Sci. Aging Knowl. Environ., 7 December 2005
Vol. 2005, Issue 49, p. pe38
[DOI: 10.1126/sageke.2005.49.pe38]

PERSPECTIVES

Living Longer and Paying the Price?

John Q. Trojanowski, M. Kathryn Jedrziewski, and David A. Asch

The authors are at The Institute on Aging (J.Q.T., M.K.J., and D.A.A.), the Department of Pathology and Laboratory Medicine (J.Q.T.), and the Leonard Davis Institute of Health Economics (M.K.J. and D.A.A.) at the University of Pennsylvania School of Medicine, and the Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center (D.A.A.), Philadelphia, PA 19104, USA. E-mail: trojanow{at}mail.med.upenn.edu (J.Q.T.)

http://sageke.sciencemag.org/cgi/content/full/2005/49/pe38

Key Words: life expectancy • demography • infrastructure • obesity • Social Security • Medicare • Medicaid

Introduction

A symposium titled "Living Longer and Paying the Price? Healthcare Costs and Longevity in America," which focused on longevity trends in the United States and the costs of living longer, was held at the University of Pennsylvania on 26 October 2005. Co-sponsored by Penn's Institute on Aging (IOA) and the Leonard Davis Institute of Health Economics (LDI), the public event attracted about 100 attendees.

The meeting sought to raise general public awareness about and stimulate discussion of dramatic demographic changes occurring in the United States and other developed countries. For example, in the coming months, those at the leading edge of the baby boomer generation will turn 60 years old and thereby open up a new chapter in this generation's profound effect on the nation. This new epoch will continue to unfold well into the future. Americans over 60 will become an increasingly larger percentage of the population; it is predicted that one in five Americans will be 65 years of age or older by 2030. Thus, the health care needs of a progressively aging United States population will continue to grow for decades. It is imperative that policy makers and government leaders work with all levels of society to plan for the social, medical, and economic changes brought about by this demographic revolution, which will have consequences for the United States and other developed countries that are more profound than those experienced during other revolutionary epochs of the past several hundred years. Thus, the IOA and LDI collaborated to design this symposium as a town meeting with experts in health economics, Social Security, and medicine to stimulate public discussion about the many challenging issues we face as an aging society as well as to consider the benefits of living and enjoying a healthy life with advancing age. A webcast of the entire symposium is available on the IOA Web site. A summary of each presentation, along with an overview of the panel discussion, follows here.

Adapting Infrastructure for an Aging Population

After opening remarks from John Q. Trojanowski (University of Pennsylvania), William Novelli (AARP) started the symposium with a talk titled "Longevity, Health, and Long-Term Care." Novelli began his presentation by posing the following questions: Can America afford to grow older? Can we do so with intergenerational fairness (that is, without sticking our children and grandchildren with the bills)? He noted that these are among the most important questions today. The increased longevity that we enjoy today is a remarkable success story, and yet there are those who see it as a problem, especially as the baby boomer generation nears retirement. Novelli further stated that, as the richest nation in the world, we can afford to grow older without leaving an economic "train wreck" for future generations. As an example of the ability of this country to reinvent its infrastructure and public systems, he noted that when the baby boomers were ready to enter school, we built more schools; we didn't say that we couldn't handle the demographic shift. As a result, we became stronger and better. The same restructuring and growth can happen now. What is needed is political will.

Novelli outlined three opportunities, to (i) transform the nation's health care system, (ii) strengthen our retirement system, and (iii) create more livable communities. He stated that transforming the health care system is perhaps this country's greatest challenge, but it may be the most important with respect to improving our quality of life. Many people believe that Medicare and Medicaid are unsustainable programs, given the aging of the population. However, many factors contribute to the increasing costs of these programs, thereby driving up the costs of health care for everyone. Such increases affect individuals, businesses, and every level of government. Novelli noted that these factors can be analyzed and evaluated to devise creative ways to fix the health care system, including (i) using information technology to improve efficiency and quality, (ii) reducing medical errors, (iii) encouraging individuals to engage in healthy behaviors and prevention, (iv) focusing care on chronic conditions, (v) ensuring access to health care for everyone, and (vi) fully supporting the National Institutes of Health, the federal agency that is primarily responsible for funding research to improve the health and well-being of all Americans.

Novelli then turned to the second opportunity, that of strengthening our retirement system. He noted that Social Security is the most successful domestic program in our nation's history, and he called for reasonable, moderate changes to achieve solvency, not a radical overhaul. He also called for changes to the current private pension system. For example, he would like to see companies with 401(k) retirement savings plans automatically enroll new employees and require them to opt out, rather than asking them if they want to join the plan. Novelli also suggested that older workers should be supported and provided with opportunities to continue working if they are able to do so. They will then remain productive and engaged and continue to make withholding contributions for Social Security, while at the same time helping to avert labor shortages from the retirement of the boomers.

For the third opportunity, that of creating more livable communities, Novelli acknowledged that most people want to live in their own homes for as long as possible, although there are many barriers that can prevent this from happening. We must solve the problems of transportation and isolation for those who can no longer drive but don't live in cities with mass transit nearby, and we must modify or build housing that meets the needs of older people and helps them remain independent. In summing up, Novelli stated that the problems will only get worse the longer we delay our efforts to solve them.

