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Health Care and Government Policy

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Laurinda Abreu

Longer and better lives

The European fountain of youth

Patrice Bourdelais

Résumé

A comparison of life expectancies at age 65 in the 25 countries with the highest life expectancies in the world shows that the European development model, in Europe and outside Europe, has led to a very significant increase in this life expectancy. Examination of this increase since 1980 also highlights the effects of the deterioration in economic and social conditions and of the cuts in social programmes in terms of lower growth (in the United States, Norway and Sweden). The age at which disabilities occur is then addressed, using two different methods: one based on mortality figures and the other on surveys of a sample of the population. While the first suggests continued progress, self-reporting surveys show a slowdown in the increase in the number of years lived without disabilities above the age of 65. This can be interpreted both as a result of the interviewees’ greater demand for an active lifestyle, and also as the beginning of the consequences on health of the economic and social marginalisation of a significant proportion of the population as a result of mass unemployment.

Texte intégral

Introduction

1The lengthening of life and quality of life are today among the topics that public health policies regularly deal with. First of all, I would like to ask a question: what does an historical overview of the last 30 years, i.e. the space of a generation, bring to current analyses? Many good-quality statistics are available which allow for internationally comparative approaches. Given that numerous historical studies have shown that the increase in European life expectancy at age 65, for example, has been slowing down, we propose here to revisit this question over the last 30 years, without ignoring the longer timescale. Has a European model of increased life expectancy above age 65 been established?

2But a gain in life expectancy constitutes real progress only when it corresponds at least in part to the maintenance of good health during the years gained. A specific study on the ageing of the French population has led to the proposal, over more than a century, to calculate a simple indicator, which of course approximates the average age at which people enter old age, i.e. the age at which disabilities appear in everyday life. The recent concept of Disability-free life expectancy corresponds to the same idea. It has prompted the construction of numerous indicators to specify how many of these years gained will be lived without disability in daily life. The last part will allow us to compare the two approaches, note the weaknesses of both and appreciate the immense progress that has been made, as well as the more worrying recent developments.

A European Fountain-of-Youth pattern

3Europe achieved the Fountain of Youth during the twentieth century, especially during its last few decades. Several indicators provide strong evidence for this phenomenon. Although life expectancy at age 65 estimates the average number of years lived above age 65, it is also a good indication of people’s state of health at that age, as a result of their life conditions since birth and also of their socio-medical conditions in the last decades of their lives. It is also obvious that their state of health at 65 has consequences for the mortality rate in the following years. Of the 25 highest-ranked countries in the world for female life expectancy at age 65, only Japan, South Korea, Australia and New Zealand are not European, but they have followed the European pattern of development through education, industry and public health policy.

4There has been a considerable increase in life expectancy at 65 in a large proportion of European countries since the Second World War, and especially since 1980 (Table 1). Some remarks need to be made. First, the situation of the USA is the worst in the group: its expectancy in 1980 was good, on a par with the French, but the improvement observed by 2014-15 was very low, the lowest of all the 25 countries (Figure 1). The US is in last position in terms of both today’s level and the increase since 1980 (Crimmins, 2016). This is consistent with the studies published by Case and Deaton (2015) showing that mortality was increasing among middle-aged non-Hispanic whites in the US between 1999 and 2013. It reversed decades of progress in mortality and was the opposite of what was being observed in European countries. The mortality of white people aged 45-54 in all the other rich countries has declined almost by half (from 400 per 100,000 to 200). Mortality is highest among less-educated populations, due to suicide, alcoholism, drug abuse, etc. – what Case and Deaton (2015) call ‘despair death’. In the 1990s the ‘despair death’ rate was 30 per 100,000 in the US and 60 in France. Recently it has been 80 per 100,000 in the US and 45 in France.

Table 1 - Life expectancy at 65 (Women, in years)

Countries

2014-2015
(in decreasing order)

1980

Japan

24.3

17.7

France

23.7

18.2

Spain

23.2

17.9

Switzerland

22.5

18.2

Italy

22.5

17.1

South Korea

22.4

15.6

Luxembourg

22.3

16.5

Portugal

21.8

16.1

Belgium

21.7

16.8

Norway

21.6

18.2

Sweden

21.5

18.1

England and Wales

21.0

16.8

...

USA

20.6

18.3

Source: OECD Data

5The reasons for this difference seem clear now: in the US income inequalities have been increasing for decades. The pay gap between workers and CEOs was eight times larger in 2016 than in 1980. During the same period, the pre-tax incomes of the top 1% of America’s households increased more than four times faster than those of the bottom 20%, and post-tax incomes rose even more! The third factor is obviously the dysfunctional healthcare system and the prescription of opioids, which are responsible for 40 per 100,000 of the deaths. The job market has also been very depressed in the US, especially in specific states. These populations are the victims of an accumulation of handicaps. The active part of the population declined between 2000 and 2015. It is less than in the other OECD countries (except Italy). Half of the unemployed men of working age are taking pain medication on a daily basis. The geographical correlation between the two factors is very high. And when access to opioids is restricted, people turn to heroin in a truly infernal trend. The US situation offers a sort of research lab in which the results of the trend can be observed. European countries know what they have to avoid if they want to maintain the improvement in people’s state of health at 65.

