And the Winner is...

It was fascinating to see how different media outlets responded to the latest “Globe Age Watch Index.” CBS News, which may have had rankings on the mind, given that US News and World Report just released its 2016 college rankings, leaves us dangling, entitling its article, “10 Best Countries to Live in for People Over 60.” The New York Times worries about all those countries that didn’t make it into the report—98 of them, accounting for just under 10% of the world’s population, leading off with the somewhat cryptic “Older People are Invisible in Key Data.” And the Guardian collapses the entire 29-page report to one number, telling us “It’s official—Switzerland is the Best Place to Grow Old.” So what exactly does the report say and what is there to say about it?

The rankings are based on four measures that the report’s authors say represent core issues of concern to older people. These are income security (which is a function of pension coverage, poverty rate in old age, and standard of living); health status (which is based on life expectancy at age 60, healthy life expectancy at age 60, and psychological well being); capability (which is defined in terms of employment level and educational status of older people, meant to serve as proxies for engagement and human capital); and enabling environment (which is assessed based on access to public transportation, physical safety, and social connections).

What the report finds is that among the 96 countries for which sufficient data was available, twenty are in the top quintile. The US is number 9, with Switzerland, Norway, Sweden, Germany, Canada, the Netherlands, Iceland, and Japan ahead of us, though not by much. The composite ranking is much less interesting than the component sub-scores. If you look beyond the overall ranking, you find that the US is 29 in income security (which would eject it from the top quintile if that were the sole indicator); it is 25 in health status (diito), and 17 on enabling community. In fact, the only area where the US performed very well was capability—which reflects the fact that it measures employment in people aged 55-64, and Americans seldom retire early unless they’re compelled to. So the picture for the US isn’t exactly rosy. What would be more interesting would be to look at similar indices for people who are over 70 (or at least for people over 65).

But the really important message isn’t how the US looks, however sobering that might be. The crucial message is that the rest of the world isn’t doing so well and the gap between the elderly in rich countries and those in poor countries is growing. Also disturbing although hardly surprising is how poorly countries are doing that are in conflict zones, countries including Afghanistan, the West Bank and Gaza, and Iraq. China, which is facing an imminent explosion in the size of its older population (and a dwindling supply of younger people to take care of them), is smack in the middle of the distribution, at 52. Greece, which is economically if not physically under siege, is way down at 79. Also in the fourth quintile, along with Greece, are Ukraine (73) and Russia (65). 

Yes, there is quite a bit of missing data here (though we can guess that the elderly aren’t doing well in Syria and Yemen and many of the other places that didn’t provide information) and yes, we can quibble with the specific measures that were used, although the basic categories seem reasonable. And in general, I’m not a fan of rankings (see for example, my commentary about Nursing Home Compare). But if used to identify which areas are in particular need of attention, I think the report is useful. For the US, that means health status and income.

Getting to Yes

In an insightful new book, medical anthropologist Sharon Kaufman persuasively delineates the forces that lead older patients to “yes.” Despite all the rhetoric about shared decision-making, about patients making choices based on their personal values and preferences, an interlinked series of powerful forces conspire to shape that “decision.” It’s not surprising, according to this compelling account, that invasive technology is used so extensively in older patients, with the threshold for what is considered old constantly rising.

The first step, in Professor Kaufman’s account, is that the scientific establishment, fueled by NIH and increasingly by private industry (medical device makers and pharmaceutical companies), develops ever more sophisticated, potentially life-extending technology. If the FDA finds the technology to be “safe and effective,” then Medicare, the insurer for virtually every person over age 65, will by and large pay for it. Once payment is assured, the technology quickly moves from being “acceptable” to being the “standard of care.” After all, surely whatever is on offer must surely be advisable. And if it might prolong life, and it’s free (or almost free), why not? Finally, the families who will often be the ones to administer or monitor the technology if patients avail themselves of it, and who will take mom or dad to the hospital when something goes wrong, find themselves in a position of feeling morally required to support the technology’s use. Sometimes that even means donating a kidney or resigning one’s job.

