Medicare was created to improve the health and well-being of older people, while protecting families. It was established to provide financial protection to individuals from the catastrophic costs of medical care, and to hospitals from losses accrued while caring for uninsured patients—the largest number of whom were older than age 65 (Corning, 1969). Medicare was conceived as a family policy, intended to protect both older adults and their children, whose standard of living could be threatened if aging parents became ill. The healthcare financing model, designed to support costs for acute and episodic medical care, matched the 1965 standard of care for heart disease, cancer, and acute stroke episodes (Lawlor, 2006).
Impact of Medicare on Older Adult Health
Medicare was the nation’s first experiment in universal health coverage, providing nationally uniform financial coverage from the federal government. When first passed in 1965, only half of older adults had health insurance, and it covered only a quarter of hospital expenses (Blumenthal, Schlesinger, and Drumhell, 1988). Now, 93 percent of older Americans (U.S. Department of Health and Human Services [HHS], 2012) and 5.6 million people younger than age 65 with disabilities are covered by Medicare Part A; 94 percent of those covered also have Part B (Eincher and Blumenthal, 2003).
Since 1965, people ages 65 and older are living longer and with substantially lower rates of mortality from chronic diseases such as stroke and coronary heart disease. They have lower disability and greater access to life-saving care for many more conditions. At the same time, out-of-pocket medical spending has declined (Eichner and Blumenthal, 2003). There is early evidence of improvements in a “compression of morbidity,” the major goal for the health of an aging society (Cutler, Kaushik, and Landrum, 2013; Freedman, Martin, and Schoeni, 2002). Older adults are healthier than ever before, while living longer.
Medicare’s Approach to Chronic Disease Care and Prevention
Medicare has had significant incremental evolution in its fifty years, with a progressive expansion of its scope and goals to better meet the country’s needs (see Table 1, page 182). This evolution can be briefly summarized as follows:
|Medicare Milestones: 50 Years of Preventive Services and Achievements|
Primary/Secondary/Tertiary Preventive Services Covered*
|July 30, 1965||
|1995 to 1999||
|2000 to 2005||
|2006 to 2009||
|2011 to 2015||
*Key: Primary Service (PS); Secondary Service (SS); Tertiary Service (TS)
** CMMI funds and evaluates many relevant demonstrations, including Independence at Home, Community Transitions in Care; creation of Accountable Care Organizations.
In sum, over the past fifty years, Medicare has recognized the heterogeneity of its beneficiaries’ health needs and incrementally addressed the need for financing clinical care matched to needs across an array of venues. These venues include diverse clinical settings, long-term care, and the home. Medicare also has addressed the financing of preventive, acute, chronic care, and hospice and end-of-life care, as well as some services by non-physicians, when initiated by physicians.
Medicare is investing in the future health of beneficiaries, through chronic disease management and establishing clinical and community services for primary (prevention of the condition), and secondary and tertiary prevention (prevention of the condition’s progression). This expansion of the principles of how to improve the health and well-being of older adults, which was Medicare’s initial goal, is foundational to what needs to be accomplished in the next fifty years.
Our Nation’s Changing Needs and Capabilities
Over the past fifty years, the United States has gone through a number of simultaneous transitions: a demographic transition (adding more than thirty years to our life expectancy, the entry of the baby boomer cohort into old age, and transitioning out of a relatively large, young workforce that was the engine of our economic growth) (Bloom, Canning, and Sevilla, 2003); an epidemiologic transition to the dominance of chronic diseases and geriatric conditions as the drivers of older people’s health status; and, an increase in our scientific knowledge of prevention and care for people with chronic conditions.
In the last thirty years, the United States has led the world in developing new effective models of care delivery for people with chronic conditions (Wagner et al., 2001; Naylor et al., 2011). We also have new expertise in the care of older persons (e.g., geriatric medicine and nursing) and in the prevention of diseases and geriatric conditions in older people (e.g., 30 percent of falls and 40 percent of delirium are preventable) that leads to better outcomes, and sometimes cost-savings (Fried and Hall, 2008; Liepzig, Hall, and Fried, 2012). Additionally, integrated geriatrics social and medical care models such as the PACE program and social health maintenance organizations have demonstrated value in integrating medical prevention and social care (Meier, Morrison, and Cassel, 1997).
In sharp contrast to fifty years ago, we now know that prevention matter for most diseases and conditions (e.g., it is estimated that 50 percent to 70 percent of cancers could be prevented) and that prevention works into the oldest ages. Preventive gerontology has developed the knowledge for a new field of health promotion and prevention for this age cohort (Hazzard, 1983; Pahor et al., 2014; Anderson and Prohaska, 2014; Prohaska, Anderson, and Binstock, 2012; Fried, 2012; Anderson et al., 2012), some implemented in clinical care, some in the community or home. But much of the knowledge we have gained over the last fifty years—in prevention and geriatrics—remains to be incorporated at scale into a twenty-first century system that can optimize health and well-being into the oldest ages.
