72 aging and health policy

hospitalizations and more chronic conditions
than younger people and use more prescrip
tion drugs and medical services (Solomon
Demographic trends indicate that health
care systems are likely to experience unprece
dented demands in the near future because
health policies have not kept up with these
demographic changes (Victor 1991: 63). Until
the twentieth century, the major causes of
death for individuals of all ages was from an
acute infectious disease, that is, an illness or
condition with a sudden onset, sharp rise, and
short courses, such as tuberculosis, diphtheria,
gastrointestinal infections, and pneumonia.
Death rates from these diseases dropped dra
matically in developed countries between 1900
and 1970 due to antibiotics and immunizations
and public health measures such as improved
sanitation and purification of the water supply.
As deaths from acute diseases declined, there
occurred an increase in life expectancy along
with a higher prevalence of chronic disease
such as arthritis, heart disease, osteoporosis,
Alzheimers disease, emphysema, and diabetes.
While some chronic diseases have an appar
ently sudden onset (e.g., heart attack), they
may in fact have long latent periods before
symptoms are manifested (Solomon 1999).
Many national health programs were enacted
in the post World War II period. Services
focused on acute medical care, reflecting the
most pressing health care needs at that time.
Yet population aging and the increase in
chronic health conditions have altered the nat
ure of service demands. Even when coverage
for acute care is adequate, in many countries,
chronic care for elderly people is poorly coor
dinated and inadequately provided because
health care systems were not originally oriented
to these problems. Yet chronic care service
needs differ considerably from those required
for treating acute disease. How well the chronic
care needs of older people are met depends on
many factors. The generosity of routinely pro
vided medical benefits, particularly long term
therapies and prescription drugs, as well as
treatment patterns of health professionals, are
part of the equation. Availability of a full range
of health and social care services needed to
support chronic care is another (Manton &
Stallard 1996).
The US does not guarantee universal access
to health care (Quadagno 2005). Most non
poor children and working aged adults are
covered by employment based private health
insurance, but anywhere from 1418 percent
lack medical insurance altogether (Hacker
2002). Government programs only cover peo
ple who are uninsurable in the private
health insurance market. Medicare is a federal
program that pays for hospital care and phy
sician services for the elderly and disabled. It
pays for approximately 54 percent of older
Americans health care expenses. Medicaid is
a joint federalstate health insurance program
for the very poor, but also pays for a substan
tial amount of nursing home care for the
chronically ill. Because gaps in Medicare cov
erage (deductibles, co payments, prescription
drug costs, etc.) leave many acute health care
needs unmet, two thirds of elderly Medi
care beneficiaries purchase supplemental
medigap policies from private insurance
companies. However, many beneficiaries of
color are not able to purchase private supple
mental insurance because of cost. They either
rely on Medicaid for additional coverage or
shoulder the burden themselves (Williams
How the prevalence of chronic disease and
need for care among elderly people will be
expressed in the future is unknown. If improved
health behaviors and medical advances succeed
in limiting or minimizing chronic conditions,
there could be a compression of morbidity,
with people experiencing fewer years of
chronic illness and living longer, healthier lives
(Manton & Stallard 1996). Alternatively,
increased future longevity could be accompa
nied by longer periods of disabling chronic dis
ease processes occurring, or more sick elderly
people with a high need for long term care
Research suggests that the compression of
morbidity thesis is more accurate. People are
living longer and experiencing fewer years of
incapacitation. Results from the National
Long Term Care Survey (NLTCS) reveal that
from 1982 to 1999, disability rates among
people over age 65 decreased about 2 percent
per year (Fries 2003). The dilemma for health
policy is that while a compression of morbid
ity may decrease the need for residential and