Individual & Social Strategies to Mitigate - Ricerca sull'intelligenza artificiale specializzata al MIT

Individual & Social Strategies to Mitigate
the Risks & Expand Opportunities
of an Aging America

Julie M. Zissimopoulos, Dana P. Goldman, S. Jay Olshansky,
John Rother & John W. Rowe

Astratto: Increasing life expectancy offers the potential bene½t of additional years of productivity and
engagement to both individuals and society as a whole. Tuttavia, it also carries substantial risks. For many,
advanced age brings increased disease and disability (including cognitive impairment), ½nancial insecurity,
and social isolation. These risks are greatest for those with the least education and ½nancial resources. An
aging society must cope with increasing demands for high-quality geriatric care, mounting stresses on so –
cial insurance programs (such as Social Security and Medicare in the United States), and the increasing
danger that the growing gap between the haves and have-nots will threaten societal cohesion. These risks
can be mitigated or aggravated by the lifestyle and savings behavior of individuals, families, employers,
and the government. We present policy options in the areas of education, work and retirement, ½nancial
security, health care, and social cohesion that can promote the bene½ts and reduce the risks of longer life.

JULIE M. ZISSIMOPOULOS is an
Assistant Professor at the Sol Price
School of Public Policy at the Uni –
versity of Southern California.
DANA P. GOLDMAN is Professor
of Public Policy, Pharmacy, E
Economics at the University of
Southern California.
S. JAY OLSHANSKY is Professor
of Epidemiology at the School of
Public Health at the University of
Illinois at Chicago.
JOHN ROTHER is President and
ceo of the National Coalition on
Health Care.
JOHN W. ROWE, a Fellow of the
American Academy since 2005, È
Professor at the Columbia Univer –
sity Mailman School of Public
Health.

(*See endnotes for complete contributor
biographies.)

The aging of America presents both opportunities
and risks. The opportunities, which are often ne –
glected,1 relate principally to the availability of large
numbers of generally ½t, experienced older persons
who can make valuable economic and social contri –
butions to society.2 Although increasing attention
is being paid to the risks of an aging society and ways
to protect against them, the United States has yet to
actively adapt to either the risks or the opportunities.
The focus of this essay is to illuminate the changing
nature of both.

For individuals, the risks of a longer life include be –
coming ill or disabled and needing extensive acute
and long-term care. The latter is particularly impor-
tant, as long-term care can deplete the patient’s ½ –
nancial resources, leaving him or her dependent on
public support. Other individual risks include isola –
tion and disengagement: increasing num bers of
older persons are living alone, with fraying connec-

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Mitigating
Risks &
Expanding
Opportu –
nities of an
Aging
America

tions to families. NOI. families themselves
are undergoing major changes in struc-
ture and function that im pede their capac-
ity to serve as a safety net for elderly mem –
bers.

Societal challenges and individual risks
are clearly linked. For instance, society is
ill-prepared to meet the surging demand
for high-quality geriatric care. The short-
falls are not only in funding but in devel-
oping and maintaining a quali½ed health-
care workforce. Likewise, society has been
slow to adapt to the need for “aging friend –
ly” environments that are safe and afford-
able and provide transportation and hous –
ing appropriate for older residents. Come il
United States faces the challenge of cover –
ing the medical expenses of a growing
number of insured aging individuals, some
of the costs are being transferred to
healthier insured populations in the form
of higher out-of-pocket costs. Allo stesso modo,
de lays or reductions in Social Security
retirement bene½ts, imposed to protect
the solvency of the trust fund, place more
pressure on the elderly and their families.
Finalmente, ensuring societal cohesion–en –
couraging an equitable society and lim –
iting disparities and tensions between
groups–is a societal challenge on a grand
scala.

