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Excellus Health Plan, Inc.

Policies for an Aging Society by Stuart H. Altman; David I. ShactmanReview by: Peggy A. GallupInquiry, Vol. 40, No. 3 (Fall 2003), pp. 306-308Published by: Excellus Health Plan, Inc.Stable URL: http://www.jstor.org/stable/29773083 .

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Inquiry/Volume 40, Fall 2003

education, we've been at it formore than twocenturies?at the University of Pennsylvaniasince 1765 and at the JohnsHopkins Universitysince 1889. Reform inmedical education is bur?dened with significant challenges. The same canbe said for thepractice ofmedicine.The authors' fifth nitiative deals with theunin?sured in our society, who have been of concernsince the 1931 report of theCommittee on theCosts ofMedical Care. Certainly Medicare andMedicaid, signed into law in 1965, provided ac?cess for these previously uninsured populationgroups. Given thedeliberations of theU.S. Houseof Representatives and the U.S. Senate overthe past four decades (including their currentattempts at prescription coverage forMedicarerecipients), I suspect we will be at it for yearsand, perhaps, decades to come.Another of theauthors' initiatives is to improvepopulation health. Three decades ago, theCalifor?nia Department ofHealth published a prescriptionfor improved population health. They suggesteda low-calorie diet, seven to eight hours of sleepeach night, alcohol inmoderation, exercise, stop?ping smoking, and the use of seat belts. Today,we should add safe sex.With my tongue incheek,how are we doing?

Improving the health caremarket throughcon?sumer choice and preventing anti-competitivepractices is another of the authors' suggested ini?tiatives. Logic says that this strategywill requirean extraordinary shift of resources frombiomedical research to the social sciences, including eco?nomics. This will be a long haul.The authors' call for a national health strategymust recognize thathealth policy is 10% legisla?tion and 90% implementation. Their call for ac?tion concludes with a coda, "Let's get best healthin return for our dollars." This is "value formoney in health," a concept that has had muchprevious press.

My concerns notwithstanding, I sign on. Fordecades, however, I have taughtmedical, nurs?ing, public health, and business students aboutthe iron triangle of health care, that is, the inex?orable tension among cost containment, qualityof care, and access to care. It seems that nocountry has ever addressed successfully thechallenges associated with health care's iron tri?angle. This book speaks from the authors' ex?perience. I hope they are correct and that theimplementation of their call for a national

health strategywill vitiate my concerns. I wishthem well.William L. Kissick, M.D., Dr. P.H.Emeritus Professor ofMedicine andManagement, University ofPennsylvaniaAdjunct Professor ofHealth Policy and

Management, Yale UniversityBranford, Connecticut

Policies for an Aging Society. Stuart H. Altaianand David I. Shactman (eds.). Baltimore: TheJohnsHopkins University Press. 2002. 400 pp.$24 (softcover).Policies for an Aging Society presents a compre?hensive array of writings about the economic,social and policy issues facing theUnited Statesinmaintaining a social insurance program forthe elderly into the 21st century. The book con?sists of 17 writings prepared by renowned ex?perts in many disciplines related to theproblems of an aging society. The work evolvedfrom a 1999 conference of these policy expertsgiven by theCouncil on theEconomic Impactof Health System Change (a research groupsponsored by theRobert Wood Johnson Founda?tion). Each chapter stands independently, whileat the same time thewritings work together toprovide many perspectives on defining and ana?lyzing the current situation. They suggest waysof solving theproblem of how to create an eco?nomically viable program for the future thatmeets theneeds of the elderly, but not at the ex?pense of other important government programsor the nation's economy. Most of this book ex?amines Social Security,Medicare, and the longtermcare portion ofMedicaid, but there also arediscussions of the government's policies forpri?vate pension programs.Each chapter addresses a different aspect ofaging policy, grouped into sections entitled "Eco?nomic Framework," "Policy Alternatives" and"Political Realities." Among theauthors, there isagreement that spending on programs for the el?derly is considerable; currently6.4% of thegrossdomestic product and 35% of the federal budgetgo to theoldermembers of our society. And thereis agreement thatwith the growth of the elderlypopulation, these programs are not sustainablein their current form.Without policy changes,