Kaufman concludes that there’s no simple fix to a health care system that relentlessly provides more and more to older and older people, regardless of cost and despite its burdens. Simple “decision aids,” with their focus on rational choice and clear depiction of risks and benefits, cannot possibly counteract the “ethical field,” the social, cultural, and market-driven environment in which patients along with their families and their doctors operate. But I think there is a ray of hope. And it may be a brighter ray than what Kaufman proposes, which is that if only we understood the complicated underpinnings of today’s reality, an understanding that she goes far to advance, we would be in a better position to change that system. 

I suspect that her linear model of the forces propelling us towards ever more technology in medicine—the scientific enterprise, the FDA, Medicare, societal norms, and patient/family morality—is actually more complex. It’s very likely a series of feedback loops, with each factor influencing and being influenced by all the others. Yes, scientific discoveries and technological inventions, when their efficacy is demonstrated in clinical trials, lead to Medicare reimbursement. But the awareness on the part of the device manufacturers and the drug companies of the circumstances under which Medicare will pay for their products also shapes what avenues of inquiry they pursue. Yes, patients’ understanding that Medicare will pay for a device or a procedure shapes their view of the standard of care. But patients’ expectations also influence Medicare’s coverage decisions.

If the health care system is even more complex than “Ordinary Medicine” suggests, doesn’t that make reform even more hopeless? Not necessarily. Precisely because the current system is sustained by multiple feedback loops, it may be possible to effect change by applying pressure on a single lever that operates in multiple loops. That lever is the Medicare program. We may not be able to reform capitalism or to change the tendency for patients to assume that whatever is paid for by health insurance constitutes necessary care. But we just might, someday, be able to modify Medicare.

Sneak Preview

Demographically, the US in 2050 will look much the way Germany and Italy do today: 20% of the population will be over age 65. Comparing the attitudes and beliefs of Germans, Italians, and Americans toward elder caregiving, as a new Pew Research Center report does, can give us a glimpse of our future.

The facts are intriguing. Twice as many Italians and Germans as Americans feel that government should bear the greatest responsibility for economic well-being in old age. This reflects today’s reality: in the US, 38% of the income among those over 65 comes from government sources such as Medicare, whereas in Germany and Italy 70% comes from public funds. It may also reflect the fact that there are fewer young people in Germany and Italy to bear the burden of caring for the older generation. The old age dependency ratio in both European countries is 30, which means there are 30 older adults for every 100 “working age adults,” defined as ages 15-64, even though 15 is seldom working age in these societies; in the US today, the dependency ratio is 19.5.

What I found particularly striking is that more older Americans continue earning money from working in old age than do their European counterparts: 32% of the income of elderly Americans derives from work, compared to 20% of that of Italians and only 13% of the Germans. It seems that Americans work more—and depend to a greater extent on working for their identity as well as for their income—than Europeans, who also have shorter work weeks and take more vacation time. And today’s Americans are far more likely to have a private pension fund of some kind, for example from their employer, than the Germans or Italians: 30% of American retirees receive private pension benefits, compared to 13% of Germans and 7% of Italians.

Those under 65 in all three countries have one belief in common: they are skeptical as to whether government old age benefits will be available to them when they retire. Paradoxically, Italians, who currently depend most heavily on the government for financial support in old age, are more convinced that adult children are obligated to provide financial help to their aging parents (87% assert this) than Americans (76%) or Germans (58%).

It’s sobering to note that though the US elderly are much better off since the introduction of Medicare in 1965, fully 20% of older Americans are poor—twice the rate in Germany or Italy. It’s also disturbing that the generous private pensions Americans received in the past are vanishing, as is employer-provided supplementary health coverage. American culture maintains an ethic of individual and family responsibility but is gradually eroding the support, both private and governmental, that makes that possible. 

