Geriatric Medicine Training and Practice in the United States at the ...

Current Status of Medical Care
for Older Adults
Expanding Numbers of the Very
Old and Increasing Medical Care
Expenditures
In 2000, the number of adults age 65 and over numbered 35 million,
about one in every eight Americans. By 2030 the number of older
Americans will have doubled to 70 million. Adults age 85 and over are
the fastest growing group in the United States (Administration on
Aging, 2001). Although the health and physical functioning of older
adults appears to be improving, there remains a concern that the
rapid growth of the oldest age groups will have a major impact on
health care costs (Schneider & Guralnik,
1990).
The Centers for Medicare and
Medicaid Services (CMS), (Health Care
Finance Administration (HCFA) until 2001),
recently released a report on U.S. health
care expenditures for 2000 (Levit, Smith,
Cowan et al., 2002). After a decade of
stability, health care spending grew to
$1.3 trillion in 2000. This was up nearly
7% from 1999 and was the fastest
acceleration in 12 years. These
expenditures represented 13.2% of the
U.S. gross domestic product. In 2000,
Medicare spending rose 5.6% to $224.4
billion. In 2000, nursing home and home
health total expenditures also rose after
several years of stable or declining rates
of spending.
Medicare and
Managed Care
The 1982 Tax Equity and Fiscal
Responsibility Act (TEFRA) authorized the
Medicare program to begin contracting
with health insurance companies for the development of managed
Medicare plans. After a slow start, the program grew rapidly in the
1990s. By 1993, 1.5 million Medicare beneficiaries were enrolled in
managed Medicare plans; enrollment peaked in 1999 at 6.35 million
(16% of eligible beneficiaries) (Berenson, 2001). Enrollment was not
uniform across the country, and some communities saw 40-50% of all
Medicare eligible adults in managed care plans (e.g., Los Angeles,
Portland, San Diego) (Health Care Advisory Board, 1996). During the
peak enrollment year of 1999, twelve states had enrollment rates
over 20%, and in California enrollment was 40% of all Medicare
beneficiaries (Berenson, 2001).
In the fall of 2001, national Medicare managed care enrollment
had declined to 14% of eligible beneficiaries (Berenson, 2001).
Administrative costs, difficulty controlling utilization, and reductions in
Medicare capitated payments to insurance companies has led to a
Table 4.2 Most Common Chronic Health Conditions in
Americans Age 65 and Older, 1996
Diagnosis
Occurrence
(per 100 persons age 65 +)
Arthritis 49
Hypertension 36
Hearing Impairment 36
Heart Disease 27
Orthopedic Impairment 18
Cataracts 17
Sinusitis 12
Diabetes 10
Source: Kramarow, Lentzner, Rooks et al., 1999
Table 4.3 Limitations of Activity Caused by Chronic Conditions in Non-institutionalized
Older Adults, by Selected Characteristics: United States, 1997-1999
Characteristic ADL Limitation (%) 1 IADL Limitation (%) 2
1997 1998 1999 1997 1998 1999
Age: Age 65 – 74 years 3.4 3.3 3.1 6.9 7.1 6.2
Age 75 years and over 10.4 9.6 9.9 21.2 20.5 19.1
Sex: Male 5.2 5.1 4.9 9.1 9.2 8.4
Female 7.7 7.1 7.2 16.9 16.4 15.1
Race and Hispanic Origin:
White, non-Hispanic 6.1 5.6 5.7 13.0 12.4 11.5
Black, non-Hispanic 11.7 11.1 11.9 21.2 21.8 20.8
Hispanic 10.8 9.9 8.6 16.3 19.3 14.1
Poverty Status 3 :
Poor 13.0 9.5 10.1 26.9 25.3 22.3
Near Poor 7.5 7.9 6.7 16.3 18.3 15.1
Non-Poor 5.3 4.6 5.5 10.1 9.7 9.7
1 Activities of Daily Living (e.g., bathing, dressing, toileting, transferring, continence, feeding)
2 Instrumental Activities of Daily Living (e.g., managing finances, shopping, preparing meals, traveling)
3 Poverty status is based on family income, family size, number of children, age of adults in family. Poor
persons are below the poverty threshold, near poor persons have incomes of 100 percent to less than
200 percent of the poverty threshold.
Source: CDC, National Center for Health Statistics, 2001
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number of insurance providers leaving the managed Medicare
marketplace. The providers that remain are charging patients higher
co-payments and deductibles, making managed Medicare a less
attractive option. The potential promise of applying managed care
principles to Medicare remains, but a new phase of public policy
initiatives will be required to reinvigorate this program (Berenson,
2001).
Home and Community-Based
Services for the Elderly
Beginning in the 1970s federal and state governments promoted
demonstration programs to reduce the institutionalization of older
adults and to improve the integration of health and social services for
the aged. The overall goals of these initiatives have been to reduce
government expenditures and improve the health and function of the