Chapter 7 Introduction

Millions of people are living longer in 21st-century America. 

By 2040, nearly 25 percent of U.S. residents will be over the age of 65, according to Census Bureau projections. Those age 80 and over are the fastest-growing segment of the population. The number of people in this age group will nearly double between now and 2035—from 6.5 million to 11.8 million—and nearly triple to 19 million by 2060. 

This increase in length of life, also known as longevity, results mainly from advances in public health, such as improved hygiene, vaccines, and other modes of disease prevention. Advances in medical science—including antibiotics and drug therapies for heart disease, hypertension, cancer, and diabetes—have also led to improvements in longevity. Another observed trend is that not only are most Americans living longer, but they are also living longer with better physical functioning. Studies that track older Americans’ changes in ability over time (measured as difficulty in performing either activities of daily living or instrumental activities of daily living) have shown a decline in the reporting of functional impairments. For example, one study found that older people experience more disability-free years than previously. The improvement has been greater for women than for men, with no difference noted by race. 

Despite positive trends in longevity, the U.S. has recently seen dramatic drops in how long a person might be expected to live. This is known as life expectancy. According to a report released in 2022 by the Centers for Disease Control and Prevention, life expectancy at birth declined nearly a year from 2020 to 2021. This decline has taken U.S. life expectancy at birth to its lowest level since 1996. American Indians had the biggest drop in life expectancy, followed by non-Hispanic/Latino whites. While there was a drop in their life expectancy for both men and women, the disparity between the two has increased. Men experienced a decline of 3.1 years while women experienced a decline of 2.3 years. Data released by the Organization for Economic Cooperation and Development in 2021 show the U.S. continues to rank low on many health indicators, including life expectancy, compared to most other member nations. 

Declines in life expectancy since 2019 have largely been driven by the COVID-19 pandemic. COVID-19 deaths contributed to nearly 74 percent of the decline from 2019 to 2020 and 50 percent of the decline from 2020 to 2021. Other causes accounting for these trends include poor diet, tobacco smoking, obesity, high blood pressure, high blood sugar, physical inactivity, and alcohol and other substance use. Behavioral modification can address these risk factors. 

Given these challenges to longevity, it is essential that health security be guaranteed across the lifespan. This requires access to affordable, comprehensive health insurance coverage that meets the needs of all populations; culturally competent care that builds trust; access to high-quality long-term services and supports; and care that addresses the needs of all populations. 

Personal behaviors are not the only determinants of healthy living and aging. Access to affordable, high-quality clinical preventive services and medical care is critical. Other factors outside the medical system also impact health and longevity. Socioeconomic factors like income, education, and occupation are some examples. Environmental conditions, neighborhood characteristics, cultural norms, and the historical legacy of discriminatory private- and public-sector practices also play a role. As such, policies and interventions to improve health must address both personal behaviors and systemic factors. A holistic framework for health promotion includes efforts inside and outside the medical system. It includes lifestyles, social policies, and even the way communities are designed. Housing, transportation, energy, and environment policies can promote community engagement and good health for people of all ages.  

By 2030, one in five Americans will be 65 years and older. As America ages, the focus of policy will shift to increasing the quality of years lived, not just the quantity. Nine in ten older Americans want to live independently in their homes and communities for as long as possible. 

Maintaining and improving cognitive health is a top concern of older adults. And it is critical to quality of life as people age. A 2017 report by the National Academy of Medicine affirmed what emerging research has shown: While cognitive aging is not synonymous with cognitive disease, it is a public health issue that warrants action by many stakeholders. The report identifies actions that the public, the health sector, nonprofit and professional associations, government agencies, and the private sector (particularly in transportation and financial services) can take to maintain and improve cognitive health throughout the lifespan. The right policies can help people improve and maintain cognitive functioning. They can address the needs of people with dementia, their caregivers, and the communities in which they live. 

The nation’s health care system is in critical need of reform. The U.S. spends more on medical care than any other industrialized nation. Yet, it falls short with regard to access, efficiency, equity, and outcomes. Research has identified serious and pervasive problems with quality of care. It has also identified disparities in access and treatment. The number and percentage of insured individuals have increased since the enactment of the Affordable Care Act (ACA) in 2010. Still, many people lack coverage or have trouble affording it. Reforming the health care system requires attention to many issues. Thus, implementing reform is a long-term endeavor that will require infrastructure changes; adjustments in expectations, behavior, and practices of all stakeholders and throughout the delivery system; ongoing research; and provider and consumer education. 

The ACA has laid the groundwork for near-universal coverage. It expanded public coverage for adults with low incomes who were previously ineligible for Medicaid, changed insurance rules to make private health insurance markets fairer and more accessible, and provided subsidies for those without access to employer-sponsored coverage who may have trouble affording insurance. The law also made several reforms to Medicare, including expanding prescription drug benefits and coverage of preventive services and encouraging adoption of health information technology, such as electronic health records. These and other aspects of the ACA are discussed later in this chapter. 

Individuals, public and private partners, and other affected parties have a shared responsibility to protect and promote health throughout the lifespan. However, there has been ongoing opposition to reform by some federal and state leaders and business interests. Fiscal challenges can also create barriers to effective reform. Strengthening and improving health care delivery is an important national goal. 

Empowering people to engage in positive health behaviors allows them to live longer, healthier lives. Access to affordable, high-quality health care, a functional public health system, a safety-net infrastructure, highly skilled workforce, and treatments and care for specific needs is critical to this goal. Eliminating health disparities are also a national priority. The health policies outlined in this chapter promote healthy living, so Americans live longer and stay active and healthy to thrive while they age.