The Implications of an Aging Population Steven P. Wallace, Ph.D. Professor, UCLA School of Public Health Assoc. Dir., UCLA Center for Health Policy Research swallace@ucla.edu The reading for today is now 10 years old, but unfortunately the trends and issues it raises are still relevant today. Key points: Demography Is Not Destiny Medicare: Myth versus Reality (not affluent beneficiaries, not overgenerous benes, not inefficient; restructuring?) LTC & end of life need work Can Promote health of older adults Challenges – shared prosperity, pt centered care, Steven Wallace - PH150 - 14 Nov 2013 1

Today’s talk Why is American growing older? Should we care? Nation’s health promotion goals Public health approach to aging

1. Why is American growing older? The Implications of an Aging Population 1. Why is American growing older? Population versus individual aging How Many People have Family age 65+, 75+, 85+ How Many aspire to live to at least 65? How many want a sick and dependent old age? Interests in child health, AIDS, environmental health, etc ... all work to help people live to old age... so don't stop! Steven Wallace - PH150 - 14 Nov 2013 3

The Implications of an Aging Population Fertility changes past century Annual live births per 1,000 women aged 15-44 years Note high rates at beginning of 1900s 127/1000 in 1910 Depression bottom 1933 @ 76 Baby boom generation (1946-1964) 1957 @123 Stable birth rates since 1980s @ mid-60s 2008 SOURCE: NCHS, http://www.cdc.gov/nchs/data/statab/natfinal2001.annvol1_01.pdf & http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf & Health U.S., 2011 Steven Wallace - PH150 - 14 Nov 2013 4

Total fertility Number expected lifetime births per woman The Implications of an Aging Population Total fertility Number expected lifetime births per woman http://www.cdc.gov/nchs/data/hestat/finalbirths04_tables.pdf How many of you are only children? Children ever born, women age 40-45 1957 1976 2002 3.7 3.1 1.9 SOURCE: NCHS, http://www.cdc.gov/nchs/births.htm Steven Wallace - PH150 - 14 Nov 2013 5

Percent women 40-45 w/o kids The Implications of an Aging Population Percent women 40-45 w/o kids About half wanted children & did not have them; the other half never wanted kids SOURCE: Pew Research Center, 2010 www.pewsocialtrends.org/2010/06/25/childlessness-up-among-all-women-down-among-women-with-advanced-degrees/ Steven Wallace - PH150 - 14 Nov 2013 6

= Fewer babies

The Implications of an Aging Population Concentration of death in old age In 1900, 41% live to old age, in 2006 83% do * In 1900, 1/5 white and 1/3 black children did not survive their 10th birthdays. Only 41% newborns made it to age 65; today 83% do. Over 1/3 make it to 85 (vs. under 1/10 in 1900). [Table 10] * Improvements in survival post 1950 MOSTLY among older adults http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_09.pdf Steven Wallace - PH150 - 14 Nov 2013 8

The Implications of an Aging Population Life expectancy at age 65 50% increase in last century white total life expectancy 1900=49.6 years, 2004=78.3 Black total life expectancy 1900=33.8 years, 2004=73.1 IMPORTANT to add life to years, not just years to life Source: http://www.agingstats.gov Steven Wallace - PH150 - 14 Nov 2013 9

The Implications of an Aging Population Life expectancy at age 65 Racial disadvantage continues into old age Source: http://www.agingstats.gov Steven Wallace - PH150 - 14 Nov 2013 10

The Implications of an Aging Population Why is America aging? Declining birth rates = fewer kids Declining mortality rates = more elderly Steven Wallace - PH150 - 14 Nov 2013 11

Population, Number Kids & Elders, 1900 - 2050 The Implications of an Aging Population Population, Number Kids & Elders, 1900 - 2050 Number of elderly will double in 30 years 2040=81.2 million 2010=40.2 million elderly Relatively easy to predict the # of elders in the future 2010 forward: http://www.census.gov/population/projections/data/national/2008/summarytables.html Source: U.S. Bureau of the Census, p25-1130 & historical statistics Steven Wallace - PH150 - 14 Nov 2013 12

Minority elderly population, 2000-2010 The Implications of an Aging Population Minority elderly population, 2000-2010 Numbers triple 30 years 2030=17.6 million Relatively easy to predict the # of elders in the future 2000=5.6 million Source: U.S. Bureau of the Census, p25-1130 & historical statistics Steven Wallace - PH150 - 14 Nov 2013 13

