[Senate Hearing 112-304]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 112-304
 
      AGING IN AMERICA: FUTURE CHALLENGES, PROMISES, AND POTENTIAL

=======================================================================


                                 FORUM

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           DECEMBER 14, 2011

                               __________

                           Serial No. 112-12

         Printed for the use of the Special Committee on Aging


         Available via the World Wide Web: http://www.fdsys.gov




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                       SPECIAL COMMITTEE ON AGING

                     HERB KOHL, Wisconsin, Chairman

RON WYDEN, Oregon                    BOB CORKER, Tennessee
BILL NELSON, Florida                 SUSAN COLLINS, Maine
BOB CASEY, Pennsylvania              ORRIN HATCH, Utah
CLAIRE McCASKILL, Missouri           MARK KIRK III, Illnois
SHELDON WHITEHOUSE, Rhode Island     DEAN HELLER, Nevada
MARK UDALL, Colorado                 JERRY MORAN, Kansas
MICHAEL BENNET, Colorado             RONALD H. JOHNSON, Wisconsin
KRISTEN GILLIBRAND, New York         RICHARD SHELBY, Alabama
JOE MANCHIN III, West Virginia       LINDSEY GRAHAM, South Carolina
RICHARD BLUMENTHAL, Connecticut      SAXBY CHAMBLISS, Georgia
                              ----------                              
                 Debra Whitman, Majority Staff Director
             Michael Bassett, Ranking Member Staff Director


                                CONTENTS

                              ----------                              

                                                                   Page

Opening Statement of Senator Herb Kohl...........................     1
Statement of Senator Chuck Grassley..............................    10

Statement of:

Rob Hudson, Professor of Social Policy at Boston University......     2
John Rother, President and CEO, National Coalition of Health Care 
  and NCHC Action Fund...........................................     4
Kathy Greenlee, Assistant Secretary for The Administration on 
  Aging..........................................................    12
Richard J. Hodes, Director of the National Institute of Aging....    16
Michael Harsh, Chief Technology Officer, GE Healthcare...........    18
Jack Rowe, Director, MacArthur Foundation Research Network on 
  Successful Aging and Professor at the Columbia University 
  Mailman School of Public Health................................    20
Robyn Stone, Executive Director, LeadingAge Center for Applied 
  Research.......................................................    22
Henry Aaron, Bruce and Virginia MacLaury Senior Fellow, The 
  Brookings Institution..........................................    26
Laura Carstensen, Professor of Psychology and the Fairleigh S. 
  Dickinson, Jr., Professor of Public Policy at Stanford 
  University.....................................................    32
                              ----------                              

                                Appendix
                  panelists statements for the record

Rob Hudson, Professor of Social Policy at Boston University, 
  Boston, MA.....................................................    38
John Rother, President and CEO, National Coalition on Health Care 
  and NCHC Action Fund, Washington, DC...........................    57
Kathy Greenlee, Assistant Secretary for Aging, Administration on 
  Aging, U.S. Department of Health and Human Services, 
  Washington, DC.................................................    61
Richard J. Hodes, Director of the National Institute on Aging, 
  National Institutes of Health, U.S. Department of Health and 
  Human Services.................................................    72
Jack Rowe, Director, MacArthur Foundation Research Network on 
  Successful Aging and Professor at the Columbia University 
  Mailman School of Public Health, New York, NY..................    76
Michael Harsh, Chief Technology Officer, GE Healthcare, Waukesha, 
  WI.............................................................    79
Robyn Stone, Executive Director, LeadingAge Center for Applied 
  Research, Washington, DC.......................................    87
Henry Aaron, Bruce and Virginia MacLaury Senior Fellow, The 
  Brookings Institution, Washington, DC..........................   101
Laura Carstensen, Professor of Psychology and the Fairleigh S. 
  Dickinson Jr., Professor in Public Policy at Stanford 
  University, Stanford, CA.......................................   106


      AGING IN AMERICA: FUTURE CHALLENGES, PROMISES, AND POTENTIAL

                              ----------                              


                      WEDNESDAY, DECEMBER 14, 2011

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2:35 p.m. in room 
SD-G50, Dirksen Senate Office Building, Hon. Herb Kohl 
(chairman of the committee) presiding.
    Present: Senators Kohl and Grassley.
    Also present: Debra Whitman, Staff Director.

             OPENING STATEMENT OF SENATOR HERB KOHL

    The Chairman. Good afternoon to everybody. We thank you all 
for being here, and we thank you for joining us at this event 
this afternoon.
    Over the past 50 years, the Senate Special Committee on 
Aging has been in the thick of the debate on issues of concern 
to older Americans. With more than 10,000 baby boomers turning 
65 every day, the issues affecting older Americans are only 
becoming more urgent.
    Throughout its history, this committee has continuously 
called attention and offered concrete solutions to a wide 
variety of problems affecting older Americans. From the cost of 
health care to retirement security to long-term care coverage 
options to employment opportunities for older Americans, and 
very much more, this committee has debated some of our 
country's most difficult issues over the past half century.
    We are also proud of the Aging Committee's long-standing 
tradition of bipartisanship. This kind of cooperation and the 
hard work of talented leaders, including Senator Grassley, who 
will be joining us today, has helped to further our country's 
commitment to caring for some of our most vulnerable citizens. 
But we cannot rest on what we have accomplished thus far. Much 
more needs to be done. And to get there, we need the help of 
experts, people like many of you who are here today.
    We need to put Social Security back on a long-term path to 
solvency and strengthen our nation's pension systems so that 
Americans can plan for a secure retirement after a lifetime of 
work. We must reign in rising health care costs and grapple 
with how to finance long-term care so that seniors can live 
independently for as long as possible.
    More than most, older adults are feeling the effects of the 
struggling economy and local service cuts. Now is not the time 
to let home- and community-based programs, such as those funded 
by the Older American Act, languish. As our nation ages, 
policies that improve the lives of older Americans will become 
even more critical to helping the entire economy.
    By 2030, when the last of the baby boom generation reaches 
retirement age, nearly 20 percent of Americans will be over age 
65 compared with 13 percent today.
    I am hopeful that we will find the courage to craft an 
innovative and effective path forward for the greater good of 
our nation's seniors and our country as a whole.
    I have been chairman of this committee for nearly five 
years, and we are all proud of everything that we have 
accomplished. But today we are here to learn from you, the real 
experts, and we look forward to this discussion.
    I also want to take a moment to recognize and thank the 
former staff of this committee, some of whom are with us here 
today. Please know that your hard work has made a difference in 
the lives of older Americans.
    With that, I will turn things over to the Aging Committee's 
staff director, Deb Whitman, who has been with me for the 
entire five years that I have been chairman, and she will be 
moderating this forum. As all of you who know Deb are very much 
aware, I will be putting you in very capable hands. We thank 
you again, and we thank all of our distinguished panelists for 
being with us today. Deb.
    [Applause.]
    Ms. Whitman. Thank you, Chairman Kohl. It has been an honor 
to serve under you for the last five years. We have done a lot 
together and looked at a lot of issues, but there is more that 
needs to be done. And the purpose of this forum today is both 
to look back at our history and look forward to our future.
    Our first panel is a distinguished group, who will be able 
to talk about the historical importance of the committee, as 
well as its impact on aging policy. I would like to introduce 
Rob Hudson, who is a professor and chair of the department of 
social policy at Boston University School of Social Work. He 
has written widely on the politics of aging, and he currently 
serves as editor of the ``Public Policy and Aging Report.'' 
Then we will have John Rother, who is the president and CEO of 
the National Coalition on Healthcare. Prior to joining the 
coalition, John served as executive vice president for policy, 
strategy, and international affairs at AARP. Mr. Rother also 
served as staff director and chief counsel at the Senate 
Special Committee on Aging under Chairman John Heinz.
    Rob.

 STATEMENT OF ROB HUDSON, PROFESSOR OF SOCIAL POLICY AT BOSTON 
                           UNIVERSITY

    Dr. Hudson. Thank you very much. Senator Kohl, Ms. Whitman, 
thank you for inviting me here. I feel like I am bringing gold 
to Newcastle in some ways. Many of the people in this room are 
closer to the events of the past 50 years or 20 years perhaps 
than I am. But I have been an observer of the committee and 
aging policy for several decades, and I am pleased to be able 
to, however briefly, share a couple of thoughts with you.
    The first thing I would like to mention is that I also 
serve as editor of the ``Public Policy and Aging Report,'' 
which is the quarterly publication of the Gerontological 
Society of America, and we have an issue that has just come out 
which is associated with this event honoring the celebration of 
the committee's 50 years. And we would be happy to make that 
issue available to anybody who would like to see it.
    As you know, the committee began as a subcommittee back in 
1959. It became a full committee in 1961. It was brought very 
much into existence by the issues around rising costs in health 
care of the early 1960s, and had a central role in the band 
wagon effect that led to be an advancement of Medicare in 1965. 
And, in the spirit of bipartisanship, it is always good to 
remember that Part A is Democratic Medicare, and Part B is 
Republican Medicare. And there is a whole history on how that 
took place in the early 1960s.
    There have been a number of legislative successes that the 
committee has been associated with around the Older Americans 
Act and events that brought it into being, and the expansions 
in the 1970s, many associated with Arthur Fleming and the 
creation of the Aging Network. It also played a central role in 
the decades-long battle to try to elevate the Commission on 
Aging's office higher into the officialdom of HEW, and later as 
HHS. And, in fact, the first paper I wrote years ago had an 
assistant secretary of the Department of HEW testifying before 
this committee, saying, ``Senator, I don't believe that the AOA 
should report to the Secretary's office. We are the Department 
of Health, Education, and Welfare. If we'd wanted to call it 
the Department of the Young, the Middle Aged, and the Elderly, 
we would have done that, but we chose not to.'' In any event, 
as we know, today there is an assistant secretary for aging, 
and the committee helped create that reality.
    A number of additional successes in the 1980s, many 
associated with the late Senator John Heinz, were very 
important. There were also, in addition to legislative 
accomplishments, the committee has been actively involved in 
oversight activity, which has been extremely important over the 
years. Some of the early efforts associated with Senators 
Smathers, Chiles, and Moss involved investigation of nursing 
home fraud and abuse, with the developments in aging 
publication of the committee, putting out reports with titles 
like, ``The Litany of Nursing Home Abuses,'' ``Drugs in Nursing 
Homes: Misuse, High Costs, Kickbacks,'' ``Doctors in Nursing 
Homes: The Shunned Responsibility,'' ``Access to Nursing Homes 
By Poor Minorities.'' These were very, very powerful reports 
when they came out, and have had an enduring effect.
    Senator Heinz and Chiles worked together in the 1980s 
around DRGs and eligibility recertification issues associated 
with the DI and SSI programs, and Senator Grassley has 
continued to be actively involved in oversight of issues, many 
associated with long-term care in nursing homes. And today 
under Senator Kohl's direction, the committee is very 
interested in issues around prescription drug costs and the 
idea of trying to indeed increase the availability of generic 
equivalents.
    In conclusion, let me just say that in its early years, the 
committee brought the needs of the aged to the country's 
attention, and played a role in the passage of a major decade's 
worth of legislation from the mid-60s to the mid-70s. Much 
attention turned to oversight in the following years, with the 
committee pressing to assure that benefits associated with 
those legislative enactments were accessible, affordable, and 
of high quality. And working with authorizing committees, both 
elected members and staff members of those committees, the 
Special Committee on Aging has been able to combine resources 
and efforts to keep a close watch on the workings of executive 
branch agencies.
    Finally, the committee, especially under its most active 
chairmen, could pick its battles, devote its resources, 
mobilize its allies in a timely and needed way, what I would 
call sort of a SWAT team for elderly. Thank you very much.
    [Applause.]

