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Yikes, we're going to be old

America's senior population is going to overtake its children. What happens then? An expert roundtable.

One of the great sea changes in the American population over the next half-century will be how old we're becoming. It's not just that Boomers are moving into retirement: it's that fewer kids are being born, shifting the population overall in dramatic ways. Remarkably, sometime between 2030 and 2040, experts predict that senior citizens will begin to outnumber children. This is uncharted territory for America.

What do the top minds in public health see coming down the pike as the population gets older, and as America's young people become more diverse—and, possibly, poorer? On October 26, POLITICO invited a select group of forward-thinking experts to Washington and asked them to look deep into the future for us, identifying trends that will challenge or revolutionize health care in coming decades. With an America getting far grayer, and fewer young people in the labor force to support their care, what should we be watching for? How can we head off problems? What follows is an edited transcript of their look ahead, and some ideas for what we can do now. (See their conversations on diversity here, and food here.)

Stephen Heuser, editor, The Agenda: When we look at the future of America in one, two, three decades, we see that the percentage of the population over age 65 is going to be steadily increasing. Living longer sounds like a great thing, but it also means more sick and infirm people. What should we worry about?

Joanne Lynn, director, Center for Elder Care and Advanced Illness, Altarum Institute: We already are much older than we were 50 years ago when Medicare was passed. Back then, the average age at death was in the late 60s, and the average causes of death were relatively abrupt. Now the average duration of disability before death is more than two years. And we are on course to triple the number of people who are over 80 before 2050.

We have done exceedingly little to prepare for this. The median person now retires with no savings beyond Social Security. The average person’s retirement savings is only $50,000, so most people will end up poor as they come to the end of their lives. Women bear the brunt of this much more than men, in part because of lower incomes throughout their lives, but especially because of caregiving.

The United States has avoided some of the caregiving problems other developed countries face because of immigration. The fact that we have a large cohort of young people as immigrants is helpful.

Tricia Neuman, director, Program on Medicare policy, Kaiser Family Foundation: In addition we have incredible disparities in health and wealth when we look at people of color. The median income for people 65 and older is $25,000 per person. And when you break it down and start to look at African-Americans on Medicare or Hispanic people on Medicare—poverty is a major concern.

Health issues will change for Medicare, too, with an aging Hispanic population in particular, which will present new health challenges, including more obesity. I think everybody at this table would like to think, “I’m going to be a healthy baby boomer, and I’m going to turn 65, and I’m going to exercise and live a really healthy life for as long as I can.” And I think a lot of people will. But there also will be people who are aging under Medicare with a fair amount of chronic conditions -- diabetes, hypertension -- that make their health care more complicated.

Medicare is pretty much an acute care program that doesn’t provide long-term services and supports. So when we think about integrating all the services that people need to experience, for not a productive, but a happy aging process, I think we need to do a lot more.

Joanne Kenen, executive editor, healthcare, POLITICO: So we will have a lot of old people without a lot of money, with chronic diseases, and they may be living by themselves without family nearby. Are Medicaid and Medicare what we need in 40 years?

Neuman: I don’t know if Medicare or Medicaid will be the organizing structures, but I can envision more integrated services for people, like senior villages, where neighbors are helping. I can envision assisted-living, independent-living retirement communities being a much more integrated service structure for people as they grow older.

Medicare or Medicaid will probably play a role, but they’re not set up to work well together right now, and separately they’re not set up to do the trick.

Lynn: The thing that is so strikingly different between this country and almost every other country is that we don’t have a local entity that watches over the delivery of services for the older population. We think it’s really nifty for there to be six insurers and eight hospitals and 30 nursing homes and 60 home-care agencies, and we think that this guarantees quality and low price. But once you have to deliver services to the home, you need something much more like a utility. And we’re wasting a tremendous amount of money on the illusion of competition.

Heuser: Are there particular models that are being tried or that research suggests would be worth doing?

Jane Delgado, president and CEO, National Alliance for Hispanic Health: At the alliance, we have supported community health centers that want to start PACE programs. Because we find that this is a very good way of coordinating services at the local level to provide a host of services to an older person.

Kenen: Maybe not everybody knows what PACE is.

Lynn: PACE is the program of all-inclusive care to the elderly. It has been recognized as something of a gem program. It has not spread, in part because the providers are comfortable where they are, [and] because of a whole series of regulations that really make it very difficult to start up and operate a PACE program.

