Healthcare and Population Aging

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1 Healthcare and Population Aging Comisión Nacional de Seguros y Fianzas Seminario Internacional Mexico D.F Noviembre 2003 Howard J. Bolnick, FSA, MAAA, HonFIA Presidente, Sección de Salud, AAI

2 Healthcare and Population Aging The Present An International Comparison Mexico s Healthcare Attainment The Future Aging Population and Other Key Healthcare Cost Drivers Policy Options for Mexico Is a Mixed Public Private Healthcare Financing System in Mexico s Future?

3 Healthcare Spending and Wealth Healthcare spending increases with national wealth Healthcare spending increases with personal wealth Mexico - $8,944 US GDP per capita - Healthcare = 5.4% of GDP Mexico s spending in less than 5.7% predicted by trend line % GDP Spend on Health Care Wealth vs. Health Care Spending, $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 GDP Per Capita ($US PPP)

4 Health vs. Healthcare Spending Population health (HALE) improves significantly with additional spending until spending reaches about $1000 US (PPP) Mexico - $483 US healthcare spending HALE Mexico has better than expected HALE for its current healthcare spending HALE (Years) Health vs. Spending, $0 $1,000 $2,000 $3,000 $4,000 $5,000 Total Health Care Spending ($US PPP)

5 Public vs. Private Healthcare Spending Mexico s public spending of 46.4% of total is very low by international standards Mexico s level of private healthcare insurance is also very low Healthcare spending will need to more than double to reach world-class HALE of 70 years Will this large increase be in public or private spending? $US (PPP) $1,200 $1,000 $800 $600 $400 $200 $0 Healthcare Spending by Source Growth Potential to World-Class HALE $20 $239 $224 Insurance OOP Public $517 $483

6 Mexico Intermediate Term Predictions (Next 10 to 15 years) Healthcare spending will increase faster than GDP growth Growth in demand will come mainly from growing middle income population As spending approaches $1000 US per person, HALE will approach 70.0 years Public sector spending will be hard-pressed to keep up with demand creating opportunity for private sector health insurance

7 Healthcare and Population Aging The Present An International Comparison Mexico s Healthcare Attainment The Future Aging Population and Other Key Healthcare Cost Drivers Policy Options for Mexico Is a Mixed Public Private Healthcare Financing System in Mexico s Future?

8 Life Expectancy is Expanding Historical Life Expectancy (U.S.A.) At Birth At 65 At 75 At 85 Expanding life expectancy is a worldwide phenomenon

9 Creating Larger Elderly Populations 65+ Population Growth, % 180.0% 160.0% 140.0% 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Luxembourg Japan Denmark Sweden Italy Belgium Germany Finland United Kingdom Greece Spain France Austria Portugal Netherlands United States Canada Australia Ireland Mexico s 65+ is projected to explode over this period from 5.2 million in 2000 to 35.0 million in 2050

10 Healthcare Costs Increase with Age Children Working Age Adults Elderly Source: EU Economic Policy Committee 2001

11 Causing Potential For Large Increases in Projected Spending Public Long Term Care Spending as % of GDP 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Belgium Denmark France Ireland Italy The Netherland Austria Finland Sweden U.K. EU Average U.S. Canada Australia Japan 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Range: 2% - 5%, EU average = 2.2% Public Medical Care Spending as % of GDP Source: OEDC 2001 (Dang, et. al.) Denmark Germany Greece Spain France Ireland Italy The Netherland Austria Portugal Finland Sweden U.K. EU Average U.S. Canada Australia Japan Projections based on demographic projections and current age-related healthcare costs Belgium

12 Is a healthcare cost crisis unavoidable? Is demography destiny?

13 Many Historical 65 + Population Increases Are Quite Large Historical Population Increase Age % 300% 250% 200% 150% 100% 50% 0% Ireland Austria United Kingdom Czech Republic Belgium Denmark France Sweden Norway Luxembourg Switzerland United States Netherlands New Zealand Slovakia Germany Iceland Finland Spain Greece Australia Poland Canada Turkey Japan Korea Mexico s 65+ population grew 189% from 1960 to 2000

14 With No Strong Aging Cost Relationship Aging Population vs. Health Care Spending, % Growth in Health Care Spending 400% 350% 300% 250% 200% 150% 100% 50% 0% 0% 50% 100% 150% 200% 250% 300% % Growth in Population 65+ Correlation r =.251, which is quite low

15 Further Historical Evidence Cause of Growth in U.S. Medical Care Spending Age/sex mix 7.2% Disposable income 17.6% Insurance coverage 5.3% Technology-inducing 69.9% Source: Peden and Freeland, Health Affairs, Summer 1995

16 There is no evidence for aging as a significant driver of healthcare cost increases.. So, what s going on here?

17 Healthcare Cost Projections Cost is an interrelated function of:!life Expectancy!Biological Morbidity!Scope, Intensity and Cost of Services (Economic Morbidity)

18 Life Expectancy: Alternative Futures Natural Aging Longer life expectancy with rectangularization of survival curves " Fixed maximum life span at 115 " Life expectancy increasing to 85 " 95% of deaths between 77 and 93 Delayed Death Longer life expectancy without limits " No fixed maximum life span Source: Fries, Milbank Quarterly, 1983 " No limit on improvements in life expectancy