STATEMENT OF JOHN ROTHER, PRESIDENT AND CEO, NATIONAL COALITION 
              ON HEALTH CARE AND NCHC ACTION FUND

    Mr. Rother. Good afternoon, Mr. Chairman. Thank you for 
holding this event. It gave me a chance to look back a ways at 
the Committee's impact on older Americans, and I think it is a 
remarkable story what has happened to the life situation of 
older people. Truly, their lives have been transformed in part 
because of the work of this committee.
    Fifty years ago, the situation of Americans 65 and older 
was very different than it is today. Economic security in 
retirement was limited to a relatively small part of the 
population. Health insurance was either unavailable or 
unaffordable for most. And there were few social services or 
housing alternatives to support those who became frail or 
disabled. Most seniors in the 1960s were dependent on family, 
neighbors, or charity when faced with adverse events, and many 
died prematurely due to poor social and physical living 
conditions or lack of good medical care.
    The changes have been profound, and, of course, there are 
still issues that need to be addressed. But I think we should 
take a second just to recognize some of the impact of this 
committee's work on the lives of older Americans.
    As Rob pointed out, I think the first thing you have to 
point to is the committee's work on health care, which 
certainly contributed to the enactment of Medicare. Medicare is 
just not a health insurance program; it has transformed our 
health insurance system. It has transformed health care in 
America, and it has certainly become a major pillar of economic 
security for seniors and the disabled. So, it is much more than 
just a health insurance program.
    The committee investigated many problems associated with 
health care, including pharmaceutical pricing and marketing. It 
did a lot of work that eventually led to the enactment of the 
drug benefit in Medicare in 2003, and, more recently, to the 
expansion of that benefit as part of the Affordable Care Act. 
And, as a result, millions of seniors each year can now take 
advantage of the very important benefits that prescription 
drugs provide without having to choose between food or the 
medicine they need.
    The committee's work also resulted in the adoption of a 
hospice benefit in Medicare. That's significant, because it 
supports the quality of life at the end of life. This is 
something that I know from personal experience, and I am sure 
others do, too. It is important not only to the person who is 
facing the end of life, but especially to the family who is 
there with them.
    Perhaps no aspect of health care has received more 
attention from the committee over the years than problems in 
long-term care, and, as Rob mentioned, the Committee has 
undertaken a long series of investigations into problems in 
nursing homes. After DRGs were enacted, the phrase ``quicker 
and sicker'' was a way of focusing attention on the problems in 
post-acute care, which had not been looked at very seriously 
until then. And as a result, now I think there is a much 
greater commitment to the whole continuum of care. So health 
care policy is no longer about just what goes on in the 
hospital, but it includes community-based care, the follow-up 
care in the home, and ambulatory care.
    Again, we still have work to do, but Medicare has been 
transformative in the way that health care today is organized. 
The benefit goes not just to people who are receiving that 
care, but to the family members as well, who are no longer 
faced with the total disruption in their lives when a parent or 
spouse becomes ill.
    The committee led efforts to support research in aging that 
resulted in the establishment of the National Institute of 
Aging at NIH. It also, as Rob mentioned, was a leading advocate 
for a strong Administration on Aging within the executive 
branch, which has been key to support of the whole network of 
aging services now vital in every county across the country.
    Housing programs are now much more responsive to the needs 
of older people, whether it is the 202 Program or a wide range 
of other housing programs. The committee's theme was the 
integration of needed services, along with the bricks and 
mortar, and putting those together. As a result, we are seeing 
much more responsive housing programs and housing options for 
people as they get older.
    A wide range of consumer protections are now in place 
through the committee's work, whether in financial products 
like reverse equity mortgages or living trusts and guardianship 
arrangements. I think the committee has had a leading role in 
giving life to consumer protections that really benefit all 
Americans, not just older Americans, but where the problems 
were easily dramatized with older people.
    Today, we still have problems with elder abuse. The 
committee has had, throughout its tenure, a focus on elder 
abuse, and the public exposure, I think, has had a tremendous 
impact in the lessening of those problems. But, again, we have 
continuing needs there.
    The committee has long championed productive aging, 
promoting employment and volunteer service options for those 
who want or need to work. And we are starting to see a change 
in the behavior of people with regards to the retirement age, 
and we are seeing a big change in the role of women in the 
workforce, in part because of the committee's advocacy to 
eliminate the mandatory retirement provisions that were in 
place until the mid-1980s. Many low income seniors have also 
been helped by their special inclusion in various job programs, 
particularly Title V, that would not exist but for the 
committee's advocacy.
    And, finally, I will just mention that income security 
today is much stronger, in part due to the committee's long 
focus on this area, whether it is the social security solvency 
amendments that were adopted in 1983, and the enactment of 
ERISA before that. The Committee also played a leading role in 
blocking what could have been very negative changes in social 
security in 1981 and again in 2004.
    The committee has focused on disability insurance, a very 
important, often overlooked issue, and it has resulted in 
changes in disability that have benefitted many of our most 
vulnerable working-age Americans.
    In conclusion, I would say that the Senate Special 
Committee on Aging continues to play a vital role in improving 
the lives of older Americans. Its work over the past 50 years 
has had a major impact on the lives of most seniors and their 
families. The chairs and ranking members, in particular, have 
used their positions on legislative committees, such as 
Finance, HELP, Budget, and Appropriations, to achieve 
legislative changes that were developed in the context of the 
Aging Committee. The committee continues to be the only place 
in the legislative branch where the situation of the whole 
person can be reviewed, where in-depth investigations can be 
launched, and where the members and staff have the time to 
delve into issues that other committees simply cannot take the 
time to consider.
    Looking forward, the committee faces the twin challenges of 
the retirement of the large boomer generation, and the ever-
increasing costs of health care. The committee's success in 
addressing these future challenges will, therefore, be critical 
to the quality of life for all Americans in generations to 
come.
    Thank you very much.
    [Applause.]
    Ms. Whitman. I would like to ask both John and Rob to think 
about the past and the future and how we can use the lessons 
that we have learned. And I want to remind everybody when they 
respond, to please turn on their microphones.
    So, John, I have found that the Aging Committee's lack of 
specific jurisdiction legislatively is an advantage because of 
the range of issues that we can address. I think you just 
referred to it as the ability to review the situation of the 
whole person, but it also makes it harder to actually move 
legislation through Congress.
    So, how has the design of a special committee then, having 
broad jurisdiction, but lack of legislative authority, been 
both a benefit and a curse over the years?
    Mr. Rother. Well, the benefit is that it's very broad 
mission allows it to be entrepreneurial--to package ideas and 
build support for those ideas that then the member, or the 
chairman, or the ranking member can take to the committee with 
legislative jurisdiction. And that is extremely powerful. Most 
of the accomplishments that I have reviewed today were 
developed in the committee. Political support was developed 
with the committee. And then, sometimes through cooperation 
with the legislative committee, but sometimes over the 
objections of the legislative committee, something was enacted 
into law.
    Of course, the downside of not having direct jurisdiction 
is that other people have to be persuaded in order to move, and 
other people have other priorities. And today, I think we face 
a particular challenge because the needs of older people are 
not often seen as a top priority, and so there is real 
competition in the public debate. And that gets reflected in 
the ability to work with other committees.
    Ms. Whitman. Rob, your testimony ended with a reference to 
the Aging Committee as being sort of a SWAT team for elders, 
and I kind of like that, especially because we have had Jack 
Mitchell, the Committee's Chief of Oversight and 
Investigations, as our private cop for several years.
    I found the committee's investigative and oversight 
authorities to be a useful way to gather information and 
highlight abuses on a wide variety of issues, including 
conflicts of interest in medicine, medical device recalls, 
nursing home abuses, and products that are aimed to elderly 
consumers.
    Can you reflect on the oversight work of the committee 
through the last 50 years, and how important has that oversight 
authority been to its mission?
    Dr. Hudson. Okay. Indeed, the oversight function has been 
very interesting, because even in reviewing the history of the 
committee, but social policy more generally, is, in the wake of 
the Great Society programs, a whole subfield in policy studies 
emerged under the rubric of policy implementation and 
oversight. There had not been enough domestic policy, apart 
from checks coming out of the Social Security Administration, 
to really worry about implementation. And I think there has 
been sort of an evolution in the committee, not 100 percent of 
course, moving toward the oversight checking on the 
implementation of various policies, including heavy duty issues 
such as fraud and abuse, but also around efficiency, and 
effectiveness, and all sorts of things from the Aging Network 
through health and disability programs across the board.
    So, I think this function is enormously important, because 
the heyday of new legislation, the new authorization, sort of 
petered out after the late 70s. And whether it is this 
committee or something else, there has been an enormous need to 
keep an eye on what providers have been doing and what agencies 
have been doing to follow up on their legal obligations to run 
programs in a compassionate and effective way.
    So, I think, A, it is critically important, and, B, just 
emphasizing what John said, that I think the committee is 
extremely well suited, both in terms of the breadth of the 
things it can examine, but also in some ways being free from 
some of the more immediate authorization appropriation issues 
that would impede a broad oversight function.
    Ms. Whitman. Anything to add?
    Mr. Rother. Well, I think, as you well know, Deb, being 
staff director of this committee is a complete luxury and a 
very unusual role, because you have the ability to look across 
a very broad spectrum of the population, of the economy, of 
needs, and you can go where you want to go. You can help set 
the agenda, lift up problems or the public to see, and promote 
broad policy solutions. And there are not too many other places 
in Congress where that ability exists.
    And, as a result, I think that the Aging Committee can be 
much more responsive to some of the social and economic 
developments, not just within the older population, but more 
broadly, compared to the committees that have to be concerned 
with reauthorizations and meeting deadlines.
    So, I really value that flexibility and breadth of vision 
for the committee, and I hope that that continues.
    Ms. Whitman. Whenever I get together with former staffers 
or former staff directors and tell them the issues that we are 
working on in the committee or thinking about working on, I am 
usually met with, oh, yeah, we did that back in 1972, or, we 
held a hearing almost exactly like that, you should see the 
report that I wrote. There are obviously perennial issues that 
both of you raised.
    But what are the issues that maybe have not gotten enough 
attention over the years, or that were touched on in the early 
years that we should pick back up based on all of the reviews 
you have done, and, John, your years of watching us work?
    Dr. Hudson. Is that directed to me?
    Ms. Whitman. Both of you.
    Dr. Hudson. Go ahead.
    Mr. Rother. Well, there is no shortage of problems that 
still need to be addressed, despite whatever attention we gave 
them. Today, there are more and more older people who want to 
continue to be productive, and the economy is not supporting 
that. And there are more and more people who need to continue 
to be productive and continue to earn. So, that is an area that 
certainly requires more and more attention.
    I also think that as we have put off for many people the 
age at which disability or frailty happens, we have this huge 
reservoir of productive capacity, if you will, that we still 
have not figured out how to tap in terms of our volunteer 
programs, in terms of helping to meet the community needs, in 
terms of how to meet the needs of younger generations. So, 
those are areas that all seem to be worthy of continuing.
    Dr. Hudson. I would just build on that. I have a concern 
about the future, having studied aging politics for a long 
time, that there has been sort of a bifurcation, and John 
alludes to it. We obviously have successful aging, productive 
aging, a lot of things that Jack Rowe has written to.
    We also have obviously a whole series of issues associated 
with chronic illness and long-term care. And politically, much 
of the success older people have enjoyed over the years is 
based on a reality and partial stereotype of being in need, 
being frail, being poor, and all the conditions we know of.
    Now, in the face of successful and productive aging, and 
volunteerism, and civic engagement, we are getting something of 
a split, which is sort of a good news/bad news situation. And, 
in short, the politics I worry about are we could end up sort 
of recreating sort of a residualized, very old population who 
gets benefits because they are just monsterably down and out 
and we feel sorry for the poor souls. And much more conflict 
and political concern about an able, productive, old population 
that basically if they do not need it, why are we giving it to 
them? And how do we address that? Do we simply raise retirement 
ages? Do we introduce new functional tests of one kind or 
another?
    And there is an ethical issue of really is the aging 
population a single beneficiary group, or is it not? And I 
think people like us need to address that question because it 
is behind a lot of the issues that we hear about today.
    Ms. Whitman. Thank you. The two agencies that are 
fundamental to the Federal government's work on aging, the 
National Institute of Aging and the Administration on Aging, 
exist today in large part to the Aging Committee's advocacy and 
drive to establish. We are fortunate to have the two heads of 
these agencies with us here today, who you will hear from 
shortly.
    But how do we get the rest of government, including the 
Labor Department, the Environmental Protection Agency, the 
Justice Department, and others to look at their own work 
through an age-friendly lens and champion the cause of older 
Americans?
    Dr. Hudson. That has been the central challenge of the 
Older Americans Act and aging policy for 40 years. It is the 
central challenge of the Aging Network, whether it should be a 
vertically integrated series of community and social services 
largely within its own purview, or should it do advocacy and 
what my late colleague, Bob Mitsock, and I call leadership 
planning in order to get mental health departments, 
transportation departments to do better by older people in the 
larger population.
    It is a very serious discussion to have about resource 
allocation. Can you do better sort of staying within the 
parameters of your world, however defined, or do you have the 
resources and the will and the ability to move and shake 
outside that relatively narrow structure and make bigger things 
happen? And I am certainly in favor of the latter, but getting 
it done is a very, very tall order.
    Mr. Rother. If I could just add to Rob's answer, one of the 
things that we used to do was to require every executive agency 
to write an annual report as to what it was doing with regard 
to the challenges facing the older part of the population. And 
that can then become the basis for follow-up, for 
investigations. And it a report seems innocuous, when actually 
it is just the opening wedge to get more responsive behavior 
out of the executive branch.
    Ms. Whitman. Thank you both. I am going to move to our next 
panel, who we will hear from the country's leading experts in 
health, research, retirement security, technology, long-term 
care, and aging services.
    We have asked these speakers to not only describe how far 
we have come over the last several decades, but also to play 
the role of fortune tellers and predict where we are headed as 
a society with a rapidly aging population.
    I also gave them the ability to wave a magic wand and 
create a new future by changing the trajectory of the path that 
we are currently traveling. And to make the challenge truly 
difficult, I have only given them each five minutes to speak. 
[Laughter.]
    Ms. Whitman. So, before they bring out their crystal balls 
and magic wands, let me briefly introduce each speaker.
    Kathy Greenlee is the Assistant Secretary for Aging at the 
U.S. Department of Health and Human Services, where she works 
to advance the health and independence of older Americans and 
their families. Previously, she served as the Secretary of 
Aging for the State of Kansas, as well as the Kansas State 
long-term care ombudsman.
    Dr. Richard Hodes is the director of the National Institute 
of Aging at the National Institute of Health. A leading 
immunologist, Dr. Hodes was named director of the NIA in 1993, 
and oversees research into the clinical, epidemiological, and 
social aspects of aging.
    Michael Harsh is vice president and chief technology 
officer of General Electric Health Care. In his role, Mr. Harsh 
oversees the diverse businesses, including medical imaging and 
information technologies, medical diagnostics, patient 
monitoring systems, and drug discovery.
    I have just been informed we have Senator Grassley here, so 
I am going to break the introductions and give him a chance to 
say a few words.

