Anticipating the needs of the U.S. aged in the 21st century: Dilemmas in epidemiology, gerontology, and public policy

Reductions in the prevalence of chronic disease, functional dependence, and associated social problems among aged Americans have been predicted on the basis of improving environmental and social conditions, more effective public health measures, and advances in medical care. Public policy makers have found such predictions attractive since improved health status in old age could significantly offset the increase in health care resources which would otherwise be required to meet the needs of the country's growing number of elderly. This paper reviews the epidemiologic model underlying such predictions. Key assumptions of the model are evaluated by examining the health and social well-being of elderly residing in a socioeconomically advantaged community with an age structure similar to that projected for the United States in the 21st century. Despite their long-standing advantages in education, employment, income, housing, health care, and community services, these elderly experienced age adjusted rates of health and social problems comparable to those found in nationwide samples of elderly. No evidence of a compression of health problems into the final years of life could be found. Considerable diversity in problem constellations suggested a need for sophisticated packages of health and support services. These findings suggest that any significant improvements in the health status of the aged due to general improvements in living conditions or health behavior are unlikely to emerge before the proportion of aged Americans doubles in the first quarter of the 21st century. If this is so, public policy in the U.S. must be directed to expanding and improving health and social services for the elderly in the foreseeable future. Attempts to hold expenditures on the aged constant, or to reduce such expenditures, would seriously compromise the health of the nation's elderly.