Aging in the 21st century: projections, personal preferences, public policies - a consumer view

Health Policy, 9 (1988) 49-58

49

Elsevier

HPE 00190

Aging

in the Zlst century:

personal preferences, a consumer view

projections,

public policies -

Anne R. Somers Department of Environmental and Community Medicine and Dentistry of New Jersey, Robert School, Piscataway, NJ, U.S.A. Accepted

19 November

Medicine, University of Wood Johnson Medical

1987

Summary The demographic revolutions of the recent past and projections of continuing increases in the number and proportion of elderly in the United States and other advanced nations pose extremely difficult economic, political, and ethical issues. However, there is growing evidence - based on changing public and professional attitudes - that humane solutions are economically feasible. Of special importance is the new emphasis on “productive aging”, “successful aging”, “preventive gerontology” and related policies and programs which already give promise of postponing the average age of incidence of chronic illness and disability and extending the productive lifespan. Simultaneously there is growing attention to the “right to die” and other indications of a new focus on the quality of life rather than the length. Such developments also offer hope for the feasibility of adequate long-term care benefits for the victims of Alzheimers and other disabling conditions that we do not now know how to prevent. However, adoption of this approach to national health policy remains an option, not a prediction. Aging; Preventive

gerontology;

This paper is written care consumer. I have in the U.S. and other have been a consumer them. Address for correspondence:

0168-8510/88/$03.50

0

Public policy; Long-term

care

primarily from the perspective of an elderly American health spent over 35 years studying health and health care policies countries. But, for more than twice that length of time, I - experiencing the results of such policies, or the lack of

Dr. Anne

1988 Elsevier

R. Somers,

Science

31 Scott Lane,

Publishers

Princeton,

B.V. (Biomedical

NJ 08540, U.S.A.

Division)

50

In my personal life and in that of my family I have known the triumphs and the failures of modern medicine; the positive and negative incentives to good health and efficient health care inherent in current U.S. health policies; the hope, the joy, the fear, and the despair of people in an aging society which has not yet decided whether we elderly are an asset or a liability; whether the “Geriatric Imperative” dictates an ever-growing burden on an already deficit-ridden nation or whether it offers opportunity for combining maturity, productivity, and compassion in a new approach to Aging in the 21st Century. My own view - based on changing public and professional attitudes - is one of cautious optimism, even with respect to the difficult and - at least in the United States - neglected area of long-term care. But, first, a word about the Geriatric Imperative.

The demographic

revolution

and the Geriatric Imperative

The dramatic demographic changes which underlie the Geriatric Imperative are now familiar: the 100% rise in median age of the population from around 16 in the early.1800~ to 32 today [l]; the increased life expectancy at birth to nearly 75 years today [2], at age 65 to nearly 17 years; the rise in number and proportion of elderly, including those over 75, even those over 85. (I limit myself to U.S. statistics - but the phenomenon is world-wide.) Progression from the current elderly ratio (12%) to the 22% projected for the mid-21st century will not be even, however. Until about 2010, when the World War II “Baby Boomers” begin to reach 65, the increase in number and proportion will be quite moderate, reaching only 13% in 2000. The dramatic expansion will come after 2010 - the period when the demographic revolution may, indeed, assume crisis proportions unless adequate adjustments are made in the meantime. Projections into the next century depend, of course, on assumptions with respect to future mortality rates and life expectancy as well as fertility rates and immigration. Most importantly, how long will the recent dramatic decline in mortality rates continue? Will average life expectancy eventually stabilize in accordance with a more or less finite “normal human lifespan”? Projections differ widely on this point, depending on different assumptions and different definitions. In 1984, the U.S. Census Bureau projected an “ultimate life expectancy” for 2080 in the range of 77.4-85.9, with a mean figure of 81.0. Others have projected 100-110 [3]. Fries projects a “normal lifespan” of about 85-86 with a standard deviation currently about 9 years, decreasing to 7 [4]. The 21st century may be over before we know the final answer to the mystery of the “ultimate” or even the “normal” lifespan. Recent figures from the National Center for Health Statistics indicate a slowing down of the rise in life expectancy, compared to the 197Os, both at birth and at age 65. During the 5 years, 1971-1976, life expectancy at birth rose 1.8 years [2]. Between 1981 and 1986, it rose only 0.7 years, less than half as fast [2,5]. At 65, life expectancy rose 0.9 years during the early 1970s; only 0.2 years during the early 1980s. The figure is now 16.9 (H. Ro-