              STATEMENT OF SENATOR CHUCK GRASSLEY

    Senator Grassley. I had to look over to see who is up here, 
distinguished people performing already. I am sorry I missed 
everything you have said so far, and I will probably miss 
everything else you say. [Laughter.]
    First of all, let me thank Chairman Kohl for his work as 
chairman of the committee. It seems like he and I have worked 
together on many issues, and he has been an extremely good 
chairman of this committee. And thank you for your hard work.
    Since Senator Kohl is going to retire, I am going to miss 
him in his retirement. But like I tell a lot of former 
senators, any time you want to come to my office, you are 
welcome to come to my office. [Laughter.]
    Senator Grassley. And, of course, with the 50th anniversary 
of this committee, and particularly since I was one of the 
charter members, in 1975 with the beginning of the House 
Committee on Aging, and serving there the six years I served 
there, obviously I wanted to serve on this Committee when I 
come to the United States. And I had the privilege of being on 
this committee probably for, I believe, about 23 or 24 years, I 
believe.
    Anyway, it is a tremendous opportunity to serve as chairman 
of the Special Committee on Aging, and I did that from 1997 
until 2001. I had the good fortune of following another good 
chairman, Senator Bill Cohen of Maine. And my successor was 
John Breaux, who was my partner on the committee as ranking 
member then. And I know I am biased, but the Aging Committee 
offers one of the greatest opportunities for service on Capitol 
Hill, and serving on the Aging Committee got me very much 
working very closely with a loyal staff member for so many 
years, both prior to my being chairman and after being 
chairman. And that is one of the people that is here in the 
audience by the name of Ted Totman. There is Ted Totman there.
    And, yeah, as I think Senator Kohl will tell you, it takes 
a pretty darn good staff for any senator to be effective, 
either as an individual senator or as chairman of a committee, 
and probably more important, chairman of the committee. And I 
think if I had anything to do with any progress on this 
committee, I would give Ted Totman the credit for that.
    This is, as I said, a great opportunity to serve as 
chairman, and even to serve on the committee. The committee has 
such a broad mandate to improve the quality of life of older 
Americans. Within that framework, there are endless 
opportunities. The Aging Committee is part consumer advocate, 
part policy work, part gumshoe detective, as I like to think 
most of my work was, and part bully pulpit. No other committee 
in the Senate can claim such broad platforms. Each chairman 
appreciates the possibilities of the committee.
    During my tenure, we had a former employee of a predatory 
lender testify with his identity hidden about how the lender 
preyed on older Americans. Katie Couric testified about the 
importance of colon cancer screening. The family members of 
victims of nursing home abuse testified about their experience 
during a two-day hearing. Their testimonies came after 
whistleblowers presented serious concerns to the committee 
about nursing home abuse and neglect in one of the biggest 
States and most progressive States of our country.
    At the committee's request, the General Accounting Office 
did a hard-hitting analysis that has been the benchmark for 
improving the quality of care ever since in our nursing homes. 
And a lot of our time covered the impending baby boom 
retirement that is now upon us and how to prepare Medicare, 
social security, and the workforce for that sea change, of 
which none of those changes suggested by our committee has 
obviously been adopted.
    Aging Committee hearings then and now convey that certain 
issues are fundamental to everyone, regardless of age. What 
kind of a society we choose to be and what role our government 
plays in shaping that society are the Aging Committee's bread 
and butter. How do we increase the prospect of a safe, 
comfortable experience in a nursing home? How is Medicare 
waste, fraud, and abuse putting beneficiaries at risk? How 
should everyone begin saving money for retirement, and how much 
savings is necessary?
    As the Aging Committee explores these questions, the 
committee offers watch over the executive branch to ensure that 
priorities do not get lost through inertia. Federal agencies 
can move slowly. Initiatives like changing the predictability 
of nursing home inspections require a lot of people doing a lot 
of work to shake up the status quo.
    There are always dozens of topics that require attention. 
Even now, Chairman Kohl and I are rattling the cages at the 
Center for Medicare and Medicaid Services to implement our new 
law on sunshine for drug company payments to doctors. Our 
partnership on this and other issues raises another positive 
point about the Aging Committee, and that is bipartisanship, or 
maybe it would be more accurately called nonpartisanship; the 
fact that this committee is not responsible for legislation--in 
other words, it does not initiate bills. It then frees the 
committee from a lot of partisanship that might otherwise 
happen. In fact, I do not remember any partisanship, and all 
the years that I was on the committee, and particularly those 
years that I worked with John Breaux.
    Aging Committee work might translate into legislation on 
some other committee, as it did for me as I followed on as 
being chairman of the Finance Committee. But the Aging 
Committee itself is able to devote the full resources to 
educating, to exposing, and to illuminating the issues of the 
day. It is a unique creation. It does valuable work for our 
entire society. Whether we are 92 years of age or even 22 years 
of age, we are all aging. Is it not that simple?
    The Senate Special Committee on Aging cannot reverse the 
aging process, but it helps to make parts of the process better 
for most everybody in America. So, I want this committee, even 
though I do not serve on it, to continue and, most importantly, 
to continue the successes going forward, so that the next 50 
years do just as good of a job for a better society as the last 
50 years.
    Thank you all very much.
    [Applause.]
    Ms. Whitman. Thank you, Senator Grassley, you were one of 
the great chairmen of the committee, as many people know.
    Next, I would like to take the opportunity to introduce Dr. 
Robyn Stone, who is the executive director of the LeadingAge 
Center for Applied Research. Dr. Stone is a noted researcher 
and authority on aging and long-term care policy. Formerly, she 
served as executive director of the International Longevity 
Center in New York, and served as the Assistant Secretary of 
Aging during the Clinton Administration.
    Next, we have Dr. Henry Aaron, who is the Bruce and 
Virginia MacLaury Senior Fellow at the Brookings Institution. 
Dr. Aaron's research has explored reforms to health systems, 
such as Medicare and Medicaid, as well as income support 
programs, including social security. He was recently nominated 
to serve as a member of the Social Security Advisory Board.
    And, finally, we have Dr. Jonathan Rowe, who is a professor 
at the Department of Health Policy and Management at Columbia 
University School of Public Health. Dr. Rowe has held many 
leadership positions in top health care organizations and 
academic institutions, including the CEO of Mount Sinai, New 
York Health System, and is founding director of the division of 
aging at Harvard Medical School.
    We are going to start with Kathy.

