Testimony

Statement by
James S. Marks, M.D., M.P.H.
Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Department of Health and Human Services
on
Preventing Disease and Preserving Health Among Our Nation's Aging
before the
The Special Committee on Aging - United States Senate

May 19, 2003

Thank you, Mr. Chairman, Senator Breaux, and Members of the Committee, for the opportunity to address a critical priority for our society, the Department of Health and Human Services, the Centers for Disease Control and Prevention (CDC), and public health – that of preventing disease and preserving health among our nation's growing number of older adults. CDC shares the priority that this Committee has placed on ensuring that the health of our nation's seniors receives appropriate and equitable attention as reflected in the scheduling of this hearing.

In my remarks today, I would like to focus on the opportunities of known prevention measures to reduce unnecessary illness, disability, and premature death among older Americans, including the critical role that Medicare-covered preventive services play in helping to preserve health and the quality of life for our nation's seniors. I would also like to highlight an innovative local model program that has demonstrated remarkable success in ensuring that seniors receive potentially life-saving preventive services.

Implications of an Aging Society

In 1900, only three million people in this country were over the age of 65. As you well know, that picture has changed dramatically a century later. Eight short years from now, the leading edge of the baby-boomers will reach age 65 and the number of older adults will increase rapidly. In the next 25 years, the population over age 65 will more than double, to 70 million older adults. This unprecedented aging of the U.S. population will present societal and economic challenges unlike anything our society has ever had to address.

Current health and aging trends have enormous implications for public health, the health care system, and our existing network of social and aging services. In terms of health care, a look at a few numbers makes the point clear: a 65-year-old costs four times what a 40-year-old costs in terms of health care dollars. Seniors already account for one-third of all health care dollars spent in the United States -- over $300 billion each year. The ongoing debate about how to rein in the growth in health care costs including Medicare has occurred during the phase of a slow, gradual increase in our number of older adults. We will soon be paddling against a relentlessly rising tide, when the first wave of 76 million baby boomers reaches Medicare age. These numbers are sobering, compelling, and require urgent action.

We cannot begin to stem skyrocketing health care costs, much less adequately ameliorate priority health problems, without addressing in a fundamentally more aggressive manner the prevention of disease and disability among older Americans. Increased emphasis on disease prevention and health promotion opportunities for aging and older adults is one of the few avenues available to address the looming impact of chronic disease and other illnesses, disabling injuries, and long-term health care costs among older Americans.

Recent CDC projections of just one major disease—diabetes—illustrate the magnitude of what we face if we do not take action now. The number of U.S. adults with diagnosed diabetes (including women with gestational diabetes) has increased 61 percent since 1991 and is projected to more than double by 2050. Diabetes costs the nation nearly $132 billion a year. The average yearly health care cost for a person with diabetes was $13,243 in 2002, compared with $2,560 for a person without diabetes. Diabetes costs represented 11 percent of national health care expenditures during 2002. Even more alarming for our health care system and for Medicare is that the greatest increase in diabetes cases over the next 50 years will be among those 75 years of age and older—a projected increase of 336 percent. This is just one example of how the aging of our nation could greatly increase national health care costs if we do not identify and apply preventive measures now.

The Role of Public Health and CDC

The 35 year increase in life expectancy for Americans in the 20th century represents a remarkable societal achievement. The same effort that led to these unprecedented gains needs to be mobilized to make added years of life for Americans as healthy and independent as possible. The goal of public health in aging, and that of CDC, is to extend health, functional independence, and health-related quality of life for as long as possible, and compress and delay periods of illness and disability so that individuals can maximize their senior years in good health, and families can maximize the years they enjoy with their senior family members. Research has shown that poor health does not have to be an inevitable consequence of growing older. Death is inevitable, but, for many people, it need not be preceded by a slow, painful, and disability-ridden decline. Our nation will continue to age – that we cannot change - but we can delay and in many cases prevent illness and disability.v

Older Americans today are likely to either need to or want to work past "retirement age." They must be healthy to do so and workplaces must promote continued health. As the U.S. population continues to age, the number of workers 55 years and older will also increase dramatically. These workers will be more susceptible to a variety of occupational illnesses and injuries. Therefore, we need to better understand this increased susceptibility and what can be done in the workplace to reduce the increased risk. For example, older workers are at greater risk of a fatal accident because of a slip.or fall than younger workers. Prevention strategies need to focus on how these types of injuries can be reduced.