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senberg, National Center for Health Statistics, oral communication, September 28, 1987). Another straw-in-the-wind relates to the narrowing of the gap between male and female life expectancy. For several decades the gap was widening until in 1975 American women could expect to live 7.8 years longer than men. Since then, however, that difference has fallen to just 7 years, the result of slower improvement for women - probably due primarily to more smoking - and greater improvement for men. Similarly, the gap at age 65 narrowed from 4.3 years in 1975 to 4.0 in 1985. Despite these potentially significant developments, reinforcing the hypothesis of a finite normal lifespan, we can certainly anticipate for the first half of the 21st century - barring nuclear war or some other major disaster - a rapidly growing number and proportion of individuals living into their 70s and 80s with a sizeable number of nonagenarians and even centenarians.

Increasing public maturity:

optimism

plus realism

How do older people view this prospect? Clearly, with mixed feelings! The optimistic view - probably held by the majority - is reflected in the sunny pages of Modern Maturity, the official magazine of the American Association of Retired Persons, distributed bimonthly to a reported membership of 25 million. Examination of the magazine’s 58 feature articles for the past year (mid-1986 to mid-1987) reveals the following breakdown by major category (admittedly somewhat arbitrary): Travel 21%) Food/Festivals 19%, Personal Finance/Retirement 16%) Hobbies lo%, Personal/Family Health 7%, Profiles of Famous People 7%, Arts, Nature and Public Policy 5% each, All others 5%. Editorial policy firmly rejects not only “negative” articles but even “negative” advertising - “anything that shows old people in a bad light” [6]. The most recent issue features an article on work and concludes, not with the traditional call for earlier retirement and better pensions, but with these words: “Will more older people want to work in the future? Our answer is yes.“[7]. A darker view reflects the growing realization of the possibility of long-term chronic illness or disability, catastrophic expenses not covered by Medicare or Medigap insurance, dwindling family and neighborly supports, the possibility of having to “spend down” to welfare status, and increasing strains on those family members who are present. This view is reinforced not only by personal and family experience but by the increasing public attention to Alzheimers, Parkinsons, ALS, and other serious chronic diseases. Indeed, Alzheimers may have replaced cancer as the most dreaded disease and has become a metaphor for what people fear most about old age. Concern for the “right to die,” adoption of “living wills”, “health care proxies” [8] and/or designation of a durable power of attorney for the purpose of making medical treatment decisions, are also increasing, reflecting growing public sophistication with respect to the risk of protracted illness and the need for advance

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planning to minimize unnecessary personal and family suffering and financial depletion. In a 1986 “Grey Paper,” published by the Older Women’s League and written mostly by Tish Sommers, first president of OWL, just three months before her own death, Ms. Sommers says: “Technological advances in medicine make us think about our own vulnerability and the circumstances we may face at the end of our lives. What if we are no longer able to make life or death decisions in our own behalf? What if we are kept alive by mechanical means long after our minds and our spirits have succumbed? What if we lose control of what happens to us?” [9]. Tish Sommers has died but her voice will continue to contribute, as it has in the past, “to the development of social policy based on humane and realistic premises”. As of 1987, 39 states legally recognize “living wills” and most of the others are considering such legislation [lo]. In one “life care” or “continuing care” retirement community near Philadelphia, 75% of some 375 residents have signed living wills and designated a durable power of attorney for this purpose (Pensswood Village, Associate Director, unpublished information, July 6, 1987). Reflecting this groundswell of public opinion, the New Jersey Supreme Court, in 1987, expanded the right of individuals to refuse life-sustaining medical treatment, saying the patients’ interests must come before those of the state [ll]. In the words of Justice Marie Garibaldi, who wrote the decision, “Questions of fate have become questions of choice” [12]. Some health experts see a special irony in this situation: precisely at the time that medical science, public health and education, improved nutrition and a generally higher standard of living have combined to produce the best life expectancy in U.S. history, an influential segment of the elderly - the presumed beneficiaries of this historic progress - are focusing public attention on the “right to die.”

