Population aging is increasing faster than ever before in many high-income and mid-income countries. Despite the relative wealth of these countries, they still might not be ready for this silver tsunami. The well-documented consequences of an aging population—including labor shortages, huge needs in elderly care, as well as predictable long-term financial expenditure in healthcare and pensions—ultimately require policy makers to make structural changes to put the aging society on firmer footing. While policy responses have been advanced to improve system resilience in many advanced economies for decades, technological and social innovations are particularly fabricated into current policy discourse. With the consensus that population aging touches on all aspects of the society, countries vary in their policy priorities and strategies; having a sustainable policy structure to support the aging populations nonetheless inextricably link to each country’s unique context and policymaking tradition.
In the United States, the nation’s decision makers have been confronting an enormous range of specific challenges for the aging society. Attempts or proposals to reform the country’s Social Security to assure its solvency date back to the late 1990s. These proposals include a major initiative during the Bush Administration of partially privatizing the old-age pension program in 2005, the creation of a long-term care social insurance program in 2010, and an increase in payroll taxes introduced in 2015, but these efforts have yet to produce meaningful outcomes. Notably, however, innovative changes have been made successfully in the healthcare system. The American healthcare system for older adults—Medicare, Medicaid and private insurances—has predominately used the fee-for-service payment system to reimburse service providers based on the service volume and cost, as well as long-term services and support for people with chronic illnesses and disabling conditions who historically rely on institutional care. Given the large portion of the elderly with chronic illnesses and unmet health and social needs, policy responses have been adopted aiming to reform the country’s fragmented healthcare structure and to facilitate the integration of care to better meet older adults’ needs. The essential component of such policy reforms is to establish a coordinating mechanism responsible for managing collaborations across services, along with payment and financing methods, thus transforming the traditional funding mechanism for how individuals and society pay for health services and elderly care. These reforms also reflect a changed view of care institutions, moving more services out of institutional settings and into the communities where people age.
At the federal level, the Patient Protection and Affordable Care Act (ACA) of 2010 laid the foundation for integrated service delivery models. The ACA established the Medicare Shared Savings Program for accountable care institutions to provide older Americans with coordinated care and chronic disease management. In addition, the ACA encouraged the establishment of the Community-based Collaborative Care Network Program to support healthcare-provider consortiums to coordinate and integrate healthcare services. Since the passage of the ACA, states are able to utilize Medicaid waivers to include a broad range of community-based preventive healthcare, long-term care, and home care services. One significant change is the Home and Community-Based Services, a Medicaid state option formalized in 2015 in order to support independent living and cost-saving, which allows Medicaid beneficiaries to receive continuous and holistic health and social services in their own home or community rather than traditional elderly care institutions. States have been going through this exercise, transitioning the funding mechanisms from institutional care to home and community care; as of the writing of this article, twenty-one states’ transition plans have gained final approval from the federal government. It is noted that digital health plays an increasingly important role to facilitate quality and integrated care and services in the United States. Additional government funding is made available for innovations using health information technology to coordinate care across sectors and improve co-management of chronic diseases, such as clinical decision support (CDS), health information exchanges (HIE), patient-centered applications, and telehealth applications.
In China, the rapid aging process has introduced socioeconomic pressures over labor supply, social security funds, and elderly care; the top-level design of policies for the aging society started in 2013, aiming to be proactive in coping with and being prepared for the aging population. Since 2013, a series of polices and policy changes have been adopted, including the “State Council’s Opinions to Accelerate Old Age Service Industry” in 2013 for the development of old-age service industry based on family, supplemented by community, and supported by institutions; the abolition of the one-child policy and its replacement with a universal two-child policy in 2016; and the government announcement in 2021 that mandatory retirement ages are to be gradually increased despite fueling public discontent. Similar to the United States, a significant innovative practice in China occurred in the field of health and elderly care. The strategy to integrate elderly care and medical services was included in the 2013 national policy. However, progress has been rather slow during initial years, largely owing to a lack of resources and poor structural arrangements. Traditionally, healthcare and elderly care were separate systems and subject to two different sets of administration and regulation in China; the idea of integration itself faced structural barriers. Also, funding for the integrated services was inadequate at best and unavailable at worst. China’s health insurance schemes at the time offered different coverage for senior citizens’ medical services, but rarely covered the services associated with long-term care and medical services offered in nursing homes or other elderly care institutions.
Since 2013, over a dozen policies were issued by various central government agencies to encourage offering medical health services at elderly care institutions, streamline the registration for integrated care service providers, establish community health clinics with enhanced capacity for long-term care, promote the shared use of health information and data, and expedite the incorporation of technology and telehealth. Since 2016, a number of local governments have embarked on long-term care financing reforms, providing funding for eligible older adults to improve equitable access and reduce the financial burden experienced by older Chinese citizens and their families. In 2019, the central government issued the National Mid- and Long-Term Plan to Actively Respond to Population Aging, which lays out five national strategies including a particular section about promoting innovation and technological development in social service delivery to assist elderly care and digital healthcare.
The idea of integrating healthcare with elderly care services is neither an American nor a Chinese innovation; many countries and the World Health Organization view this framework as a viable solution to the growing needs of the health and care for aging societies. The embedded values of integrated care, such as ‘collaborative’, ‘coordinated’, ‘transparent’, ‘empowering’, ‘comprehensive’, ‘co-produced’ and ‘shared responsibility and accountability’, underscore the belief that this integrated framework possesses the potential to support senior populations and improve their overall wellbeing. At the same time, it is socially and economically cost efficient. In the United States, integrated healthcare policies reflect a changed policy orientation, moving away from a system designed to cure specific diseases towards one that rewards volume of services; the new policies give priority to cost savings and care quality, but nonetheless through the transformation of traditional funding mechanisms. In China, healthcare integration policies are made at the top and are rather comprehensive, aiming to decentralize healthcare service delivery, attract private investment in elderly care, and promote collaborations across public hospitals, private elderly care institutions, and community social care agencies. It is noted that policy reforms in both the United States and China have no intention to progressively socialize healthcare and elderly care programs or substantially increase the public transfers to seniors; public support for older adults in both countries has been and is still moderate compared to many European welfare states.
To effectively respond to older adults’ intensive medical, social, and behavioral needs, an integrated health and elderly care system by all means is built upon and depends on data sciences and technological innovations. Current digital health capabilities demonstrate the potential to accelerate the implementation of integrated care, and robotics and big data are increasingly used in communities and at home to support health management and elderly care. For instance, smart homes with built-in remote monitoring systems and electronic transmission of seniors’ physiological data as well as recently designed and built digitalized community senior centers allow big data analytics for personalized care, enhancing the capacity to integrate disease management and care coordination. While many digital health and elderly care tools have gone beyond the prototype stage, in order to make them widely available and user-friendly in order to provide robust support to the care processes, the gap between the understanding and the uptake of all these technologies should be fully noted. Rural-urban and interregional disparities in accessing digital healthcare and technology are well documented in both the United States and China. Thus, it is necessary to aggregate evidence on what works to address policy and structural barriers. Technological innovations change the outlook for aging societies profoundly. It is essential to build a collective vision to reorient social and economic policies for a healthy and productive global aging society.
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Dr. Qingwen Xu is a Professor at NYU Silver School of Social Work and MSW program coordinator in NYU Shanghai. Dr. Xu’s research is situated at the interaction of globalization, community care, and wellbeing of vulnerable groups.
Yuanyuan Hu is a doctoral student at NYU Silver School of Social Work. She is also a mental health clinician primarily working with minority older adults in New York City. Her area of interest is geriatric mental health.