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Public Health and Aging America: Uncharted Adventures

Public Health and Aging America: Uncharted Adventures. J. James Cotter, PhD Assistant Professor and Vice Chairman, Division of Quality Health Care, Department of Internal Medicine Assistant Professor, Department of Gerontology Virginia Commonwealth University. Defining the Aged.

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Public Health and Aging America: Uncharted Adventures

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  1. Public Health and Aging America: Uncharted Adventures J. James Cotter, PhD Assistant Professor and Vice Chairman, Division of Quality Health Care, Department of Internal Medicine Assistant Professor, Department of Gerontology Virginia Commonwealth University

  2. Defining the Aged • 40 - Age discrimination • 50 - AARP discounts • 60 - Older Americans Act • 65-67 - Medicare and Social Security • 75 - frailty marker • 85 - the old-old

  3. Best Years of My Life • 84% of all Americans say they would be happy to live to be 90 • What defines old age • decline in physical ability - 41% • decline in mental functioning - 32% • reaching a specific age - 14% National Council on Aging survey, 2001

  4. Growth of the Aging Population

  5. Life Expectancy National Vital Statistics Report, Vol. 47, No. 28, December 13, 1999; National Research Council, 1988

  6. Number of Centenarians Jeanne Calment, died in 1997 at the age of 122. A 65 year old must live 57 more years to catch her record.

  7. Changing structure of society • New aging pyramid • Traditional aging pyramid

  8. Changing Dependency

  9. Growing diversity

  10. Dychtwald’s 5 Social Train Wrecks • Using 65 as a marker • Epidemic of chronic disease • Caregiving crunch • Poverty in old age • Elder wasteland Dychtwald, Age Power, 1999

  11. Healthy Indulgers (18%) Ailing Outgoers (29%) Health Hermits (36%) Frail Recluses (17%) Gerontographics Life-stage Model Moschis, American Demographics, 1996

  12. Facts About the 50-Plus Markethttp://www.agewave.com/ • More than $2 trillion in income • 70% of the financial assets in America • 50% of all discretionary income - $13,286 per household • The 50-plus consume 74% of all prescription drugs, a $100 billion market. • Today's 50-plus adults represent 80% of all luxury travel • Number of 55-plus health club members jumped 119% (1987-1995); the number of 65-plus members jumped 669% .

  13. Changing Family Structure Source: US Census, 2000

  14. Older People of the 21st Century • General • smaller families, reconfigured families • suburbs • women in the work force • social movements • Health • prevention is key • disability  dependence • influence of lifestyle • influence of lifetime access to health care Silverstone, Gerontologist, 1996

  15. Social Security Reform • “Raising the normal or earliest eligibility age for retirement could have substantial net positive effects on the financial integrity of the Old-Age and Survivors Insurance Trust Fund and the Disability Insurance Trust Fund.” • GAO Social Security Reform: Implications of Raising the Retirement Aged, August 27, 1999

  16. Aging Network Based on Torres-Gil, The New Aging, p.56

  17. Social Policies (1) • Income Policy: • OASI, • private and public pensions, • SSI, • tax benefits (property, capital gains exclusion, SS exempt) JJC

  18. Social Policies (2) • Health Policy: • Medicare (HI), • Medicaid, • LTC • fragmentation • institutional bias JJC

  19. Social Policies (3) • Housing Policy: • Section 202, • Section 8, • CCRCs, • mobile home parks, • ACRs, boarding houses, Assisted Living JJC

  20. Social Policies (4) • Social Services: SSBG(XX), OAA • Civil Rights: ADEA, EEOC • Volunteer Policy: • Senior Companion, • Foster Grandparent, • RSVP, • SCORE JJC

  21. Older Americans Act • AoA, SUAs and AAAs • Nutrition Services • Supportive Services • Research and Demonstration Projects • Ombudsman and Elder Rights JJC

  22. State Level • Health and Human Resources • Aging • Social Services • Health • Medicaid agency • Housing • Transportation JJC

  23. Politics of the aging - definition participation by and for the elderly in the political process.

  24. Key Events in Aging Politics • 1. Social Insurance - Social Security • 2. Senior Lobby - Townsend/AARP / Gray Panthers • 3. Aging Network-AoA, SUA, AAA • 4. Medicare / Medicaid • 5. Older Americans Act • 6. SSI and COLA • 7. Medicare Catastrophic Coverage Act • 8. Voting Behavior • 9. White House Conferences on Aging • 10. 1994 Republican Congress JJC

  25. Political Participation • Higher voting rates • Identity as senior citizens • Age-based organizations

  26. Voting

  27. Current Political Issues • Medicare (Rx) • Social Security (Privatization) • Generational tensions (Private) • Longevity (Financing) • Health care reorganization (HMOs) • Long-term care (Tax Credit) • Housing (Assisted Living) JJC

  28. Hopes for New Aging Politics • Away from the interest-group nature of the politics • Away from age-segregated policies and programs • Aging support for non-aging issues • Educate younger persons about longevity • Private troubles - public issues Torres-Gil, New Aging, 1992

