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The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
July 1, 2019
The Health of Aging Populations State Health Policy Leadership
Christopher F. Koller, President
Back to President’s Blog: The View from Here
“My, how you are aging! So what are your plans for the future?”
This is hardly considered an appropriate way to start a conversation with somebody. We have been conditioned to resist and even take offense at references to our aging, associating it with diminishment, frailty, and dependence. It is far better, in this line of thinking, not to encourage reflection and planning but to opt for denial, resistance, and willful ignorance: Age is “a state of mind” to be contested.
Not only is this reaction ageist, it ignores benefits that can come with aging, such as the wisdom of perspective and the respect of others. Freed of the need to achieve and secure in self-acceptance, old age can be a period of satisfaction and greater appreciation.
Yet─polite to acknowledge or not─we are each growing older. And so is the country as a whole. By 2030, people over 65 will comprise 21% of the U.S. population, compared to 15% now, and by 2035, there will be more people over 65 than kids under 18.
This will result in tremendous changes in our society. By 2035, the Social Security Administration estimates there will be only two workers for every retiree, down from three in 2009. This demographic shift will affect how we care for older people, how we pay for and support that care, and even how we organize our economy and our communities. We will need to think about housing, transportation, technology, workforce issues, and much more from the perspective of an older population.
Just as we want to deny the reality of our own aging, public policy wants to ignore the implications of this demographic reality. As we are seeing with responses to climate change, legislative politics is structured to respond to immediate needs and defend current interests, rather than anticipate and plan for future ones.
There are exceptions, however, and they are worth calling out. Notable are state-level activities, initiated by the executive branch of governments. Most recently, California Governor Gavin Newsom signed an executive order to establish a Master Plan on Aging for the state, building on similar work in Colorado, Washington, Connecticut, and Minnesota.
Medicaid spending is driving state budgets, and the costs of care for older and disabled populations are driving Medicaid spending. Costs, however, are not the driving concerns for state plans on aging. Good planning documents, instead, develop shared answers to fundamental societal questions. An aging plan should be guided by a vision for what “life, liberty, and the pursuit of happiness” mean for an older person. Bruce Chernof, MD, president of The SCAN Foundation, would include: physical, psychological, and social well-being; financial security; self-worth; a supportive physical environment; and a supportive social community of family and friends.
Aspirations are not the same as obligations, however. So an aging plan also clarifies what society owes older persons. The answers we have developed for our youth also apply to older people: a basic set of physical resources like food, shelter, health care; policies that reinforce the centrality of families in caring for one another; and safe, inclusive physical and social communities.
Planning efforts that attempt to wade through these conceptual questions can sometimes be pointless exercises in paper production. If done well, however, they can also chart a direction for collective efforts for years to come. As the SCAN Foundation points out in a policy brief that supports Newsom’s executive order, good planning efforts are marked by clear executive branch leadership, rational priorities, a comprehensive approach, stakeholder involvement, and public accountability for implementation and monitoring.
When I was health insurance commissioner in Rhode Island, many of our policy conversations─on questions concerning topics like provider reimbursement, conduct of health insurers, and Medicaid policy─ended up in a dead-end lament: “If only we had a real plan for health care in the state, it would give us the answer.” This reflects a mistaken notion of the benefits of a good public plan. It is not an instruction manual for specific administrative decisions. Instead, planning is long term in nature. It facilitates statutory development. public investments, and intergovernmental activity.
Washington’s and Minnesota’s policies for older populations have each been guided by long-term aging plans for over a decade. It is not by coincidence that these states rank first and second in the Long-Term Services and Supports State Scorecard, which assessed state performance in five categories of health care for older persons. Nor is it coincidence that Washington was the first state in the country, after years of debate, to pass a law establishing a new social insurance program that uses a mandatory payroll tax to pay for an individual, flexible account to cover caregiving expenses.
It is relatively easy to wax publicly and poetically about childhood. Not so for aging. Celebrating physical and mental growth is more uplifting than pondering increasing wisdom, decreasing physical capacities, and a future both certain and unknowable. Thinking about living in an older country─like considering our own aging─can be disconcerting. It will inevitably demand changes that can only be ignored for so long.
A strong planning process, led by government with public input and accountability, can instill trust and assure older adults’ well-being for longer periods. Like a frank discussion about our own aging, it will not answer every question about our future. But good public planning can draw on the collective wisdom and strength that emerges as we age, and make our communities better for Americans of all ages.
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