Public and private strategies to mitigate
the individual and societal risks of aging
must consider several fundamental issues.
Primo, longer and healthier lives extend the
length of time that many people can en –
gage productively in society. For others,
Tuttavia, innovations in medical science
designed to prolong life can also prolong
periods of disability, which can limit abil-
ity to work and increase medical expenses.
Among those aged seventy and older, rates
of functional impairment have declined
since the early 1980s, although more
recently the trend has flattened.3 Obesity
may be contributing to declining rates of
physical function, though lower rates of

smoking and greater educational gains
may have bene½cial effects. The decision
to leave the labor force is not solely driven
by poor health but also by the intrinsic ½ –
nancial incentives (or disincentives) In
pub lic and private pension systems. Those
who are able and who choose to work long –
er have more time to accumulate private
savings and maximize public bene½ts.

Secondo, gains in life expectancy have not
been distributed equally across society. Ed –
u cation is closely tied to the “longevity div –
idend”4: life-expectancy disparities by edu –
cation are astonishingly large.5 In 2008,
white males with sixteen or more years of
education lived 14.2 years longer than black
men with less than twelve years of educa-
zione. The same gap for women was 10.3
years. And these disparities between the
ed ucational extremes continue to wid en:
In 1990, the gap in life expectancy be tween
the most and least educated white females
era 1.9 years; In 2014, it was 10.4 years.

Finalmente, the current environment in the
United States is not conducive to disease-
prevention efforts, even though evidence
suggests more proactive risk-factor pre-
vention would yield high returns.6 With
average tenure in health plans sometimes
as low as four years–and with the govern –
ment ½nancing care after age 65–employ –
ers and health plans clearly underinvest in
disease prevention. Così, a much stronger
effort is needed to prevent disease before
it occurs.

Both individuals and institutions share

the responsibility to protect the elderly
against the dual risks of physical frailty and
outliving their resources. Generalmente, how –
ever, the strength of the forces that miti-
gate risk is eroding just as the risks them-
selves are growing.

Social Security bene½ts, pensions, E
private savings are the main economic re –
sources that support living expenses in re –
tirement. This “three-legged stool,” how-

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ever, generally only supports high-income
households,7 with lower-income house-
holds often missing one or more of these
sources of support. Although social pro-
grams such as Social Security and Med i –
care may substitute for private savings, So –
cial Security alone will only provide enough
resources to keep a household marginally
above the poverty line. Così, for many
house holds, savings and private pensions
–possibly augmented by support from
other family members–are necessary to
pro vide for adequate retirement consump –
zione. NOI. savings rates, Tuttavia, have de –
clined during the last thirty years.8 Even
if individuals designate private savings for
retirement, unexpected life events can
have profound effects on economic securi –
ty later in life.9 Job loss, the loss of a spouse
through death or divorce, or ill health can
disrupt savings plans and leave individuals
permanently worse-off, unable to regain
their economic and noneconomic posi-
zioni. The consequences of these shocks
can also affect families and households and
be transmitted intergenerationally when
children have access to limited economic
resources and social support.

Health shocks are often unexpected
and sometimes unavoidable. Tuttavia, In –
dividuals may take actions over their life-
times to delay or avert declining health.
Preventive health behaviors such as main –
taining a healthy diet, exercising regularly,
and avoiding harmful activities such as
smoking can support long-term health.
Changes in lifestyle (smoking, exercise)
and treatment of risk factors (high blood
pressure, high cholesterol) have decreased
the incidence of some diseases of old age,
including stroke and, more recently, heart
attack and some forms of cancer. In addi-
zione, volunteering may offer substantial
health promotion and disease prevention
bene½ts, as discussed by Dawn Carr, Lin da
Fried, and John Rowe in their contribution
to this volume, “Productivity and Engage –