Joshua Sharfstein, associate dean for public health, Bloomberg School of Public Health, Johns Hopkins University: I have a longer-term horizon question. If you were to ask, “How are kids doing?” you can look at the infant mortality rate, the school graduation rate, the third-grade reading rate. There are a whole bunch of things we can use to assess how they’re doing. How do you do that for older adults? I don’t think there’s a statistic.

As a result, there is very, very little conception of senior issues as public health issues. If you’re going to make progress on a public health issue you have to know what you’re talking about.

Heuser: So it sounds like we have a data problem.

Sharfstein: Yes, there is a data problem. As an example, with more electronic data in health care we can measure adverse outcomes at a population level in ways that haven’t been done before.

Heuser: So you’re describing a vision of a world in which there’s a large population of increasingly isolated people. They’re older, relatively overweight, and with various pharmacological burdens. That could be a crisis. Does anybody have blue-sky ideas to head it off?

Ruth Katz, executive director, Health Medicine and Society, The Aspen Institute: I think there is going to be more understanding, more evidence that health is far more than access to an insurance card. How do we get policymakers to think about health more broadly so you can address it more broadly? Because I think that’s the big question for 20 years down the pike.

Alan Morgan, CEO, National Rural Health Association: I love this discussion because we’re talking about 10, 20 years in the future, and we’re describing an older, sicker population, workforce shortages, fewer resources and assistance from the federal and state governments.

That’s rural health care today. Where we’re headed is where I’m already functioning in rural America. I’m still trying to get to a point where our membership feels comfortable discussing this, but moving toward a global budgeting system [where providers are paid a set amount per year based in part on their patient population ] could be part of the solution.

Sharfstein: You’re singing my song.

Morgan: But I don’t think providers are comfortable with that yet. And I’m still concerned about my long-term employment when I discuss this. But once you get to that environment, then you can start to address other issues, like transportation and home care. And other professionals as well, like community health workers, dental assistants. These are the discussions we’re having right now in rural.

Sharfstein: Some rural hospitals, particularly in Maryland, have started with global budgeting. Pennsylvania is also likely to be looking at a rural health model with global budgeting. What a global budget does is flips the incentives so the hospital will benefit if people are healthier and not coming in with hip fractures. It’s a great model for rural hospitals to consider, and it turns the hospital into much more of a creative partner for all these other things to happen. I don’t think it’s going to solve all these problems, but it’s kind of hard to imagine things getting solved if the hospital is dependent on hip fractures to stay open, to stay running.

Morgan: That’s exactly right.

Heuser: I want to move to the other end of the spectrum, which is children. We know that in the future, kids are going to be a smaller part of the population overall. They’ll be disproportionately diverse. What challenges does it raise?

Sharfstein: If you think about the health of children, you can almost start and stop with their success in school. If you look at any population of kids, how they’re doing in school is the best metric for their health. All education issues are health issues by another name. Because kids who don’t do well in school have all kinds of challenges that could predispose them to all sorts of health problems.

Avik Roy, president, Foundation for Research on Equal Opportunity: One of the big challenges for younger generations is that the breakdown of families and communities in social structures, particularly for lower income communities of all ethnicities, urban and rural, has gotten a lot more pronounced in the last 50 years.

The elderly grew up in more intact communities than the children of today. And the problems look—I don’t want to say intractable, because that sounds pessimistic—but they have defied every public policy intervention that we’ve tried up to this point. And there’s probably no more serious public policy problem that we have in terms of ensuring that these children grow up healthy because poverty and broken schools are linked to educational outcomes. And that leads to poor health care outcomes.

Kenen: You said everything we’ve thrown at them has failed. What do you want to try?

Roy: There are two things in particular. One is a nonpartisan or ideological emphasis on intact families. It used to be that this was an ideological discussion about whether family breakdown was a real problem and I think that’s no longer true.

The three strongest correlators for poverty are one, whether you grew up in a family where both biological parents were in the home. No. 2, did you graduate from high school? And three, did you not have a kid before you turned 19?

And so I think the empirical research has coalesced in a way that perhaps allows us to think about what we can do about ways in which we unwittingly subsidize certain family outcomes.

Another area of research is the idea of relocation grants, some sort of tax credit or subsidy that allows people in broken communities to relocate to a different community. Because a lot of times, moving to a different community has been shown to provide significant differences in outcomes.

Tyson Brown, co-director, Center for Biobehavioral Health Disparities Research, Duke University: Just one obvious point -- it’s important to not conflate correlation with causation. There’s a great deal of empirical research that suggests that the data runs in the opposite direction, that economic inequality and disadvantage actually leads to unstable families.