   STATEMENT OF KATHY GREENLEE, ASSISTANT SECRETARY FOR THE 
                    ADMINISTRATION ON AGING

    Ms. Greenlee. Thank you, Senator Kohl, Senator Grassley, 
and the rest of the committee. I am pleased to join you today 
to celebrate the 50th anniversary of this particular committee. 
1961 was an important year for seniors, and it is just fabulous 
to be able to join you and really recognize the value of this 
committee. And as both Senators Kohl and Grassley mentioned, 
that aging is a nonpartisan issue. It is quite appropriate, I 
believe, that this committee has always operated in a 
nonpartisan fashion or bipartisan fashion, to help advance 
issues that sometimes have never been looked at before, but can 
be surfaced here in this committee.
    There was another key event in 1961, and that was the first 
year that there was a White House Conference on Aging. At that 
time, Dr. Arthur Fleming was the secretary of the Department of 
HEW, Health, Education, and Welfare. I wanted to share with you 
a quote from Dr. Fleming from 1961 since we are celebrating 
that very important year. So, I quote: ``We have not yet 
adjusted our sense of values, our social and cultural ways of 
life, our public and private programs, to accommodate the 
concerns of this vast legion of old and aging people. For far 
too many people, old age means inadequate income, poor or 
marginal health, improper housing, isolation from family and 
friends, the discouragement of being shunted aside from the 
mainstream of life.'' That is the end of the quote.
    One of my greatest professional regrets is that I never had 
the opportunity to meet Dr. Fleming, and I know many of you 
have and worked with him as a colleague. There are many times I 
wish we could talk to him still and say, now what, Dr. Fleming? 
I mean, he was such a visionary, both through his service as 
Secretary and as the Commissioner at the Administration on 
Aging. We have done many things in 50 years; that is the reason 
we are here to celebrate the accomplishments. But I wanted to 
share the quote to also point out that we still have work to do 
to achieve the vision and the issues he raised back in 1961, 
that the work will continue. And our mission is critically 
important.
    As Deb said, she asked us three questions and gave us 5 
minutes. I have probably used a great deal of that already. 
Each of these questions could be the subject of an entire 
course in college. The first question is, how far have we come 
over the five past decades, and where are we today?
    You could look at the past five decades, and I have had the 
opportunity to do this in some sense, and I believe that there 
are four large social movements that have informed each other 
in the past 50 years--the movement of people with intellectual 
and developmental disabilities and their families, the movement 
of people with physical disabilities, the movement of people 
with mental illness and mental health issues and their 
advocates, as well as aging. Those four social movements have 
been propelling us forward to support dignity, and 
independence, and community living. I wanted to frame those 
four as I list the key milestones that I see when I look at the 
past 50 years.
    For me, most importantly, would be 1965, with the passage 
of Medicare, providing acute care services for seniors and 
people with disabilities, and Medicaid, which now, as you know, 
supports long-term care funding for people in institutions and 
in the community, and, of course, the passage of the Older 
Americans Act, which has always had the role of providing 
preventative services to help people remain independent and in 
their community for as long as possible.
    I would also call out 1987. OBRA 87 and the Federal Nursing 
Home Reform Act was critical to changing the lives, the 
experience and the quality of care of individuals living in 
nursing homes. I first read over OBRA 87 when I was the long-
term care ombudsman in Kansas. If you have not read OBRA 87, 
you should because as soon as you put it down, you will pick up 
the IOM study from the year before, because when you read the 
law that was passed, you will ask, why were these laws needed? 
What was happening that caused a Federal response to this 
magnitude? OBRA 87 was visionary and impactful, and leads much 
of the culture change work we are doing still in nursing homes.
    This was followed in 1990 by the Americans with 
Disabilities Act, which has had a significant impact on the 
lives of people with disabilities and seniors as we integrate 
into community settings of all types. Following the ADA, of 
course, was the 1999 decision of the Supreme Court in the 
Olmstead case, the Georgia case, brought to us primarily from 
the field of developmental and intellectual disabilities. This 
is why these issues have informed each other, which, of course, 
gave us the requirement that States provide community-based 
services as a placement, if appropriate, and something that 
they are able to fund.
    And then, of course, 2010. I believe the Affordable Care 
Act is another huge leap forward for seniors in this country. 
As we have expanded coverage, we have provided additional 
benefits for seniors, preventative benefits, wellness benefits, 
and worked to protect the life of the program by tackling 
fraud.
    That is my list. Any of us could look back at the last 50 
years, and pull out things that have all kept moving us forward 
toward community care. Those issues, along with Social 
Security, have done much to address the poverty issues and the 
health issues that Dr. Fleming recognized in 1961.
    Deb's second question, where will we be in the next two 
decades? That is a little smaller than the first question. I 
think it is a time of demographic challenge, and I know we all 
have the information about the number of baby boomers turning 
65--9,000 or 10,000 a day in this country, and that will 
continue; that one of the fastest growing segments is the group 
that is 85 years old and older.
    I believe that this is an opportunity as well as a 
challenge for this country, and John mentioned that earlier. 
Talking about what I call social capital, which is the number 
of healthy, long lives we have and we have coming that can 
build additional assets and resources as people continue to 
stay in the workforce, or older adults who move out of the 
workforce into second careers, encore careers, and 
volunteership. This will be something we so much need as we 
continue to provide community supports and livelihood in the 
community for seniors. This, I think will change the future.
    There are also other advances that we will take advantage 
of in the next 50 years--technologies, exciting innovations 
with regard to how to support individuals and families with 
technologies.
    I think another issue that we have to recognize as a huge 
opportunity for us is this incredibly diverse nation that we 
live in, and the incredible diversity of the seniors that we 
have, and what a rich blend they bring to us as a community and 
as a country. We need to support all individuals as they age 
and embrace them and the richness of their lives, and also 
support person-centered approaches--respect, dignity, 
independence, and valuing self-determination.
    If I could change two or three things--I think it was the 
final thing on my list of two or three things, which is hard to 
narrow down. But to me, they seem to be, I think, obvious. I am 
completely committed to the issue of prevention across the 
lifespan. I believe it is imperative as we move forward to talk 
about health and wellness, that we frame prevention from this 
particular angle, that we talk about prevention as a life span 
approach. Investing in children, investing in middle-aged 
individuals, and investing in seniors is all worth the 
investment. For those of us who work in the field of aging, 
sometimes it is hard to get attention to people who are older, 
but it is worth the investment. It is never too late to be 
healthy. And for a senior, falls prevention, medication 
management, chronic disease management, is the type of 
prevention that we need to continue to support to help them 
with good quality of life, and long life, and less expensive 
care. So, prevention is one of the three things that I would 
change or continue to push.
    The second thing on my list would be what I call a more 
holistic approach to integrating the three huge systems of 
acute care delivery, long-term care delivery, and community 
services; that these three systems create both the barriers and 
impediments as people try to navigate through and receive care. 
They must continue to be integrated. I believe the Affordable 
Care Act brought us tremendous opportunity with this 
integration.
    What we are doing at the Administration on Aging right now 
is focusing specifically on care transitions and training the 
Aging Network to take advantage of their 45 years of 
experience, to partner with acute care providers and long-term 
care providers to help people return to the community in a 
successful way, and live there longer. I believe integration of 
these three systems has to continue, and we have all kinds of 
opportunities to deliver better quality care at less cost. So, 
I would put that on my list as second.
    And the third is I believe we need to continue to focus on 
the community and the family as the focal point for our 
delivery of services, and this is where the Older Americans Act 
was visionary. The Older Americans Act was the original home- 
and community-based service program in this country for older 
adults. We need to continue to support it, and we need to 
continue to help family caregivers and the other partners--the 
questions you were asking. It is not just about working within 
HHS, or even at AOA, but working with the Department of 
Transportation, and HUD, and the other Federal agencies to 
tackle all of the issues that are there and present. If we will 
be successful in community tenure for older adults, we must 
tackle transportation. It, to me, is one of the hardest issues 
in front of us as we help people stay independent.
    I think there is much we have done, much we can do still to 
achieve Dr. Fleming's vision. We can continue to fight to 
reduce poverty and isolation, maintain dignity, and increased 
choices for older persons and people with disabilities.
    I am pleased to be serving as the Assistant Secretary for 
Aging. I am pleased to be able to participate with the work of 
this committee, with all of the advocates, both here and across 
the country. This is fabulous work, it is meaningful work, and 
things that we can do so that in 50 years when they come back, 
what we do will be on this list because there is so much more 
ahead of us and so many more opportunities with such a vibrant 
and positive aging America.
    Thank you.
    [Applause.]
    Ms. Whitman. Thank you, Secretary Greenlee.
    Dr. Hodes.

    STATEMENT OF RICHARD J. HODES, DIRECTOR OF THE NATIONAL 
                       INSTITUTE ON AGING

    Dr. Hodes. Chairman Kohl, thank you again for the 
opportunity to be here and participate in the celebration of 
the 50 years of this Special Committee on Aging. The National 
Institute on Aging was established in 1974, very much through 
the offices of this committee. And since that time, we have 
worked very closely through our joint goal in improving the 
quality, as well as length of life for older Americans.
    It is a very different world now than it was 50 years ago. 
Some of this is illustrated in statistics. The Census' most 
recent estimate in 2010 is that there are approximately 
Americans over age 65; that is, 40 million more than there were 
50 years ago, more than double that number. The trends are 
going to continue as we see the demographics progress, so that 
there were estimates again this past year of about 1.9 million 
Americans aged 90 and older. That is expected to increase by 
2050 to nine million--truly enormous changes.
    The changes are not just national but international and 
worldwide. Sometime in this decade, the number of individuals 
in the world over 65 will exceed that of children under five 
for the first time in human history, with enormous implications 
reflecting on the successes we have had in prolonging life and 
health, but also the challenges to a society that is very 
different than the species ever enjoyed in the past.
    We have, in addition to extending life, seen great evidence 
that it is possible to improve the quality of years. And over 
the closing decades, the 20th century, for example, studies 
showed a very gratifying decrease in the rates of disability in 
older men and women, demonstrating that by prolonging life, we 
are not by any means committing people to life with disability, 
but a life with hope of avoiding that disability.
    As we tried to juxtapose what has happened in the past, the 
present, and the future, the studies that continue to monitor 
these trends give us pause and real warning as we look at the 
generations that are going to be the next generations of the 
elderly, the baby boomers, emerging, whether the trend is in 
part due to lifestyle issues, such as obesity, inactivity, that 
really threaten to compromise, if not reverse, some of the 
enormous changes that we have made. And this, again, translates 
to some of the needs and hopes for the future.
    We have made progress in understanding how to treat and 
prevent some of the very important causes of disability and 
death in the elderly. So, for example, the identification of 
effectiveness of treating hypertension in older men and women 
with relatively inexpensive and well-tolerated treatments has 
shown really to very dramatically reduce the risks of coronary 
vascular disease, of heart attacks, of strokes, congestive 
heart failure. More recently, it has been shown that it is 
possible to reduce the risks of diabetes mellitus in older men 
and women, contrary to the expectations of some, showing that 
individuals over age 60 through a lifestyle intervention, that 
show the ability to change diet and exercise and activity that 
was remarkable. Seventy-one percent reduction in the rates of 
disability in that age group, which if translated to the public 
would be an enormous advance in quality of life, as well as the 
burden on society for medical care, and, most importantly, to 
improve the quality of life.
    There are other areas in which we have made progress. For 
example, understanding the nature of cognition in aging has 
been translated in some very practical ways to understanding 
what it is about cognitive changes that can interfere with 
important life tasks, such as driving, or the important markers 
of independence, but also as viewed by some of risk in older 
men and women behind the wheel. It has been possible to 
understand the cognitive characteristics which predict who is 
at risk for driving accidents. More importantly still, it has 
been possible to show that cognitive training can alter 
performance on these laboratory computer-driven tests. And, of 
course, most importantly, the recent demonstration, in at least 
one report, that this kind of training can reduce by more than 
50 percent the risk of accidents by older drivers.
    Not only has this been a laboratory finding, but it has 
been one embraced by various aspects of private and public 
sector, so that several motor vehicle bureaus in the country 
are now using this test in evaluating driving abilities, and 
that now most recently some of the insurance companies are 
actually giving discounts to individuals who go through this 
training, reflecting the way that very real consequences come 
from research endeavors.
    There are other areas--threats to well-being, individual 
and public, are not yet met. One of the more prominent and 
evident is in Alzheimer's disease, one of the more frightening 
diseases to all of us, to the community, to individuals, to the 
public.
    This year, the passage of the National Alzheimer's Plan 
Act, an enormous rededication to a concerted effort to try to 
ultimately decrease the progression, prevent disease, is the 
hallmark of the new iteration of national/international public/
private partnerships to that end.
    We have learned an enormous amount about genetics and 
genetic risk factors, about brain imaging, and biochemical 
testing that can identify the very early stage of disease, even 
before there are symptoms. We now have the challenge before us, 
the very real challenge, of translating that into 
interventions.
    So, in terms of the present and where we stand, we have a 
society which has seen an extension of the life expectancy over 
the 20th century from some 47 years in this country at the 
beginning of the country to 77 at the end. We have challenges 
before us, which threaten to compromise or reverse that through 
the trends we see in disability, related lifestyle changes, and 
a commitment to the need to go further.
    In terms of the magic wand, the things that we need to the 
future to make the trajectory of life and health of older 
Americans as successful as can be, they really fall into 
several categories. There are things we know how to do--
preventing heart disease, preventing diabetes--where the 
translation into practice is not what it needs to be. And there 
the challenge is to find ways to disseminate best practices 
into practices that transfer to individuals and their life 
expectancy and their health expectancy.
    There are other areas, such as those represented by 
research ongoing in conditions such as cancer and Alzheimer's 
disease where we need to learn a lot more about translating the 
dramatic high tech basic findings that we have now into 
ultimate interventions.
    And, in addition to these disease-specific areas, the 
research of the National Institute on Aging, facilitated by 
this committee into the very basic process of aging itself, 
offers a new set of opportunities that have become all the more 
relevant in recent years. So, for example, it has been found 
that changes in chromosome structures called telomeres, or in 
oxidative damage, or in the senescence of individual cells are 
very much related to dysfunction in organs and tissues and the 
health and well-being of experimental systems and humans.
    And most recently it has been shown, for example, that 
eliminating the very small number of cells that are senescent, 
that have a very specific phenotype when one looks under the 
microscope or analyzes their gene expressions. Eliminating a 
very small number of cells in experimental animal systems can 
in fact reverse the manifestations of aging in multiple 
tissues, and providing an opportunity to execute what many in 
the field of aging research would argue that, in addition to 
disease-specific interventions, better understanding the basic 
processes that accompany aging may allow interventions that 
will, in fact, have global impacts, not on a single disease, 
but on many of the undesirable consequences of aging, so that 
it becomes less of an age, less of a time of life when disease 
threatens, and more of a time when the enormous potential and 
productivity of older men and women are able to execute 
themselves.
    And we at the NIA and NIH in general are committed to this 
kind of research and the support provided, and are grateful 
again to the support over this past 50 years by you and by this 
committee. Thank you.
    [Applause.]
    Ms. Whitman. Next, we have Michael Harsh.