ment in an Aging America: The Role of
Vol unteerism.”10

Although some risky health behaviors
(such as smoking) have declined over time,
others (such as poor diet and minimal
exercise) have increased, leading to rising
obesity rates. Between 1970 E 2000, IL
prevalence of overweight children and ado –
lescents tripled, and obesity in adults dou –
bled, affecting 33 percent of the popula-
tion.11 Evidence is accumulating that sug –
gests that this steady, decades-long increase
may be abating, as the rise in obesity and
overweight rates appears to have flattened
during the past decade.12 However, Questo
may mean that some populations are reach –
ing a saturation point in obesity levels. Re –
search also points to evidence that al –
though being overweight is less dam ag ing
to older persons than to the young, the con –
sequences of the decades-long rise in obe –
sity will be felt for many years to come.13
Individual efforts at self-protection
against health-related problems (and their
attendant ½nancial stresses) are important.
But they are often not enough to mitigate
the risks associated with longevity, E
families and other institutions are need-
ed to protect against ½nancial insecurity
and the consequences of physical frailty.

The American family has long served as

a vital safety net for older persons. Among
older Americans who report needing at
least some help with activities of daily liv –
ing (adls, or simple activities such as feed –
ing, dressing, and grooming oneself ) or in –
strumental activities of daily living (iadls,
or more complex skills such as managing
½nances and transportation), almost one-
half receive help from a family member.14
Caregiving from family members is even
more prevalent and intensive in response
to cognitive diseases such as dementia and
Alzheimer’s disease, which typically strike
at older ages. We have estimated in our past
research that Alzheimer’s disease results in

Julie M.
Zis si mo poulos,
Dana P.
Gold man,
S. Jay Olshansky,
John Rother &
John W. Rowe

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144 (2) Primavera 2015

Mitigating
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Aging
America

almost $30,000 worth of unpaid caregiving annually. If family members were un avail – able to provide this care–which ranges from running errands and accompanying older family members to the doc tor to bath ing, toileting, and administering med – i cations–on an unpaid basis, the addition – al cost would be more than the total Med- icaid spending for these indivi duals.15 Family support is central to ameliorat- ing the risks of aging. As described more fully in the essay by Frank Furstenberg, Caroline Sten Hartnett, Martin Kohli, and Julie Zissimopoulos in their contribu tion to this volume, “The Future of Intergen- erational Relations in Aging Societies,” the primary type of support provided by the younger to the older generation in ad – vanced economies is caregiving.16 Finan- cial assistance is more likely to flow from the older generation to children and grand – children. Current and ongoing changes in the structure and function of the family may disrupt these intergenerational trans – fers of ½nancial and non½nancial resources, thus compromising the family’s collective ability to hedge against risks. Decreases and other changes in marriage and childbearing diminish the likelihood of either children or spouses supplying care to a disabled older adult. Rates of mar – riage have declined and marriage has be – come a less central and stable institution. Childbearing, robust one half-century ago, has slowed. A larger number of couples in which both spouses work has required women and men to develop more com- plex routines of managing work and fam- ily roles. Adding to this burden, greater in – vestment by parents is required today in childrearing and parental support: societal expectations of more higher education, as well as the dif½culties young adults face in entering the workforce, have extended the period of young adults’ dependency on parents. The rise in the number of seniors adds potential capacity to assist younger generations, but at the same time, it cre- ates greater obligations for the support and care of elderly family members when they become frail and incapacitated. In sum, an aging society has clearly cre- ated more risk for the individual just as the buffers against these risks have begun to erode. This makes it all the more im – perative that effective, well-designed pub – lic programs are created to help. Social insurance programs in the United States (both means-tested and not) play an important role in protecting individuals against ½nancial insecurity. The leading so – cial insurance programs are the Social Se – curity retirement program (oasi: the Old- Age and Survivors Insurance Trust Fund), the Social Security Disability Insurance pro gram (di), Unemployment Insurance, Work ers’ Com pensation, and Medicare. So cial in surance programs are intended to insure in divi duals against the risks of un – employment, disability, and old-age ½nan – cial in se curity and inability to work. Essere – cause of their large scale, they have a great – er impact on poverty than means-tested programs such as Tem porary Assistance for Needy Families. The oasi program has the greatest im – pact on poverty among the elderly. Without counting oasi, the poverty rate among old – er Americans was 55 percent in 2004. How – ever, the poverty rate falls to nearly zero with oasi bene½ts. The Disability Insur- ance program reduces rates of poverty among the disabled to nearly zero as well.17 Work by the MacArthur Foundation Re – search Network on an Aging Society ½nds that public expenditures on Amer icans aged sixty-½ve and older are project ed to rise from $1.2 trillion in 2010 A $4.4 trillion
In 2050. Public expenditures on the elderly
and disabled, while extremely ef fective in
ensuring ½nancial security at old er ages,
are not without drawbacks. Some studies
posit that means-tested aid programs dis-

