Wager Mage
Wager Mage
Photo: RODNAE Productions
The average life expectancy in the United States is 9.1 years for 80-year-old white women and 7.0 years for 80-year-old white men.
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Read More »As compared with mortality in Sweden, France, England, and Japan, mortality in the United States is relatively high before the age of 65 and relatively low at the age of 80 and after. Possible reasons include both current health-related policies and conditions and lingering cohort effects of earlier conditions. Greater heterogeneity in social and economic status and health insurance coverage in the United States may account for much of the disadvantage at younger ages in this country.16-19 Medicare, Medicaid, and Social Security reduce this heterogeneity at older ages. Whereas 84.3 percent of Americans under 65 had health insurance in 1991,20 98.4 percent of the elderly had Medicare coverage.21 Reduced survival of disadvantaged groups also decreases heterogeneity at older ages. More than in Japan or Europe, the elderly in the United States may demand high-quality health services and may modify their behavior to limit their risk factors. More rapid reductions in cholesterol levels, hypertension, and smoking in the United States may reflect this.22-26 In the United States, elderly patients may receive more effective medical care than elderly patients in Japan or Europe. The United States devoted 12.4 percent of its gross national product to health care in 1990, as compared with 5 to 8 percent in Japan and Europe, where cost control produces de facto rationing of health care for the elderly.27 Japan, with the world's highest life expectancy at birth (76.2 years for boys and 83.0 years for girls) and a rapidly aging population, spent only 6 percent of its gross national product on health care in 1990. Copayments impede access to care and increase rates of illness among elderly Japanese with low incomes. Shortages of long-term care facilities and rehabilitation services also adversely affect the health of elderly Japanese. In 1987, 29 percent of hospital stays were for more than six months; the majority of these hospitalized patients were elderly (69 percent), many of them (40 percent) with strokes.28 In Denmark, where health care spending is limited to 5.9 percent of the gross national product, there are 6-to-12-month waits for cataract and hip surgery. The wait for cardiac procedures exceeds three months. The effects of such delays are not benign for persons who are 80 or older. Four persistent cohort effects may also be important. First, the well-educated tend to be relatively healthy. Elderly people in the United States may be better educated than those in Europe or Japan.14 Second, immigrants may be healthier than the contemporaries they left behind.29 Descendants of immigrants may also be relatively healthy. Many elderly people in the United States are either immigrants or the children of immigrants. Third, high mortality at younger ages may leave a select group of robust survivors at advanced ages. This may contribute to the U.S. advantage over Sweden at older ages.30 Fourth, adverse health conditions at younger ages may increase impairment among the survivors and elevate subsequent mortality rates.31 The relatively high mortality at older ages in Japan could be a legacy of poor health conditions before the 1950s. Because few severely debilitated people will survive into their 80s, however, this effect may be less important at advanced ages.32 The plausibility of most of these explanations depends on whether medical care and personal behavior can substantially improve health among the very old. Health changes once accepted as normal features of aging (e.g., frailty and senility) are now viewed as age-related diseases (e.g., osteoporosis and the dementias).8,9 New estimates of the age-related loss of physiologic functions are lower than earlier ones.33 Decreases in mortality in recent decades and differences in survival between subpopulations suggest that medical and public health interventions substantially affect survival at older ages.2-4,8,9,34
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Read More »Increasing longevity may not raise costs disproportionately.35 In 1989–1990, the Medicare cost for those who died at the age of 70 was $6,457 in each of the last five years of life. The corresponding cost for those who survived to 100 was $1,800 per year, because their costs, both in and before the final year of life, were low. Cost-effective therapies are emerging, including antibiotics for ulcers,36 exogenous estrogen for postmenopausal women,37,38 angiotensin-converting–enzyme inhibitors,39 and geriatric-evaluation units.40 The U.S. success in increasing survival after the age of 80 was neglected in the debates over health care reform in this country. To understand the strengths and weaknesses of the U.S. system, it is important to consider the causes of success at older ages as well as the problems at younger ages.
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