Health Care in the 21st Century
William D. Novelli
Executive Director and CEO, AARP
ACP-ASIM Dinner
American College of Physicians
Washington, DC
May 21, 2002
Today is a special day for me. Not just because of the opportunity to be here with you this evening…Today is my birthday. I'm 61. I tell you that not because I expect any presents-though this dinner was quite nice-and not because I expect you to sing "Happy Birthday."
I tell you that because when I was born in 1941, 61 was considered old. After all, life expectancy was only 62. I don't feel old. And, I don't feel young either. I just feel good-happy to be where I am.
Age has many benefits. One of them is the sense and the patience to stop and define terms, which is the first thing I want to do this evening. Let me begin with the elderly, with older people.
Who are they? What are they? We can say arbitrarily that they are people who have reached a certain age. That age can be 50 or 65 or anything else we choose, and perhaps for administrative reasons we have to make that choice. It would be hard to run Medicare, for example, if we decided that some people were officially senior members of the population at 49.8 and others at 73.7. A specific number may help define, but it is not determinative. Let me explain what I mean with a little story.
A couple of years ago, a member of AARP's Board said that her mother considered herself old-not middle-aged, but old-just after she turned 50. This member was 79 at the time and thought she was just beginning to get old. This is not, I think, an exceptional case. People really are aging more slowly than they used to. They certainly perceive themselves to be aging more slowly. Moreover, both life expectancies and actual lives are getting longer and longer. A hundred years ago, life expectancy in America was less than 50. Today it is nearly 80. When Henry Ford announced a retirement program for workers when they reached 65, he was offering virtually nothing since few people lived that long. Some 70 years later, however, one American in eight is that old.
Here are a few more ways to underscore the importance of the point:
- In 1900, 13 percent of the population was 50 or older.
- Today it is more than 27 percent-or nearly 80-million people.
- In less than 20 years, it will be 35 percent-more than one in three Americans.
- The median age in the U.S. today is about 34. By 2020, it will 38-and it will be even higher in countries like Italy, Japan, China, and France, where the replacement rate is falling.
- People turning 50 have half of their adults lives ahead of them.
These changes-for which we can in large part thank public health measures like sewers and vaccines and advances like improved medications and treatments-have altered the idea of aging and our society as well. We derive, on the one hand, a "vitality bonus," more years of happiness and productivity. But they leave us facing, on the other hand, the plain fact that more people will need more care.
What is further changing our culture-and will soon put more pressure on health care-is the Baby Boomer generation, the people born between the end of World War Two and the arrival of the Beatles. We pay close attention to boomers because there are so many of them-about 76 million, nearly 10 percent more than the generations on either side of them. We also need to pay special attention to them as they age because they will be as demanding and innovative as they have been all their lives. They have set the tone and determined the mood of this country for a long time-and they're not about to stop now. Their contributions and their needs will continue to affect the outlook and the well-being of America. They will change aging in America and in other countries as well.
Adapting to this change-or rather, to all these changes-is serious business. At AARP is to use the age of 50 as the tipping point for aging. Like any other number, it is arbitrary. It is, of course, the eligibility age for membership in AARP. It also has the advantage of being young enough to plan, to look ahead in one's own life, and to make changes that will lead to a healthier and better quality of life as one gets older.
Last year, we began a series of reports on the state of 50+ America. Our first report was "Beyond Fifty: A Report to the Nation on Economic Security." That report looked at how over 75 million people age 50+ are faring as they prepare for and experience retirement. The study also identified some new trends that are emerging as the baby boomers turn 50. One of the most significant is that retirement security today and in the future must be built on four strong pillars, one of which is health insurance. Our research told us that escalating health-care costs so profoundly affect the pocketbook that adequate health-care insurance must be the fourth pillar of retirement security. Out-of-pocket health costs average 19 percent of income for persons 65 and over in the U.S. The percentages are even higher for those with low incomes: those without Medicaid spend almost HALF of their total income on health care. Without significant protection from health-related expenses - especially for prescription drugs and long-term care - few people in today's 50+ America can be economically secure. And, as all of you know, neither of these two important benefits is included in Medicare.