Dædalus, the Journal of the American Academy of Arts & Scienze

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courage saving, although the em pirical evi –
dence on this is mixed.18 The evidence on
the effect of oasi on saving is also mixed.
Social insurance programs do not only
exist to buffer individuals from risk and
assist them when they are in need; they are
also a reflection of society’s values and of
the greater social and political context. Noi
are entering an era in which people are ex –
pected to take increased personal respon-
sibility for their health and ½nancial situ-
ations. This is driven in part by the view
that our social insurance system has be –
come unaffordable (driven largely by our
aging population), which has in turn cost
young people their sense of ½nancial se –
curity. A successful aging society in the
United States will require that each age
group develop a sense of shared sacri½ce
and bene½t. It will also require policies that
promote economic growth and job oppor –
tunities for all ages. Finalmente, it will need a
social insurance system that reflects shift –
ing risks and changes to the traditional buf –
fers against them. In their essay “Resetting
Social Security” in this issue of Dædalus,
S. Jay Olshansky, Dana Goldman, and John
Rowe also discuss in detail possible ap –
proach es to modi½cations in eligibility and
timing of Social Security bene½ts.19

The U.S. government faces the combined
challenge of the future ½nancial shortfall
of the Social Security trust fund and rising
medical expenses of Medicare and Medi-
caid bene½ciaries. The growth in health
care costs has for many years far exceed-
ed the growth of gross domestic product
(gdp). Some good news may be on the ho –
rizon, Tuttavia: since 2010, real per capita
health care spending has grown at an es –
timated annual rate of just 1.3 percent.20
The causes of the slowdown are not yet
fully understood. Health care prices–not
just use–are lower, implying that the slow-
down may be due to something more than
the recent recession. The Affordable Care
Act’s Medicare reforms, which reduce

Med icare payments to private insurers and
medical providers, may also be a contrib –
uting factor. This trend however, may be
temporary and population aging will drive
up costs in the future. Inoltre, the retire –
ment of baby-boomers, combined with
declining fertility rates producing fewer
workers, has dampened economic growth.
Without new sources of government rev-
enue, slower growth reduces the amount
of revenue available for the social insur-
ance programs the elderly have come to
rely on. What role should individuals, fam-
ilies, society, and government play in mit-
igating the risks that old age brings? IL
choices made today and in the future will
rede½ne U.S. society going forward.

The growing momentum of the funda-

mental restructuring of private pensions
in the last two decades–from traditional
de ½ned-bene½t plans to de½ned-contribu –
tion plans such as 401(k) plans–is a critical
factor in the aging of the United States.21
De½ned-bene½t pensions are usually based
on age, ½nal salary, and job tenure; Essi
gen erally provide a monthly income once
the employee is eligible for full bene½ts and
retires. About 60 percent of the pension
wealth of the oldest baby-boomers resides
in de½ned-bene½t pension plans.22 On the
other hand, de½ned-contribution pension
values are not directly tied to age and ten –
ure, and they increase at rates that depend
on market return and whether and to what
extent the employer decides to match con –
tributions. The growing prevalence of de –
½ned- contribution plans will increase
work ers’ opportunities to supplement So –
cial Security income but shifts investment
risk from the business sector to the house –
hold.

