While most of the current healthcare debate has focused on how to cover the tens of millions of uninsured Americans and who should pay (granted, these are critically important issues), after thirty-five years working at the intersection of gerontology and healthcare, I'm convinced that we have the WRONG healthcare system for our aging nation. If your train is headed in the wrong direction, it doesn't help to give everyone a seat. And, since the U.S. currently spends nearly twice as much per capita on healthcare as all the other modernized nations, while our national life expectancy ranks a humiliating 42nd worldwide, it's not that we throw too little money at the problem, but that we may not be spending it in the wisest ways.
The Age Wave is Coming
Until recently, most people died relatively young of infectious diseases, accidents, or in childbirth. When the first US census was taken in 1790, half the population was under the age of 16 and less than 2 percent of the 4 million Americans were 65 and older. As a result, society rarely concerned itself about the needs of its aging citizens. The elderly were too few to matter.
However, during the past century, advances in medical diagnostics, pharmaceuticals, surgical techniques, and nutrition have eliminated many of the problems that once caused most people to die young. And so, the irony is that our medical successes have produced tens of millions of long-lived men and women who now struggle for decades with debilitating chronic illnesses such as heart disease, cancer, arthritis, osteoporosis, COPD and Alzheimer's -- that our system is absolutely NOT prepared to handle -- causing immeasurable suffering and trillions of misspent tax dollars.
With the average life expectancy having vaulted to 78 (and rising), the 13% of our population over 65 now accounts for: 44% of hospital care, 38% of all emergency medical services responses, 35% of all prescriptions, 26% of all physician office visits and 90% of all nursing home use. And, the first of the 78 million boomers will become eligible for Medicare in only 18 months!
The Four-Part Solution
#1: Multiply the amount of scientific research needed to delay or eliminate the diseases of aging.
In May 1961, President John F. Kennedy looked to the sky and stated, "I believe this nation should commit itself, before this decade is out, to landing a man on the moon and returning him safely to earth." In response, we mobilized all of our science and energy to realize that dream a short eight years later.
Similarly, in order to avert the costly chronic disease pandemics looming in our future, we must bring about a commitment of sufficient intelligence, creativity and resources to replace unhealthy aging with healthy aging.
The dollars that have been committed to the life sciences to battle the diseases of aging, however, are woefully inadequate to get the job done. For each tax dollar we currently spend on treating disease, only about one cent goes to fund the scientific research that could delay or prevent some of these dread pandemics in the first place. For example, it is estimated that if we could postpone the onset of Alzheimer's disease by five years, half of all the nursing-home beds in America would empty.
#2: Make disease prevention and self-care a national priority.
Let's be honest....we've become a nation of gluttons. We eat too much, exercise too little and then get angry at the healthcare system when we're sick. This lack of proper prevention, self-care and disease management winds up being a key factor in many of our eventual struggles with illness. This is even true among the elderly. For example, 9% of the 65+ population remain chronic smokers, a third don't exercise regularly, 40% are overweight and 23% are considered obese.
According to the Centers for Disease Control, more than 50 percent of our potential for lifelong health is determined by our personal behaviors. Maintaining a healthy lifestyle can reduce heart disease, hypertension, non-insulin-dependent diabetes mellitus, colon cancer, and osteoporotic fractures -- most of the most common diseases of aging.
Our healthcare system should be focused on helping and motivating us all to compress the various diseases of old age into the shortest possible time at the very end of life - and thereby raise the odds of living long and well (which would please both Mr. Spock and Dr. Spock). (I wonder why Michael Moore neglected to mention self-care in his otherwise provocative documentary Sicko? Was it because it's far easier to "blame the system" than it is to take responsibility for one's own role in the problem?)
#3: Replace medical incompetence with aging-ready healthcare professionals.
When the leading edge of the baby boom arrived in the mid-1940's, America and its institutions were totally unprepared. Waiting lists and long lines developed at hospitals across the country, apartments and homes didn't have enough bedrooms for boomer kids and there was a shortage of baby food and diapers.
With the coming age wave, we should be preparing armies of "aging-ready" healthcare professionals. We aren't. Less than one percent of all the physicians in America have been trained and certified as geriatricians. However well-intentioned they may be, most primary-care physicians have received little or no continuing education in geriatrics. The same holds true in nursing, allied health, and pharmacology.
Every medical school in the United Kingdom has a department of geriatrics. But with 130 medical schools, there are, amazingly, only thirteen such departments in the entire United States. Because of limited geriatric competency, every week our physicians make millions of costly mistakes: misdiagnoses, inappropriate surgeries and punishing complications due to faulty medication management (polypharmacy).
If AARP, the AMA, the Centers for Medicare and Medicaid Services and all health insurers required physicians, nurses, and other health professionals to attain basic geriatric competencies in order to be eligible for reimbursement, mistakes and do-overs would shrink, and we'd have better-cared-for older adults at a far lower cost.
#4: Palliative care: death with dignity.
A century ago, 75 to 80 percent of all deaths took place at home with family and friends on hand. Roughly the same percentage of all deaths now occur in institutions -- hospitals, extended care facilities, and nursing homes.
In fact, Medicare spends approximately 28 percent of its total budget on patients in their last year of life -- sometimes when the attempt to prolong life merely means an expensive, inhumane, high-tech death. And something that no one seems willing to talk about is the fact that the extension of dying in this fashion all too often becomes a capitalist feast as some medical companies see their profits grow, the longer the dying process is extended.
We'd be wise to shift the emphasis for the dying patient to "palliative care" or hospice care -- which focuses on the relief of symptoms, controlling pain, and the provision of emotional and spiritual support for the patient and their family. Such treatment requires relatively little apparatus and technology, is much less costly than the procedures currently in place in most hospitals and provides for a far more humane and dignified last stage of life.
The Challenge Ahead
On January 1, 2011, the first baby boomer will turn 65. Whether we grow old sick, frail, and dependent -- or vital, active, and productive -- will depend on our ability to dramatically alter the orientation, strategies, skills, and financial incentives of our current healthcare system. And so, while we're focusing now on the coverage and financing of our damaged healthcare system, we should also focus on re-visioning healthcare's purpose -- to create long-lived, productive and healthy men and women.
I welcome your thoughts and reactions!
Ken Dychtwald, Ph.D. is a psychologist, gerontologist and author of sixteen books on aging, life transitions, and retirement-related issues including Age Wave, The Power Years, Healthy Aging: Challenges and Solutions, and his new book, With Purpose: Going from Success to Significance in Work and Life (with Daniel J. Kadlec, Collins Life; 3/09). The founding CEO of Age Wave, he lives with his wife and children in the San Francisco Bay Area.