While continuing to pursue technologic advances and assuring access to health care are essential, there is also much to be gained from more widely applying prevention strategies with demonstrated effectiveness. The evidence is convincing if not overwhelming that prevention is worth the investment for the health and safety of older adults. A recent Institute of Medicine report noted that the return on investment in medical care for cardiovascular disease reaped benefits at 4 to 1, but investment in behavioral change returned a remarkable 30 to 1 advantage. It is imperative that we bring the health advantages of prevention to older adults around the country.

CDC has identified the following critical priorities for the agency in addressing the health of our nation's seniors:

  • Increase the use of early detection services (e.g., screening for chronic diseases such as cancer, cardiovascular disease, diabetes and its complications)
    Chronic diseases account for nearly 75 percent of all deaths in this country. Additionally, they are by far the leading causes of disability and long-term care needs, and represent nearly 75 percent of all health-related costs. Although chronic diseases are in no way limited to older adults, these conditions, such as cancer, heart disease, diabetes, and arthritis, are heavily concentrated in adults aged 50 or older. Early detection and appropriate follow up care saves lives and may reduce costs. However, over ˝ or 50 percent of older Americans (50 years of age or older) have not had recommended colorectal cancer tests within appropriate screening intervals, even though Medicare covers the cost for all eligible Americans over age 65. Among women aged 65-69, over 30 percent have not had a mammogram within the recommended time interval; yet another Medicare-covered benefit that is underutilized.
  • Increase the use of adult immunization
    Influenza and pneumonia (invasive pneumococcal disease) contribute to over 42,000 deaths each year. Despite the fact that Medicare covers immunizations for these two diseases, more than a third of individuals age 65 and older do not receive an annual flu shot at the recommended interval and 40 percent have not ever received a pneumonia vaccination.
  • Promote healthy lifestyles
    Research has shown that healthy lifestyles are more influential than previously thought in helping older people avoid the deterioration traditionally associated with aging. People who are physically active, eat a healthy diet, do not use tobacco, and practice other healthy behaviors significantly reduce their risk for chronic diseases and can delay the onset of disability by 7 to 10 years. Research has shown that the rate of disability among individuals who practice healthy behaviors is one-fourth the rate of those who do not. A person is never too old to benefit from improved nutrition, being physically active, or quitting smoking.
  • Reduce hazards and risk factors leading to injuries
    Falls are the most common cause of injuries to older adults. Half of the 250,000 older adults hospitalized each year for hip fractures cannot return home or live independently afterwards, and one-quarter die within the first year after fracture. Simple measures such as removing tripping hazards and installing grab bars in the home can greatly reduce older Americans' risk for falls and related fractures.
  • Increase the use of disease self-management techniques
    Programs that teach older adults how to better manage chronic illness can reduce both pain and health care costs. Arthritis is the leading cause of disability among American adults. The Arthritis Self-Help Course, developed by the Arthritis Foundation to help people with arthritis better manage their disease, has been shown to reduce arthritis pain by 20 percent and visits to physicians by 40 percent. However, less than 1 percent of Americans with arthritis who could benefit participate in such programs, and courses are not available in many areas.

CDC and the public health community in our states and communities have a continued role to play in bringing the benefits of prevention to our nation's seniors. Working closely with other federal agencies, such as the Administration on Aging, public health brings the focus on health, the knowledge of what works, and the links to the clinical community. What CDC brings to the table is its well-recognized scientific expertise, long-standing experience in prevention research, ability to evaluate health promotion programs and identify those that work, established public health network and ability to work with states and communities to implement disease prevention and health promotion programs, and unique surveillance capacity to better guide programmatic efforts.