The rising number of de½ned-contribu –
tion plans that pay in lump-sum distribu-
tions rather than annuities also places the
responsibility for ½nancial decisions more
squarely in an individual’s hands. This too

Julie M.
Zis si mo poulos,
Dana P.
Gold man,
S. Jay Olshansky,
John Rother &
John W. Rowe

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Mitigating
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applies to the increasingly common prac-
tice of paying lump sums from de½ned-
ben e ½t plans. Older individuals must de –
cide whether to spend the payout imme-
diately or whether to roll it over and save
Esso. If they decide to save it, they must deter –
mine how to invest it and at what rate they
should spend it in retirement in order to
not outlive their savings. Inoltre, IL
greater prevalence of de½ned-contribution
pension plans with more retirement assets
held in stocks have made retirement plans
subject to changes in the stock market, COME
the recent recession has underscored.

The movement from de½ned-bene½t to
de½ned-contribution plans is one example
of how individuals are being asked to man –
age their own ½nances and retirement as –
sets. The shift to a “personal-responsibil-
ity” retirement model will only be success –
ful if ½nancial literacy rises. Financial in –
struments are becoming more complex,
and some individuals may be ill-equipped
to make complex investment decisions.
The fact that many elderly do not choose
the best Medicare Part D (drug bene½t)
plan is just one example of this de½cit.23 Fi –
nancial literacy is highest among the most
educato, but the rate of college com ple –
tion is flattening, so ½nancially under-lit-
erate populations will likely rise if this
trend continues.24

Other buffers protecting ½nancial se curi –
ty in retirement are also eroding. Employers
today are less likely to offer their work ers
retiree health insurance bene½ts. Ac cord –
ing to the Employee Bene½t Re search Insti –
tute (ebri), In 2010, 17.7 percent of work-
ers were employed in establishments that
offered health coverage to early retir ees,
down from 28.9 percent in 1997.25 Those
that continue to offer retiree health bene –
½ts have made changes in the bene½ts they
offerta, including raising premiums, tight –
ening eligibility, and reducing bene ½ts.

Just as with ½nancial models in retire-
ment, there has been a shift in health care

toward a personal-responsibility model.
Per esempio, many individuals now have
“consumer-directed health plans” that car –
ry high deductibles and encourage indivi –
duals to control their use of health care ser –
vices. Medicare bene½ciaries must now
choose from a large menu of insurance
choices when signing up for prescription
drug coverage through Medicare Part D.
Choosing an optimal health insurance plan,
Tuttavia, requires an understanding of in –
surance terms that many people are unfa-
miliar with26 and an understanding of
how different bene½t designs affect out-of-
pock et spending.27 Many older adults do
not un derstand the unique design of Part
D plans, a knowledge de½cit that ex poses
them to a coverage gap.28 This gap may
have long-term health consequences when,
as research shows, bene½ciaries with
chron ic disease must forgo their medica-
tions as a result.29
Despite these challenges, feasible policy

options can lower the overall risk to both
individuals and society and increase the
likelihood that the United States will re –
main cohesive, produttivo, secure, E
equitable as it emerges from this demo-
graphic transformation. Based on the in –
for mation presented in this essay and in
the other essays in this volume, the Mac –
Arthur Foundation Research Network on
an Aging Society offers the following ½ve
recommendations as a way forward.

1) Enhance life-long learning and increase
the likelihood that older workers can func –
tion effectively in the labor force:

• Offer incentives for reinvesting in skill
development, especially for blue-collar
workers.

• Encourage work site–based education –

al and training programs.

• Provide resources that support alterna –
tive ways to update skills; encourage

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lifelong learning beyond the classroom.
An example is the Mozilla/MacArthur
Foundation Badges for Lifelong Learn –
ing Program, an emerging model of
peer-to-peer learning that creates cre –
dentials for informal learning that is
not currently captured by traditional
credentials (such as college degrees).

2) Ensure that older persons are produc-
tively engaged in society, either through
paid work or volunteering:

• Create incentives for employers to of –
fer more flexible employment models
that ½t the needs of older workers.
• Create incentives for volunteering.
• Increase funding for federal senior vol –

unteer programs.