Professional

reinforcement

A shift of emphasis is also apparent in the new fields of Gerontology and Geriatric Medicine. There is, of course, major concern with the special problems of the very old and the severely disabled, including those with Alzheimers and related diseases, incontinence, decubiti, and general functional and financial dependence. This concern should - and I am sure will - continue. But, increasingly, professional interest is focusing on the prevention, postponement, or control of the major chronic diseases leading to disability and dependency. This is especially true of research. One of the first geriatricians to stress the importance of prevention was Frank Williams, Director, NIA. As early as 1979, he wrote, “Many of the conditions that predispose the elderly to functional dependency are amenable to preventive intervention” [ 131. The following year, James Fries, a rheumatologist from Stanford Medical School, published the first of several papers articulating the concept of “compression of morbidity”, based on the assumption that the average age of incidence of serious

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chronic illness or disability can be pushed back further or faster than the average age of death [4,14,15]. The thesis is controversial since it challenges a fairly common assumption that improvement in age-specific mortality rates is likely to exceed improvement in morbidity rates and thus lead to more, rather than less, disability. While it is obviously true that the greater number of elderly in the population will, almost certainly, lead to more overall illness and disability, Fries maintains that this need not be so for morbidity and disability rates; that is, any given person need not anticipate more morbidity or disability. In defense of his view, he marshalls considerable documentation. For example, a long-term study of male employees of the DuPont Company, 1957-1983, found a 28% drop in the age-adjusted incidence rates of myocardial infarction, compared to a 20% drop in 30-day case fatality rates over the same period [16]. Analysis of short-term hospital stays in U.S. hospitals over a 13-year period suggests that the average age of hospitalization for cardiovascular disease increased more rapidly (an average of 4 years) than did life expectancy (2 years) over the same period [4]. Studies of osteoporosis have projected that osteoporotic fractures could be reduced by 50% by the mid-2lst century if only currently available preventive techniques were adequately used [17]. Other researchers have demonstrated significantly increased bone density in regular runners over age of 50 after careful matching with community controls [18]. (On this point, I offer a bit of personal anectodal evidence: I have just become a director of Pennswood, the previously cited CCRC in Pennsylvania. At the first meeting I was both surprised and delighted to hear the Medical Director report that serious falls and fractures have almost disappeared among the residents - despite the fact that the average age is 81 and they are 3/4 female. He attributes this to aggressive calcium and hormonal therapy for the prevention of osteoporosis (Pennswood Village, Medical Director, unpublished information, July 6, 1987).) While it is true that “trade-offs” between morbidity and mortality will continue to occur, occasionally resulting in prolonged disability and higher overall costs, Fries maintains the opposite is more likely to be the case, as demonstrated by recent experience with heart disease and lung cancer. Moreover, many disabling diseases, such as osteoarthritis and back pain, are rarely fatal and any reduction in incidence in these areas clearly contributes to the net reduction in morbidity. Even in the case of morbidity associated with senescence (e.g. failing eyesight and hearing, osteoporosis, fractures, dental problems) preventive or corrective measures are frequently available. It is not the purpose of this paper to try to settle the continuing controversies between the advocates and opponents of the “compression of morbidity” thesis. It is my purpose to state, as a consumer/patient, that the concept encapsulates - albeit in rather obscure language, what most people pray for - the longest possible healthy life followed by a quick death (preferably not a violent one). I also want to emphasize that this approach appears in line with a number of important related concepts and programs that have emerged in the past few years from a number of separate individuals or groups.