Heuser: So Tyson, where do you see challenge arising?

Brown: Health is driven by a number of biological, psychological and social factors. I see some of the drivers of inequality, things like residential segregation, as leading to unequal opportunities for quality education.

Heuser: Which is also tied to health.

Brown: Which is also tied to health, absolutely. I think about the exploding incarceration rates over the last 30, 40 years. And there’s empirical evidence by a number of researchers that suggest that the divide with having a parent incarcerated really varies dramatically across racial and ethnic lines and that there are real significant health consequences for the children as well as for the mothers or partners of those who are incarcerated. Those are fundamental structural factors that are contributing to inequality that may be exacerbated in the future.

Sharfstein: I just wanted to add that the American Academy of Pediatrics made a major focus on child poverty because they see that as driving a huge amount of poor health in kids.

Kenen: There’s also stress levels in inequalities. If you’re growing up in violence, in poverty, stress ends up affecting health.

Delgado: It affects your genes and what gets turned on and off.

Neuman: That goes across the age spectrum, because the stress of aging affects your physical health.

Brown: That’s the primary mechanism that people are theorizing is responsible for how inequality gets under the skin. Duration of exposure to chronic stress and neighborhood stress have long-term implications for health in the long term. That’s driving these inequalities.

Heuser: What are some smart interventions, things that we are pretty sure from the research might work? Things that we will wish that we had started trying now?

Sharfstein: One small bright spot is what’s happening on teen pregnancy. Teen pregnancy is dropping. Access to private health care makes a difference. It’s not getting in a lot of these underlying issues, but it’s helping.

Delgado: Having Head Start for kids is really good. We also need to have better day care so parents who want to work can work. That’s a real issue.

Kenen: Are we connecting Head Start with the health services?

Delgado: At one time we did and they had a [health screening] program, but Head Start has a fight every year just to survive. Even though we have good data showing that kids who go through Head Start are more likely to graduate later.

Lynn: Some countries guarantee that a child who makes it through at least high school or sometimes college will have a job with benefits. And in the District of Columbia, where I was in public health, our youth in the public schools have almost no chance of a job with benefits if they graduate. They’re more likely to be incarcerated within five years than to have a job with benefits. And it seems at the very beginning, we should try to get people on the track to productive work and guarantee a job.

Sharfstein: The problem in the United States is less that kids can’t get to a doctor to get basic medicines or other treatments. It’s that when they get to the doctor, the things that are really the risks to their health are risks that the doctor can’t do much about. That’s why the major advocacy effort for the pediatricians is not about billing codes for pediatricians. It’s about whether the U.S. can take on poverty.

Samantha Artiga, associate director, Kaiser Commission on Medicaid and the Unisured, Kaiser Family Foundation: In the past couple of years and partially spurred by a decreasing coverage, we’ve seen a growing recognition of the broad components that impact health, and recognizing that an insurance card isn’t going to fix all of those components.

When I look ahead, I feel like we are potentially on the edge of a new recognition of the need for better integration between the health care setting and public health and between other sectors. Recognizing that you have to address these broader social needs, like food and housing and safety in order to ensure health.

And I think we are seeing some emerging models in Medicaid that are trying to better coordinate these services as part of the health care setting, but one of the biggest challenges remains the style of financing across different sectors. Because of that, I think integration and coordination will remain challenging as long as those financing streams are separate.

Kelly Brownell, dean, Sanford School of Public Policy, Duke University: The food entitlement programs, like food stamps, have proven highly cost-effective and beneficial. But somebody was mentioning stress, and there’s very interesting research showing that where people deposit fat on the body is affected by stress and high stress leads to adverse deposition of fat in certain parts of the body.

There’s also some studies that came out very recently showing that stress affects how the body absorbs nutrients so that if you’re under stress, you’re going to have more deleterious effects from eating nonhealthy foods and less beneficial effects from eating healthy ones.

Kenen: Even your fat cells are responding to stress. [LAUGHTER]

Brownell: They are. And it just shows how inequality undermines so many parts of what we do. These individual programs we’re talking about are fantastic. But we’re just putting a finger in one part of the dike, it’s still springing lots of holes, and inequality seems to be the water that’s pushing against the dike.

Getting policymakers more interested in addressing inequality issues seems like it might go a lot of ways. It’s, of course, the hardest thing to do, the hardest thing to make progress on, but it would have so many beneficial effects.