Prepare for dramatic growth in the elderly population

Between 2010 and 2030, unprecedented growth will occur in the elderly 65+ population of the United States. This group will:

• Increase from 40.2 million to 72.1 million persons.
• Expand from 13.1% to 19.3% of the overall population.
• Constitute more than half of our total population growth—31.9 million of 63.3 million persons overall.

Thus, we very reasonably can anticipate that these shifts will lead to major social and cultural changes as well. Because one of every five Americans will be elderly, compared to slightly more than one in 10 now, many more locales in the United States will have the look and feel that Florida does today. This will be particularly true of rural areas, which already have large elderly populations. More of our leaders will be elderly (witness the two Presidential candidates this year). More elderly persons will remain in the workplace into their 70s and 80s, and more enclaves of elderly persons will exist in our urban communities. Our businesses and culture will cater much more to the elderly, because this population group will represent such a large segment of the market, yet many elderly persons also will be poor.

These demographic shifts will have dramatic effects on the prevalence of behavioral health conditions. In 2030, about 18 million elderly persons will have one or more mental illnesses, compared to 10 million elderly persons today. Similarly, about 5.3 million elderly persons will have a substance use condition, compared with 3 million elderly persons today. For each group, the growth in prevalence of these conditions among the elderly will exceed the total number of persons being treated in the public sector for these conditions across all age groups today.

Equal attention

Since the founding of the National Institutes of Mental Health (NIMH) in 1949, and even much earlier, behavioral healthcare has focused upon the care of adults. About three decades ago, care of children also became a focus. Yet, despite the fact that the elderly population already is very large, this group has yet to receive equivalent attention, either in our college and university training courses or in our community care settings.

Today, the elderly population no longer can be ignored by behavioral healthcare. The demographic shifts described above will generate dramatic new demands for care by elderly persons. Without careful planning, we will run the risk of this new demand for behavioral healthcare overwhelming our state, county, and city care systems.

What can be done now to avert this coming crisis?

National Demographic and Insurance Planning. First, we must engage in careful demographic and insurance planning at the national level. We will need to determine where elderly persons are likely to reside, which of them are likely to have family care givers living nearby, which are likely to have appropriate health insurance coverage, which are likely to remain in the workforce, which are likely to develop behavioral health conditions, etc. We also will need to examine the appropriateness of Medicare and Medicare supplemental policy benefits for behavioral health conditions. (Although Medicare mental health benefits now have a copay that is the same as that for physical health conditions, Medicare is not currently covered by national parity legislation.). We can expect that the total annual cost of Medicare will escalate from about $600 billion today to about $1.1 trillion in 2030. And this is a conservative estimate based on the current benefit structure.

New Service Suite. Second, we must begin to plan for a whole new suite of behavioral healthcare services for elderly persons in our emerging integrated primary care homes and health homes. These new services will not only include clinical services, but also community interventions designed to reduce social isolation (now known to be as deadly as smoking) and to promote increased community participation by elderly persons. As national “stay at home as long as possible” initiatives grow in concert with the expansion of the elderly population, we can anticipate that many of these services will be provided where the person resides rather than in a traditional office setting.

College and University Pipeline. Third, we must initiate a new college and university pipeline of providers trained in modern geriatric behavioral healthcare. This new cohort needs to be adept at both clinical and community interventions with the elderly. These providers also must have the capacity to work effectively in integrated care delivery teams because many elderly persons will have serious and chronic physical co-morbidities. Finally, and equally important, they must be particularly adept at being able to work with elderly persons who may develop progressive age related frailties, such as impaired sight, hearing, and capacity to focus.

Care Extenders. Fourth, we must be very creative in extending our capacity to work with this very large, new population. Several examples come to mind. Peers would be excellent as community outreach workers who engage in home visiting and encourage community engagement by elderly persons. Video cams on cell phones would be an excellent way for providers to remain in personal contact with elderly clients between visits. Retired behavioral health providers who volunteer or work a reduced schedule would be excellent for augmenting professional staff.

Rather than be surprised and unprepared for this demographic transition which will result in dramatic growth of the elderly population, we have the opportunity to prepare in a rational and deliberative manner. Let’s begin now.