The Implications of an Aging Population Percent 65+, 1950 to 2050 Baby boom 1950: China, Japan, Egypt all had low % (5) elderly. Japan changed fastest, China coming on soon as one-child policy works into adulthood. Will be first country to become “old” before it becomes “rich.” Egypt still very young! US 8% to 16% in 70 years(1950-2020) Italy 8% - 16% in 45 years Japan 8% to 16% in 25 years China 8% to 16% in 20 years (2010-2030)! 2000 Source: World Population Prospects: The 2008 Revision, http://esa.un.org/unpp Steven Wallace - PH150 - 14 Nov 2013 14

Growing Diversity of Elderly in California, % nonLatino white The Implications of an Aging Population Growing Diversity of Elderly in California, % nonLatino white The composition of California’s elders is also changing rapidly. Not long ago it was 2/3 nonLatino white. The latest projections show a pretty linear decline in the coming years in the proportion white. Source: California Department of Finance, January 2013 http://www.dof.ca.gov/research/demographic/reports/projections/P-2/ Steven Wallace - PH150 - 14 Nov 2013 15

Growing Diversity of Elderly in California The Implications of an Aging Population Growing Diversity of Elderly in California By 2050, the largest group of elders in the state will be Latinos. Not shown are Asian elders (18% in 2050) and African Americans (5%). This means that the way services WERE designed need to be adapted to address an increasingly diverse population of elders. 2000 from: California Department of Finance, July 2007 www.dof.ca.gov/HTML/DEMOGRAP/ReportsPapers/Projections/P3/P3.asp Source: California Department of Finance, January 2013 http://www.dof.ca.gov/research/demographic/reports/projections/P-2/ Steven Wallace - PH150 - 14 Nov 2013 16

The Implications of an Aging Population 2. Should we care? Steven Wallace - PH150 - 14 Nov 2013 17

The Implications of an Aging Population 2012 Elections Romney The tease. Age & race in politics. Common pattern. BUT – there is NO difference by age among groups other than whites. REPEAT. http://www.gallup.com/poll/154712/presidential-election-age-factor-among-whites.aspx Obama http://elections.nytimes.com/2012/results/president/exit-polls Steven Wallace - PH150 - 14 Nov 2013 18

Total Dependency Ratio [0-18 + 65&up / (19-64)]*100 The Implications of an Aging Population Total Dependency Ratio [0-18 + 65&up / (19-64)]*100 What does this tell us? Highest TOTAL dependency will be lower than peak of baby boom. But more will be made up of older adults. http://www.census.gov/prod/1/pop/p25-1130/p251130b.pdf Sources: U.S. Census, P25-1130 (1996) Steven Wallace - PH150 - 14 Nov 2013 19

Labor Force Participation Rates The Implications of an Aging Population Labor Force Participation Rates http://www.bls.gov/opub/mlr/1999/12/art1full.pdf Rising Women’s LFP means more workers per nonelderly adult in both young & middle age! Source: Fullerton, Monthly Labor Review, Dec 1999 Steven Wallace - PH150 - 14 Nov 2013 20

Percent GDP spending on health vs. % population age 65+, 2006 The Implications of an Aging Population Percent GDP spending on health vs. % population age 65+, 2006 U.S. Germany Canada France Italy Australia What is the relationship between the % elderly and the % of national wealth spent on health care? None! Countries with the highest % elderly (Italy & Japan) have among lowest spending. Japan has HIGHEST life expectancy! UK Spain Japan Sources: Older Americans 2008 and http://www.who.int/whosis/whostat/EN_WHS09_Table7.pdf Steven Wallace - PH150 - 14 Nov 2013 21

Leading causes of death falling Persons Age 75-84, U.S. The Implications of an Aging Population Leading causes of death falling Persons Age 75-84, U.S. ++ Health of elderly is IMPROVING Why use DEATH??? CBV = stroke Lower Respir ~ COPD, includes chronic bronchitis, emphysema, asthma, and other SOURCE: NCHS, http://www.cdc.gov/nchs/datawh/statab/unpubd/natality/natab2003.htm And Health US 2008. Steven Wallace - PH150 - 14 Nov 2013 22

Disease patterns of the elderly U.S. 2010-11 The Implications of an Aging Population Disease patterns of the elderly U.S. 2010-11 Note arthritis is common…. Not cause of death but high cause of disability. Increase in Diabetes Also Hypertension 46% - 56% Cause for concern!!! Source: http://www.agingstats.gov Steven Wallace - PH150 - 14 Nov 2013 23

