Back to The Fourth Pillar: Meeting the Cost of Health CareFrom Planning for the Future
p. 29-40, published 2002
Self-assessed health, the reporting of health as excellent, very good, good, fair, or poor, is a summary measure that assesses physical, emotional, and social aspects of health and well-being. Self-reported health correlates highly with mortality. According to the National Center for Health Statistics (NCHS), research has also demonstrated that elderly persons who report their health as poor are at increased risk for physical declines, independent of the severity of other medical conditions.
The AARP, using this gauge of population health, finds that trends over time show greater proportions of older Americans reporting their health as “excellent” or “very good.” Among those aged 50 to 64, the percentage increased from 46 percent in 1982 to 54 percent in 1999. For those aged 65 to 74, the percentage increased from 35 percent to 42 percent. However, smaller gains were made among older age groups. Approximately 33 percent of those aged 75 to 84 reported their own health as “excellent” or “very good” in 1982, compared to 35 percent in 1999. And for those aged 85 and older, this percentage declined over the same time period.
At all age levels, Kentuckians are more likely to rate their own health as “fair” or “poor” than the average American.
Percent of Persons Who Reported Own Health as “Fair” or “Poor,” KY and US, 2000
Compared with the U.S., proportionately more Kentuckians aged 45 and older report their own health as “fair” or “poor.”
Similar patterns among the age groups are found among both men and women at both the state and national levels.
Approximately the same proportion of men and women aged 45 and older in Kentucky report “fair” or “poor” health.
Non-Hispanic whites in Kentucky are relatively healthier than minorities. Approximately 33 percent of non-Hispanic whites report their own health as “fair” or “poor” compared with 41 percent of minorities.
It is important to note that not only do more of Kentucky’s elders currently view themselves as less healthy than the average older U.S. citizen, but also that this trend permeates throughout all age groups, including the future and near old.
The health status of those retirees who view Medicare as their most important source of health care in retirement is another way to gauge the extent of dependence on the program and thus the ultimate cost of that dependence. A recent study showed that the response to a single question about general health status strongly predicts a person’s subsequent use of health care services. In this study, researchers found that in the year after sample respondents assessed their own health as excellent, very good, good, fair, or poor, age- and sex-adjusted annual health care expenditures varied fivefold, from $8,743 for beneficiaries rating their health as poor to $1,656 for those rating their health as excellent (see Bierman et. al.). Using a probit model, we analyzed the relationship between a Kentucky retiree’s reliance on Medicare as a source of health care in retirement and the likelihood that a person views his or her own health as poor, fair, good, very good, or excellent.
Those retirees most reliant on Medicare are more likely to rate their own health as “fair” or “poor.”
How would you describe your health in general? (by importance of Medicare)
The results of the model show that those for whom Medicare is the most important source of health care in retirement are more likely to rate their own health as “fair” or “poor” than those with another source of health care.
Those who indicated another source of health care, such as employer-sponsored health care, as their most important source of health care in retirement are more likely to assess their own health as excellent, very good, or good.
Smoking is directly linked to an expanding range of serious health consequences, and while this message has been communicated to the American public over the course of decades, it has not resonated with Kentucky’s disproportionately poor and undereducated population. Smoking rates tend to be higher among lower-income, less-educated Kentuckians, the most likely recipients of Medicaid now and in the future. Clearly, Kentuckians must become more aware and more responsive to the health consequences of smoking and their associated costs. At a rate of 31 percent, Kentucky ranked first among the states in the percentage of adult smokers 18 years and older in 2000. Moreover, Kentucky has the highest lung cancer death rate in the nation. Nearly 8,000 Kentuckians die each year due to tobacco-related illnesses. The health care costs attributable to smoking in Kentucky have been estimated to be as high as $1 billion a year, much of which is shouldered by public programs (see Miller et. al.). Kentucky’s relatively high proportion of future elders compounded by relatively high smoking rates hold considerable implications for future health care spending.
Incidence of smoking declines with age, but smoking rates among Kentucky’s Boomers and elderly continue to exceed national averages.