Next week, we will release the second report in our "Beyond Fifty" series. This one builds upon last year's report to offer a "Report to the Nation on Trends in Health Security." Now, I don't want to give you all the details of the report, but I would like to share with you some of the trends we see on the horizon and what we are doing to begin to address them.
Changes in the health security of 50+ Americans have been-and will continue to be- driven largely by five primary factors:
- Increased reliance on prescription drugs and other new health technologies has brought about major changes in the delivery of health care and has driven health-care costs and coverage structures.
- Chronic diseases and conditions are common among people over age 50, especially in the oldest age segments. They have placed greater demands for a health-care delivery system that provides more than just acute care. While there is a high prevalence of chronic conditions among the 50+ population, even among the 50-64 year-olds, the systems that serve the chronically ill remain oriented largely toward acute medical care. Increasingly, the health-care needs of this population involve a range of services that span the spectrum of physician, inpatient, outpatient, and long-term care.
- Greater longevity-and the functional limitations that accompany old age-have highlighted the need to live more independently and increased awareness of the quality of life, especially during the last stages of life.
- There is increasing recognition among those who provide or pay for care that patients need to be treated as customers who, if given information to make choices about quality and value, will "vote with their feet." Informed decision-making is an increasingly important-yet often missing-dimension in consumer thinking about health security. For those needing long-term care especially, the challenge of navigating a fragmented, uncoordinated, patchwork of public and private programs.
- High and rising health-care costs make care less accessible for many 50+ Americans. Average spending per person over age 50 has increased fueled largely by the increase in chronic conditions and spending for prescription drugs. Out-of-pocket spending on prescription drugs and long-term care represent the greatest health-related financial risk for older Americans.
At AARP, we have several initiatives underway to address these trends and concerns. We recognized long before we did this report-and this report certainly confirms it-that Medicare needs to cover prescription drugs. Getting prescription-drug coverage in Medicare is our top legislative priority, and we're pulling out all stops make it happen.
While modern medicine increasingly relies on drug therapies, the benefits of these prescription drugs elude more Medicare beneficiaries every day. Drug costs continue to rise unabated. Employer-based retiree health coverage is eroding. Managed-care plans in Medicare have scaled back their drug benefits. The cost of private coverage is increasingly unaffordable. State programs provide only a limited safety net. Therefore, the need for a Medicare drug benefit will only continue to grow.
Given the prominence of drug therapies in the practice of medicine, if Medicare were being designed today - rather than in 1965 - not including a prescription-drug benefit would be as absurd as not covering doctor visits or hospital stays.
Our members tell us just how urgent the need is. Many echo the sentiment expressed by the concerned daughter who wrote us this letter: "My parents are on Medicare AND paying for gap insurance, and yet they cannot afford their medications. They would have so much more dignity in their life if they didn't have to use every discretionary penny for drugs. I hope we as a nation can find a way to help our older people live a life of health, safety and dignity."
A recent poll conducted for AARP found that 81 percent of the respondents age 45 and over favor making prescription drugs part of Medicare, and eight in ten also consider it a very important priority for the President and Congress.
Yet, the challenge in crafting a workable Medicare drug benefit is considerable. To succeed, it must attract enough voluntary enrollees to make it a viable program, and it must meet the "kitchen table test." Our members expect to pay their fair share. But, they will sit down at their kitchen tables and carefully consider whether the benefit that's offered provides real value that they are willing to pay for.
Our members are also realistic. They recognize that a Medicare drug benefit may not be as generous as most working Americans have now, but they do expect Congress to begin this year to provide a meaningful benefit that meets the kitchen table test and that includes, at a minimum:
- An affordable premium and coinsurance;
- Catastrophic stop-loss protection that limits out-of-pocket costs;
- A benefit that does not expose beneficiaries to a gap in insurance coverage,
- Additional assistance outside of Medicare for low-income persons; and
- Quality and safety features to curb unnecessary costs and prevent dangerous drug interactions.
We strongly believe that sound public policy should drive the funding of a prescription-drug benefit, not the other way around. A Medicare prescription-drug benefit will require a sizable commitment of federal dollars at a time when budget constraints are greater than last year.