If we want to focus on the family as the locus of care—and we shouldn’t kid ourselves into believing that older people won’t need care—we need to make sure that we develop rather than destroy what infrastructure there is in which those caregivers operate. That means more flexible and part time job options for caregivers (as well as for older people themselves) and technology that helps caregivers monitor remotely. It means developing a cadre of workers who can supplement the services provided by families and earn a decent wage doing do. It involves providing respite for caregivers so they can get mental health breaks and go on vacation. It involves nothing less than a societal makeover.

The Benefit of Medicare and the Medicare Benefit

When Congress first introduced a hospice benefit into the Medicare program in 1982, it did so out of the recognition that patients who are very near the end of life need special treatment. Conventional medical care doesn’t work well for them; another type of care, focused intensively on symptom management and delivered principally in the home, tends to be far more beneficial. The problem—aside from the psychological issue of both patients' and doctors’ reluctance to acknowledge the imminence of the end of life—was how to pay for this kind of labor-intensive care. The legislation, introduced on a trial basis at first and then on a permanent basis in 1986, instituted an approach to payment that offered patients a trade: either Medicare paid for what was assumed to be life-prolonging care (for example, hospitalization and chemotherapy) or Medicare paid for what was assumed to be exclusively comfort-oriented care (for example, home nursing and medications such as morphine). The nice clean boundaries between life-prolongation and comfort-maximization turned out to be rather fuzzy: sometimes palliative care prolongs life more than does aggressive, high-tech medicine and sometimes the treatments that are thought of as life-prolonging, such as radiation therapy, are the best way to maximize comfort. But leaving aside the issue of whether we should decide what counts as life-prolonging on a case-by-case basis rather than by category (ie viewing all chemotherapy as life-prolonging), the fundamental principle remains—health insurance benefit packages necessarily involve both inclusions and exclusions.

The trouble with the structure of Medicare is that it provides well for the extremes, for people who are very vigorous or who are imminently dying, but it doesn’t provide well for those who are in between. To be fair, Medicare has evolved over the past ten years and pays far more attention than previously to people with chronic diseases and increasingly greater attention to people with multiple chronic diseases. It has introduced disease management programs, typically involving nurses who help patients adjust their own medications for diseases such as diabetes or heart failure. But patients who are frail or who have moderate to severe dementia benefit from many of the same intensive home care services as dying patients. They also often want to avail themselves of many of the same kinds of high-tech care as robust older patients. Medicare rightly balks at the prospect of paying for everything—it’s just too expensive. So what people with frailty and advancing dementia need is their own special Medicare benefit that is midway between conventional Medicare and the hospice benefit. They need what I call intermediate care; the way to pay for intermediate care is through a new benefit tier.

The comprehensive package—sandwiched between the intensive package and the palliative package—would be modeled on the Program of All-Inclusive Care for Elders (PACE), a very successful program in which only a very small number of patients have enrolled, providing integrated, multidisciplinary care outside the hospital or nursing home. Unlike PACE, it would not focus on the adult day health center (many older people don’t want to go to “daycare,” where lots of the PACE services are delivered) and it would not require that patients change physicians (an impediment to joining PACE as currently conceived). In exchange for the enhanced home services, the intermediate care benefit package would exclude a variety of high tech, high expense medical care that is seldom useful for frail or very demented patients. It would not cover ICU care. It would not cover surgery for devices such as the Left Ventricular Assist Device, a kind of partial artificial heart. It would exclude dialysis, which doesn’t prolong life in frail elders. What the intermediate care benefit would provide is a coordinated, integrated approach to care, with plans in place for what to do in the most likely scenarios for a given patient—what to do when the patient with advanced heart failure develops pulmonary edema, when the patient with advanced emphysema develops pneumonia, or when the patient with moderately severe dementia develops a fever. These plans would involve intensive home treatment or transfer to a skilled nursing facility, but not the current approach of emergency room—hospital—rehab—home. It would look similar to another variant of Medicare than has been proposed, called MediCaring. 

