Chapter 7 Introduction

In twenty-first century America, millions of people are living longer. Between 1975 and 2015, life expectancy at birth for the total U.S. population increased by 6.2 years.

The Census Bureau projects that by 2030 more than 20 percent of U.S. residents will be over the age of 65. Those age 80 and over are the fasted growing segment of the population. The number of people in this age group will nearly triple between 2010 and 2050 from 11 million to about 31 million.

This increase in longevity results mainly from advances in public health, such as improved hygiene and vaccines. Advances in medical science—including antibiotics, drug therapies for heart disease, hypertension, cancer, and diabetes—have also led to improvements in longevity. However, life expectancy has increased more for some people than others. According to the Centers for Disease Control and Prevention, a 65-year-old white man will live on average almost two years longer than a 65-year-old black man. Further, the life expectancy for white women without a high school diploma has dropped by five years.

Another observed trend is that not only are most Americans living longer, 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. One study found that older people experience more disability-free years than they did previously. The improvement has been greater for women than for men, with no difference by race. Another found that, between 1990 and 2010, healthy life expectancy (the number of years a person can expect to live in good health) for the U.S. rose from 65.8 years to 68.1 years.

Despite the positive trends in longevity, U.S. rankings on important indicators, including longevity, fell between 1990 and 2010 compared with then 34 Organization for Economic Cooperation and Development countries. Statistics from 2019 show that the U.S. continues to rank near the bottom for longevity and other health indicators. These include rankings for maternal mortality, life expectancy, healthy life-years, and disability rates.

The leading risk factors 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.

While personal behaviors may affect longevity and disability, they 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. Policies and interventions aimed at improving health must address both personal behaviors and systemic factors. The health policies in this chapter promote healthy living so Americans not only live longer, they also stay active and healthy to thrive while they age.

Health-promotion efforts should take place both inside and outside of the medical system as part of a holistic framework that includes lifestyles, social policies, and even the way communities are designed. Policies for housing, transportation, energy, and the environment should promote community engagement and good health for people of all ages.

One in three Americans is now age 50 or older. As America ages, policymakers must also focus on 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—a top concern of older adults—is critical to increasing quality of life as people age. A 2015 report by the Institute of Medicine (now known as 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 action steps 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. However, many people still 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.

However, the ACA does lay the groundwork to create a framework 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.

Despite fiscal challenges and ongoing opposition by some federal and state leaders and business interests, a commitment to strengthening and improving health care delivery should be a goal. Individuals and public and private stakeholders have a shared responsibility to protect and promote health throughout the lifespan.

Found in Health