By Linda P. Fried
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:
- Shortly after Medicare was enacted, it added the funding of graduate medical education to its mission (Rich et al., 2002).
- Medicare finances a healthcare system that has been progressively reshaped, recognizing that 87 percent of Medicare beneficiaries live with one or more chronic diseases, 65 percent have two or more, and 20 percent have five or more. The latter group accounts for 66 percent of Medicare costs (Anderson, 2005). Beginning with the financing of hospitalization with the option of Part B for outpatient care by physicians (1965), Medicare has evolved to cover home health services (1980); hospice care (1985); quality standards for certified nursing homes (1987); the PACE model of outpatient capitated long-term care for nursing home–eligible Medicare beneficiaries (1990); funding of Medicare Advantage (Part C); capitated hospital and outpatient care (with potential access to pharmaceutical care and, in some cases, preventive benefits such as vision and dental care, 1997); and, Part D funding of prescription medications (2003) (see Table 1, below).
- Medicare has put a tentative toe into the waters of clinical disease prevention and mental illness treatment, and, more recently, prevention of geriatric conditions such as falls (see Table 1, page 182), as well as some community-based prevention. Beginning in 1980, Medicare has continued to add clinical primary prevention services recommended for older adults by the U.S. Preventive Services Task Force (USPSTF), until finally covering all (1980, 1995, 1997, 2000, 2008) USPSTF recommendations (2011). It has invested more in secondary prevention, such as screening for early detection of chronic diseases and geriatric conditions, and some disease self-management and behavioral modification programs. The 2010 Affordable Care Act (ACA) encompassed key aspects of population health improvement and defined structures (e.g., Accountable Care Organizations) that encourage Medicare-funded entities to engage in community prevention (Kassler, Tomoyasu, and Conway, 2014; Hacker and Walker, 2013).
|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:
Extend clinical prevention to comprehensively cover all adults from age 50 and older with the full set of vaccinations, screenings, and preventive services recommended by the USPSTF (USPSTF, 2015). This life course approach to prevention will help ensure that people reach age 65 in good health, and that their health is optimized into their seventies, eighties, and beyond. Promoting coverage from the ACA and extending coverage for all clinical preventive services to those older than age 50 who remain uninsured can achieve this recommendation. There is strong evidence now that those who turn age 70 in good health are positioned for longer and healthier future lives—at no additional cost to Medicare (Lubitz et al., 2003).
In addition to chronic disease screening and prevention, Medicare should adopt the following strategies:
- Screening and primary, secondary, and tertiary preventive intervention aimed toward conditions of aging. Diseases, once present, become risk factors for other poor outcomes, including more chronic diseases, depression, falls, frailty, cognitive impairment and dementia, disability and dependency, adverse drug effects, and even death. A patient with any one disease would benefit from screening and identification of interventions to prevent the development of additional conditions and functional decline. Provision of coverage for oral health care, vision and hearing examinations, glasses, and hearing aids is critically important in preserving health and independence.
- Tailored prevention for each person can be effective, targeted to risk factors and health conditions, and would consider modifying factors such as frailty and prognosis (Walter and Covinsky, 2001; Beard et al., 1992; Boyd et al., 2005). States have been more innovative than Medicare in these areas, using waivers to allow flexible, targeted interventions. For example, Oregon Medicaid developed a State Innovation Model allowing the purchase of an air conditioner to prevent respiratory distress.
- Emphasize shared risk factors and social determinants of health. Several key health behaviors (physical inactivity, poor nutrition, smoking, and social isolation) lead to multiple chronic diseases, depression, falls, frailty, and disability. Ensuring adequate income, affordable and safe housing and transportation, and access to services also are vital. While not part of clinical practice responsibilities, such external factors are necessities that must concern Medicare providers.
- Create integrated health systems between Medicare, Medicaid, Public Health, and the Administration on Aging (AOA) to improve health and well-being in later years. Such systems need to include funding of services in clinical, community, and home settings, as well as primary, secondary, and tertiary prevention, and supportive care. Following the framework offered above, along with that of the IOM (IOM, 2012), can eliminate the siloes of prevention and health promotion and supportive care.
The following are four examples of such integration:
Chronic disease self-management is a pillar of the National Prevention Strategy for empowering Americans to achieve better health and wellness (HHS, 2015). Small group workshops, led jointly by clinical and trained lay staff, are effective for both older and middle-age adults to learn self-management skills.
