With the recent failure of the proposed American Health Care Act, everyone is wondering, now what?
Some say Trump and the Republicans will let the Affordable Care Act collapse, while others think the ACA will be amended piece by piece. But both sides are asking the wrong questions – or rather, aren’t asking the right one: How can the U.S. health care system be reconstructed for an aging population?
Answering this question could provide the opportunity to forge fresh, bipartisan solutions for the most important health care megatrend of the 21st century.
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A U.S. health care policy framework will be effective only if it addresses the twin trends of longevity -- people living longer lives and population aging – both of which drive our skyrocketing health care costs and impact our ability to pay for those costs. But neither Democrats nor Republicans have proposed (or even discussed) viable solutions.
The health care debate is stalled in part because it rests on outdated assumptions. When we died in our 60s, and when each family had four or more children, those in traditional working age could support those in traditional retirement. But these conditions have changed. Average life expectancy is approaching 80 and babies born today are likely to live to 100, with more older adults suffering for longer with chronic conditions like heart disease, diabetes, cancer and Alzheimer’s, breaking family and national budgets.
This has serious public policy implications. National public insurance systems, like the ACA or the UK’s National Health Service, hold health care as a right of citizenship. This is a nice sentiment, but 21st century population aging makes it unworkable. For example, the National Health Service was founded in 1948, but has been foundering since the 1970s due to a profound shift in the age structure of the British population. With more than 60 million Americans age 60+ facing increased health care needs, any national insurance plan will struggle to answer the question of “who will pay?”
But solutions are possible, if we reframe the debate. Instead of a focus on who is paying, we should place our emphasis on how to reduce the spending itself. How do we create a healthier aging? Three changes offer the greatest potential:
First, shift from what amounts to “sick care” to true health care, which prioritizes prevention and wellness to preserve functional ability. As the new World Health Organization Strategy on Health and Ageing lays out, this requires dedicating our resources to keeping people well and enabling healthy, active aging, not just treating disease. We must tackle the “conditions of aging,” such as declines in vision, hearing and oral and skin health, which have traditionally been under-addressed. We need different definitions and expectations of health that include these conditions, faced by the nearly 1 billion of us on the planet over age 60.
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Organizations like the WHO and the American Skin Association are leading the way. For example, just last week, when Americans were witnessing the AHCA fiasco, the American Skin Association issued its “Seven Principles for a Lifetime of Healthy Skin” to guide functional ability both for 100-year lives and acute older American needs. Healthier skin across our life course could profoundly affect spending during an era of longer lives.
Second, shift our approach to elder caregiving, from largely government-subsidized institutional care to private in-home care. The 80+ demographic is the fastest growing segment of our society, and high-quality home care can mitigate the huge costs associated with older adults’ physician visits, hospitalizations, re-hospitalizations and medicine compliance. Done right, this model of home care can also deepen cost savings by deploying modern innovative technologies, such as remote patient monitoring.
Third, shift away from reflexive criticism of private-sector innovation from the pharmaceutical and medical device industries. Spending on novel therapies for costly and lethal diseases was once considered part of the miracle of 20th century innovation. We need to revive this celebration of biomedical progress, whether it’s prosthetics for more active aging, a cure for Alzheimer’s or an application of the childhood immunization approach to adult vaccines as a part of 21st century prevention strategies.
All of these breakthroughs require a basic, society-wide attitude change to understand that spending on these therapies is not a cost, but an investment. Pharma innovation in the latter part of the 20th century was a critical driver of our 21st century longevity. Why not re-engage this innovative sector as a partner to improve the quality of our long lives, reduce disease, and manage the aging cost burden?
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Sure, changes to the ACA may still come. But rather than waiting for unlikely political consensus on insurance policy, we should refocus the debate on the bigger picture of aging in American society and how we can manage the associated health costs and challenges.
