Reimagining Medicare for Longer Lives

Demographic and Epidemiological Shifts

• Life expectancy for those born in 2000 is projected to be 75 (higher for women), extending an additional 16 years after reaching Medicare age compared to just 12 years for the 1900 cohort.
• The population has shifted from dying quickly of acute diseases to living longer with chronic conditions that worsen gradually over time.
• By 1950, life expectancy at birth was 67; for those making it to age 65, they could expect another 13 years, indicating a slower progression of aging-related decline than in the early 20th century.

Redefining "Old" and Care Models

• Panelists agreed that "old" is not a chronological number but a state of mind defined by vibrancy, activity, and a lack of health obsession, noting significant variability among seniors (e.g., 92-year-olds who remain active).
• The John A. Hartford Foundation's "Age-Friendly Health Systems" initiative promotes the "4 Ms" framework: What Matters (goals/preferences), Medication safety, Mentation (cognition), and Mobility.
• Current health systems lack reliability in applying geriatric best practices; while pockets of excellence exist, major health systems (e.g., Ascension, Kaiser, Trinity) are slowly adopting these models, often prioritizing specific disease management over the holistic 4Ms approach.
• The underlying structure of the US healthcare system remains anchored in 1965 acute-care models despite the transition to a chronic disease management reality.

Medicare Advantage and Private Sector Innovations

• Medicare Advantage now accounts for approximately one-third of Medicare spending, with roughly $59 billion in spending last year.
• UnitedHealth serves about 15 million members across all products and is experimenting with care models that combine reimbursement methodologies with patient-centric support, moving beyond traditional fee-for-service.
• The STARS program in Medicare Advantage has demonstrated higher rates of preventive services (e.g., colonoscopies, mammograms) which correlate with better population health outcomes.
• New policies allow Medicare Advantage plans to cover social determinants of health (SDOH) benefits, such as air conditioners for asthma patients, though implementation remains variable.

Policy Consensus and Legislative Trends

• There is bipartisan agreement on moving from volume-based care to value-based care, evidenced by legislation like MACRA and the Chronic Care Act (which makes Special Needs Plans permanent).
• The ACA's Innovation Center (CMMI) was established to allow Medicare demonstrations that are not budget-neutral, enabling investments in care coordination and technology that yield long-term savings.
• The Congressional Budget Office (CBO) has begun to credit policies like prescription drug coverage when they result in reduced hospitalizations or cures, shifting from strict five-year budget neutrality scoring.
• The 2016 Hospital Association consensus indicated that providers intended to move toward value-based care regardless of election outcomes due to employer and senior constituency pressures.

Barriers to Implementation

• Administrative burden is described as "astronomical," with physicians citing excessive time spent on paperwork, manual data entry (e.g., 12-15 clicks to verify a flu shot), and reliance on fax machines despite available technology.
• Payment models still prioritize procedures and volume over shared decision-making and time-intensive care coordination, making it financially difficult for practices to hire community health workers or invest in wellness.
• Current quality measures are criticized as "process-oriented" checkboxes (e.g., counting medication possession rather than adherence or control) rather than outcome-based metrics.
• Healthcare IT interoperability remains a major failure, with a $36 billion investment over 10 years yielding fragmented systems where providers must navigate different portals and forms for each payer.

Social Determinants and System Integration

• Isolation, housing insecurity, food deserts, and lack of transportation are identified as critical threats to senior health, often driving unnecessary ER visits and hospitalizations.
• Community Health Workers (CHWs) are being deployed to bridge trust gaps, assist with health literacy, and navigate complex systems for vulnerable populations.
• There is a noted siloing between aging services, social services, and medical services, with a vision to create a "social movement" demanding age-friendly systems that integrate these domains.
• The CLASS Act (long-term care insurance) failed in the Affordable Care Act, leaving a gap in funding for assisted living and memory care, which are not covered as Medicare benefits.

Future Directions and Strategic Recommendations

• Terri Fulmer recommends Congress review "Reframing Aging" and "The Longevity Economy" and engage with the Milken Institute and "unusual suspects" rather than traditional healthcare stakeholders.
• Nancy-Ann DeParle and Ephraim Castillo suggest that rather than waiting for new legislation, the private sector and CMS should continue experimenting with scalable models and present solutions that Congress can adopt.
• There is a call to streamline administrative burdens by creating a "clearing house" for interoperability and harmonizing measures across payers to reduce the need for specialized administrative staff.
• The healthcare system is projected to shift further toward home-based care and away from traditional face-to-face models to accommodate complex care needs.
• While the Medicare Trust Fund is not in immediate "panic mode" (expected issues around 2024-2026), the need for a bipartisan fix is acknowledged as inevitable when demographic pressures increase.