Disability at age 65+ is decreasing The Implications of an Aging Population Disability at age 65+ is decreasing Age-adjusted disability rates falling: 35% in 1992 to 29% in 2009 ADLs: getting out of bed/chair, walking, bathing, dressing, eating, using the toilet May be a combination of changing disease patterns, medical technology (hip, knee replacements), assistive technology (speaker phones), early diagnosis & treatment. Source: www.agingstats.gov Steven Wallace - PH150 - 14 Nov 2013 24

Fair/poor self-assessed health at ages 65 -75 decreasing The Implications of an Aging Population Fair/poor self-assessed health at ages 65 -75 decreasing Fair & poor (versus excellent, very good, & good) self assessed health declining, i.e. good health improving! SRH is excellent indicator of global health status Source: NCHS, Health U.S. 2008, http://www.cdc.gov/nchs/hus.htm Steven Wallace - PH150 - 14 Nov 2013 25

The Implications of an Aging Population Help With Daily Activities, Community Residents W/2+ ADLs, By Age Source: Kaye H S et al. Health Affairs 2010;29:11-21 Major Sources Of Help With Daily Activities Among Community Residents With Two Or More Activities Of Daily Living (ADL) Needs, By Age http://content.healthaffairs.org/content/29/1/11.long Steven Wallace - PH150 - 14 Nov 2013

Demography is not destiny The Implications of an Aging Population Demography is not destiny Proportion of the elderly population does not necessarily determine health care spending Higher rates of illness & disability, but… Continued health improvements can counter increased needs caused by growing population Public health approaches are the most promising to improve health outcomes of the elderly Steven Wallace - PH150 - 14 Nov 2013 27

3. Nation’s health promotion goals The Implications of an Aging Population 3. Nation’s health promotion goals #1-Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death Focus on the quality of the years, not just their quantity 4 goals: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. Steven Wallace - PH150 - 14 Nov 2013 28

Beyond disease: Geriatric health The Implications of an Aging Population Beyond disease: Geriatric health Chronic conditions: Falls, Disability, Urinary incontinence, Oral Health Environment: Food insecurity, Social support, Polypharmacy, Healthy communities See Wallace, Steven P. “The Public Health Perspective on Aging.” Generations. 29:2(2005) http://www.generationsjournal.org/generations/gen29-2/article_thepublichealth.cfm Everyone worries about Alzheimers … or cancer… or a stroke, BUT many issues that are not diseases impact healthy aging Steven Wallace - PH150 - 14 Nov 2013 29

Multiple falls by age, California The Implications of an Aging Population Multiple falls by age, California Not only are falls most common among the oldest adults, but the oldest are also the most likely to suffer from injuries and even death as a result of their falls. Source: 2010-11 California Health Interview Survey Steven Wallace - PH150 - 14 Nov 2013 30

Food insecurity by income, age 65+ California The Implications of an Aging Population Food insecurity by income, age 65+ California It is particularly concerning that almost one quarter of low-income older adults with diabetes report food insecurity—a group that has the most difficult dietary requirements. Adults with diabetes living in food-insufficient households have been shown to have greater risk of complications from their diabetes and higher utilization of medical care. Source: 2010-11 California Health Interview Survey Steven Wallace - PH150 - 14 Nov 2013 31

Disability – Long term care The Implications of an Aging Population Disability – Long term care Does Medicare cover prolonged nursing home care? (35% correct) Does Medicare cover in-home personal care aid for chronic conditions? (21% correct) Voters age 40+ .. Most do not know coverage! NH no=35% Home Care no=21% Steven Wallace - PH150 - 14 Nov 2013 32

Geriatric Issues - Summary The Implications of an Aging Population Geriatric Issues - Summary Several challenges to healthy aging are common among the oldest and poorest elders Healthy aging is more than avoiding disease Steven Wallace - PH150 - 14 Nov 2013 33

4. Public health approach The Implications of an Aging Population 4. Public health approach Definition of Public Health = Assuring the conditions under which people can be healthy (Institute of Medicine, Committee for the Study of the Future of Public Health. The future of public health. Washington, DC: National Academy Press, 1988) Population / community / system focus Interest in prevention vs. cure Emphasis on health vs. disease Steven Wallace - PH150 - 14 Nov 2013 34