Medicare is a great program but it needs substantial modification to truly benefit all those it is intended to serve: the robust, the frail and the demented, and the dying. Just as we don’t expect one antibiotic to treat all infections or a single chemotherapeutic agent to treat all types of cancer, we cannot expect one benefit package to make sense for all older patients. Offering three distinct packages, an intensive package, a comprehensive package, and a palliative package, as I argued in my book The Denial of Aging, would go a long way to making Medicare work for everyone.

The Coming Cataclysm

Some time in the next 6 years the world will experience an unprecedented cataclysm. Not a tsunami or an epidemic or a large scale war, although those are possible, too. This seismic shift will go undetected by the majority of the world’s population and yet it will change our lives. Between 2015 and 2020, for the first time in world history, the population of people over 65 will be greater than the population of children under 4.

It’s all nicely laid out in a report issued a few months ago that didn’t get very much attention. I didn’t notice it at all. It was the US Census Bureau’s Report “65+ in the United States” and it consists of nothing but statistics. Most of the observations and the predictions are nothing new: the population of older people has grown (it reached 40.3 million in 2010); the median age is increasing (up from 22.9 in 1900 to 37.2 in 2010); life expectancy has shot up (going from 47.3 at birth in 1900 to 78.7 at birth in 2010 and going from 11.9 years at age 65 in 1900 to 19.2 years in 2010); more women than men make it to old age (in the over 90 set, there are only 38 men for every 100 women); the population is becoming more diverse: 84.8% of the population self-identify as white in 2010 compared to 86.9% in 2000).

But buried amid the welter of interesting but not novel data about the US are some striking statistics about the entire world. First and foremost is the unprecedented demographic shift that will take place between 2015 and 2020: the total number of people over age 65 will exceed the number who are 4 or younger. This is because both fertility and mortality rates have been falling. As a result, people over 60 went from 8% to 11% of the population between 1950 and 2011, but by 2050 they will make up 22% of the world's population--2 billion people. Looked at a little differently, the global population is projected to increase by a factor of 3.7 between 1950 and 2050, but during that same century, people who are 60+ will go up by a factor of 10 and people who are 80+ by a factor of 26. 

Today, the countries with the highest proportion of people over 60 are Japan (31%), Italy (27%), and Germany (26%) with 7 other European countries not far behind. But the countries that are aging most rapidly include 4 in the Middle East (UAE, Iran, and Oman) and 4 in Asia (Singapore, Korea, Viet Nam, and China).

Accompanying the shifting age distribution will be an ever more dramatic dependency ratio: the number of people over 65 for every 100 people aged 20-64. This means that fewer and fewer young people will have to sustain more and more old people. And it will be in the low and middle income countries that all this transformation will be occurring most rapidly.

The reason all this matters is that it will put an enormous strain—economic, medical, and social—on everyone, but especially on the poorest countries in the world. It will affect demand—for goods (more walkers than tricycles) and for labor (more personal care attendants than elementary school teachers). The net effect may be as destabilizing as nuclear weapons. As a position paper published by the State Department and the National Institute on Aging put it, global aging represents a “triumph of medical, social, and economic advances over disease”—but it also represents an enormous and most governments have not even begun to plan for the long term.

So we have one more thing to worry about, along with climate change and religious fundamentalism and infectious diseases. What can we do about it? We do not need to accept the doomsday scenario of massive workforce shortages, asset market meltdowns, economic growth slowdowns, financial collapse of pension and healthcare systems, and mass loneliness and insecurity. But we do need to take steps now.

There are lots of interventions that can make a difference. 

One is to raise the normal legal retirement age. Another is to use international migration. A third is to reform health care systems, incorporating new models of long term care. A fourth is to encourage businesses to employ older workers, enabling them to work part time and facilitating their continuing productivity through environmental modifications that address mobility, vision, hearing, and other deficits. Economists, sociologists, demographers, historians and physicians at places including the World Bank and the Stanford University Center on Longevity have come up with a menu of strategies.

It’s up to all of us to pressure both the private and public sectors to act. Contact your senators and representatives. Write letters to the editor to major newspapers. The time to act is now.