Saturday, December 31, 2016

Early Indications December 2016: The Future of Aging

We grow too soon old and too late smart.
      -Proverb variously attributed to Swedes, Germans, and Dutch

While it is common to note that the U.S. worships youth and beauty in contrast to other cultures that revere age and wisdom, the demographic tidal wave that is the baby boomer generation will change aging just as it changed higher education (the explosion of college attendance), childrearing norms (compare baby strollers and birthday parties in 1960 and 1980), family structure (marriage rates have plummeted since World War II), the workplace (cube farms), and the built landscape (McMansions). Speaking only of the U.S., and not of those wise Dutch, German, Swedish, or Chinese elders, what will we see in the next 25 years? The short answer: lots of big changes.

-Medical breakthroughs
When life expectancy was shorter, body and mind wore out at more or less the same rate. As life expectancy increases, dementia, on one hand, as well as crippling orthopedic and spinal conditions both increase in likelihood: the possibility of mind failing before body, and body before mind, means that heartbreaking scenarios of both asymmetries are on the upswing. (See this.) Exoskeletons, 3D-printed artificial joints, and other mobility solutions can help with the latter class of conditions, while new Alzheimer’s and other dementia drugs are getting more attention, given the growing market need (see this). Just as fertility treatment advanced markedly in the baby boomer’s childbearing years, expect new medical miracles to address the aging process.

Whether or not the aged will be able to pay for these new medicines and devices remains an open question. Social Security is both underfunded and insufficient for a moderate lifestyle, pensions are less available and often underfunded for the public-sector employees lucky enough to get them, and the tab for the everyone-his-own-investment-analyst experiment known as the 401(k) defined contribution approach will soon be coming due. As of 2013, only 53% of U.S. families had a retirement plan, and of those aged 56-61, the median account was valued at only $17,000. The mean account value for that age cadre — $163,000 — is clearly boosted by a very few families with extensive or even adequate resources: in round numbers, a 65-year-old couple needs about $850,000 to generate $50,000 a year (the “average” U.S. income) for 20 years, assuming 1% inflation and 3% investment returns, not counting Social Security. Fidelity Investments estimates that same couple will pay $260,000 in out-of-pocket health care expenses, not counting nursing homes or related costs. (More here.) Most American families will not be able to afford to retire under the current rules.

The question then becomes, what happens? After rising for more than 50 years running, U.S. life expectancy might be dropping: earlier this month, the National Center for Health Statistics announced that death rates for 8 of the top 10 causes of death increased in 2015. Life expectancy at birth dropped about a month for women and 2+ months for men. One year does not a trend make, but it’s possible we could be seeing an effect of the growth in income/wealth disparity that has characterized so much of American life in the past 30 years: one hypothesized cause of an increase in death rates for white middle-age people is the increase in so-called diseases of despair: alcoholism, overdoses, and suicide. Whether through despair, diet/lifestyle, or limited access to care, financial stress and low income most likely reduce life expectancy. 

-Safety nets
So if life is getting harder, life expectancy lasts 20+ years beyond age-65 retirement, and savings are minuscule, what will government do? One colleague of mine suggests that Medicare could expand to include food stamps or some other nutrition component. Perhaps there will be wider calls for a public option for health care coverage. Social Security was originally instituted in the Great Depression, and the nation is a very different place 80 years later: might government old-age insurance be redefined in the coming decade, especially given the coming bust in 401(k) assets relative to need? That bailout will dwarf both Wall Street’s and Detroit’s proppings-up after 2008. Will the retirement age will increased from 65 to reflect modern longevity? (In 1935, when Social Security was introduced, the U.S. life expectancy was 61; it is now about 79.) I can’t see the current collection of national safety nets — VA, Social Security, Medicare/Medicaid, disability, SNAP — being able to withstand another 10 years without being reworked.

-Living arrangements
The prevalence of 2 or 3 adult generations living in close proximity fell dramatically after World War II: the growth of suburbs filled with single-family detached-houses, with limited walkability, along with the rising number of nursing and retirement homes, meant that grandparents less commonly lived with their grandchildren. The numbers are difficult to track, given the changing makeup of care resources: adult day care, in-home service providers, nursing homes, and adult care communities can all overlap both in structure (a community agency can offer both adult day care and hospice, let’s say) as well as by person: transitions from one type of care to another are common as health needs change, offspring move in or out of town, spouses die, and finances change.

Multigenerational families are on the upswing in the U.S., and elders are part of the picture, but those aged 25-34 are moving in with their parents in stunning numbers. According to figures from the Pew Foundation, 11% of adults 25-34 lived in a multi-generational household in 1980. That proportion had more than doubled as of 2012, and by 2014, more young adults (18-34) lived with parents than with a spouse or significant other. As those unmarried millennials age, how will they change our assumptions about, and institutions related to, aging? Or will they marry in traditional numbers, only later? As the costs of aging rise, how will families, and real estate, adapt? How will Uber and, later, autonomous vehicles change where elders live and what they do with their days?

-Religious practice
The U.S. church landscape is changing profoundly. These changes matter for aging, insofar as churches are often providers of both formal and informal support networks, but aging matters for some churches, especially “mainstream” Protestantism. Consider that U.S. population grew 65% in the half-century between 1965 and 2015. In that same period, the Episcopal church lost 49% of its adherents, Presbyterians (PCUSA) 47%, and United Methodists 33%. Even among Roman Catholics, where membership pretty closely tracked population growth, parishes are closing: those 70 million self-described Catholics don’t attend Mass very often, statistically speaking. Catholics also have a supply-side issue getting men to join the priesthood; staffing parishes is a problem for many denominations, especially those without access to women clergy. Another side effect of the drop in mainstream church membership and attendance relates to the growth of towns and cities: those 19th-century church buildings are often located in prime real estate at the same time that maintenance and heating costs for big, old buildings with creaking structure and infrastructure (wiring, plumbing, HVAC) are non-trivial. The continuing shift in American church affiliation will affect both the look of our cities and the delivery of social services to many, including the aged.
It should be clear that demographics, medical science, social institutions, government programs, religious faith, and technological change are wound together into a yarn ball: telecommuting and Uber will let people who can’t drive work at jobs they currently can’t get to. A stock-market decline could wipe out even more people than were decimated by 2008, given how many more baby boomers are out of the work force since then, making sharing living quarters a necessity. Older people feel more vulnerable, and scams of various sorts prey on many of them, including politicians, at the same time that elders are outliving their churches. Social networks facilitate the spread of fake news, rumors, and other misinformation, both frightening people further and making real solutions harder to design and implement. Jobs and work tasks are changing incredibly fast, making older expensive workers expendable, yet intellectual capital is leaving U.S. companies via retirement (particularly in process manufacturing) without clear backup plans in place. With so many strands to the issue, no single initiative can be considered in isolation; the side effects of policy (think of the home mortgage interest exemption as just one example) are often nearly as important as the primary objectives. Whether it’s robotics, social networks, autonomous vehicles, or telepresence for work or family ties, the new elderly will be key factors in many technological waves of the coming decades.