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(1) “Preventive Gerontology” is the intriguing concept advanced by William Hazzard, formerly of Johns Hopkins, now Chairman, Department of Medicine, Bowman Gray School of Medicine. Hazzard defines “Preventive Gerontology” as “the attenuation of time- and age-related processes to the extent that they fail to become symptomatic until the person approaches the upper limit of the human life span” [19). Whereas Fries concentrates on broad policy implications, Hazzard focuses on the individual physician and challenges him/her to a three-part role in the prevention of chronic disease: (a) a personal evaluation of the scientific data-base from which individual preventive strategies are derived; (b) support for general community preventive programs, including living up to a preventive role-model; and (c) development of a consistent pattern or style of professional practice with individualized intervention strategies for individual patients. (2) “Productive Aging” is the term coined by Robert Butler, former Director, National Institute on Aging, now Chairman, Department of Geriatrics and Adult Development, Mt. Sinai School of Medicine, N.Y.C., to stress “mobilization of the productive potential of the elders of society” [20]. First elaborated at a Salzburg International Seminar in 1983, now institutionalized in The Center for Productive Aging which is part of the Mt. Sinai Department of Geriatrics, the concept and its implications achieved international attention at a conference entitled “The Promise of Productive Aging: The Future for Japan and the U.S.” held in Washington, April 1987 and sponsored jointly by Mt. Sinai Medical Center, the Japan Shipbuilding Industry Foundation, and the Alliance for Aging Research. Both the Salzburg and the Washington conferences started by emphasizing the science base for the potential of “productive aging.” A. Svanborg of Sweden documented the fact that recent cohorts of Swedish 70-year-olds are healthier and more able than their predecessors. “While the risk of falling ill does increase in old age, more years of relative health have been added to average life expectancy” [20]. James Birren, former Dean, Leonard Davis School of Gerontology, University of Southern California, documented the persistence of mental competence even into old age: “While becoming more vulnerable to disease, the individual may generate new roles, develop new concepts and perceptions of self and society, and take up new careers and vocations . . . . The performance of the brain is an example. The normal brain remains active throughout life . . . . Birren’s outlook implies that aging at the social and psychological levels is highly malleable” [20]. Out of the Salzburg Seminar, there emerged a set of Principles. The first two of these were as follows: “Health care should enable people to function to the limit of their physical, psychological, and social capacities. Therefore, care that emphasizes health promotion, disease prevention, and integration of services is preferred over institutionalization. Any services that induce dependency should be discouraged”. “Productive participation in society is essential to health”. (3) “The Disuse Syndrome” is a term coined by Walter Bortz of the Palo Alto Medical Foundation, California. According to Bortz: “The identifying characteristics are cardiovascular vulnerability, obesity, mus-

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culoskeletal fragility, depression and premature aging. The syndrome is experimentally reproducible and the clinical features are subject to both preventive and restitutive efforts that are happily cheap, safe, accessible and effective” [21]. (4) “Successful Aging” is the title given to a multimillion dollar research project funded by the MacArthur Foundation and directed by John Rowe of Harvard Medical School. The study involves a long-term effort to identify the causes and “predictors” of “successful aging” and hopes to produce a “risk profile” to facilitate early positive intervention in the aging process [22]. One of the first fruits of this project was a 1987 article by Rowe and Kahn in Science, entitled “Human Aging: Usual and Successful” [23]. Pointing out that “a major component of many age-associated declines can be explained in terms of life style, habits, diet, and an array of psychosocial factors extrinsic to the aging process”, they conclude with a strong recommendation for greater emphasis on health promotion and disease prevention in the elderly. “A revolutionary increase in life span has already occurred. A corresponding increase in health span, the maintenance of full function as nearly as possible to the end of life, should be the next gerontological goal. The focus on successful aging urges that goal for researchers, practitioners, and for older men and women themselves.” (5) In 1982, the Carnegie Corporation of New York established an “Aging Society” Project which resulted in the book, Our Aging Society: Paradox and Promise [24]. Among its important findings was “the unexpected and unexplained extension of the adult prime” (L. Bronte, Presentation, Monmouth Medical Center, Long Branch, NJ, May 28, 1987). (6) In a popular New York Times article entitled “Old Age Is Not What It Used To Be, ” psychologist Carol Tavris says: “Adult life used to be fairly predictable, and so were theories of aging. It was simple: the older you got, the more you lost - sex drive, memory, brain cells, energy, intelligence. When psychologists first studied adult development, they would come around every few years and draw conclusions about the inevitable losses associated with age. Now they come around every few years and find that Grandma refuses to mind the grandchildren; she and Harry have bought a Winnebago and are camping in Yosemite. Aunt Sarah took up marathon running and local politics at the age of 73. And Uncle Fred retired at 58 from Amalgamated Teabiscuit & Muffins to become a jazz musician. Growing old is not what it used to be.” Generalizing, she continues: “In separating the biology of aging from its psychology, researchers have begun to realize that many of the presumed psychological deficits of old age would occur to people of any age who were deprived of loved ones, close friends, meaningful activity and intellectual stimulation” [25]. The opposite side of this medal is obvious: love, friendships, meaningful activity and intellectual stimulation are important antidotes to aging. (7) At the other end of the “Compression of Morbidity” spectrum, Daniel Callahan, one of the nation’s foremost biomedical ethicists, has just published an important book, Setting Limits: Medical Goals in an Aging Society [26]. In it, he says,