   STATEMENT OF MICHAEL HARSH, CHIEF TECHNOLOGY OFFICER, GE 
                           HEALTHCARE

    Mr. Harsh. Boy, as I am up here today, I realize that now I 
need glasses, so I guess it has changed.
    I am Mike Harsh. I am the vice president and chief 
technology officer for GE Healthcare. We are a $17 billion 
diagnostic health care IT and life science division of General 
Electric.
    It is a pleasure to be here. I want to thank Senator Kohl 
for the opportunity, Senator Grassley for hosting this program, 
and for your leadership in advancing American health care.
    You know, I have led R&D at GE Healthcare in Milwaukee, 
Wisconsin, Senator Herb Kohl's home State, for quite a while. I 
have had a chance to work at our GE global research labs in 
upstate New York just outside of Albany. Additionally, I am a 
member of the College of Fellows of the American Institute for 
Medical and Biological Engineers. My 34 years of seeing health 
care innovation up close and its impact on patients, health 
care providers, and society as a whole provides the foundation 
for my comments today in this important forum on the 
challenges, promise, and potential of aging in America.
    Medical technology has come a long way in the last 100 
years. Developments in IT, imaging, biology, have really 
changed the medical paradigm from a see and treat it--and I 
just want to say again, see it and treat it way of treating 
disease--to where we are moving towards a predict and prevent. 
That will dramatically change how physicians are able to 
address the increasingly complex needs in a global aging 
population.
    You know, there has been an explosive growth in medical 
technology in the last century, you know, with the development 
of x-rays. As the 21st century dawns, you know, governments 
have put pressure on health care systems to be more productive. 
Technology must now align with the new realities of health 
care, providing patient and diagnostic economic value. 
Specifically, society is demanding that technology reduce the 
overall cost burden of delivering care. Technology must help 
deliver higher-quality and efficient health care to an 
increased number of individuals, thus, increasing access while 
lowering overall costs.
    As diagnostics and therapy shift to the molecular level, 
molecular diagnostics will enable earlier, more precise disease 
detection and allow physicians to understand more about the 
individual patient. Life sciences will enable the next 
generation of biotherapies, which increasingly will be 
delivered in tandem with diagnostics. Now, let me give an 
example. In neurodegenerative disease, molecular agents and 
biomarkers for in vivo or in body and in vitro testing will 
help determine the pathology behind early cognitive impairment, 
leading to earlier diagnosis and treatments. Bio signatures are 
what we call these. With the advent of disease-modifying drugs, 
this brings the opportunity to improve people's quality of life 
as they age, and this is particularly significant for our 
seniors who could experience memory loss and impairment through 
a neurological condition, such as Alzheimer's and dementia.
    Now, looking forward, here are some concepts representing 
how technology may change the future of medicine. Health 
monitoring will be a part of everyone's existence. Again, 
looking at the bio signatures that we can monitor, we will have 
early warning systems that alert people when very early changes 
in their bodies, at a stage when disease is typically easier to 
treat, but before we see symptoms. You can look at reversing 
the course of the disease. Manufacturing artificial blood, 
repairing tissues, and reconstructing organs with these cell-
based therapies and tissue engineering is just another 
possibility that we see.
    Now, two or three things that have changed could put us on 
a better path to the future. I think, number one, and I want to 
say this, is effective regulation of medical devices is 
necessary for ensuring patient safety and protecting public 
health. And, number two, we need to move the system from a sick 
care system over to a truly preventative health care system. 
And this is really key for everyone in this room. Aging starts 
the day we are born. Prevention, combined with prediction in 
early diagnosis, enabled by the convergence that we see today 
between the biosciences, the diagnostic tests that we have and 
the equipment, the IT systems, mean that it is already possible 
to diagnose diseases on that were undetectable in the 1980s. 
Again, this means better quality of life for our seniors and 
our aging population.
    In conclusion, the future of health care technology holds 
tremendous promise for increasing patient access, earlier 
diagnosis and treatment of disease, improving health care 
quality and decreasing overall health care costs. All of us 
hopefully will experience this aging process, and health care 
innovation increasingly make possible an unprecedented quality 
of life for seniors in which living old can be living well.
    We all know America was built on the premise of what might 
be possible, a notion that spurs great achievement. That same 
promise holds true for health care.
    I would like to thank you for allowing me the time to be 
here and celebrate this 50-year achievement of the Senate 
Special Committee on Aging. I am a technologist; I want to 
paraphrase one technology guy I always looked up to, and that 
is Albert Einstein. He had this great statement. It was, 
``Imagination is more important than knowledge. Knowledge is 
limited to all we know, while imagination embraces the entire 
world, all there ever will be to know.''
    I want to thank you for your time today.
    [Applause.]
    Ms. Whitman. Next to discuss healthy aging, Dr. Jack Rowe.

STATEMENT OF JACK ROWE, DIRECTOR, MACARTHUR FOUNDATION RESEARCH 
   NETWORK ON SUCCESSFUL AGING AND PROFESSOR AT THE COLUMBIA 
           UNIVERSITY MAILMAN SCHOOL OF PUBLIC HEALTH

    Dr. Rowe. Thank you very much, Senator Kohl, and Ms. 
Montgomery, Ms. Whitman, for including me in this set of 
conversations.
    I would like to convey some of the thoughts that my 
colleagues at the MacArthur Foundation Research Network on an 
Aging Society and I have developed with respect to the agenda 
of the committee. We start with a clear view that if we 
continue our preoccupation with entitlements, and we really 
continue to view the entire problem as balancing the Medicare 
and social security trust funds, that we will be in very big 
trouble.
    The fundamental observation is that the core institutions 
of our society, whether it be work, retirement, transportation, 
or education, were not designed to support a population that is 
going to have the age distribution of our future society. And 
so, unless we are able to find a way to hasten the adaptation 
of those core institutions, even if we balance the entitlement 
trust funds, we will not have a society which is productive or 
equitable or cohesive. We will have a society in which the 
tendencies to be torn apart and have generations pitted against 
generations, and have pitted against have-nots, will be 
aggravated even further than they are now.
    Let me comment on two general areas. One is health care, 
which I am going to just comment on because Ms. Whitman said 
that, some of these problems are not new, that they have been 
around a long time. And why have you not solved these problems? 
Why did you not solve these problems ever? I certainly concur 
that these issues are heardy perennials with these issues, but, 
you know, it is not so much whether the problem is a new 
problem, but whether or not it is a problem whose time has 
come. And it seems to me that with respect to health care, we 
may be in a situation where we can solve one of the core 
problems.
    One core problem is providing access to health care for 
people, but it is a hollow promise to provide access to health 
insurance to everyone and not have providers there who are 
capable of providing the care. We know we have a dramatic 
shortage of primary care providers, and we know, especially 
with respect to older persons that there are not enough 
geriatric specialists, and that the general health care 
workforce does not have enough expertise in the care of the 
elderly. The Institute of Medicine had a report a couple of 
years ago on this that I testified on to Senator Kohl and his 
committee at that time. And the Institute of Medicine has 
followed up with a more recent report on nursing as well that 
includes these issues.
    I think the time has come for many of those well thought 
out and generally well-received recommendations be implemented. 
The window of opportunity is opening now. We are changing the 
way we pay for health care. Affordable care organizations focus 
on preventing admissions and readmissions and on paying for 
quality. All these changes are removing some of the barriers 
that we have had before to enhance geriatric care. I am very 
optimistic about that.
    With respect to the issue of productivity and the 
workforce, there are two or three observations. One is that we 
need to understand what the future population is going to look 
like. And Richard Hodes pointed out that the decades-long, 
quite substantial, progressive reduction in disability we saw 
may have ended at the beginning of the last decade, and things 
have been going perhaps sideways since then. And that may 
result in our having a population of older people with greater 
demands for personal care services than we had been expecting 
or hoping. We were feeling that disability was going to 
progressively decline. It may not. And there are even studies 
now that suggest that disability is increasing in the near 
elderly.
    We were also thinking that the older population was going 
to be able to participate in the workforce because they are all 
going to be fit, and it looks like perhaps that is not the 
case, since the disability rate may be increasing in the near 
elderly. And technology may help there, but we need to 
understand that better.
    We also need to understand how we can incent employers to 
keep people in the workforce. We need to work with employers to 
de-mythologize the well-known, and Mr. Aaron can talk to this 
better than I, lump of labor fallacy that you need to get older 
people out of the workforce in order to make room for younger 
workers. That is just not the case. I believe prevailing 
economic opinion would support that. But I think we have an 
opportunity to work with employers, now that evidence is 
available that productivity is retained in the older workforce 
well into the 60s, if we can get some of the right incentives 
in place.
    Let me end with just two quick points. One is that I think 
our attitude, and this has been mentioned already, should be a 
life course attitude. We have got to get rid of this 
counterproductive children against the elderly approach with 
people writing articles about how much more money is spent on 
old people than children, when, of course, they are including 
health care, but they are not including education, in the 
equation. We do not have time for that. We have to go to the 
next room, sort of, you know. And we have to start looking 
across the workforce and look in a way that is 
intergenerational.
    That last point that I would make, and this was suggested 
by Lisa Berkman, one of the colleagues in the Network, is maybe 
we can learn something from the environmental movement here. 
Whenever you want to do something in a community, you have to 
do an environmental impact assessment. What impact will this 
activity have on the environment, positive, negative, neutral? 
Fine. Maybe we need an aging society impact assessment. Maybe 
every time something gets done, somebody needs to stop and say, 
wait a minute, what is the impact of this on a society with a 
fundamentally different age distribution, or is this actually 
moving in the wrong direction, or the right direction, or is it 
neutral? And just having to do that, just like John Rother 
pointed out, just having to write a report at the end of the 
year is sometimes therapeutic, and so that I think that there 
may be some benefit.
    Thank you again for including me here today.
    [Applause.]
    Ms. Whitman. Next, we have Robyn Stone to talk about the 
future of housing.