We are urging the Congress to earmark $350 billion for prescription drugs and reforms that strengthen the program. To find the additional funds required to ensure a viable benefit, Congress should establish a reserve fund equal to the amount of surplus in the Medicare trust fund, roughly $400 billion. This will give Congress the flexibility to craft a prescription-drug benefit that is closer to what many believe adequate coverage will cost, and will better ensure that such a plan can be driven more by policy than by numbers.
We realize that Congress and the Administration are being squeezed by competing demands and limited budget dollars to meet those demands. While prescription-drug coverage is the number one priority issue facing Medicare, it is not the only issue. Medicare needs simplifying, providers need to be paid fairly and other reforms are needed. Congress faces a difficult task in finding a balance among these competing demands, but should look for ways to prioritize and meet them.
To be affordable and sustainable, the Medicare drug benefit will need strong and effective cost containment measures. We believe the government and health-care consumers all have a role to play in cost containment. To that end, we have initiated a national campaign to educate our members and the general public about the wise and safe use of medications - including generic drugs.
Research shows that even though people 45+ are taking lots of prescription drugs-especially those 65 and older-they are not realizing the full benefits of these drugs because they're not taking them as directed. Moreover, many are not using generics despite their comparable efficacy and lower cost. We know this is a great frustration to physicians who prescribe medications to help their patients, but can't be sure they are taking them as prescribed-or in many cases, even filling the prescriptions.
So, as part of our effort to get prescription-drug coverage into Medicare and drive down costs to make the program sustainable over time, we are undertaking this effort to educate consumers about how to purchase medications more cost efficiently, and how to use medications wisely.
We want to ensure that adults 50+ use their prescription drugs wisely. And, we want to take a leading role in educating people about generics so they feel comfortable taking them if it is medically appropriate. This is especially important because direct-to-consumer advertising for name brand drugs often seems to suggest that they are the most effective therapy or the only therapy, even when similar alternatives could work just as well.
Our campaign has three broad objectives:
- Improve the nation's health-especially Americans 50+ and Medicare beneficiaries.
- Reduce health-care costs by increasing the appropriate use of generic medications when they are medically appropriate and reducing the incidence of inappropriate drugs being prescribed to people over 50.
- And, support ongoing advocacy for a prescription-drug benefit in Medicare.
This comprehensive consumer education campaign includes:
- A national print and television ad campaign aimed at reaching Americans age 50+. TV spots will appear on nightly news shows, daytime programs and public affairs shows. Print ads will appear in national magazines-such as Time, Newsweek, People, Readers' Digest and Good Housekeeping-and opinion leader publications-such as The Washington Post, New York Times, Roll Call, The National Journal, and Congress Daily. The campaign will run from April through August 2002.
- An 8-page educational insert in the September/October issues of AARP Modern Maturity and My Generation. Reprints of the insert will be further distributed through state offices and campaign partners.
- Partnerships with national corporate and non-profit associations, including the American Geriatrics Society, United Health Care, and others.
- Distribution of Point-of-Sale materials (counter card with "take one" inserts) on the wise use of prescriptions. These will be at retail pharmacies and physicians offices nationwide.
- New content on AARP's web site that includes consumer information on the wise use of medications, as well as links to other articles and resources on prescription drugs.
Our goal is for medications to do people the most good, and at the same time help to lower the cost of prescription drugs. We also want to make the point that our own health and well-being are in our hands just as much as they are in our doctors'.
But helping people take responsibility for themselves is where well-being begins. We are all familiar with the phrase "a healthy mind in a healthy body." The entire statement is, "Pray that you might have a healthy mind in a healthy body." Prayer is fine, but getting regular check-ups also helps. So does proper use of medication, giving up smoking and drinking only in moderation. Staying engaged with people and life around you helps and so does a sound diet.
In 1991, 22 percent of Americans were obese. By this year, the percentage had increased to 30 percent, and the projections for 2025 are 42 percent. That is scary. As all of you know better than I, being seriously overweight is a precursor to many dangerous conditions and diseases-diabetes, heart attack, stroke, liver failure, and bone damage being just a few.
