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Managing Medicare's Costs

Wellness could change the pattern of retirement health care costs

As a society we’re living longer even while we’re getting fatter. Longer lifespans would at first seem to be incompatible with rising obesity rates, but the evidence is that they are occurring simultaneously. Over the last two decades, a 65-year-old’s average remaining life expectancy has increased by almost two years. Yet according to a 2013 data brief from the Centers for Disease Control (CDC), more than 35% of people age 60 and over are obese, roughly twice the percentage of 20 years ago.

How can rising lifespans and increasing obesity take place at the same time? One answer is that the increased prevalence of obesity is being offset by lower rates of smoking. Another is that people with serious chronic diseases caused by obesity can now live extra years because of medical advances.

It’s also true that the averages may be misleading. The 65-and-older population is large – about 42 million people – and sizable segments have seen their remaining lifespans pulled in opposite directions.

One group — call them the least healthy – have actually seen their life expectancies reduced. Researchers concluded, based on a study of 20 years of government mortality records, that adults who do not have high school educations have seen their lifespans shortened to the point that they are not much better than the lifespans of adults in the 1950s and 1960s. Much of that decline can be traced to unhealthy lifestyles, since people who do not have high school educations have elevated rates of obesity and smoking.

The healthiest group, on the other hand, has more than compensated with what seem to be ever-lengthening lifespans. People in this group are better educated and more likely to engage in wellness behaviors. They have lower rates of obesity and they typically do not smoke cigarettes or drink alcohol to excess. As the chart below indicates, gradually increasing percentages of seniors are following these healthy practices, even while obesity rates are climbing.

chart
Education, income, obesity, and smoking are the most reliable predictors of a group’s average lifespan. They are not the only ones, though, because race, gender, and family history also play roles. A number of experts maintain that a healthy lifestyle is the best indicator, but that it is overlooked by researchers who concentrate on easily identifiable traits like education, race, and income.

Wellness — taking deliberate actions to stay healthy — is closely tied to education. If you have at least two years of college, that opens the door to a better job, higher income, and in many cases employer-subsidized health insurance. And through reading and learning, education leads to a greater awareness of the importance of exercise and nutrition.

If you could get those same things without going to college, the longevity gap would mostly disappear. The Hispanic population has lower levels of education and income, but according to the most recent CDC data, they have longer remaining life expectancies at age 65 than do other racial groups. The keys to their longevity are almost certainly their lower rates of smoking and alcohol use as well as their strong family ties.

The growing percentage of seniors who adhere to healthy lifestyles will affect their health care costs in retirement in several ways. First (and most obvious), people who live longer will pay more in premiums and cost-sharing. Second, as additional people live to older ages, they are more likely to need long-term care in their homes or in institutions, neither of which is covered by Medicare.

But the most interesting outcome could be that people who follow healthy lifestyles may be able to delay disability. That in turn will postpone their need for long-term care. According to one analysis of Medicare records, disability is already being squeezed into smaller time frames near the end of life. This analysis included 10,000 sets of patient records per year for an 18-year period.

During that time frame, the disability-free life expectancy for 65-year-olds increased by 1.6 years, or almost three times as fast as 65-year-olds’ life expectancies increased. Thus the proportion of their lives that people were disabled shrunk. The authors did not discuss the reasons why disability was reduced so much, but seniors’ greater attention to healthy lifestyles was a likely factor.

Maybe the best example of a lifestyle behavior that can postpone disability is regular physical exercise. Medical researchers have known for 60 years that older people in good health exercise more often than older people who are not in good health. But that doesn’t prove that regular exercise produces good health in older people. It could mean only that people who make it to old age in good health are more likely to exercise regularly.

A landmark government-funded study published two months ago in the Journal of the American Medical Association found that exercise helps to prevent and delay disability. More than 1,600 sedentary people ages 70-89 were recruited for the study, the only requirement being that they had to be able to walk a quarter mile on their own. The recruits were divided into two groups. One group attended frequent educational classes about aging but did not exercise. The other group exercised regularly and with increasing intensity.

The experiment lasted about two and one-half years. At that point, people in the regular-exercise group were 18% less likely to have had a disability and almost 30% less likely to have had a permanent disability. One researcher not associated with the study concluded that “we can’t say frailty can be prevented in all people, but we can compress it to a smaller proportion of the end of life.”

Insurance companies can of course boost their profits by helping to keep their policyholders healthy. Two years ago a survey of more than 40 Medicare Advantage plans, each with more than 10,000 members, found that all of the plans promoted exercise and good nutrition, offered wellness discounts and sponsored smoking cessation programs. Medicare Advantage plans routinely offer a free gym membership as an extra benefit, knowing it will attract people who like to exercise.

The largest gym membership program for seniors is Silver Sneakers, which gives its members free access to their neighborhood health clubs. The company says on its web site that 65 Medicare health plans offer the Silver Sneakers program to their members and that there are more than 11 million potential members in Medicare Advantage and employer plans.

But with the exceptions of some employer plans, wellness programs and gym memberships are non-existent in Medicare fee-for-service coverage. Medicare does cover an annual wellness visit in which your primary care physician discusses what you should follow a healthy lifestyle. And Medicare also covers obesity counseling, smoking cessation, and alcohol abuse coverage. Except for those limited benefits, you are on your own. ◊◊

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