  • CDC is currently working closely with the Administration on Aging (AoA) to bring together the respective strengths of the public health and aging networks. Whereas the public health network provides sound expertise and capacity to implement effective prevention and health promotion programs, the aging network has a long history of providing aging-related services to seniors. CDC and AoA recently supported an assessment of the health promotion needs of state health department and state units on aging in relations to older adults. Results included a clear message that the aging network is looking to public health for science-based health promotion and disease prevention strategies that are tested and proven effective. State units on aging also expressed that they do not have the time, resources, or expertise to develop and test health promotion interventions. CDC's strength is its ability to demonstrate the effectiveness of a prevention strategy or program and help states and communities put it into practice. CDC is also uniquely positioned to take the results of research conducted through is Prevention Research Centers program, by the National Institute of Health's National Institute on Aging (NIA), or other venues; to build public health interventions based on the results of that research; and to make these interventions available widely in terms that local communities and area agencies on aging can understand and easily apply.
  • The growing science base for the benefits of prevention among seniors needs to be shared and implemented widely in public health practice. CDC is poised, through its leadership role in the public health community, to ensure that the growing body of evidence that we can change the health of seniors is applied throughout public health practice. To a certain extent, it is as if we have not fully engaged in applying public health practice to older populations. For example, a 2-year-old girl is more likely to be "up-to-date" on needed preventive services than is her 65-year-old grandmother. We have sometimes not recognized that healthy behavior choices can improve the health of older Americans even when those healthy choices are begun later in life. CDC can play a key role in raising much-needed attention to the critical needs of seniors on our national public health agenda.
  • CDC can help increase the use of preventive services by seniors through public education, changing the way we offer preventive services to seniors, and influencing changes to medical practice. The Congress and the Centers for Medicare & Medicaid Services (CMS) have emphasized the value of selected prevention measures – chronic disease screening and adult immunization -- by ensuring that they are covered benefits under the Medicare program. However, coverage alone does not ensure use. CDC data from the states have shown that very few older adults have received all recommended covered services. In some states, as few as one in nine seniors is up to date on covered services. Despite payment by Medicare for more than 20 years, delivery of pneumococcal vaccination – arguably on of the simplest of clinical preventive services – has reached less than 56 percent of those aged between 65 and 74. Among African-Americans, the delivery rate is less than 40 percent -- less than four out of ten. Medicare-covered preventive services are available, they are effective, and they are provided at little to no cost for the beneficiary. Yet, they are under-utilized. Clearly, there is a gap to be bridged.

CDC working with other DHHS agencies and public health, can help close that gap. We can provide public education about the value of preventive services to seniors. We can identify how to modify national delivery of preventive services to make services more accessible to seniors (for example, providing services at times and in places that are convenient for seniors taking into account their transportation needs and combining services to minimize the need for multiple visits). We can influence help educate physicians to promote use of preventive services by seniors. When a 68-year-old woman visits her doctor's office, she is generally there for a specific complaint--her arthritis, her heart disease, her diabetes, or perhaps some combination of chronic or other conditions. The question of whether she has had her flu and pneumonia vaccine may never come up. The recommendation that she be screened for colorectal cancer may not enter into the conversation during what is likely to be a very brief office visit when other health matters are more urgent. Specific recommendations from a physician are critical in increasing use of preventive services by seniors.

An Example of Success

There is good news in that many of these challenges are being successfully addressed by small programs operating on minimal dollars in limited geographic areas of the country. Among the most innovative models is a program covering a 4-county area in portions of Connecticut, Massachusetts, and New York. The Sickness Prevention Achieved through Regional Collaboration -- or SPARC -- program is conducted by a non-profit organization that acts as a local bridge among local public health departments, the medical community, and community-based organizations to increase the use of Medicare's clinical preventive services -- chronic disease screenings and adult immunizations -- among the older population. One of SPARC's especially effective strategies has been to promote and help the medical community to combine preventive services for ease of access. SPARC has demonstrated great success in enhancing the provision of preventive services within clinical practices, facilitating public access to prevention, and establishing local accountability for the delivery of services. SPARC does not deliver preventive services but helps local communities do a better job of providing the services themselves. SPARC's advantages include:

  • Improves access to preventive care across governmental jurisdictions;
  • Establishes new points of access for preventive services;
  • Provides local prevention outreach and patient education tailored to diverse and underserved communities;
  • Assures community-wide access to vaccine supplies and monitors local outcomes;
  • Capitalizes on economies of scale;
  • Creates a central locus of accountability, and;
  • Provides a forum for key and varied players to jointly address critical issues and challenges.

