A Prescription for the Next 50 Years of Medicare
A wish list from the Dean of Columbia's Mailman School of Public Health
(This article is adapted from "A Prescription for the Next Fifty Years of Medicare" in the Summer 2015 issue of Generations: The Journal of the American Society on Aging.)
Fifty years ago next month (July 30, 1965), Medicare was created. Its goal: 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 65.
I’d like to offer a prescription for the next 50 years of Medicare.
But first, a brief review of how Medicare and older Americans’ health have changed in the past 50 years.
When Medicare started, only half of older adults had health insurance and the program covered only a quarter of hospital expenses. Now, more than 90 percent of older Americans are covered by Medicare Parts A and B. Older adults are now healthier than ever, too, while living longer.
Medicare has evolved to cover, among other things: home health services; hospice care; quality standards for certified nursing homes; funding of Medicare Advantage (Part C) and Part D funding of prescription medications. Medicare has put a tentative toe into the waters of clinical disease prevention, mental illness treatment, and prevention of geriatric conditions such as falls.
4 Goals for Medicare for the 21st Century
Medicare can and must continue evolving. 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 what we, as a society, do to assure the conditions in which people can be healthy).
When coverage, care and public health are delivered to the same population, after only 10 years, the addition of public health approaches saves 90 percent more lives and reduces costs by 30 percent. After 25 years, the benefits of these approaches would save 140 percent more lives and lower costs by 62 percent.
The following are four strategies for incorporating public health goals into Medicare:
1. 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 United States Preventive Services Task Force. This approach will help ensure that people reach age 65 in good health and that their health is optimized into their 70s, 80s and beyond. 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.
Medicare should also adopt screening and 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. Provision of coverage for oral health care, vision and hearing examinations, glasses, and hearing aids is critically important in preserving health and independence.
2. 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 prevention and supportive care.
Currently, there are innovative programs integrating medical care and social services for people who are eligible for both Medicare and Medicaid. Lessons from these demonstrations need to be disseminated more widely and more programs integrating a broader array of social services need to be developed.
Further, there are new public health models for physical and cognitive activity necessary for health that Medicare should prescribe and support, such as exercise programs and Experience Corps, a senior volunteer program designed to significantly increase the health of older adults through sustained increases in physical, cognitive, and social activity in roles supporting the academic success of children in public elementary schools.
3. 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 would create a critical mass of health professionals who are experts in geriatrics and who would design, lead, and staff better health systems in a coordinated continuum of geriatrically-guided prevention and care across home, community and clinic.
4. Create a shared data collection and referral system, tracking the needs, services, demonstrations, outcomes and programs across Medicare and the Centers for Disease Control at the national, state, and local levels and AOA and Medicaid. This could be done with accessible, searchable databases for individuals, family members, community health workers, health care providers and health systems.
With improved health, and social institutions that support health promotion, and active social and civic engagement by older adults, the United States can experience the full benefits of our longevity. The transformation of Medicare in the ways described above could allow the 21 century to experience these full benefits.