Aging Policy From a Multilayered Geographic and Life Course Perspective

Extract

Contemporary challenges to healthy aging in communities across the United States are shaped by the complex, multilayered nature of the federal, state, and local contexts in which aging occurs. We introduce a framework for thinking in this multilevel way, as well as acknowledging the differences experienced by more and less socially advantaged groups as they age through the life course in sometimes distinct health contexts. Our framework draws on two prominent models—the ecological model (Bronfenbrenner, 1979; Smedley & Syme, 2000) and the life course perspective (Elder et al., 2003)—but focuses specifically on key elements of space and time relevant for the within- and between-country disparities we discuss. We highlight the promise and challenge of this framework for improving research and policy aimed at supporting healthy aging and reducing disparities in health and longevity.

Healthy Aging Across the United States: Increasingly Unequal

While the United States spends more on health care than any other wealthy nation, by a considerable margin, the population health returns are disappointing (House, 2015). The U.S. health and longevity crisis—marked by the faltering standing in morbidity and life expectancy relative to peer nations—has occurred despite massive spending on health care and has galvanized attention from researchers and the media in recent years. It is often illustrated by contrasting post-1980 trends in U.S. life expectancy versus those in other high-income countries. For example, Figure 1 shows trends in female life expectancy across 22 high-income countries, where the United States is the enlarged dot. The U.S. trend is unequivocally alarming. Moreover, the poor performance of the country as a whole obscures profound disparities between U.S. states. Overlaying states with the highest (Hawaii) and lowest (West Virginia) female life expectancy in 2018, Figure 1 makes it clear that some states are actually performing on par with high-income countries, while others are extremely far behind. Within-state geographic units also show substantial heterogeneity, with gains in life expectancy at age 65 greatest in large metropolitan areas and coastal regions, while nonmetropolitan areas and interior areas of the United States lag behind other parts of the country and all Organization for Economic Cooperation and Development (OECD) comparison countries (Vierboom & Preston, 2020).