Percentage of Smokers by Age Group, KY and US, 2000
The percentage of smokers in Kentucky is higher than the national average among those aged 45 and older, although it is considerably smaller than the 31 percent estimated for the general adult population.
This trend is seen among all age groups, although the gap between U.S. rates and those for Kentucky narrows considerably as age rises.
The largest gap between the percentage of smokers in Kentucky and the U.S. average is found among the Baby Boomer generation, in which both percentages reach their peaks.
While we see a high percentage of persons who smoke well into their mid-50s both in Kentucky and at the national level, Kentucky’s proportion of smokers in this age group remains considerably larger.
While encouraging declines are seen as individuals age, this may be at least partly attributable to the onset of poor health related to smoking.
Some public health experts characterize obesity—defined as excessively high amounts of body fat in relation to lean body mass—in the United States as epidemic. And older Americans are not exempt from the effects of obesity. A recent study from the AARP found an 85 percent increase in the prevalence of obesity among Americans aged 50 and older between 1982 and 1999. Obesity increases the risk of serious illness, including high blood pressure, type 2 diabetes, coronary heart disease, congestive heart failure, stroke, gallstones, gout, osteoarthritis, sleep apnea, and some forms of cancer (e.g., breast, prostate, and colon). A body mass index of 30 or higher, which correlates with someone who is approximately 5’4” tall and 30 pounds overweight, indicates obesity. The Centers for Disease Control and Prevention (CDC) report a rising trend in the prevalence of obesity among Kentucky adults. The percent who are considered obese has increased steadily since 1985 from between 10 to 14 percent to approximately 20 percent or greater by 2000.
Similar to national levels, over half of all older Kentuckians are overweight, with over one third of those classified as “obese” to “severely obese.”
Median Body Mass Index by Age Group, KY and US, 2000
Body mass index measures weight relative to height, with very high BMIs indicating obesity.
Adults with BMIs between 20 and 24.9 are considered normal or healthy weight. Anything above this range is considered overweight or obese.
The median BMI for all age groups, excluding those 75 and older, indicates an overweight population for both Kentucky and the nation, although Kentucky’s median levels are slightly higher.
In addition, more than half of both samples can be classified as overweight, obese, or severely obese, which puts them at higher risk of a variety of detrimental health conditions.
While we may not be worse off than the rest of the nation, we can still expect to find a relatively unhealthy older population in general due to the occurrence of high median BMIs.
An important way to counteract obesity and other risk factors leading to poor health is to make lifestyle changes or change unhealthy habits. According to the AARP, nationally fewer than one third of persons aged 50 and older are eating the recommended portions of fruits and vegetables, less than half are exercising or trying to increase their level of physical activity, and less than 20 percent are trying to lose weight by combining diet with increased physical activity.
To gauge the awareness among Kentucky’s older population of how lifestyle affects health, we asked whether the respondents had made a variety of changes to improve health. We specifically asked if they had changed their diet, lost weight, started exercising, quit smoking, quit drinking, or started taking vitamins to improve their health during the five years prior to the survey. One caveat is that our question does not account for those who did not need to make these changes because they were already leading healthy lifestyles.
Approximately half or less of Kentucky’s older population report having made key lifestyle changes in the previous five years to improve health.
Have you made any of the following lifestyle changes in the last 5 years to improve your health?
We can see that the percentage of persons responding that they had recently made these changes does not change much by age cohort of younger or older than age 65. The awareness levels are somewhat constant across these two age groups.
If Kentucky wants future retirees to be relatively healthier than current retirees, this may indicate a need for heightened awareness of the effects of lifestyle choices on health.
Although the saying “better late than never” may hold true in some circumstances, community and public health campaigns may want to emphasize a “better-earlier-than-later” attitude among our coming retirees to preempt poor health later in life that results from the unhealthy and avoidable choices many are making now.