It is estimated that if only 5 percent of adults with one or more chronic conditions were reached by such a strategy, there would be a potential net savings of $364 per participant. This would translate into national savings of $3.3 billion (Ahn et al., 2013). Such approaches are essential components of prevention, and Medicare needs to finance such services in medical and non-medical settings (Greenlund et al., 2012).
Physical activity programs accessed in diverse settings are a highly cost-effective approach to maintaining health and function across a wide variety of health outcomes (Brawley, Rejeski, and King, 2003). A range of options, all tailored to individual abilities, needs to be available to older adults, from participation in supervised group walking programs or indoor exercise programs for strength and balance to pool exercise (Fried, 2012).
Further, there are new public health models for physical and cognitive activity that Medicare also should prescribe and support. One example is a “walking school bus” model in which older adults get their exercise by walking children to school each day. Another is Experience Corps, a senior volunteer program designed to significantly increase the physical, cognitive, and social activity of older adults through carefully designed roles to support the academic success of children in public elementary schools (Tan et al., 2006; Fried et al., 2004; Fried et al., 2013; Frick et al., 2004; Rebok, 2004; Carlson et al., 2008).
- When volunteering fifteen hours per week, Experience Corps volunteers with low activity show a 110 percent increase in kilocalories expended per week, compared with a 12 percent increase in controls—and to the level sought by formal exercise programs. Participants also demonstrate improved cognitive executive function and brain activation in corresponding regions of the prefrontal cortex (Carlson et al., 2008), and there appears to be a substantial return on investment in health and function for older adults (Frick et al., 2004). These community-based programs should be prescribed by clinicians and be reimbursed by Medicare.
- In Medicare, Accountable Care Organizations (ACO) were created to manage integrated care for a population of patients. Many have suggested that ACOs will be more successful in this mission if they act as follows: invest in the health of the communities from which their patients are drawn, not just in their panel of patients (Hacker and Walker, 2013); incorporate non-clinical members into their care teams; and, directly help address social and community barriers to care and health (Kassler, Tomoyasu, and Conway, 2014). Obvious first steps include partnering with local public health departments to link patients to existing community prevention programs, and collaborating with local senior and other community centers to conduct clinical prevention services and outreach, leveraging their influence to support health-promoting characteristics of their neighborhoods (Kassler, Tomoyasu, and Conway, 2014).
- Medicare should support new mechanisms for finding and bringing older at-risk adults in the community into care and supporting their successful engagement. Little attention has been paid to the transitions from community to medical care, or the transitions from clinical recommendations to uptake in the community. For example, there are AOA services for home-based screening and evaluation of older persons who are cognitively impaired, abused, wandering, or unable to care for themselves. This screening is generally unfunded or under-funded, and often there are no good mechanisms for bringing those evaluated into care. Adequate funding, perhaps through Medicare, with implementation by a geriatrically trained public health department, could provide greater clinical ability and bridges into medical care.
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.
Expand support of health professional training. Medicare should support the education of graduate medical and public health professionals to better serve an aging population. This education would create a critical mass of health professionals who are experts in geriatrics. These professionals would gain the skill sets to integrate public health and medical frameworks, to design, lead, and staff better health systems, and to effectively work in teams in a coordinated continuum of geriatrically guided prevention and care (Fried and Hall, 2008; Leipzig, Hall, and Fried, 2012).
The Lancet Commission report of 2011 (Frenk and Chen, 2011) recommended that interprofessional teams of health providers be educated to lead the health systems of the future. The IOM report, Retooling for an Aging America (Rowe, 2008), also makes specific recommendations for preparing a healthcare workforce and a health system for an aging population. The report calls for investing in the training of geriatric healthcare professionals, community-based services and resources, and team-based care that extends into the home and long-term-care settings.
- Create a shared data collection and referral system, tracking the needs, services, demonstrations, outcomes, and programs across Medicare and the CDC, at the national, state, and local levels, and AOA and Medicaid. It is critical to track complementary health-promoting initiatives, preventive services indicated for older adults, and also environmental and policy changes that support these preventive needs; this could be done in accessible, searchable databases for use by individuals, family members, community health workers, healthcare providers, and health systems. It is unfortunate that some practitioners know about innovative community programs and make appropriate referrals, while others do not. And it is unacceptable that isolated older adults suffer alone from inadequately treated chronic conditions when they are eligible for care and support just beyond their reach.
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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