Future Trends in Life Expectancy

S. Jay Olshansky (University of Illinois at Chicago) took a biodemographic approach to address the question "Will Life Expectancy Continue to Increase?" Briefly, the biodemography of aging refers to the science of analyzing aging and longevity patterns as well as past and future causes of death to uncover the biological forces that produce such patterns and trends over time. Thus, an understanding of the biodemography of aging emerges from research in many disciplines, including population sciences, medicine and epidemiology, and molecular and evolutionary biology. This research is leading to new insights that are revolutionizing how epidemiologists view the causes and expression of disease, all of which have an important impact on how government and society will plan for the dramatic demographic changes occurring in the United States and other developed countries. Indeed, estimates of future life expectancy can have profound effects on public policy, including federally funded programs for the elderly such as Social Security and Medicare.

Although many analyses of how long Americans will live in the 21st century continue to predict steady increases like those of the 20th century, Olshansky and his colleagues provide compelling evidence for more cautious predictions based on changes in the diet and lifestyle of Americans that have resulted in increased rates of obesity and related metabolic disorders (see Tuljapurkar Perspective, Olshansky Perspective, and Mizuno Review). The prevalence of obesity is rising rapidly such that more than 60% of adults in the United States currently are obese or overweight. Americans in the coming decades are therefore more likely to be afflicted by obesity-related disorders such as type 2 diabetes, coronary heart disease, cancer, and dementia. Such changes may end the progressive extension of the average life expectancy that has occurred over the past ~200 years in the United States and other developed nations. Indeed, Olshansky noted that in the past 3 decades, the rise in life expectancy at birth in the United States has decelerated, and there do not appear to be any unequivocal life-extending technologies on the horizon that would clearly justify higher estimates of life expectancy.

Thus, Olshansky cautioned that, unless measures are taken to reverse the growing prevalence of obesity, the related health consequences will have profound effects on life expectancy in the United States such that the youth of today could live less healthy as well as shorter lives than their parents. This view is in sharp contrast to prevailing views of many gerontologists, and it contradicts the predictions of many mathematical demographers who assume that the pattern of longevity in the United States will follow that of other longer lived nations and who extrapolate from historical trends on life expectancy into the future. However, the sobering data presented by Olshansky cannot be ignored in planning to meet the challenges of the demographic changes that will affect developed countries in the decades ahead.

A View from the Social Security Administration

Stephen C. Goss [United States Social Security Administration (SSA), Office of the Actuary] described both his office's role in estimating life expectancy and some of those estimates and the factors contributing to them. Goss noted that his office at SSA does indeed look to the past to estimate the future. However, only those factors that affect the population as a whole can have a substantial effect on overall life expectancy, such as clean water, sanitation, and the increased availability of medical care that occurred after World War II. Furthermore, these kinds of extrapolations make sense only when we believe that conditions of the future will be the same as conditions of the past. That situation is never fully the case.

Goss noted that the 20th century showed two periods of substantial decline in population death rates. A large decline in death rates occurred during the period surrounding World War II (1936 to 1954) and is attributed to medical advances (particularly the development and use of antibiotics) and improved standards of living. Another decline in death rates occurred in the period after the start of Medicare and Medicaid (1968 to 1982) and is attributed to the provision of medical care to vulnerable populations. In agreement with Olshansky, Goss noted that there was a much slower reduction in mortality in the remainder of the 20th century.

Goss drew attention to the fact that the optimists among actuaries and demographers believe that advances in medical technologies will lead the way toward further increases in life expectancy. These advances include those coming from the human genome project and other scientific breakthroughs. Although these assumptions have merit, the pessimists among actuaries and demographers believe these types of breakthroughs may occur many decades into the future and that past increases in health care spending, to which some past gains are attributed, are unsustainable in the future. And like Olshansky, these individuals also cite the rise in obesity as a potentially important reason for their pessimism.

Goss concluded his presentation by stating that his office at SSA expects continued, but slower, increases in life expectancy at younger ages, but perhaps similar or even improved increases in the population over the age of 65 in the future.

Panel Discussion

These presentations were followed by a lively panel discussion moderated by David A. Asch (University of Pennsylvania). Olivia S. Mitchell (University of Pennsylvania) fielded the first question, "Should increases in life expectancy change our definitions of aging and retirement?" Her reply was that retirement expectations of workers themselves would need to change. The boomers will redefine retirement, but everyone should start at birth to prepare for the third phase of life to ensure that they have the work skills and physical capacity that will be needed. The symposium wrapped up with a final question to all of the panelists, including Alice H. Wade (SSA), "What are each of you doing to prepare for the third phase of life?" Each panelist offered advice, which included (i) exercise, (ii) invest in yourself, (iii) maintain good nutrition, (iv) maintain a positive outlook and attitude, (v) connect with your family, (vi) find a satisfying job, and (vii) avoid habits and lifestyles that are known to shorten life. Many of the recommendations by the panelists also emerged from a previous IOA symposium held earlier this year in conjunction with Penn's Edwin and Fannie Gray Hall Center for Human Appearance titled "The Art and Science Of Anti-Aging Therapies: Convergence of Theory and Practice," a webcast of which also is available on the IOA Web site and a summary of which appeared in SAGE KE (see Trojanowski Perspective).


December 7, 2005 Citation: J. Q. Trojanowski, M. K. Jedrziewski, D. A. Asch, Living Longer and Paying the Price? Sci. Aging Knowl. Environ. 2005 (49), pe38 (2005).








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