• Consider the bene½ts and the costs of
establishing Medicare as the primary
payer for health bene½ts of older work –
ers who are eligible for the program.

3) Encourage individual and societal ½ –
nancial security:

• Change 401(k) participation from vol-
untary opt-in to a default option of
par ticipation and a voluntary opt-out,
and require savings rates of 6 per cento.
• Offer paid leave for family caregiving.
• Ensure that Social Security continues
to provide individuals and families
with ½nancial security while shoring
up trust fund solvency through bene½t
reform.

4) Provide high-quality health care to all:
• Strengthen geriatric training and in –
crease requirements for demonstrated
competence in geriatric care for all lev –
els of health care providers.

• Provide ½nancial incentives such as
loan forgiveness and scholarships for
individuals training in geriatric care.
• Channel resources through Medicare
to providers (nurses, physicians, E

oth ers) with additional training and
de monstrated competence in geriat –
rics. This must include the diagnosis
and management of common disor-
ders of late life, including delirium,
dementia, falls, incontinence, poly –
phar ma cy (use of more than four med –
ications, which raises the possibility
of harmful interactions), and frailty; COME
well as diseases especially common in
older persons, such as diabetes, cardio –
vascular disease, and arthritis.

• Establish training programs tailored

to speci½c caregiver situations.

• Launch caregiver support programs as
a place to discuss challenges in a con –
½dential setting.

• Expand the National Family Caregiver
Support Program to help reimburse
costs of caregiving and provide fund-
ing for caregivers to be temporarily re –
lieved of their duties, allowing them to
maintain their responsibilities for an
extended time.

5) Build a culture of shared sacri½ce and
bene½t across the generations:

• Promote generationally cohesive com –
munities by encouraging individuals
from different generations to interact
productively together, reducing inter –
generational tensions.

• Establish programs to involve seniors
in schools and youth in senior services.
• Avoid exclusive reliance on age-segre-

gated housing and services.

• Emphasize the bene½ts of social insur –
ance programs across the entire age
span.

Taken together, these options provide a
general blueprint for the types of policies
that should be put in place to increase the
likelihood that our country will maintain
its resilience in the face of this demograph –
ic change.

Julie M.
Zis si mo poulos,
Dana P.
Gold man,
S. Jay Olshansky,
John Rother &
John W. Rowe

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Mitigating
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endnotes
* Contributor Biographies: JULIE M. ZISSIMOPOULOS is an Assistant Professor at the Sol Price
School of Public Policy and the Associate Director of the Schaeffer Center for Health Policy
and Economics at the University of Southern California. Her research has been published in
such journals as The Journal of Economic Perspectives, Journal of Health Economics, Journal of
Human Resources, and Demography.
DANA P. GOLDMAN is the Leonard D. Schaeffer Chair in Health Policy at the University of
Southern California. He is also the Director of the Schaeffer Center for Health Policy and
Economics. He serves as a health policy adviser to the Congressional Budget Of½ce, and his
research has appeared in the New England Journal of Medicine, JAMA: The Journal of the American
Medical Association, Demography, Journal of the American Statistical Association, and Health Affairs.
S. JAY OLSHANSKY is Professor of Epidemiology at the School of Public Health, Division of
Epidemiology and Biostatistics at the University of Illinois at Chicago. He has published
articles in such journals as The New England Journal of Medicine, JAMA, Scienza, The Scientist,
Scienti½c American, and Health Affairs.
JOHN ROTHER is President and ceo of the National Coalition on Health Care. Prior to joining
the Coalition, he served as the Executive Vice President for Policy, Strategy, and International
Affairs at the aarp. He was also Staff Director and Chief Counsel of the Senate Special Com –
mittee on Aging under the direction of Chairman John Heinz (r-pa) and Special Counsel for
Labor and Health to Senator Jacob Javits (r-ny).
JOHN W. ROWE, a Fellow of the American Academy since 2005, is Professor at the Columbia
University Mailman School of Public Health and Chair of the MacArthur Foundation Research
Network on an Aging Society. He is the author of Successful Aging (with Robert L. Kahn, 1998)
and was the Chair of the Institute of Medicine of the National Academies project the Future
Health Care Workforce for Older Americans, which authored the report Retooling for an Aging
America: Building the Health Care Workforce (2008).