An important element of a healthy lifestyle, exercise has been shown to decrease the risk of many chronic conditions, including arthritis and heart disease. Studies have shown that a sedentary lifestyle, which is defined as one that does not include at least 20 minutes of physical activity three times a week, can lead to serious health complications. Despite the fact that physical activity is associated with numerous health benefits, leisure-time physical activity trends in the past decade have remained unchanged, with approximately a quarter of U.S. adults meeting recommended levels of physical activity. In recent years, most experts have begun to recommend that people of all ages include a minimum of 30 minutes of physical activity of moderate intensity (such as brisk walking) on most, if not all, days of the week, with acknowledgment that even greater health benefits can be obtained through more vigorous intensity or longer duration of physical activity. Of interest to the older population, muscle-strengthening exercises can help reduce the risk of falling and fracturing bones, thereby improving the ability to live independently.
Proportionately fewer older Kentuckians engage in physical activity than older citizens nationally.
Percent of Persons Engaging in Physical Activity in Previous Month, KY and US, 2000
Kentuckians aged 45 and older do not fare well in comparison to their counterparts at the national level in the area of physical activity.
Kentuckians 45 years old and older tend to be less physically active than those at the national level.
According to estimates from a national survey, when respondents were asked if they had participated in any physical activities or exercise in the preceding month, approximately 53 percent of Kentuckians aged 45 and older said “yes” compared with 69 percent nationally.
This pattern emerges for all age cohorts. The proportion of Kentuckians who engaged in physical activity in the month before the survey is smaller at every age level than national proportions.
Only about half of each age group in Kentucky participated in any physical activities or exercise in the preceding month compared to approximately two thirds of older Americans nationally.
Limitations in various aspects of physical functioning affect the ability of elders to live independently. While it is well-known that declines in health accompany old age, what is less well-known is the extent of these declines. As expected, a greater proportion of older Kentuckians are limited in a variety of levels of physical functioning, ranging from vigorous exercises to everyday activities such as eating, dressing, and bathing, than are younger Kentuckians. Our survey also asked Kentuckians to indicate if they are physically limited in such things as pushing a vacuum, climbing a few flights of stairs, bending, lifting, stooping, or walking one block. The older the cohort examined, the greater the proportion of those Kentuckians who were limited in these activities. However, various other factors determine a person’s health beyond the simple aging process. It has been suggested that each generation of elders is different and healthier than the one preceding it. It is expected that tomorrow’s elders—today’s Baby Boomers—are more likely to remain active and engaged, factors that have been associated with better health. Additionally, higher levels of education and income increase the likelihood of good health.
Members of Kentucky’s Baby Boomer generation are less likely to be physically limited in their elder years than current Kentucky retirees.
Estimated Likelihoods of Physical Limitations of KY Retirees Compared to Workers, by Age, 2000
We used probit regression modeling to assess how age, gender, education, income, and urban or rural residence affect the likelihood of physical limitation.
Using the means of these characteristics for retirees and workers, we were able to compare differences in the likelihood that a person from each of these populations would be physically limited at each age.
The results show that although the likelihood of limitation increases with age, the likelihood for workers is lower than that of retirees for each age.
Although only two types of physical functions are shown here, the comparative difference persists throughout all physical functioning levels analyzed (see Appendix F).
In each of the models, income was statistically significant in determining the likelihood that someone would be physically limited. For all but limitations in vigorous activities, education was also a statistically significant determinant. That is, the higher the level of education and income, the less likely a person will be physically limited.
Kentucky Baby Boomers are more educated and wealthier than retirees.
Healthy lifestyles and changes in population health status ultimately affect the prevalence of chronic diseases and resultant death rates. Today, nearly three out of four Americans die as a result of chronic illness. Although developed nations have made great strides in their efforts to prevent, manage, and treat a variety of health problems, for the past two decades heart disease and cancer have remained the leading causes of death for Americans aged 50 and over. Heart failure and malignant neoplasms or cancer cause more than half of all deaths for the U.S. population aged 45 and older. Other major causes of death for people over age 50 are stroke and diabetes.
Kentucky ranks high among the states in death rates caused by cancer, heart disease, stroke, and diabetes. Kentucky’s cancer death rate for all ages in 2001 ranked eighth among the states, while it ranked seventh in deaths due to heart disease in 1998. For deaths due to cerebrovascular disease or stroke, Kentucky is near the median, ranking 25th among the states in 1998. In 1999, it ranked 13th among the states in deaths due to diabetes.