STATEMENT OF ROBYN STONE, EXECUTIVE DIRECTOR, LEADINGAGE CENTER 
                      FOR APPLIED RESEARCH

    Dr. Stone. Thank you for this opportunity to talk about 
this issue. And I am actually in my brief five minutes, I am 
going to try to frame the issue of housing within the larger 
issue that I know so well, which is really long-term care 
policy. And the reason I speak to housing in terms of that is 
that really housing and services are co-equal. You cannot have 
a long-term care system, you cannot remain in the community for 
as long as possible, you do not have shelter, as well as the 
services to support you.
    And I want to start by saying that long-term care and 
housing policy has really come a long way since this committee 
was established in the 60s. And I actually started in the mid-
70s as a director of a Title VII nutrition program. This was 
actually before Title VII was folded into Title III of the 
Older Americans Act. So, I have been around aging services for 
a very long time.
    And I do want to highlight the fact that although families 
and other unpaid caregivers continue to provide the bulk of 
services in all settings today, a fragmented formal system has 
evolved over the past 50 years to meet the long-term care and 
housing needs of our Nation's elderly population.
    I want to commend the committee for a number of things. 
Certainly with the advent of Medicaid and, to a lesser extent, 
Medicare, we have a nursing home market today that was really 
started in the 1960s. And from that very start, the committee 
has been a vigilant advocate for resident rights and quality, 
including its advocacy for, first, the ombudsman program, which 
started in the 70s, Nursing Home Reform Act, which OBRA 87, 
continuing efforts to really have strong oversight and 
enforcement, and the recent culture change provisions that are 
in the ACA.
    However, one of the major moves, and Kathy spoke to this, 
is the shift towards home- and community-based services. That 
can be attributed in large part to actually the Aging Network 
in the late 60s and early 70s, culminating in the Medicaid 
waiver programs in the early 80s, albeit tremendously variable 
across States.
    The Congregant Housing Services Act, supported by the 
committee early on in 1978, was actually the first national 
program to link affordable elderly housing with services. And, 
by the way, that program has been frozen for a number of years 
as we see the 202 program and a number of other housing 
programs really slipping away between our fingers. And I am 
going to return to that in a little bit.
    The field has also experienced a great growth in primarily 
the private sector assisted living market, with some 
experimentation with residential alternatives through various 
State-based Medicaid waiver programs. Despite the fact that 
most individuals needing long-term care also suffer from 
multiple chronic conditions that often need medical 
intervention, care delivery has developed primarily in silos. 
But one of the first programs to actually integrate acute, 
primary, and long-term services, the OnLok program in San 
Francisco. And many of you may not know this, but it was 
initially developed through a Title IV AOA demonstration grant 
in the early 1970s, which was supported very strongly by this 
committee. So, integration really had its source through this 
committee and through the Older Americans Act.
    Three decades later, the program of all-inclusive care for 
the elderly, known as PACE, is a permanent Medicare provider, 
and really has set the gold standard for service integration 
and care coordination. And over the years, the committee has 
supported experimentation with a range of integrated 
approaches, and was a strong advocate for the most recent ACA 
demonstrations designed to improve quality and reduce costs.
    Until 2000, the paid long-term care workforce was just an 
afterthought. The committee was instrumental in raising this 
issue as a priority, and the efforts have included hearings 
following the release of the seminal IOM report, ``Retooling 
for an Aging America,'' which Jack was the chair of, and 
advocating for the inclusion of education and training 
opportunities for long-term care professional and direct care 
workers in the ACA. And the committee remains committed to this 
area, as is evidenced by its ongoing work to get funding for 
these authorized programs.
    So, where do we go from here? And this is where housing 
really comes in. The United States is still a relatively young 
country compared with most countries in the developed world. 
But the three issues that loom large over the next 20 years 
include how modes of service delivery might evolve in response 
to consumer preferences, ability to purchase care, and changes 
in public policy; whether and how a quality, competent 
workforce will be developed to meet the service demands; and 
how services and housing can be made affordable for the vast 
majority of older adults who are at risk for needing long-term 
care and for the Federal and State governments that currently 
foot much of the bill.
    My vision for 2030, while it is not possible to predict the 
service system that will evolve, would include these elements. 
Family caregivers will probably continue to play a pivotal role 
in the delivery of long-term care services. To the extent, 
however, that it is financially feasible and preferred, they 
will augment their hands-on care and oversight through the 
purchase of home- and community-based services and technology. 
Technological advances, including the development of web-based 
social networks, sensors, and electronic medication reminders, 
will support more long-distance caregiving, leading to an 
expansion of geriatric care managers and brokers to assist in 
these efforts.
    The ability of technology, of course, to complement 
informal caregiving is contingent on the mitigation of the 
myriad barriers to the development, adoption, and wide scale 
use.
    The committee has a major role to play in ensuring that 
family caregivers continue to receive support, and that they 
are integrated into the long-term care decision-making process. 
The National Family Care Support Program, which was created in 
2000, at least formulae acknowledged family caregivers as a 
specific target population, but to date that program has been 
really limited in its funding. Ongoing advocacy will be 
required to expand the magnitude and scope of that program, as 
well as other efforts to really help to alleviate caregiver 
burnout and burden.
    The primary role of nursing homes in 2030, in my vision, 
will be to provide post-acute care to medically complex 
individuals being discharged from the hospital, or those who 
require significant rehab, such as the events following a 
stroke or opposed hip replacement. I do not believe that we 
will need nursing homes in 2030. This is, however, contingent 
on affordable options out in the community. These facilities 
could also provide a venue for the delivery of palliative care 
to individuals in the active stage of dying, who were not able 
to remain at home or in another residential setting.
    By 2030, the demand for home- and community-based options 
will increase substantially, and home-based care will be 
provided by a combination of in person and electronic 
monitoring systems to facilitate the potential for a larger 
proportion of the elderly long-term care population to receive 
services in their own homes or apartments. In addition, the 
expansion of universal design features in building, 
construction, and modifications will help to create home 
environments that adapt to the needs of individuals as they age 
and become more disabled.
    Now, many individuals will be living in NORCs, naturally 
occurring retirement communities. They can be vertical or they 
can be horizontal, across streets, blocks, or neighborhoods of 
single family homes. Regardless of this configuration, 
community members will take advantage of the economies of scale 
and joint purchasing power afforded by living in NORCs to 
organize packages of social, wellness, health, and long-term 
care services that are available in the community.
    Now, prior to the passage of Medicare and Medicaid, one-
third of the elderly lived in poverty. During the following 
three decades, that percentage decreased precipitously. At the 
same time, the gap between the haves and the have nots within 
the older adult group has actually expanded, particularly for 
non-white elderly. And the latest recession, which 
disproportionately affected current and soon-to-be retirees, 
raises serious questions about how future cohorts of older 
adults, facing long-term care decisions, will be able to pay 
for services. Ironically, those who are currently at either 
financial extreme are more likely than modest and middle-income 
elderly individuals to have access to service options. Low-
income elderly at least can qualify for Medicaid. They may also 
have access to publicly subsidized housing and community-based 
care. They may also qualify for publicly subsidized programs 
that will assist them to live in the community.
    Financially secure elderly individuals have the resources 
to pay privately for home care, and when that is no longer 
viable, to move into an assisted living facility. Individuals 
who want the security of a continuum of services may sell their 
homes and move into a continuing care retirement community, or 
they may create their own village, a grassroots membership-
based nonprofit organization that provides support and 
community to residents who wish to remain in their own homes or 
in apartments.
    For the vast majority of the elderly and their families, 
however, affordability of long-term care service options is, 
and will remain, the ultimate concern. What we need to do, and 
one of the most thorny issues that must be addressed if 
affordable residential options are to be available in the 
future is we have got to figure out how to cover housing costs 
for individuals who can no longer remain in their own homes or 
rental apartments due to financial and/or health reasons. 
Currently, low- and modest-income, older adults who have spent 
down their assets and income to qualify for Medicaid will have 
their room and board covered if they enter a nursing home, but 
Medicaid reimbursement rates for other residential settings, 
such as assisted living or adult foster care, are generally not 
sufficient to cover the costs of room and board. And for those 
who do not qualify for Medicaid, there are no financial 
mechanisms.
    Recognizing that Medicaid assisted living has not provided 
an affordable option, a number of States, including Vermont and 
Oregon, have brought together staff from Medicaid and State 
housing agencies to explore how they can more efficiently 
package their service and congregate housing dollars to better 
serve their dual eligible populations. At the national level, 
HUD and DHHS are finally exploring ways to better integrate 
low-income senior housing and services. These efforts reflect a 
growing recognition that affordable shelter and services are 
both essential to the development of a viable community-based 
system for moderate- and low-income older adults, groups that 
are largely likely to represent a large proportion of future 
cohorts of America's elderly population.
    The nexus between housing and services, therefore, is, is a 
perfect place for the committee to focus its attention as we 
move into the future. Thank you very much for allowing me to 
speak to you today.
    [Applause.]
    Ms. Whitman. And batting clean up to talk about income 
issues, we have Dr. Henry Aaron.