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“the future goal of medicine in the care of the aged should be that of improving the quality of their life, not in seeking ways to extend that life”. (8) Finally, of special interest to statisticians, actuaries, and other technical experts is the concept of “active life expectancy” developed by Dr. Sidney Katz and colleagues [27]. “Instead of death, the end point of an alternative active life expectancy is loss of independence in the activities of daily living”, as measured by the ADL index. The authors believe the new measure can be used for both actuarial and epidemiological purposes including identification of high-risk populations for which preventive health and medical care can compress morbidity during the last years of life. There are, of course, major distinctions between these concepts, programs, and statements. One is primarily methodological; two are addressed primarily to practicing physicians; one to older people themselves; one is a basic science research project; the others involve various aspects of public policy. But what they have in common is an emphasis on aging as a positive - rather than a negative - process, on the ability of the elderly simultaneously to promote their own health and contribute actively to society: and on the importance of focusing public policy on the quality of our lives rather than the length.

Public policy: some implications for the growing long-term care insurance debate I return now to my original theme, “Projections, Personal Preferences and Public Policy” and repeat the question raised at the outset: “Does the Geriatric Imperative dictate an evergrowing burden on an already deficit-ridden nation or does it offer opportunity for combining greater maturity, productivity, and compassion in a new approach to Aging in the 21st Century?” I hope I have made clear my belief that we do have this opportunity and that I am joined in this belief by some of the most distinguished geriatricians, gerontologists, psychologists, and ethicists in America. At the same time, I must emphasize that this positive approach remains a policy option, not a prediction. Inadequate conviction, inadequate resources, inadequate courage, above all, inadequate vision, or just plain selfishness - on the part of the elderly as well as the young could result in failure by default and lead to the type of self-defeating intergenerational conflict and stalemate already predicted by some pessimists. This is not the place even to try to spell out the many changes in U.S. social policy that will be needed to assure a positive response to the Geriatric Imperative. I conclude with three broad statements of principle which summarize my overall approach as I contemplate the difficult policy debates that lie ahead. (1) Life involves a complex network of mutually supporting rights and responsibilities on the part of both the individual and society. In our large, complex, heterogeneous, and highly organized democracy, the relation between rights and responsibilities often becomes attenuated and at times almost disappears from view. In the last analysis, however, we ignore this relationship at our peril.

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(2) U.S. Aging Policy, as in other areas, must reflect this balance of rights and responsibilities. The inevitably large costs of providing high-quality acute and longterm care to the elderly must be accompanied by an obligation on our part (I speak as an elderly consumer myself) to take the best possible care of our own health and to remain active, productive (I do not shy away from Dr. Butler’s term) and a contributing member of society as long as possible. This is particularly appropriate since we now know that health, activity, and productivity are generally complementary, rather than antithetical. At the same time, society has the responsibility to do everything possible to promote health, activity, and productivity on the part of the elderly, including appropriate environmental controls, basic health care, consumer education, and financial incentives to individual health-maintenance behavior. (3) Focusing specifically on long-term care, the major U.S. gap in health protection for the elderly today, this suggests the need for linking the increased financial protection, so badly needed, to increased emphasis on health promotion and disease prevention. This can be done in various ways - some direct, some indirect. Elsewhere, I have suggested varying Medicare Part B premiums by $1-2 a month based on smoking status [28]; or varying private long-term care insurance premiums by smoking status and perhaps other, risk-factors for chronic disease or injury such as use of seat belts, smoke detectors in home, control of high blood pressure if present, moderate exercise, corrected vision if necessary, etc. [29]. The “sin taxes” - on tobacco and alcohol - could be increased and the revenues specifically earmarked for long-term care benefits. The counter-arguments are familiar - “blaming the victim”, “excise taxes are regressive”, etc. But the alternative may well be no significant progress in long-term care benefits as well as continued erosion of Medicare’s acute care benefits. Conversely, to the extent that we do reduce the rate of incidence of cardiovascular disease, cancer, osteoporosis, emphysema, auto accidents, violence, and other preventable diseases and injuries, and the disability resulting therefrom, it is obvious that we can provide more adequate protection to the victims of Alzheimers and other conditions that we do not now know how to prevent. Similarly, if the average age of retirement could be pushed back even a year or two we could provide more adequate Social Security and other pensions when they are really needed. The major argument against this used to be unemployment. But the coming labor shortage, reflecting the “Baby Bust” generation, combined with the changing nature of the American economy, with its shift from heavy industry to service jobs, make it both more urgent and easier for older people to continue healthy, active, and productive as long as possible and thus contribute to the good health care most of us will need and want before we die.