  29. AARP • The most powerful interest group in Washington - Fortune magazine, Dec 8, 1997 • Revenue $469 million (1994) - selling services • 1,700 employees • Its political strategies cannot alienate its members • MCCA and support for health care reform antagonized some members • How much attention to low-income aged • Able to coalesce aging into a viable political force? • Under attack on its lobbying and non-profit status Torres-Gil, New Aging, 1992

  30. Policy Dilemmas • How do we involve older persons? • How can we break the needy/greedy image cycle? • How do we balance public and private responsibility? • Where does federal control end and state control begin? • How can we prepare young for aging? JJC

  31. Healthier Older Population ? • Fries (1984), Compression of morbidity • Palmore (1986), relative health of elderly has improved • Rogers (1990), living longer and healthier • Manton (1995), significant decreases in prevalence of 16 medical conditions • Cassel (2000), declining or postponing disease? • Natl Acad Sciences (2001), 65+ disabled down 6.5% since 1982 (26.2% v 19.7%)

  32. Prevention: Mortality, Disability and Morbidity % surviving Age

  33. In Search of the Secrets of Aging • Caloric restriction • Syndrome X • Heat Shock Proteins • Hormones • Immune system • Longevity genes • Cell senescence • Oxygen radicals • Glycation • DNA Repair

  34. Biomedical model Acute episodes Individual Cure Disease Multi-factor approach Chronic illness Communities Adaptation Person /disease Institute for the Future:Health Care Paradigm Shift

  35. Financing Medical Care • HMOs • Personal responsibility

  36. Health Care Premium and Cost Annual % Increase, 1991-2000 Source: Center for Studying Health System Change, 11/00

  37. Health Care Financing • "Soaring" prescription drug costs will likely soon lead to "large increases" in workers' health insurance premiums and to "changes or cutbacks" in prescription drug benefits. • Hartford Courant, 4/24/01

  38. Percent Change per capita in Health Care Expenditures, 1998-2000 Source: Center for Studying Health System Change, 11/00

  39. “Workers Pay More for Care” (USA Today, 4/5/01) • % of Rx price rather than flat co-payment • Varying percents based on type of condition - chronic, acute, lifestyle • Two-tier health plans - limited benefits • Varying co-payments - will AMC reputation cost more? • Increase share of premiums > 33%

  40. Paths to ReformBlumenthal, NEJM, 2001 • Defined contribution plans • Medical savings accounts • Increased co-payments • Increased deductibles • Government price controls

  41. Economic Value of Long-term Care Source: Arno, Levine, Memmot (1999) Health Affairs

  42. Delivering Medical Care to Older Persons • Geriatricians/ Anti-aging physicians • Geriatric Training for Health Care Professionals • GEMs • Telemedicine

  43. Need for Primary Care Physicians certified in Geriatrics Source: Alliance for Aging Research, 1996

  44. Ronald Klatz, M.D.founding physician of the anti-aging medicine movement • Today's boomers will live, on average, to see age 100. Some boomers will celebrate their 130th birthdays healthy, happy, with full mental and physical faculties intact. • New method to collect organs from non-beating heart donors, expanding the bank of organs for transplants • A genetically engineered "gene therapy" cure for male pattern baldness. • At home 2-way telemedicine consultations between many elderly persons too frail, too weak, or just too busy to drive to their doctor appointment. • Inhaled drug delivery systems e.g. Insulin

  45. Geriatric Medicine Update “Loss of function from habitual inactivity, poor nutrition, disease” • Exercise - improved walking, balance, ROM = decreased risk of morbidity, mortality, institutionalization • Exercise, dietary restriction, sodium limit - 60% of older hypertensive patients weaned from medication • Biophosphanates - decrease bone resorption • NSAIDs, estrogen = possibly effective against cognitive decline Applegate and Pahor, JAMA, 1997

  46. Improving chronic conditions • Counseling/ Tx on smoking cessation • Counseling/ Tx on diet • Counseling/ Tx on exercise

  47. Self-reported arthritis prevalence per CDC MMWR May 04, 2001 / 50(17);334-6

  48. Model of Telehealth Telehealth Tele-education Telemedicine Telecommunications / Internet Patients Students Providers

  49. Telemedicine and geriatric care • A telemedicine system as a care modality for dementia patients in Korea. • Lee et al. Alzheimer. Dis. Assoc. Disord. 2000 • "Electronic House Call" with a primary care physician - 61% reported they were comfortable using the computer system without assistance. No negative effect on physician relationship seen. (Bratton and Cody, Mayo Clinic Proc, 2000)

  50. Electronic minders • Infrared sensors can follow Shizue Ozasa's every move as she maneuvers around her room. • Chips in her shoes can trigger locks should she try to leave. • A database can record everything she does. • Big Brother at his most benevolent--and most lucrative. • NAIS Care Owada, a nursing home in Osaka Oldies Look Golden to Japan Inc. (WSJ)

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