 STATEMENT OF HENRY AARON, BRUCE AND VIRGINIA MACLAURY SENIOR 
               FELLOW, THE BROOKINGS INSTITUTION

    Dr. Aaron. Mr. Chairman, thank you very much for the honor 
and pleasure of being able to participate in this event. I have 
to comment that as a person whose last name begins with two 
A's, I am not accustomed to speaking last----[Laughter.]
    Dr. Aaron [continuing]. But I am sure it will be good for 
my character.
    I want to take an even broader look at the history of what 
it means to grow old in the United States than was the charge 
given to us, to look at the last five decades. I am going to 
look at four cohorts, starting with the Americans born in 1860 
and moving forward through 1890, 1930, and 1960.
    If we go back and look at that oldest age cohort, we will 
discover that the process of growing old was radically 
different from what it is today. Three-quarters of the men who 
were born in 1860, and who still managed to be alive at age 65, 
had to continue to work until they died, became disabled, or 
were put out of work by economic calamity. Precisely such a 
calamity did occur--the Great Depression--when the 1860 cohort 
was 69 years old.
    By 1932, a quarter of the workforce was unemployed. The 
elderly were more likely than the young to lose their jobs and 
less likely to find new ones. Protracted unemployment, bank 
failures, plunging stock prices, and collapsing real estate 
values destroyed the savings of those in the middle and working 
classes who had scrimped and saved for retirement. That has a 
distressingly contemporary feel to it, actually.
    Private charities were overwhelmed. Public charities dried 
up as State and local governments ran out of money as revenues 
plummeted.
    The first social security check was not paid until those in 
the 1860 cohort had reached age 80, and few were eligible for 
benefits. For the one-third of the 1860 cohort, only one-third, 
who survived to their 69th birthday when the Depression hit, 
the final years were actually pretty grim.
    For those who were born in 1890, at the end of the 19th 
century, the cohort benefitted from steady, if unspectacular, 
growth in incomes. The improvements in health and education 
were substantial, but even so, more than a third of those who 
reached age 20, of women, were dead by the time they reached 
their 65th birthday, and 40 percent of men who reached age 20 
were dead by the time they reached age 65.
    This cohort reached age 65 in the mid-1950s. At that time, 
fewer than half of them had health insurance. Coverage was 
often uncertain because insurers could and did raise premiums 
sharply or refused to renew coverage for those whose health had 
begun to deteriorate.
    Congress had passed the Social Security Act in 1935, 
subsequently increased benefits, and extended coverage in 1939, 
and again in 1950. Because of those liberalizations, members of 
this cohort born in 1890 received benefits that were greater 
than the earmarked taxes that they and their employers had 
paid, but the benefits were not very large. Only about a third 
of taxable earnings was the benefit level until age 50.
    Moving ahead yet again to those born in 1930, there were 
2.6 million births in that year. That cohort enjoyed advantages 
that had been unavailable in previous generations. The 
educational achievements were striking, but the economic 
advances were absolutely breathtaking. Between the end of World 
War II and the mid-1970s, output per person more than doubled. 
At the start of their working lives, members of the 1930s 
cohort earned hourly wages three times higher than those that 
had been earned by those born in the 1890 cohort had earned in 
their first jobs. And by the time the 1930 cohort retired or 
turned age 65, average earnings in the Nation had risen by an 
additional third.
    As they approached retirement age in the mid-1990s, members 
of this cohort had options and resources that few of their 
parents had enjoyed. Most had assets that provided substantial 
financial security, including social security. They also had 
better protection against medical costs than ever before. 
Medicare had been enacted in 1965 and provided basic health 
insurance coverage for the elderly and for the disabled, and 
eight out of 10 of those covered by Medicare also had 
supplementary coverage on top of that.
    Now, whatever the future may hold for people born back in 
those years, the circumstances represented a revolutionary 
improvement over the experiences of their predecessors.
    The cohort born in 1960 was still better educated than any 
of their predecessors. As a striking fact, nearly 90 percent 
graduated from high school, and the fraction of the people who 
were born in that year who got education beyond college was as 
high as the proportion who had graduated from high school a 
century earlier. Furthermore, people born in 1960 told 
pollsters that they hoped to retire earlier than had their 
predecessors. To a significant extent, however, they discovered 
they were not able to do so, and continued to work a bit longer 
than people had previously.
    My time is nearing its end, but I do want to say a few 
words about the prospects for the future, which seem to be a 
bit more troubling.
    The past record of more or less continued growth in income, 
and improvement in educational performance and, as we have 
heard, health results, are now in jeopardy. Average earnings of 
men have fallen for about four decades. High school completion 
rates nationally are falling. Male college attendance rates and 
completion rates are falling. The one encouraging bright spot 
is the continued increase in female college attendance and 
completion rates.
    But for a variety of reasons, I think private calculations 
and shifts in public policy, workers are likely to continue to 
work to older ages in the future than they have done in the 
past. This is a good trend for reasons that Jack Rowe indicated 
in his remarks. It simultaneously provides resources to those 
affected, and lightens the burden of support for the rest of 
the population.
    I also want to endorse in my last comment something that 
Jack said in his. As I look around the room, I think I see far 
more people under the age of 40 than over the age of 60. And I 
consider that a very good sign for our prospects of avoiding 
the kind of intergenerational fratricide that he so correctly 
deplored in his concluding remarks.
    Thank you.
    [Applause.]
    Ms. Whitman. So, we have had an incredible panel of 
speakers. I am going to take the opportunity to ask some 
questions before our last speaker. And we are going to have 
Laura Carstensen later wrap some things up.
    But I thought I would take the opportunity to pick your 
brains on some of the projections of the future, and the 
pathways in which we as a committee can grow as well. 
Specifically, several of you talked about the opportunities to 
transform our approach on health from one based on disease 
treatment to one based on prevention. I think Secretary 
Greenlee, Michael Harsh, and several others talked about this 
as being the future of health care, and having such a 
significant potential to improve both the health and the 
longevity of older Americans.
    But what practical steps do we need to do to make that 
shift toward prevention, and what are the things that we can 
put in place now that will pay off in the future? Question for 
anyone who wants to answer, but first Secretary Greenlee.
    Ms. Greenlee. Well, you will be pleased to know that Dr. 
Hodes and I have met. I went over to talk to him fairly soon 
after starting this job because I believe that what we need to 
be focused on quite a lot is research, both research based from 
universities, and research based at the NIA that we can 
translate into our network. What the Aging Network is really 
called to do at this point that is different is gather a 
different kind of outcome data that we need to continue to 
focus on, building the case and showing the evidence and the 
outcomes for both health and medical savings, cost savings. 
That is the piece that is new.
    If you think about the Older Americans Act nutrition 
program, which is 40 percent of our funding, we can demonstrate 
how many millions of meals we serve. We believe that that is a 
valuable output that we should be measuring. But we must add to 
that outcome a measurement of the long-term impact on health 
and the avoidance of other more chronic health conditions or 
acute episodes. With that research we will be able to continue 
to engage with policymakers.
    Ms. Whitman. Yes.
    Dr. Rowe. I think we need to move beyond the view that the 
critical period for intervention and prevention is youth. There 
is an implicit feeling that people have that, if you are trying 
to prevent something in old age, well the horse is out of the 
barn, and older individuals, do not respond to change, et 
cetera. And with the exception of maybe flu shots, prevention 
just is not something that has to do with geriatric care.
    My favorite example is the diabetes prevention program, 
which showed, as many of you probably know, that a fairly 
intensive lifestyle intervention, reduced the onset of diabetes 
in a high-risk population by 58 percent. People of all ages who 
were included--young adults, middle aged, and older persons. It 
turns out that the age group that had the greatest positive 
effect from the intervention were the older persons. A very, 
very significant finding.
    So, I think as we develop policies, as we fund programs in 
Medicare and Medicaid, as we educate health care providers, 
whether they are nurses or physicians, we need to change the 
set of information and beliefs that they have about prevention 
throughout the life course. That would be, I think, a very 
significant advance.
    Ms. Whitman. Dr. Hodes, Mr. Harsh.
    Mr. Harsh. Yeah. I guess one thing I would like to say is, 
you know, we have got research going on right on different 
aging studies, one with Mayo Clinic, where we are looking at 
essentially, you know, we call it bio signature, but there are 
a lot of signatures that you can pick off by looking at the 
combination of many different tests, very simple screening 
tests, before you wind up with a very expensive scan, before 
the symptoms really present themselves in a way that will find 
people kind of fumbling through the health care system, which, 
you know, really costs a lot of money and does not help. And 
there are ways that we can pull this information out much 
sooner so that we can actually look at bringing that care up 
much quicker, and really driving, you know, costs out of the 
health care, and increasing quality of life.
    So, again, when I look at some of the big challenges I see 
right now where we are headed is things around just 
computational biology and being able to really get after how do 
I compare apples and oranges? You know, what are the signatures 
that I want to look at when I look at the genomics, all the 
omics levels? These are the things where I see where the 
research is going where we can start to pull this diagnosis 
farther upstream.
    Dr. Hodes. I think that I would enjoy commenting to the 
topics that Mike and Jack have mentioned. Just to elaborate on 
it is this, 71 percent decrease in incident cases of diabetes 
in the group 60 and older with a very reasonable lifestyle 
intervention.
    In terms of how to now translate that, this is one of the 
categories where we know something works. How do we make it 
happen? An example, I think, within the Federal purview, at 
least, that is promising, are the conversations we have had 
between CMS and at NIH. So, Don Berwick, Francis Collins, and a 
group from each of our agencies, converging to look at cases in 
which perhaps at least innovative thought about how appropriate 
incentives and even compensation for effective prevention can 
occur.
    So many of you will know that after this laboratory setting 
intervention, which prevented diabetes onset, there have been 
continuations of those, now looking at setting, such as the 
YMCA, so the diabetes prevention study in the Y to see whether 
it will be effective in such a setting, looking for practical 
ways to make this happen. So, this is the kind of collaboration 
across agencies and ultimately with public forces that can be 
enormously productive in terms of government and other private 
sectors.
    I would just note another partnership that has been 
particularly gratifying over these past years has been ADNI, 
the Alzheimer's Disease Neuroimaging Initiative. It is designed 
to look at, as I mentioned briefly in passing, early changes by 
neuro-imaging, by other molecular signatures, that precede 
clinical disease, the notion being that if one can find those 
early changes, one has a better opportunity to intervene early 
and prevent them, and you can also track the success or failure 
of interventions.
    Government, imaging companies, bio tech, pharma,have all 
been collaborators in this very important initiative with the 
FDA and NIH and a number of private and public sector 
philanthropies as well, an enormous partnership because it 
reflects the fact that there is common conviction that in those 
so-called pre-competitive spaces, we can look for opportunities 
that will profit nobody preferentially in the short term, will 
profit everyone in the long term, aimed at prevention to echo 
that.
    But the partnerships are there, and I think the room for 
optimism is in the fact that they are recognized and reflected 
in partnerships across this breadth of agencies, national and, 
in fact, international.
    Ms. Whitman. Thank you.
    John.
    Mr. Rother. Just a quick comment, that we typically think 
of prevention in individual terms. I think the new frontier is 
going to be the social aspects of prevention, whether it is in 
the food supply, the environment, or even the level of stress 
in our societies. And I think that is going to raise some very 
tough questions about how we go about keeping people healthy 
when it is going to require magnitude order of changes 
throughout the economy and our culture.
    Ms. Whitman. Good point. The reaction to large and growing 
budget deficits lately has been to look for ways to cut 
spending on a wide range of programs, benefits, and services. 
However, we are now facing increasing demands on these 
programs, both due to the economic downturn and the aging in 
the population. How will an era of prolonged fiscal restraint 
impact the futures each of you have predicted? And when is 
spending today truly an investment in the future? And I am 
opening that up to anyone who wants to answer it. As you know, 
we have all got a lot of scissors out here on Capitol Hill, and 
we are cutting as ruthlessly as we can. What things do we need 
to protect? What things are the most valuable?
    Mr. Harsh. I can just start from a technology standpoint 
and instrumentation standpoint what our focus has been because 
would say, although it was there to some extent, you know, I 
was around when imaging just exploded. And it was, like, if you 
could image faster, see more, get greater coverage, more 
resolution, wow, that was great. When I look at it today, you 
know, we do not start a program unless we fully know up front 
what it is going to do in terms of increasing the access of 
that technology for health care, what it is going to do for the 
total cost, and is it going to deliver better quality of 
outcomes and quality to the patient? So, everything we do today 
has completely changed our head around making sure that we 
fully manage quality access and costs in every one of our 
development programs that we start on.
    Dr. Hudson. There is no magic answer to this, but I think 
it is important to keep in mind as one sector or the other 
worries about cutting costs, and all sectors worry about 
cutting costs. It could be the public sector. It could be the 
private sector. It could be the formal care giving sector. It 
could be the informal family sector. But costs are shifted; 
they are not eliminated. And public policy people need to keep 
that in mind, particularly in the area of aging and long-term 
care, that formal services that are not available and 
traditional kinds of things that Robyn has been talking about 
are going to fall to the informal sector.
    And that dissertation we had last year at the National 
Academy of Social Insurance investigated why 37 million 
caregivers have no real political presence, and they really 
cannot afford a lot more burden. So, I hope public policymakers 
keep that in mind as they try to escape the immediate dollar 
figures they are concerned with.
    Ms. Whitman. Robyn.
    Dr. Stone. Yeah, I guess I think there are some ways to 
think about some making lemonade out of lemons in times of 
fiscal constraints. And one of the things that really moved me 
to look at affordable senior housing and linkages with services 
is the potential for the economies of scale of large numbers of 
folks living together where you have the potential to actually 
redistribute dollars as opposed to needing new dollars.
    And I say this with the caveat that this could pie in the 
sky if it is not operationalized well, and that is to say that 
I think there are a lot of efficiencies and economies to be 
gotten out of our current system, and that is really dependent 
on how those decisions are made, who gets the resources, and 
how they are used.
    And one of the things that you can do that other committees 
really cannot, because you are not wedded to the jurisdiction 
of a particular committee, is to look across jurisdictional 
issues. So, for example, you can look at services and housing, 
and think about how you redeploy resources in a different way 
that is going to be a win/win. And if we find, for example, 
that you are able to serve large groups of seniors living in 
properties that through prevention, service integration, and 
self-care management, and some of those savings can be accrued, 
they need to then be brought back and put into the housing 
site.
    So, I think there needs to be a lot more experimentation 
around how we use current dollars because I think there is a 
lot of room for that in this system. Going forward is a 
different question, but going across jurisdictional lines, 
which is so hard in Congress, at least you have the potential 
to be able to do that, to look at these various pots of dollars 
that could be used in a different way, which is very, very 
difficult for agencies to do in the executive branch. I know 
because I have been there. And I think you can at least raise 
the question of how these dollars could be used differently.
    Ms. Whitman. Thank you.
    Henry Aaron.
    Dr. Aaron. If there is one basic principle or law in 
economics, it is when the price goes up, you tend to buy less 
of it. As we live longer, the price of social insurance in 
general goes up, and, therefore, there are very strong 
pressures to buy less of it.
    Now, the point here, I think, is that, and I am going to 
state what I think is a solution, but not how you get there. 
And that, it seems to me, is the core problem. The solution is 
for people to be able, for a larger share of their lives, to be 
able to support themselves, which mean working longer, if they 
are able to do so. This is an extremely controversial area. And 
finding ways to create incentives so that people choose to do 
so, and businesses choose to employ them, it seems to me is the 
key.
    I say that because by any reasonable metric, current levels 
of benefits in the United States are, if anything, 
parsimonious. They are low compared to what past levels of 
benefits have been, and compared to those available in other 
countries. So, the challenge is, I believe, to sustain benefit 
levels within a system in which people have incentives and 
abilities to continue working until later ages.
    Ms. Whitman. I am going to move forward to our last 
panelist because I want to save a little bit of time at the end 
for audience questions. I have several of my own that I will 
throw in if nobody else takes the microphone.
    To close our forum, I have asked the wonderful Dr. Laura 
Carstensen to not only share her reflections on the last 
panel's presentations, but also to take an even broader view 
and discuss how the culture of aging is transforming our 
society.
    Laura Carstensen currently is a professor and the Farleigh 
Dickson, Jr., professor of public policy at Stanford 
University. She is also the founding director of the Stanford 
Center on Longevity, which explores innovative ways to solve 
the problems of people over 50, and improve the well-being of 
people of all ages.
    Thank you so much, Laura.