One local provider in a SPARC community has said of the program, "SPARC frees us to take care of sick patients." Local health departments see the benefit as well. One local health department staffer commented to my staff, "The program is well-thought out and grounded in science. They provide so much of the infrastructure and keep us focused on preventive strategies in the midst of so many competing priorities. SPARC expands our ability to do good public health work."

Through rigorous evaluation supported in part by CDC, SPARC achievements include:

  • Increased by 94 percent pneumococcal vaccinations delivered in Dutchess County, NY (as demonstrated by Medicare reimbursement data);
  • Doubled the use of breast cancer screening among women attending flu clinics where SPARC made mammography appointments available; and
  • Doubled the rate of pneumococcal vaccinations in Litchfield County, CT, representing twice the increase seen in surrounding counties where SPARC was not available.

SPARC's mission in relation to older adults is clear and well-defined. It does not provide a new service; it does not compete with the medical care system. Rather, its one overarching aim is to increase the use of Medicare-covered clinical preventive services. It does so by providing critically needed coordination and linkage between the clinical care world, the social services world, and the older adults themselves in the communities that it serves. In a very fragmented system, SPARC provides the focal point and the glue to ensure that the Congress' intent is fulfilled -- that the nation's older adults receive potentially life-saving preventive services. SPARC represents a particularly noteworthy catalyst for enabling an effective community-based response to a national priority.

SPARC is currently available on an extremely limited basis in a very specific geographic area. There is nothing unique about the area that SPARC serves. These same results can be achieved elsewhere. In fact, its impact may be even greater in more rural and isolated communities.

SPARC is a good example of the role that public health and CDC plays nationally in supporting local efforts to change the course of health for our seniors. CDC is just beginning to do in aging what we have done in so many other public health areas. We evaluate public health programs in the field (as we did with SPARC), identify those that work, and make these programs available to states and local communities throughout the country.

Current CDC Efforts

In recent years, CDC has placed increased priority on addressing the health of seniors and collaborated closely with its sister agencies--AoA, CMS, NIH, the Health Resources and Services Administration (HRSA), and the Agency for Healthcare Research and Quality (AHRQ). Recently, CDC and AoA, through state-based counterparts--the state Chronic Disease Directors and the National Association of State Units on Aging-- conducted an assessment among state-based staff in the public health and aging networks to better determine priorities, needs, and collaboration around older adult health in the states. Respondents indicated that support at the national level for science-based, health promotion/disease prevention programs for older adults is a key priority for the states. CDC can play a critical role in identifying, disseminating, and implementing effective programs in states and local communities.

Support to States and Communities

In response to this assessment, CDC and AoA have jointly funded 10 states to have their state public health and aging offices work together on projects designed to improve older adult health. Thirty-one states applied for an average of $10,000. The ten funded states are now targeting such issues as promoting regular physical activity and increasing the use of clinical preventive services. A key requirement of our grants is that state units on aging and state health departments must work together, a first in many of the funded states.

To further support efforts in states and communities, CDC has initiated work with several key national organizations, such as the National Council on the Aging, the American Society on Aging, and the Center for Medicare Education at the American Association of Homes and Services for the Aging to establish national-level resources on which states can readily draw. Among anticipated outcomes of work with these organizations are the development of a "best practices" compendium for older adult health; web-based modules addressing key health issues for older adults; and effective communication tools related to Medicare-covered preventive services for the public, caregivers, and providers.

CDC also supports 36 states to improve the quality of life for people with arthritis. Arthritis is the leading cause of disability affecting almost 70 million Americans. CDC-funded states are developing action plans with partners such as Arthritis Foundation affiliates, conducting pilot projects, and building arthritis programs. In many states, such programs are geared towards increasing the number of Americans who can take advantage of the demonstrated benefits of the Arthritis Self-Help Course and physical activity programs for people with arthritis. In addition, CDC and NIH co-funds research to better determine why arthritis occurs and progresses. CDC is supporting research to find effective strategies to improve the quality of life among persons with arthritis.

