced age. We also emphasize that many elderly people who live with chronic illnesses still find life worth living and can contribute to society. There is also, however, a third group for whom brain disease has eradicated the ability to participate in life or for whom physical disabilities have become so onerous that life no longer seems worthwhile. The policy debate rages about their right to die and about the ethical standards that should guide the use of life-supporting treatment, including even food and water, for the most severely disabled patients. This debate will have an enormous impact on the life expectancy of the most extremely dependent in our society and increasingly for those who reside in nursing homes. Quality of life. Another major question is how health policy can be focused to improve quality of life. There is enormous need for research and development in this area: basic research on the cau ses of osteoarthritis, Alzheimer’s disease, and other degenerative age-related diseases; and research on which strategies and health services organizations can most effectively provide long-term care. Long-term care financing. Finally, we must confront the financing of long-term care. This is more than a matter of economics; it also involves our society’s culture and values. Almost all other developed countries have confronted these needs more effectively and directly than the United States has. Two examples illustrate the range of policy choices. In Sweden, it is the norm that a frail elderly person will move to one of a large network of high-quality long-term care institutions, which are financed through the government and supported by taxation- A majority of Swedish women are in the work force and contribute taxes that support this long-term care network. At the other extreme is Japan, which has recently overtaken Sweden in worldwide life expectancy comparisons. Japan has a long tradition of caring for elderly people at home. There are few nursing homes, although that number is beginning to grow, and much long-term care is delivered in Japanese hospitals. It is still not the social norm for Japanese women to work outside the home; thus, a built-in caregiver is at home for elderly persons in need. Clearly, circumstances in the United States are different from those of Japan and Sweden, both culturally and economically. Nonetheless, our society still must face the task of caring for its elderly citizens. The answer to long-term care financing in this country must, in some way, be consistent with our diverse yet uniquely American values. Policy priorities. Several policy priorities emerge from our review of the changing health care needs of an aging society. First, we need access to better-quality institutional care and better funding for home care of
98 HE ALTH AFF AIRS | Su mmer 1992
We thank Jeff Goldsmith, Dorothy Rice, and Jacob Brody for their helpful suggestions, and Sylvia Furner for her assistance in obtaining the Longitudinal Study on Aging data. This work was supported by The Pew Charitable Trusts (Health of the Public Project) and National Institute on Aging (NIA) Grant no. K07 AG06188-02. NOTES 1. National Center for Health Statistics, Health, United States, 1990 (Washington, D.C.: NCHS, 1990) 67. 2. J.B. McKinlay and S.M. McKinlay, “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century,” Milbank Memorial Fund Quarterly 55, no. 3 (1977): 405–428. 3. L.M. Verbrugge, “Recent, Present, and Future Health of American Adults,” Annual Review of Public Health 10 (1989): 333–361. 4. J. Tsevat et al., “Expected Gains in Life Expectancy from Various Coronary Heart Disease Risk Factor Modification,” Circulation (April 1991): 1194–1201. 5. S.J. Olshansky et al., “Trading Off Longer Life for Worsening Health: The Expansion of Morbidity Hypothesis," Journal of Aging and Health (May 1991): 194–216. 6. S.K. Nishimoto, S.M. Padilla, and D.L. Snyder, “The Effect of Food Restriction and Germ-Free Environment on Age-related Changes in Bone Matrix," Journal of Gerontology 45 (1990): B164–168; D.K. Ingram et al., “Dietary Restriction and Aging: The Initiation of a Primate Study,” Journal of Gerontology 45 (1990): B148–163; S. Goldstein, “Replicative Senescence: The Human Fibroblast Comes of Age,” Science (September 1990): 1129–1133; and R.A. Lockshin and Z.F. Zakeri, “Programmed Cell Death: New Thoughts and Relevance to Aging,” Journal of Gerontology 45 (1990): B135–140. 7. K. Manton, E. Stallard, and H. Tolley, “Limits to Human Life Expectancy: Evidence,
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severely disabled persons. The major barrier to both of these is not lack of knowledge or skill, but inadequate financing mechanisms. In addition, we must develop effective and efficient care for the less severely disabled. With millions of people expected to live many years of life with chronic conditions, new residential arrangements that maximize independence will be required. To enhance a vital aging society, flexible and creative approaches to housing, work, transportation, and education are needed. Changes are also needed in the way health care providers are trained. Since many of the health problems of the elderly require “hightouch,” not “high-tech” care, health professions training and reimbursement policies should encourage the use of nurses, nurse aides, rehabilitation therapists, and social workers as well as physicians. Finally, the study of amelioration and prevention of the nonfatal diseases of aging should become a major medical research priority. These challenges to our health care system are diverse. That we face them at all is the price of our success at surviving. We need not look ahead to 2010, however, to know the importance and difficulty of these challenges, because they are upon us today.
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