We also conclude in our Beyond Fifty Report that obesity threatens to undermine many of the health gains we have made in the past 20 years.
Lack of fitness, apart from contributing to being overweight, brings on its own problems, including a slowed metabolism, depression, brittleness of bones, and poor circulation. A recent study reported in the New England Journal of Medicine found that poor physical fitness is a better predictor of death than any other risk factor, including smoking, high blood pressure and heart disease. Being a couch potato is not funny-or fun. So we are telling our members to get off their… couches.
We will provide constant reminders-through all the channels of communication we have at our disposal-that exercise and fitness matter. And let's not underestimate the value of message reinforcement. In 1964, the Surgeon General warned about the dangers of smoking and we began seeing warning messages everywhere. People didn't all throw away their Camels and their Marlboros the next day, but more and more have-or never started smoking at all. Adult smoking is down by over 50 percent in those years. In the same way, education about fitness may be painstaking-but it's worth taking the pains to avoid the worse pain of an unhealthy body.
So we are getting our message out-including telling people what they can do to exercise-through grassroots activities, our publications, state activities, community service, new products and services to help with fitness, and through partnerships with others. And we are looking for more organizational partners.
We already have some wonderful allies in our efforts to improve fitness among older men and women. With a grant from the Robert Wood Johnson Foundation we just launched pilot fitness programs in Richmond, Virginia, and Madison, Wisconsin. Interventions in these two cities will provide the experience and knowledge we need to expand this Be Active for Life program in the future.
And last year, in partnership with USA Triathlon, we introduced our Tri-Umph Classic Triathlon-swimming, biking, and running-in six cities. This was the first such multi-sport event for people over 50. And we didn't just tell people to sink or swim. The program begins with an optional six-to-eight week training course. These successful events have expanded our commitment to physical activity and have paved the way for more. This year, we will hold the Tri-Umph Classic in 15 cities. Fitness takes work, but the sweat equity pays off. We look forward to seeing more triathlons for adults 50+-and more 50+ adults in great shape as the years go by.
Aging is a process, not a chronology. So, we must understand the process that people go through-and the needs they have-as they strive to continue living independently, as they face the need for long-term care, and confront decisions and seek quality care at the end-of-life.
As part of our Life Choices Campaign, we are working with other organizations to develop ways to help people with life choices around these issues. We are developing a national, integrated program in collaboration with our partners, and we have identified the outcomes that will set the direction for this work. We anticipate a long-term, collaborative effort that will include advocacy, community service, information and education and other strategies. We see this as an important opportunity to make a real difference in people's lives and in the nation's well being.
One area where we could really use your help is end-of-life care. We need to eliminate the barriers to using Medicare's hospice benefit so more people will take advantage of it. More health-care professionals need to be trained in geriatrics and trained to manage pain better as well as deliver palliative care.
And, families need to communicate with each other about their end-of-life wishes-from drawing up advanced health-care directives to burial arrangements. In today's America, end-of-life quality care is sadly lacking. We can do better. And, we will when Americans demand that we do better.
And that brings me back to where I began. We have come a long way in my 61 years, but there is still much for us to do. We are fighting for prescription-drug coverage in Medicare. We are promoting wise use of medication and physical activity. But there is a great deal of room for improvement. Independent living and long-term care and improving care at the end of life present us with serious challenges, but also great opportunities to make a difference.
Look at some of the progress we have made-Medicare, prohibitions against mandatory retirement because of age, medical advances in therapies and diagnostics, the founding of the National Institute on Aging, a growing awareness that health and fitness mean more than chronological age, better health for people over 50, longer life expectancies. There is a lot to feel good about because we know more and more about aging, and aging itself is getting better for us all.
As physicians, you have contributed greatly to this progress. In the same way, we all can collaborate in the work that remains to make aging secure, healthy, independent and productive. No one can do it alone. No one ever has. There is no such thing as a monopoly on good ideas or hard work.
I am greatly encouraged about the potential that we have at AARP to work in partnerships to accomplish great things. Together, we can help future generations understand that age is just a number; and life is what you make it.