Goals for Medicare for the Twenty-First Century
Medicare can and must continue evolving into a system that optimizes health and function in aging, while supporting a coordinated continuum of prevention and care matching the needs of an aging population. To date, a major missing piece has been the full incorporation into the health system of public health’s science of prevention and health promotion for older adults.
Public health is defined by the Institute of Medicine (IOM) as “what we, as a society, do collectively to assure the conditions in which people can be healthy” (Institute of Medicine [IOM], 1988). We now understand that about 20 percent of health is created by the right medical care system, and amplified when coverage and care are complemented by public health interventions at the population level.
Milstein et al. (2011) have demonstrated that when all three dimensions—coverage, care, and public health—are delivered to the same population, after only ten years the addition of public health approaches saves 90 percent more lives and reduces costs by 30 percent; after twenty-five years, the benefits of these approaches would be even larger, saving 140 percent more lives and lowering costs by 62 percent. Centers for Disease Control and Prevention (CDC) Director Dr. Tom Frieden has provided a framing of the pyramid of approaches that are needed to create health (Frieden, 2010). However, Medicare has only begun to foreshadow them.
Bringing Investment in Healthy Aging into Medicare
The CDC’s Healthy Aging Research Network defines healthy aging as a key goal for longer lives, involving the development and maintenance of optimal physical, mental, and social well-being and function in older adults (CDC, 2006).
Preventing disease, geriatric conditions, and loss of independence from disability or cognitive decline is of primary concern to older adults. Disability in particular is a threat to quality of life and the ability to engage in the world, and is associated with markedly increased healthcare needs, costs, and reliance on supportive care. Investing in primary, secondary, and tertiary prevention of these conditions are crucial goals for an aging society.
The following are four strategies for incorporating public health goals into Medicare:
In addition to chronic disease screening and prevention, Medicare should adopt the following strategies:
The following are four examples of such integration:
Currently, there are innovative programs integrating medical care and the Medicaid-supported social services for those people who are dually eligible for both Medicare and Medicaid (Musumeci, 2014). Lessons from these demonstrations need to be disseminated more widely, and more programs integrating a broader array of social services (including screening and eligibility determination for benefits, such as Electronic Benefit Transfer, utility assistance, and rental or other housing assistance) need to be developed.
Medicare should collaborate with the AOA and the public health system to develop transitional and cross-setting programs that can recognize the need for medical care and establish access, and transition individuals effectively back into the community. This may be an opportune moment to reconceptualize the Older Americans Act as a critical component for developing an integrated prevention, health, and social services delivery system.
Ultimately, the added goals for Medicare in the next fifty years should be to build and sustain the health of our aging society. This will require significant systemic changes that integrate our existing Medicare, Medicaid, and AOA programs, and clinical prevention aligned and integrated with public health goals and frameworks and the CDC. This is essential not only for treating illnesses and disability, but also for actively preventing them (Cassel, Besdine, and Siegel, 1999; Rowe, 1999; Crosson, 2009).
The ultimate goals for all should be the provision of the best medical care, public health, and community and home supportive services to attain higher levels of health and function in aging, minimize risk of disease and disability, optimize autonomy and the ability to age in place, and manage diseases and geriatric conditions effectively. With improved health, and social institutions that support active social and civic engagement by older adults (Fried, 2012; Anderson and Prohaska, 2014; Marshall and Altpeter, 2005), the United States can experience, across society, the full benefits of our longevity. Health into the oldest ages can unleash the potential of what I think we should consider to be a new, and third, demographic dividend: the valuable social capital of older adults in a society of longer lives. With long-term transformation of Medicare in the ways described above, the twenty-first century could experience these full benefits.
Linda P. Fried, M.D., M.P.H., is dean of the Mailman School of Public Health, senior vice president of Columbia University Medical Center, DeLamar Professor of Public Health, and professor of epidemiology and medicine at the Mailman School of Public Health in New York City. She also is co-designer and co-founder of Experience Corps, which puts older adult volunteers to work in public schools in roles that boost students’ academic performance and improve elders’ health and well-being.
The author would like to acknowledge Dr. Ruth Finkelstein, assistant professor of Health Policy and Management and director of the International Longevity Center, Columbia University Mailman School of Public Health, for her review and important counsel in the development of this article. The author is deeply appreciative of the outstanding work by Maria Andriella O’Brien, M.P.H., M.B.A., Alice Topping, M.P.H., and Nida Raja in supporting the preparation of this article.
The entire Summer 2015 issue of Generations is available on AgeBlog thanks to the generous support of The Benjamin Rose Institute on Aging, Compassion & Choices and Robert Wood Johnson Foundation President's Grant Fund of the Princeton Area Community Foundation. Click here to read more.
This article is taken from the Summer 2015 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic, “Medicare at 50.” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.
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