1 One exception is John Wallis Rowe and Robert L. Kahn, Successful Aging (New York: Dell, 1998).
2 David Lowsky, S. Jay Olshansky, Jay Bhattacharya, and Dana P. Goldman, “Heterogeneity in
Healthy Aging,” The Journals of Gerontology: Biological Sciences & Medical Sciences 69 (6) (2014):
640–649.

3 Robert Schoeni, Vicki Freedman, and Linda Martin, “Why is Late-Life Disability Declining?"
Milbank Quarterly 86 (1) (2008): 47–89. Among the working-age population, results are con-
flicting, in part because of variation in how disability is de½ned and measured in surveys. Vedere
Richard Burkhauser, Andrew Houtenville, and Jennifer Tennant, “Measuring the Population
with Disabilities for Policy Analysis” in Lifecycle Events and Their Consequences: Job Loss, Family
Change and Decline in Health, ed. Kenneth A. Couch, Mary C. Daly, and Julie M. Zissimopoulos
(Stanford, Calif.: Stanford University Press, 2013).

4 S. Jay Olshansky, Daniel Perry, Richard A. Mugnaio, and Robert N. Butler, “In Pursuit of the Long e vity

Dividend,” The Scientist 20 (3) (2006): 28–36.

5 S. Jay Olshansky, Toni Antonucci, Lisa Berkman, Robert H. Binstock, Axel Boersch-Supan, John
T. Cacioppo, Bruce A. Carnes, Laura L. Carstensen, Linda P. Fried, Dana P. Goldman, James
Jack son, Martin Kohli, John Rother, Yuhui Zheng, and John W. Rowe, “Differences in Life Ex –
pectancy Due to Race and Educational Differences are Widening, and Many May Not Catch
Su,” Health Affairs 31 (8) (2012): 1803–1813.

6 Dana P. Goldman, Yuhui Zheng, Federico Girosi, Pierre-Carl Michaud, S. Jay Olshansky, David
Cutler, and John W. Rowe, “The Bene½ts of Risk Factor Prevention in Americans Aged 51 Years
and Older,” American Journal of Public Health 99 (11) (2009): 2096–2101.

7 John Karl Scholz, Ananth Seshadri, and Surachai Khitatrakun, “Are Americans Saving ‘Opti-

mally’ for Retirement?” Journal of Political Economy 114 (4) (2006): 607–643.

100

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8 NOI. Department of Commerce, “Seasonally Adjusted Annual Rate,” psavert Series (Washing –

ton, D.C.: Department of Commerce, 2014).

9 Kenneth Couch, Mary C. Daly, and Julie M. Zissimopoulos, eds., Lifecycle Events and Their Conse –
quences: Job Loss, Family Change and Decline in Health (Stanford, Calif.: Stanford University Press,
2013).

10 Dawn C. Carr, Linda P. Fried, and John W. Rowe, “Productivity and Engagement in an Aging

America: The Role of Volunteerism,” Dædalus 144 (2) (2015).

11 Katherine M. Flegal, Margaret D. Carroll, Cynthia L. Ogdent, and Lester R. Curtin, “Prevalence
and Trends in Obesity among U.S. Adults, 1999–2008,” JAMA 303 (3) (2010): 235–241.
12 Katherine M. Flegal, Margaret D. Carroll, Brian K. Kit, and Cynthia L. Ogden, “Prevalence of
Obesity and Trends in the Distribution of Body Mass Index among U.S. Adults, 1999–2010,”
JAMA 307 (2012): 491–497.

13 Linda G. Martin, Vicki A. Freedman, Patricia M. Andreski, and Robert F. Schoeni, “Recent
Trends in Disability and Related Chronic Conditions among People Ages 50 to 64,” Health
Affairs 29 (4) (2010): 725–731.