References 1 U.S. Bureau of the Census, Current Population Reports, Projections of the Population of the U.S., by Age, Sex. and Race: 1983 to 2080. Ser. P-25, No. 952. Government Printing Office, Washington. DC, 1984.

58 2 U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Health, United States, 1986, DHHS Pub. No. (PHS)87-1232, Government Printing Office, Washington, DC, 1986. 3 Butler, R.N., The longevity revolution, Mount Sinai Journal of Medicine, 54 (1987) 5-8. 4 Fries, J.F., Aging, illness, and health policy: implications of the compression of morbidity, Perspectives in Biology and Medicine, in press. 5 New York Times, U.S. fertility at low and life expectancy at high, September 8, 1987. 6 Currie, D., Modern Maturity comes of age, Press-Telegram, Long Beach, California, 1987. 7 Bird, C., The shape of work to come, Modern Maturity, 30 (1987) 33-45. 8 The New York State Task Force on Life and the Law, Life Sustaining Treatment: Making Decisions and Appointing a Health Care Agent, New York City, July 1987. 9 Sommers, T. et al., Death and dying: staying in control to the end of our lives, Gray Paper, Older Women’s League, Washington, DC, 1986. 10 Society for the Right to Die, Handbook of Living Will Laws, Society for the Right to Die, New York City, 1987. 11 Sullivan, J.F., Right of patients who wish to die widened in Jersey, New York Times, June 25, 1987. 12 Malcolm, A.H., A judicial sanction for death by assent, New York Times, June 28, 1987. 13 Filner, B. and Williams, T.F., Health promotion for the elderly: reducing functional dependency. In U.S. Department of Health, Education and Welfare, Public Health Service, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, Vol. II, Background Papers, DHEW (PHS) Pub. No. 79-55071A, Government Printing Office, Washington, DC (1979) 365-386. 14 Fries, J.F., Aging, natural death, and the compression of morbidity, New England Journal of Medicine, 303 (1980) 130-135. 15 Fries, J.F., The compression of morbidity, Milbank Memorial Fund Quarterly/Health and Society, 61 (1983) 397-419. 16 Pell, S. and Fayerweather, W.E., Trends in the incidence of mvocardial infarction and in associated mortality and morbidity in a large employed population, 1957-1983, New England Journal of Medicine, 312 (1985) 1005-1011. 17 Brody, J.A., Prospects for an aging population, Nature (London), 315 (1985) 463-466. 18 Lane, N.E., Bloch, D.A., Jones, H.S. et al., Long-distance running, bone density, and osteoarthritis, Journal of the American Medical Association, 255 (1986) 1147-1151. 19 Hazzard, W.R., Preventive gerontology: strategies for healthy aging, Postgraduate Medicine, 74 (1983) 279-287. 20 Butler, R.N. and Gleason, H.P. (Eds.), Productive Aging: Enhancing Vitality in Later Life, Springer, New York, 1985. 21 Bortz, W.M. II, The disuse syndrome, The Western Journal of Medicine, 141 (1984) 691-694. 22 MacArthur Foundation, J.D. and C.T., Successful aging: the focus of MacArthur Foundation study, Press Release, Chicago, September 1985. 23 Rowe, J.W. and Kahn, R.L., Human aging: usual and successful, Science, 237 (1987) 143149. 24 Pifer, A. and Bronte, D.L. (Eds.), Our Aging Society: Paradox and Promise, Norton, New York, 1986. 25 Tavris, C., Old age is not what it used to be, New York Times, Good Health Magazine, September 27, 1987. 26 Callahan, D., Setting Limits: Medical Goals in an Aging Society, Simon and Schuster, New York, 1987. 27 Katz, S. et al., Active life expectancy, New England Journal of Medicine, 309 (1983) 1218-1224. 28 Somers, A.R., Why not try preventing illness as a way of controlling Medicare costs?, New England Journal of Medicine, 311 (1984) 853-856. 29 Somers, A.R., Long-term care can be made affordable to many, Wall Street Journal, September 8. 1986.