19 Biological Morbidity: Alternative Futures Compression of morbidity 1 Elderly live longer and healthier lives Healthy Lifestyle and early non-medical interventions postpone onset of clinical morbidity Onset of chronic conditions of aging are delayed more rapidly than life expectancy increases Expansion of morbidity 2 Elderly live longer, but sicker lives Longer life expectancy and Unchanged Lifestyle does not postpone onset of chronic conditions 1 Fries, James F., Aging, Natural Death, and the Compression of Morbidity, NEJM, July 17, Brody, Jacob A., Prospects for an Aging Population, Nature, June 6, 1985

20 Economic Morbidity: Alternative Futures Compression of Care Less and/or lower cost medical care and frailty care "Medical technology and De-institutionalized frailty care become Cost-Reducing "Ethics of Social Solidarity and Death with Dignity allow healthcare systems to become Increasingly Constrained Expansion of Care More and/or higher cost medical care and frailty care "Medical technology and Institutionalized frailty care remains Cost- Increasing "Ethics of Individual Rights and Conquering Death force healthcare systems to become Increasingly Unconstrained

21 Life Expectancy Changes in Life Expectancy, Biological Morbidity, and Economic Morbidity Life Expectancy Economic Morbidity Biological Morbidity Today Expanded Life Expectancy (Natural Aging or Delayed Death) Expansion of Morbidity Equilibrium of Care Compression of Morbidity Equilibrium of Morbidity Expansion of Care Equilibrium of Morbidity Compression of Care Equilibrium of Morbidity Unhealthy Healthy Onset of Disease Onset of Care

22 Future Healthcare Cost Scenarios The Good. Favorable Trends Develop " Life Expectancy Natural Aging Compression of mortality near end of natural life " Biological Morbidity Compression of Morbidity Elderly live additional years in good health " Economic Morbidity Compression of Care Effective, inexpensive technology and favorable healthcare ethics Future cost Increases: lower than historical growth

23 Future Healthcare Cost Scenarios The Bad. Continuing Today s Trends " Life Expectancy Natural Aging Compression of mortality near end of natural life " Biological Morbidity Equilibrium of morbidity Elderly live additional years, years with chronic conditions increases about the same " Economic Morbidity Equilibrium of Care Technology continues to expand scope of expensive diagnostic and palliative care. End of life debility and illness often treated with aggressive medical interventions, Future cost Increases: continuation of historical growth

24 Future Healthcare Cost Scenarios The Ugly. Unfavorable Trends Accelerate " Life Expectancy Delayed Death Continued mortality improvement without limit " Biological Morbidity - Expansion of morbidity Elderly live additional years often in poor health " Economic Morbidity Expansion of Care Technology continues to rapidly expand the scope of expensive diagnostic and palliative care End of life debility and illness treated with increasingly aggressive medical interventions Future cost Increases: higher than historical growth

25 Future Healthcare Cost Scenarios Healthcare Spending 2050 $3, $US (PPP) $2,500 $2,000 $1,500 $1,000 $500 $0 UGLY Historical Growth Continues BAD GOOD Growth Current Current 2000 World-Class HALE 2050 Range Key Drivers: Technology, Lifestyle, Ethics

26 Implications " There is a healthcare cost crisis " Demography is not destiny - aging populationis a causative factor, but not the major one " Life Expectancy Elderly are living longer " Biological Morbidity Elderly may be living healthier, mainly due to healthier lifestyles " Economic Morbidity: Future cost increases will be determined mainly by factors that are external to healthcare systems Medical technology will the major causative factor in growth of healthcare spending Ethics play a very important secondary role

27 Healthcare and Population Aging The Present An International Comparison Mexico s Healthcare Attainment The Future Aging Population and Other Key Healthcare Cost Drivers Policy Options for Mexico Is a Mixed Public Private Healthcare Financing System in Mexico s Future?

28 Mexico s Population is Aging

29 Mexico s Work Force Is Growing

30 Mexico s Health Care System Does Not Provide Universal Coverage Wealthy Private Insurance and IMSS (2.4%) Moderate IMSS or ISSSTE (42.3%) Income Near Poor Uninsured (54.7%) or SSA (.3%) Poor Young Working Ages Retired Age

31 Evolutionary Option #1: EU Social Insurance System Wealthy Public Health Insurance and Private Supplemental Insurance Moderate Income Near Poor Public Health Insurance Poor Young Working Ages Retired Age

32 Evolutionary Option #2: US Health Care System Wealthy Income Moderate Near Poor Private Insurance Private Insurance or Uninsured Public Insurance (Medicare) and Private Supplement al Insurance Poor Public Insurance (Medicaid) or Uninsured Medicare and Medicaid Young Working Ages Retired Age

33 Mexico s Challenges Mexico is committed to universal coverage Prospects are for rapidly growing health care costs Increasing wealth Rapidly growing formal workforce Rapidly growing elderly populations IMSS and SSA not likely to be able to accommodate growth Private health insurance will NOT be able to satisfy need for the elderly and poor --- public sector is only solution for these groups Public sector is NOT likely to satisfy needs of the growing workforce --- private sector is likely to be only real solution for this group How might these formidable challenges be accommodated?

34 Mexico s Options Health Care System Goals Structural Option Universal Access Cost Quality Private Voluntary Markets Not Possible Uncontrolled to Managed Wide Range Incomplete Mixed Public-Private System (US System) Near Universal Access Possible Some Control Narrowed Range Complete Mixed Public-Private System (Mexico) Achievable Moderate Control More Narrow Range Social Insurance System (EU Systems) Achieved Controllable Uniform

35 Mexican s Best Option for the Future? Wealthy Moderate Private Insurance and Out-of-Pocket Income Near Poor IMSS, ISSSTE, SSA Poor Young Working Ages Retired Age

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