Determining what works in prevention and getting it out to states and communities
A critical role of public health is to move research from "the bench to the trench," i.e., to communities that are distant from our best universities and medical schools, to ensure that promising research findings and effective intervention strategies reach the individuals they are designed to benefit. To that end, CDC is investing in research that.helps not only to identify what works in prevention, but to ensure that such research is put into practice in communities.

  • CDC is supporting the "Healthy Aging Research Network," a network of centers located at 7 academic institutions around the country conducting public health research on effective strategies for improving older adult health. Recently, the network has initiated collaboration with the National Council on Aging to better delineate and disseminate information on "best practices" for prevention and health promotion for older adult health. Traditionally, prevention research has focused on those under age 65; the Healthy Aging Research Network is changing that.
  • CDC continues to evaluate, identify, and disseminate programs that work, like SPARC. Another example of a program CDC has evaluated and disseminated is the "Senior Wellness Project," partially supported through CDC's Prevention Research Center program, which was developed at the University of Washington in Seattle in collaboration with the state's largest non-profit agency serving seniors, the local HMO, and other partners. Working through the network of senior centers to engage participants in activities tailored to the needs of seniors with chronic illnesses (e.g., chronic disease self-management education and tailored physical activity) this program has reduced hospitalizations and improved functional status among its participants.
  • CDC joined with the Robert Wood Johnson Foundation, AARP, NIA, and over 40 other key national health and aging organizations to develop the National Blueprint: Increasing Physical Activity Among Adults Age 50 and Older. This landmark report delineates for the first time key science-based strategies for promoting physical activity in this age group. CDC is now working with partners to disseminate and implement strategies identified in the Blueprint.
  • CDC participated in updating the Transportation Research Board's National Academy of Sciences Report, "Transportation in an Aging Society," and will continue to work with organizations such as the National Safety Council to assess knowledge, attitudes, and perceptions related to older driver safety.
  • CDC is providing leadership to eliminate racial and ethnic disparities among people 65 years and older. The Racial and Ethnic Adult Disparities in Immunization Initiative (READII) is a two-year demonstration project to identify best practices in eliminating influenza and pneumococcal vaccination disparities among African-Americans and Hispanics 65 years and older. A Department of Health and Human Services priority, CDC is implementing the READII project in five sites (Chicago, Illinois; Rochester, New York; San Antonio, Texas; Milwaukee, Wisconsin; and the Mississippi Delta region) with the support of AoA, CMS, HRSA, and AHRQ. Local READII sites are working with public health professionals, medical providers, and community organizations to identify interventions that eliminate these vaccination disparities, such as improving the healthcare systems' provision of influenza and pneumococcal vaccination to seniors, increasing public awareness and demand, and enhancing access to vaccination services for seniors in a variety of settings.

Monitoring Health Status and Risk Factors Among Older Adults

The aging network, state health departments, and national health and aging organizations need critical surveillance data on older adult health to better target their programmatic efforts. CDC currently provides information to health and aging professionals on how to use its web-based surveillance data on older adults. However, the nation's rapidly changing demographics require new thinking about key health indicators for this population. To advance efforts in this area, CDC is committed to developing better measures of older adult health and quality of life, providing critically-needed data analyses and reports to states and communities, and better delineating existing and projected health disparities.

In conclusion, I would like to thank the Committee again for its leadership and commitment to the health of our nation's seniors. Positively impacting the health of older adults offers some of our most promising prevention opportunities. We know that even the oldest of the elderly can benefit from prevention.

While quality medical treatment for diseases is critically important, our nation needs a better balance between treating diseases and preventing them. There is much we can do to prevent diseases and conditions that contribute so heavily to disability, the need for long-term care, and to our spiraling health care costs. Older adults have never had a more urgent need for prevention, nor has our society. We look forward to working with you to have the healthiest older adults in history.

Thank you.

Last Revised: May 21, 2003