Unhealthy lifestyle choices often lead to unnecessarily early losses of life and productivity for many older Kentuckians.
Causes of Death, KY and US, 1999
As shown, Kentucky’s death rates are higher than the U.S. average for all causes combined and for each major cause of death.
The most pronounced differences between rates of death in Kentucky and at the national level are seen among Kentuckians who die of cancer (malignant neoplasms) and heart disease, both of which can be attributed to lifestyle choices.
As Kentuckians age, we see widening disparities between death rates here and at the national level for both stroke (cerebrovascular disease) and diabetes.
Quality of life is greatly affected by a person’s mental status. At any age, happiness and peace of mind enrich quality of life. Nervousness and sadness detract from the overall quality of life of seniors in their retirement years. What’s more, stereotypes of elderly behavior may prevent family members from detecting and thus seeking treatment for depression and other mental disorders that can severely erode quality of life. Depression is a common yet often overlooked disorder among the elderly. Suicide ranks among the 10 leading causes of death for Americans aged 50 to 64, and rates increase exponentially among aging men, with the highest rates among men aged 85 and older. Among women, rates decline past middle age.
In addition, Blazer found a link between depression and dementia. In fact, both appear to increase the risk of developing the other. The difficulty of caring for persons with these disorders also puts caregivers at risk of developing depression. Identifying and appropriately managing depressive symptoms should help to improve well-being, sustain physical and social activity, and reduce the need for residential care.
Poor mental health leads to lower quality of life in later years for the elderly and, in turn, adversely affects the health of their caretakers.
Average Mental Health Scores, KY and US, by Age Cohort
The national average mental health score for the general adult population was normalized to a mean of 50 and a standard deviation of 10. Anytime a scale score is below 50, the mental health status is below average, and each point is one tenth of a standard deviation.
We do not find a statistically significant difference between average U.S. and Kentucky scores for those aged 45 and older.
However, a slight downward trend was found in the scores as age rises, indicating poorer mental health among Kentucky’s elderly.
Approximately 74 percent of Kentuckians aged 45 and older reported that they felt happy, and 63 percent said they were calm and peaceful all of the time, most of the time, or a good bit of the time during the previous month.
About 17 percent reported feeling nervous and 13 percent said they were blue, while about 6 percent felt so down in the dumps that nothing could cheer them up all of the time, most of the time, or a good bit of the time during the previous month.
The more engaged older citizens remain as they age, the more healthy and the less dependent they are likely to be. A high level of interaction with friends and family offers seniors important emotional support and, in many cases, meets the care needs of seniors without formal health or elder-care services. Unfortunately, the ability to maintain social contacts is disrupted, as poor health begins to incapacitate individuals. A reciprocal relationship exists between health and social engagement. According to NCHS, while poor health may disrupt social activities, maintenance of social engagement has been shown to have a positive effect on overall health status and longevity.
Despite its considerable benefits, the numbers and types of social activities reported among older Americans declines with age. In 1995, for example, contact with family was the most common type of social activity among persons aged 70 and older. While women were more likely to talk on the phone and with neighbors than men, both genders reported comparable levels of social interaction. As expected, disabled persons were less likely to have left the house for a social engagement than nondisabled persons.
Health limitations can lead to a loss of social contacts as individuals age.
How much of the time during the past month has your health limited your social activities?
We found that health was likely to limit the social activities of older Kentuckians.
Only about 8 percent of those aged 45 to 54 reported that their health had limited their social activities all of the time, most of the time, or a good bit of the time, compared to 37 percent of Kentuckians aged 75 and older.
In an effort to keep older Kentuckians engaged on a social level, we should be aware of the physical limitations they face in maintaining social connections and take steps to bridge the resulting gaps.
As a consequence of the loss of social interactions that result from declining health, some older citizens become more reliant on government services and formal health services than might otherwise be necessary.
The development of community centers, transportation that caters to the needs of the disabled, and a higher level of awareness among community volunteers of these special needs are but a few of the ways in which we can begin to avoid some of the consequences of isolation among older citizens.
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