STATEMENT OF LAURA CARSTENSEN, PROFESSOR OF PSYCHOLOGY AND THE 
  FAIRLEIGH S. DICKINSON, JR., PROFESSOR IN PUBLIC POLICY AT 
                      STANFORD UNIVERSITY

    Dr. Carstensen. Thank you, Deb. It is a great privilege to 
be here with my distinguished colleagues today. Thank you very 
much for including me.
    The changes that we are living through today at this point 
in human history represent a remarkable cultural achievement. 
Rob Hudson and John Rother spoke about the history of the 
Senate Special Committee on Aging, and the role that that has 
played in culture and improving the welfare of aging 
individuals. And then, Henry Aaron brought it back even further 
in history to the 1800s, and made the point very eloquently 
that how you age really depends on the year you were born. So, 
history is important.
    And it may be useful for me to just zoom out even farther 
and talk about just how remarkable and quickly this change, 
again, that we are experiencing today came about.
    More years were added to average life expectancy in the 
20th century than all years added across all prior millennia of 
human evolution combined. In historical terms, in a blink of an 
eye, we nearly doubled the length of the lives that we are 
living.
    Now, during most of human evolution, life was short. It 
hovered somewhere around 18 or 19. We do not know for sure, but 
lots of people did not survive. And this length of life was 
really just barely long enough to ensure survival of the 
species. I mean, in humans you have to grow old enough to be 
able to reproduce, and then hang around long enough to make 
sure your offspring can grow old enough to reproduce. Touch and 
go.
    Now, evolution did act on aging through natural selection. 
It acted in a way that evolution acts at a snail-like pace. And 
life expectancy inched up and inched up and inched up over 
hundreds and thousands of years.
    By 1800 in this country, life expectancy was somewhere in 
the mid-30s. By 1900, it was 47. And less than a century later, 
life expectancy was 77. Today, it is 78. And this increase is 
not finished with us yet. In recent years, a month or so has 
been added to average life expectancy at 65 every year.
    Now, across that very same period that life expectancy was 
going up so dramatically, fertility rates were falling and fell 
by half; in some parts of the world, even more. And it was 
these two phenomena together that created aging societies. If 
life expectancy had gone up, but fertility had remained high, 
we would not have aging societies; we would have more long-
lived people. But those two forces together created and 
restructured the distribution of age in the population.
    In the United States, which reflects trends found in most 
developed countries, the proportion of older people in the 
population went from 4 percent in 1900 to 13 percent today, and 
it will increase to about 20 percent by 2030. Now, of course, 
in other parts of the world, in Japan and much of Europe, this 
proportional change is even greater. In Germany, already 16 
percent of the population is over 65. In Japan, it is 20 
percent now, and will go to 28 percent by 2030. We are young 
kids on the block compared to most developed nations.
    Now, keep in mind as we talk about these numbers and we 
talk about this increase in life expectancy that the innate 
capacity to live longer has not changed. We are no genetically 
heartier than our ancestors were 10,000 years ago. What has 
changed are the odds of making it to old age. And they have 
changed so much that that pyramid that has represented the 
distribution of age in the population with many, many at the 
bottom winnowed to a tiny peak at the top, those who survived 
to very old age, is being reshaped into a rectangle.
    The story of how we somehow launched ourselves into this 
era of very long life does not actually begin with a story 
about old people at all; it begins with a story about babies. 
The kind of increase that we saw in life expectancy in the 20th 
century, the average length of life came about largely because 
fewer of the young ones dies. In 1900, 25 percent of babies 
born in the United States died before they reached five, and 
many more of them died before they reached 12. And of the 
survivors, a large percentage were orphaned before they reached 
18. Death was common at all ages, but it was especially common 
in the very early lives. Life expectancy increased so much 
because we saved the lives of the youngest among us.
    So, how did we do that? Well, the short answer is science 
and technology. The remarkable increase in life expectancy is 
really a product of culture, the crucible that holds science 
and technology and large-scale efforts to change behavior, to 
change the way we live, so that we improve the health and well-
being of entire populations.
    Our ancestors in the 20th century discovered the causes of 
diseases and the ways that they spread. They instituted grand 
public health programs that vaccinated people against diseases 
that they would never have to suffer. They did not stop there. 
They pasteurized milk, they purified the water ways. They 
implemented the systematic disposal of waste, and historians 
today write that you can thank your garbage collectors as much 
as your physicians for this increase in life expectancy because 
that reduced the spread of disease.
    But we did not stop there, or, I should say, they did not 
stop there. As fertility rates fell, we came to invest 
increasingly in the youngest among us. Laws were passed that 
kept children out of factories and mines. Public education 
became available in every State in this Nation. We came to 
understand the nutritional needs of young children through 
science, but then through culture we developed food 
fortification programs in the United States and Europe that 
built vitamins into the food supply, and virtually eliminated 
rickets and other nutritional disorders in just 20 years. In 
other words, we built a world that is exquisitely designed to 
support young life.
    So, here we are at a point in history where four, five, and 
conceivably six generations may be alive at the same time. This 
is a game changer in human history, a dramatic change. By 2015, 
as you heard, there will be more Americans over the age of 60 
than under 15, and by 2030, all nations around the world, all 
developed nations, let me say, will be old nations.
    Now, the fact that most children born in the developed 
world today are having the opportunity to live out their full 
lives, having the opportunity to grow old is a fantastic 
cultural achievement. But the dramatic increase in the numbers 
of people who are making it into their 60s and 70s and 80s and 
90s is generating a profound mismatch between the cultural 
norms that guide us through life and the length of our lives. 
And we humans are creatures of culture. We look to culture to 
tell us when to get an education, when to marry, when to start 
families, when to work, when to retire. And life expectancy 
increased so quickly that we are immersed in cultures designed 
around lives half as long.
    So, when we think about older society, it is no wonder that 
mostly there is concern. You know, we see a crisis on the 
horizon. We fear that aging societies are going to break the 
bank, force young people to bear undue burdens, and eventually 
force societies to make stark choices between whether to 
provide services and resources for our children or our parents 
and our aging selves.
    I do not have to tell folks in this room that Medicare is 
in real financial trouble, and there are real vulnerabilities 
associated with age. As you heard from Robyn Stone and 
Secretary Greenlee, older populations mean populations with 
more chronic diseases and more people who require better care, 
better prevention, those people who are the very most 
vulnerable among us.
    And societies today are enormously ill prepared for 
populations of older people, older people especially with 
chronic diseases. And if nothing changes, societies will be top 
heavy with frail, and dependent, and disengaged people with 
relatively few people to support them. And if that is the 
future of our Nation, then we will endure many hardships.
    But as you have heard from so many of my colleagues this 
afternoon, that future is not an inevitability. In fact, when 
you think about how quickly we doubled life expectancy, it is 
amazing that older people are doing as well as they are. I 
mean, today the physical and the social environments that we 
live in were quite literally built by and for young people. The 
tacit uses are staircasers of automobiles, of parks, of 
telephones, of highways, of train stations, of housing, 
workplaces. These were all built around young populations, so 
we expect workers to be agile and fast. Medical science, a key 
part of culture, has focused more on cures for acute diseases 
than on prevention of chronic diseases. And many societal roles 
were also designed when life expectancy was 47. And so, they 
were designed without the knowledge of the unique capabilities 
that older people, older citizens, may bring to this country.
    So, even though agism is often invoked, and, to some 
degree, has to play a role in this, we live in a world that 
only recently came to have large numbers of older people. Now, 
even so, research has shown us in recent years that the aging 
process is not best characterized by a sweeping downward 
trajectory. There are many aspects of functioning that actually 
improve with age; knowledge, expertise, emotional stability go 
up. And we have also observed already at this point in human 
history that among the affluent and the well-educated, we are 
seeing people flourish into very advanced ages. People who 
exercise, who live particular lifestyles, fare better in old 
age than people who do not. So, we see lots and lots of 
variability, and to scientists, variability speaks against 
inevitability. Variability in aging means that it is not aging 
per se that is the culprit, but rather something about the way 
that we are aging.
    It is time now for a profound change to culture. We have 
never needed to invest in science and technology more than we 
need to invest today. And the really good news, as you heard 
from Richard Hodes and from Michael Harsh, is that the 
potentials of science and technology are truly breathtaking. We 
need to rise to the challenges of aging populations. We need to 
find cures for diseases like Alzheimer's disease and arthritis. 
We need to find ways to make technology available to help 
people monitor their own quality of life and their own health 
state, and to allow people, even those with significant chronic 
diseases, to live independently.
    If we invest in improving the lives of people 50 and older 
as much as our ancestors did 100 years ago to improving the 
lives of the youngest among us, then older societies can be 
better societies than we have ever known. In order to do so, we 
will need to do, as Jack Rowe argues so forcefully, shift our 
unis of analysis from only focusing on the elderly to focusing 
on society. Aging societies will fail or succeed largely based 
on the new meanings that we ascribe to both healthy and 
unhealthy lives.
    As John Rother said this afternoon, we need to consider and 
really dwell on the possibilities for major lifelong social 
investments, ones as large as the concept of public education a 
century ago. And if we do, then we can transform societies in 
ways that will make aging societies better societies. And to 
fail to do so would represent a real tragic squandering of this 
truly remarkable gift of life.
    Thank you.
    [Applause.]
    Ms. Whitman. We chose to end with Laura because her 
predictions of a long, bright future ahead, and the challenges 
we face in a positive way, are really the lens at which I think 
the committee views our future.
    I have appreciated all of the speakers today. You have 
given me a long agenda of items that the committee needs to 
address in our last year of Chairman Kohl's leadership, and 
also into the future.
    I am going to take the option of not keeping you here for 
questions because many people are headed over to the 
Gerontological Society of America's reception that is being 
held in 325 Russell, and you will probably be able to ask 
questions of the individuals, if the audience does not mind, at 
that opportunity.
    But, again, I thank you all, especially the audience 
members, former staffers whose shoes that we all hope to fill 
every day and aspire to contribute to the way that they have in 
the past. I thank you all to my speakers today; each and every 
one of you was terrific. And I thank you to the vision of the 
future that we are all hoping to create.
    So, thank you very much.
    [Applause.]
    [Whereupon, at 4:45 p.m., the hearing was adjourned.]
                                APPENDIX
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