If you could invest $56 billion each year in improving health care for older adults, how would you spend it? On a hugely expensive medication with questionable efficacy — or something else?
This isn’t an abstract question. Aduhelm, a new Alzheimer’s drug approved by the Food and Drug Administration last month, could be prescribed to 1 million to 2 million patients a year, even if conservative criteria were used, according to Biogen and Eisai, the companies behind the drug.
The total annual price tag would come to $56 billion if the average list price, $56,000, is applied to the lower end of the companies’ estimate.
That’s a huge sum by any measure — more than the annual budget for the National Institutes of Health (almost $43 billion this year). Yet there’s considerable uncertainty about Aduhelm’s clinical benefits, fueling controversy over its approval. The FDA has acknowledged it’s not clear whether the medication will actually slow the progression of Alzheimer’s disease or by how much.
“This drug raises all kinds of questions about how we think about health and our priorities,” said Dr. Kenneth Covinsky, a geriatrician and professor of medicine at the University of California-San Francisco.
Since most Alzheimer’s patients are older and on Medicare, the medication would become a significant financial burden on the federal government and beneficiaries. Several experts warn that outlays for aducanumab, marketed as Aduhelm, could drive up premiums for Medicare Part B and Medicare supplemental policies and raise out-of-pocket expenses.
A likely additional cost: lost opportunities to invest in other improvements in care for older adults. If Medicare and Medicaid must absorb drug spending of this magnitude, other priorities are less likely to receive attention.
I asked a dozen experts — geriatricians, economists, health policy specialists — how they would spend an extra $56 billion a year. Their answers highlight significant gaps in care for older adults. Here’s some of what they suggested.
Make Medicare more affordable. High out-of-pocket expenses are a growing burden on older adults and discourage many from seeking care, and Dr. David Himmelstein, a distinguished professor of urban public health at Hunter College in New York City, said extra funding could be directed at reducing those costs. “I’d cut Medicare copayments and deductibles. I think that would go a long way toward improving access to care and health outcomes,” he said.
On average, older adults on Medicare spent $5,801 out-of-pocket for health care in 2017 — 36% of the average annual Social Security benefit of $16,104, according to a report last year from AARP. By 2030, out-of-pocket health expenses could consume 50% of average Social Security benefits, KFF predicted in 2018.
Pay for vision, hearing and dental care. Millions of older adults can’t afford hearing, vision and dental care — services that traditional Medicare doesn’t cover. As a result, their quality of life is often negatively affected and they’re at increased risk for cognitive decline, social isolation, falls, infections and depression.
“I’d use the money to help pay for these additional benefits, which have proved very popular with Medicare Advantage members,” said Mark Pauly, a professor of health care management at the University of Pennsylvania’s Wharton School of Business. (Private Medicare Advantage plans, which cover about 24 million people, usually offer some kind of hearing, vision and dental benefits.)
Over 10 years (2020 to 2029), the cost of adding comprehensive hearing, vision and dental benefits to Medicare would be $358 billion, according to the Congressional Budget Office.
Support family caregivers. Nearly 42 million people provide assistance — help with shopping, cooking, paying bills and physical care — to older adults trying to age in place at home. Yet these unpaid caregivers receive little practical support.
Dr. Sharon Inouye, a geriatrician and professor of medicine at Harvard Medical School, suggests investing in paid services in the home to lessen the burden on unpaid caregivers, especially those tending to people with dementia. She would fund more respite care programs that give family caregivers short-term breaks, as well as adult day centers where older adults can socialize and engage in activities. Also, she recommends devoting substantial resources to expanding caregiver training and support and paying caregivers stipends to lessen the financial impact of caregiving. For the most part, Medicare doesn’t cover those services.
“Providing these supports could make a huge difference in people’s lives,” Inouye said.
Strengthen long-term care. Shortages of direct care workers — aides who care for older adults at home and in assisted living facilities, nursing homes, residential facilities and other settings — are a growing problem, made more acute by the coronavirus pandemic. PHI, a research organization that studies the direct care workforce, has estimated that millions of direct care jobs will need to be filled as baby boomers age.
“We could greatly improve the long-term care workforce by paying these workers better and training them better,” said Dr. Joanne Lynn, a geriatrician and policy analyst at Altarum, a research and consulting organization.
Help people age in place. Most older adults want to age in place, but many need assistance over time, surveys show. Will they be able to climb the stairs? Cook for themselves? Do the laundry? Take a shower?
Simple solutions can help, including relatively inexpensive home renovations (installing handrails on staircases, grab bars in bathrooms and better lighting, for example) and assistive devices such as raised toilet seats, shower stools or scooters. But Medicare doesn’t pay for renovations or certain helpful devices.
Covinsky of UCSF would make a program known as CAPABLE (Community Aging In Place — Advancing Better Living for Elders) a Medicare benefit, available to all 61 million members. That program combines at-home visits from an occupational therapist and a registered nurse, usually conducted over 10 weeks, with up to $1,300 in services from a handyman.
Evidence shows it has a significant positive impact, helping seniors perform daily activities and stay out of nursing homes. The total cost: $3,000 per person. “For less than one infusion of aducanumab, you can greatly improve someone’s quality of life and well-being,” Covinsky said.
Find out what older adults need. Sarah Szanton, director of the Center for Innovative Care in Aging at the Johns Hopkins School of Nursing, developed CAPABLE. She would use $56 billion to assess every older adult annually to “figure out what they need to be able to live comfortably and independently. From that, I would generate a list of tailored interventions” — specific action items that might include CAPABLE or other programs, she told me.
Initiatives that could use extra funding might focus on managing depression, preventing falls or structuring activities for people with dementia, Szanton said.
Focus on prevention. A growing body of evidence suggests that dementia could be prevented — perhaps up to 40% of the time — if people didn’t drink excessive amounts of alcohol, controlled blood pressure and obesity, managed depression, used hearing aids, stopped smoking, and regularly engaged in exercise, social interactions and cognitively stimulating activities, among other strategies.
“If I had $56 billion to spend, I’d focus on prevention,” said Laura Gitlin, a dementia expert and dean of Drexel University’s College of Nursing and Health Professions.
“There is more evidence for these strategies than there is for Aduhelm at the moment,” said Dr. David Reuben, chief of UCLA’s geriatrics department and director of its Alzheimer’s and dementia care program.
Invest in social determinants of health. The health of older adults is shaped by the environments in which they live, their interactions with other people and how easy it is to fulfill basic needs.
Recognizing this, Dr. Anthony Joseph Viera, a professor of family medicine and community health at Duke University School of Medicine, said he would invest in “transportation for the elderly. Safe housing. Food. Programs that reduce social isolation. Those would end up helping a lot more people.”