Aging Candidates, But No Aging Policy

We have the oldest slate of presidential candidates in history, but this has not led to policy proposals or policy discussion of the needed responses to our aging society. This is somewhat surprising given the political centrality of Florida in this upcoming election. The agenda and need for a national aging policy could not be more compelling, but we have  experienced radio silence in this campaign. 

Both candidates and their surrogates have pledged to “defend” Social Security and Medicare, as well as address problems with Veteran’s benefits and the performance of the VA. Clinton has said “I won’t cut Social Security….I’ll defend it, and I’ll expand it.” Donald Trump has not issued formal proposals for Social Security and Medicare but has indicated in various speeches that he plans to “leave social security the way it is.” Both candidates have indicated they would oppose raising the retirement age. While Hillary Clinton has indicated she would support expanding benefits to certain groups, and raise payroll taxes (particularly by raising certain payroll caps). Donald Trump has pledged no cuts in benefits and no changes in cost-of-living adjustments. He opposes payroll tax increases. Hillary Clinton opposes privatization; Donald Trump has been largely silent on the issue.

Neither candidate has offered testable policies for Medicare reform. Hillary Clinton has expressed an interest in health care delivery system changes that would improve quality and value, but the specifics of these changes is unknown.

The major interest and advocacy groups – AARP, NCOA, the Alliance of Retired Persons, and others – have put surprisingly little pressure on the campaigns to articulate a coherent and comprehensive platform on aging policy. (It is not for lack of organizational numbers: Christine Day has estimated that there are more than 1000 aging-based interest groups in the United States, and at least five times that many if you take account of local chapters and subdivisions of those organizations.) For all of this organizational might, there has been virtual radio silence about aging policy in this campaign.

Both candidates have indicated concern about Alzheimer’s and related dementia, and pledged increased funding. (The 2017 budget proposal supports a 40 percent increase in Alzheimer’s research funding — $1.39 billion — to implement the research agenda outlined in the National Plan to Address Alzheimer’s. Disease.)

The popular press, partly prompted by Bernie Sanders campaign, has pointed out the lack of a national plan or policy direction to deal with the massive problem of retirement income security that will confront the baby boom population. Irrespective of the marginal financing and benefit changes that are being discussed for social security, a large proportion of the population lacks private pensions, savings, or other assets to cover the extended periods of old age it will experience.

At this late moment in the Presidential campaign, we can stipulate that both Social Security and Medicare obviously need a refresh and a rethinking. Social Security would benefit from some incremental (forward) reforms of its financing structure to assure long term security of it benefits. The program should also revisit its distributional effects and its coverage of low-income workers and a host of vulnerable groups. Medicare has a huge challenge to reform the delivery system, restructure its incentives, continue to tilt the cost curve down, and reallocate resources to high valued care. .

Beyond Social Security, Medicare, and Alzheimer’s research is a vast and compelling policy agenda for our aging society that is latent:

Active/Productive Aging: Our institutions, public policy, and national attitudes have not shifted to facilitate the movement of millions of baby boomers into alternative roles as they age. This is a major economic resource loss, a contributor to late life mental health and physical health decline, and lost opportunity for improved civil society. The costs of policy, organizational, and program changes to take advantage of our aging population are low, but the potential benefits are enormous. However, there is no policy leadership or home for this agenda.

Prevention/primary care/chronic care: Outside the traditional boundaries of Medicare and Medicaid lies a vast public health agenda for an aging society. New science has revealed that there is tremendous “plasticity” in old age, meaning that older persons have tremendous physical and social capacity for physiological and behavioral change that can alter the course of disease, quality of life, and even life-expectancy. If one takes into account the accumulation of obesity, mental health, and other chronic conditions trending forward with the baby-boom population, it is more important than ever to design and implement a public health strategy for an aging population. Unfortunately, this perspective has no policy home, except for a small but mighty group in CDC.

Workforce development for an aging population: We face a workforce crisis, from top-end professionals such as geriatricians to lower skilled workers such as nurse assistants who are necessary to provide the vast amounts of caregiving that will be demanded with population aging. For example, the supply of geriatricians has been declining during this period, a function of both fewer doctors being trained and many doctors leaving geriatrics. Fewer than 100 medical students in the entire national economy each year are now entering geriatric fellowship programs. The workforce problems are becoming even more dire in certain geographies in the nation, particularly in rural areas that are dramatically aging. Comprehensive workforce policy for an aging society would encompass immigration policy, medical education, nursing and the allied health professions, mental health providers, social work, and low-skilled labor.

Technology for an aging society: We take for granted the need for R&D for renewable energy or precision medicine, but there has not been the same mentality about bringing the power of technological advance to bear on our aging society. Largely out of public sight, industry is developing robotics, telemedicine and telepsychiatry, body and home sensors, and assistive technologies, with incredible implications for supporting older persons and an aging society, especially in home settings. This revolution is occurring without policy support or investment.

Long-term services and supports: The repeal of the CLASS Act portion of the Affordable Care Act set long-term care coverage back a decade or maybe more. In the meantime, private insurance products have become more complex and uncertain for consumers. A number of organizations have put forward policy proposals to finance long-term care services and supports, but they have had little national policy visibility or uptake. Medicaid programs, encouraged by the federal government, have pursued numerous structural innovations — “Real Choice Systems Change,” Person-Centered models, PACE models, Cash and Counseling, and Self-directed programs. Beyond financing, the potential of private market innovations in services delivery – so-called Greenhouses, Health Homes, caregiver supports, etc. – have been percolating but have no real avenue for dissemination and replication.

Physical Infrastructure for an aging society: An international movement is producing urban, suburban, and rural environments to respond to an aging society. Known as age-friendly communities, aging-in-place initiatives, and naturally occurring retirement communities, these projects are re-imagining the physical infrastructure (e.g., roads, sidewalks, and community centers), transportation, and social support systems to promote independence and supportive communities. The U.S. has virtually no policy, funding, or policy leadership to implement these large-scale infrastructure ideas.

Running through all of these elements of our (missing) national aging policy is the lack of institutions, Congressional leadership, or policy advocacy. The creation and revision of public and private organizations has not kept pace with the scale of the demographic transformation under way. The federal government has no coherent resource base, coordination, or policy leadership in aging. The outposts of aging policy – the Senate Special Committee on Aging, the Administration on Aging within the Administration for Community Living, the National Institute on Aging in the National Institutes of Health, etc. – are too disparate. They lack the power to create a coherent and comprehensive national policy on aging. Great people in each of these outposts have tried to create visibility for these issues, but the scale and power of these actors is just too small.

As far back as the 1970s, analysts worried about the “Tsunami” of the aging of the baby boom. Not much has changed in the ensuing 40 years. We still have worries, but still not a policy agenda.

Despite broad awareness of the social and economic implications of global and national aging, we have not developed the social policy responses to this demographic. The lack of any discussion of aging policy in our presidential campaign is symptomatic of the larger lack of visibility and urgency of these important policy challenges.