The Implications of an Aging Population Types of prevention Primary – prevent problem from happening, e.g. immunizations Steven Wallace - PH150 - 14 Nov 2013 35

The Implications of an Aging Population Types of prevention Primary Secondary – detect problem early and treat before serious harm results, e.g. blood pressure or breast cancer screening Steven Wallace - PH150 - 14 Nov 2013 36

The Implications of an Aging Population Types of prevention Primary Secondary Tertiary – after a health problem has happened, maximize independence & quality of life, e.g. rehab, in-home supportive services Steven Wallace - PH150 - 14 Nov 2013 37

Falls - a public health approach The Implications of an Aging Population Falls - a public health approach Primary – Promote physical activity, reduce polypharmacy, universal housing design (for all older adults) Secondary - Strength training, environmental modifications (for at-risk older adults) Tertiary – Counseling to decrease fear of falling, improve primary care ID/treatment of falls, social support interventions Note – most prevention activities are most effective when promoted at a community or group level, eg providing safe/interesting places for exercise (not just individual information); instituting pharmacy monitoring systems See Rizzo J, Baker D, McAvay G, Tinetti M. The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Medical Care 1996; 34(9):954-969. Steven Wallace - PH150 - 14 Nov 2013 38

Poverty – a cross cutting risk The Implications of an Aging Population Poverty – a cross cutting risk Primary – Assure a living wage with adequate health care and pension Secondary – Maintain the communal risk feature & disability benefits of Social Security Tertiary – Provide public assistance (SSI) at the Elder Economic Security Standard level project at the UCLA CHPR is to calculate the EESS for California. Steven Wallace - PH150 - 14 Nov 2013 39

Poor and near poor, Age 65 & Over, California 2010 The Implications of an Aging Population Poor and near poor, Age 65 & Over, California 2010 * nonLatino # may be of any race Source: U.S. Census, 2011 American Community Survey Steven Wallace - PH150 - 14 Nov 2013 40

Distribution of household expenditures, 2010 The Implications of an Aging Population Distribution of household expenditures, 2010 Source: 2012 AgingStats.gov Steven Wallace - PH150 - 14 Nov 2013 41

The Problem: Federal Poverty Guideline The Implications of an Aging Population The Problem: Federal Poverty Guideline The current measure needs to be revised: it no longer provides an accurate picture of the differences in the extent of economic poverty among population groups or geo-graphic areas of the country, nor an accurate picture of trends over time. The current measure has remained virtually unchanged over the past 30 years. Yet during that time, there have been marked changes in the nation’s economy and society .... (National Research Council, 1995, page 1) The federal standard of “poverty” is outdated, inaccurate, and inadequate Steven Wallace - PH150 - 14 Nov 2013 42

Elder Economic Security Standard (EESS) The Implications of an Aging Population Elder Economic Security Standard (EESS) Adjusted for local (county) costs of living versus national average Takes actual costs of basic necessities for older households Includes housing, food, transportation, health care, and other costs Steven Wallace - PH150 - 14 Nov 2013 43

The Implications of an Aging Population Elder Standard Index 2011, Single older adult , LA City & Humboldt County Monthly Expenses Los Angeles City Humboldt County Owner w/o Mortgage Renter, One Bedroom Renter, One Bedroom Housing $496 $1,137 $358 $688 Food 258 253 Transportation 239 Health Care=Good 182 403 Miscellaneous 237 251 Elder Index Per Month $1,422 $2,053 $1,504 $1,833 Elder Index Per Year $17,062 $24,640 $18,049 $22,001 Humboldt costs MORE for owner w/o mortgage because of higher HEALTH CARE costs. RENTER higher in LA. Health care costs are higher than rent for couples in 16 California counties where HMOs are not common. FPL = $10,980 Note: Numbers may not add up to total due to rounding. Steven Wallace - PH150 - 14 Nov 2013 44

The Implications of an Aging Population Conclusions The U.S is becoming older as a nation Demography is not destiny with improving health and changing medical practice Healthy aging goes beyond adding years to life and focuses on adding life to years – involves increased attention to chronic and nonfatal conditions Public health approaches to prevention using multilevel interventions are possible to reduce challenges to healthy aging… including using a more realistic assessment of “poverty” Steven Wallace - PH150 - 14 Nov 2013 45

The Implications of an Aging Population Thank you www.healthpolicy.ucla.edu Steven Wallace - PH150 - 14 Nov 2013 46