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Book Reviews

Social Security, Medicare, and Medicaid longterm care will use 70% of the federal budgetby 2030. Furthermore, there is general agreementthat theseprograms have been beneficial, particu?larly for reducing poverty among the elderly.In addition to economic statistics and programdescriptions, early sections of the book explainthe uncertainty associated with making accurateprojections about the future.As an introductionto the economics of social policy for theelderly,Henry Aaron warns that economic projectionshave limited value, while acknowledging thatthey are the basis of "every study or proposalregarding Social Security and Medicare"(p. 63), and thatpolicy analysis for the future iseven more uncertain. He is critical of analystslike himself, calling them "wannabe policymakers" (p. 68). This chapter provides a basisfor the reader tounderstand the economic projec?tionspresented by Eugene Steuerte and Paul VandeWater in their"user's guide to long-termbud?get projections" (p. 81).Recent economic news clearly demonstratesAaron's point about how difficult it is tomake ac?curate economic forecasts and, by extension, todevelop clear plans for the future of social pro?grams. The size of thefederal debt will affectpre?dictions about how much money is available forsocial programs. In theirdiscussion on long-termbudget projections, Steuerte and Van de Watermake reference to theBush administration's plantopay down some portion of thefederal debt overthenext 10 years. Yet, theWhite House recentlyannounced that for 2003 the government willhave a deficit of $455 billion, the largest ever.As would be expected when many experts inthefield address such a complex issue, the bookpresents many differentperspectives of the sever?ityof theproblem as well as the best solutions.Whether there even is a fiscal "crisis" ahead isdebated. JosephWhite calls it "the entitlementcrisis thatnever existed" (p. 140), and advocatesmaking some policy changes now (such as reduc?ing national debt and controllingMedicare costs)but leaving significant policy changes to thosewho live in the future. Theodore Marmor andJerryMashaw concur, saying thatmany of theclaims thatSocial Security is facing a fiscal crisisaremotivated by "ideologic opposition" (p. 175)to social insurance. Furthermore, theybelieve thefinancial problems of the futurecan be managedby the "modest adjustments" (p. 176) proposed

by theBall Plan within the 1996 Social SecurityAdvisory Council. In contrast,Richard Lamm de?scribes the growth in demand and sees loominga serious problem thatcould bankrupt thecountryunless we make considerable policy changes nowto achieve "intergenerational equity" (p. 205).The book provides a critical examination ofmany of thekey strategies forreforming thefinan?cial structure, eligibility requirements and ser?vices provided by social programs for theelderly. Mark Pauly considers taking SocialSecurity andMedicare away from the social insur?ance model, and introducing defined contribu?tions, more market-based cost controls forMedicare, and income-related eligibility. Alterna?tively, Alicia Munell supports maintaining de?fined benefits, arguing thatpayments based "onone's skills as an investor isnot consistentwith thegoals of amandatory Social Security program" (p.249). John Geanakoplos, Olivia Mitchell, andStephen Zeldes give a detailed explanation ofthemeaning of "privatizing" Social Security.They conclude that,while thereare possible ben?efits fromprivate accounts, the returnwill not beas high as itsproponents suggest. In a later chap?ter,Norman Ornstein adds that thepublic appealof these private accounts also has faded with thedrop in the stockmarket. The age of retirementwill have amajor impact on the cost of programsfor theelderly, and JosephQuinn shows that sinceabout 1985 more elderly Americans have beenworking, many in "bridge jobs" thatare betweenfull employment and retirement. Public policychange is one reason for this increase, but olderAmericans today are probably healthier, andmanyhave less physically demanding jobs than theirpredecessors. Lynn Etheredge describes a compre?hensive retirement policy that integrates publicand private programs toprovide work incentivesand necessary benefits in an efficientmanner.After examining themany policy options forreform,Ornstein and Robert Binstock (in sepa?rate chapters) assess the political environmentfor implementing these changes. Both authors ex?plain how theAmerican political environmentcan hamper making changes, but theycall forde?veloping a comprehensive aging policy. Finally,the book ends with a chapter written by VictorFuchs giving a holistic view of the situation, con?sidering thehealth and financial condition of theelderly, and promoting policies that encouragesaving and paid work.

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Policies for an Aging Society covers aging pol?icy broadly and in depth, and the text providesgood explanations for the technical concepts dis?cussed in the book (which range from regressionanalysis tonet present value). Itwould be usefulto have a glossary for unfamiliar terms or forwords that have been heard by everyone butmay have many definitions; thiswould be espe?cially helpful for students because thesewritingsinclude somany disciplines. This book does notpresent a unified perspective on social policy re?form,but rathereducates thereader by presentinga wealth of information and statistics to help inunderstanding thecurrent situation, theproposalsfor reform, theireffects and their likelihood. The

book does not intend to answer all questions. Sowe are left to decide forourselves whether babyboomers?who really are theproblem?will actlike "greedy geezers" who compete with the restof society for government support, or whethertheywill be "socially responsible" (p. 356). Hope?fully, itwill be the latter and we can, as a nation,work together to create an equitable social insur?ance program thatprovides for all who need it.Peggy A. Gallup, Ph.D.Associate ProfessorDepartment ofPublic HealthSouthern Connecticut State University,New Haven

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