14 These calculations are based on the 2004 survey of the Health and Retirement Study; Vedere
University of Michigan Health and Retirement Study (hrs), http://hrsonline.isr.umich.edu.
15 Lynn Feinberg, Susan C. Reinhard, Ari Houser, and Rita Coula, Valuing the Invaluable: 2011
Update–The Growing Contributions and Costs of Family Caregiving (Washington, D.C.: aarp
Public Policy Institute, 2011), 2.

16 Frank F. Furstenberg, Caroline Sten Hartnett, Martin Kohli, and Julie M. Zissimopoulos,
“The Future of Intergenerational Relations in Aging Societies,” Dædalus 144 (2) (2015).
17 Yonatan Ben-Shalom, Robert A. Mof½tt, and John Karl Scholz, “An Assessment of the Effec-
tiveness of Anti-Poverty Programs in the United States,” nber Working Paper 17042 (Camera-
ponte, Massa.: National Bureau of Economic Research, 2011).

18 Vedere, Per esempio, Erik Hurst and James P. Ziliak, “Do Welfare Asset Limits Affect Household
Saving? Evidence from Welfare Reform,” Journal of Human Resources 41 (1) (2006): 46–71.
19 S. Jay Olshansky, Dana P. Goldman, and John W. Rowe, “Resetting Social Security,” Dædalus

144 (2) (2015).

20 Executive Of½ce of the President of the United States, Council of Economic Advisers, Trends
in Health Care Cost Growth and the Role of the Affordable Care Act (Washington, D.C.: Executive
Of½ce of the President of the United States, novembre 2013), http://www.whitehouse.gov/
sites/default/½les/docs/healthcostreport_½nal_noembargo_v2.pdf.

21 Nicole Maestas and Julie Zissimopoulos, “How Longer Work Lives Ease the Crunch of Pop-

ulation Aging,” Journal of Economic Perspectives 24 (1) (2010): 139–160.

22 Alan Gustman, Thomas Steinmeier, and Nahid Tabatabai, “What the Stock Market Decline
Means for the Financial Security and Retirement of the Near-Retirement Population,” Journal
of Economic Perspectives 24 (1) (2010): 161–182.

23 Florian Heiss, Adam Leive, Daniel McFadden, and Joachim Winter, “Plan Selection in Med –
icare Part D: Evidence from Administrative Data,” Journal of Health Economics 32 (6) (2013):
1325–1344.

24 Organisation of Economic Co-operation and Development, Education at a Glance, 2011: OECD

Indicators (Paris: oecd Publishing, 2013).

25 Paul Fronstin and Nevin Adams, “Employment-Based Retiree Health Bene½ts: Trends in Access

and Coverage, 1997–2010,” EBRI Issue Brief (377) (ottobre 2012).

26 Silvia Barcellos, Amelie C. Wuppermann, Katherine Grace Carman, Sebastian Bauhoff, Daniel
l. McFadden, Arie Kapteyn, Joachim K. Inverno, and Dana Goldman, “Preparedness of Amer –

Julie M.
Zis si mo poulos,
Dana P.
Gold man,
S. Jay Olshansky,
John Rother &
John W. Rowe

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101

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Aging
America

icans for the Affordable Care Act,” Proceedings of the National Academy of Sciences 111 (15) (2014):
5497–5502.

27 Heiss et al., “Plan Selection in Medicare Part D.”
28 John Hsu, Vicki Fung, Mary Price, Jie Huang, Richard Brand, Rita Hui, Bruce Fireman, E
Jo seph P. Newhouse, “Medicare Bene½ciaries Knowledge of Part D Prescription Drug Program
Bene½ts and Responses to Drug Costs,” JAMA 299 (16) (2008): 1929–1936.

29 Geoffrey F. Joyce, Julie M. Zissimopoulos, and Dana P. Goldman, “Digesting the Doughnut

Hole,” Journal of Health Economics 32 (6) (2013): 1345–1355.

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