6On the other hand, since the 1980s the improvement in the Nordic countries – Norway and Sweden – has been very small. Mortality from birth to age 64 is very low but it seems that the progress made beyond 65 is less obvious and the level not excellent. Rising tobacco consumption among women is probably part of the explanation but it is also clear that the longevity of less-well-educated Swedish women is lower than that of less-well-educated French women, for instance. The question of the safety net has to be addressed. Between 1980 and 2015 social programmes and measures were maintained more in France (at high financial cost) than in Sweden.

7At the opposite extreme, South Korea, in last position in 1980, has shown tremendous improvement (44%) and is now at the same level as Luxembourg, Switzerland and Italy. Japan, at a better level in 1980, is now the first in the world, after strong growth (37%). These are two countries that did not rank very highly in 1980 (South Korea especially) but where economic growth has had a spectacular effect on the health status of the population. The improvement in Portugal has also been really high, linked to the decision by Mário Soares in March 1977 to start negotiating Portugal’s accession to the European Economic Community (EEC), which it finally joined in 1986. Economic development has been very strong since then and the country’s efforts to meet EEC requirements, including in the public health domain, produced spectacular results not least in the people’s state of health and life expectancy (Lallo and Raitano, 2018).

8The improvement in public health and decrease in mortality is not a war won forever; the US example is very clear in that respect, and the levels in England and Wales and the Nordic countries show the same thing, albeit in a less dramatic way (Public Health England, 2016). Several studies in Sweden, for instance, have investigated the lack of improvement there compared to Japan and France. The main differences are Sweden’s higher rates of mortality due to cancer and cardiovascular disease (sometimes leading to dementia) (Drefahl et al., 2014). Less investment in the health and care system can have these measurable consequences.

Figure 1 - Life expectancy at age 65 (women). Comparisons 1980-2014/15

Figure 1 - Life expectancy at age 65 (women). Comparisons 1980-2014/15

OECD Data

Figure 2 - Increase in life expectancy at age 65 (women, %)

Figure 2 - Increase in life expectancy at age 65 (women, %)

OECD Data

The threshold of old age

9It is obvious that in the countries at the top of the improvement ranking, 70- and 80-year-olds cannot be compared to their grandparents or even their parents in the 1980s. Their state of health is really better today and their activities and roles in society are highly visible. But the representation of age is more stable than reality and has become an obstacle to a clear view of the phenomenon. The notion of demographic ageing based on a decade-by-decade comparison of the percentage of people over 65, for instance, implicitly assumes that it makes sense to compare 65-year-olds in 1950, 1980 and today. All the research clearly shows that that is not the case: older people’s state of health, their place in the succession of generations, their economic situation and their social and cultural roles have dramatically changed. Then why not measure the ageing of the population according to a designated ‘age of entry’ into old age that varies over time? For instance the threshold could be the age of a person who has an average of ten years to live. It provides a life-expectancy horizon but is very sensitive to the person’s state of health in their last years of life. It is not enough to estimate their state of health over the long term (Bourdelais, 1994). Demographers and some epidemiologists have been criticised for taking the easy way out by considering that changes in mortality are an indicator of state of health. The objection is justified. Recent medical advances may add a few extra years of life without a person’s health being improved. Yet, on a broader chronological and social scale, the correlations become clearer: in the 1980s the various countries in the world were in a similar ranked order for mortality by age 50 and general state of health at that age. In France, the differences between the various social classes in their mortality and in their state of health seem to go hand in hand. Furthermore it also seems that there is a strong correlation between disability and mortality. Since the early twentieth century, when Alfred Sauvy invented the notion of demographic ageing (Sauvy, 1928), life expectancy at 60 has increased dramatically: from 1927 to 2015, it jumped from 13.8 to 22.9 years for men and from 15.8 to 27.3 years for women. It is clear that when Sauvy proposed this notion, he only had in mind a long period without any clear progress in mortality for people over 60 since the middle of the nineteenth century! And the improvement has been even greater since the mid-1970s, especially for men. So, if we concentrate on just the last 35 years (1980-2015) – one generation – and consider the age of a person who still has ten years to live, the changes are very marked: this age has risen from 71.4 to 78.0 for men and from 75.8 to 81.8 for women.

10The indicator chosen to reveal that change can be a combination of the age at which a person is likely to have ten years to live and the age with a probability of surviving for five years before the onset of disabilities. This probability indicates a sort of stable state of health. As epidemiological surveys in the 1970s showed that this age was around 75, we have chosen the probability of surviving for five years at 65 for men and women in 1985, and look for the age with the same value at each census before and after 1985. This is a good indicator for the state of health, and adding the age with an average probability of surviving for ten years complements it with a sort of life-expectancy horizon. Weighting these criteria by two thirds and one third, respectively, results in the values shown in Table 2 (Bourdelais, 1996).

11A clear improvement began before just the Second World War and developed tremendously afterwards, especially since the 1970s (Figure 3).

Figure 3 - Changes in the threshold of old age (France)

Figure 3 - Changes in the threshold of old age (France)

Table 2 - Changes in longevity and the threshold of old age

Ten years to live

Old-age threshold

Year

Men

Women

Men

Women

1825

65.5

66.7

59.6

60.4

1860

66.5

67.0

60.2

61.0

1900

65.7

67.2

59.2

62.4

1910

65.8

67.8

59.3

62.6

1927

66.7

69.1

60.6

64.5

1937

66.9

70.1

60.6

65.5

1947

69.0

72.0

63.7

68.0

1957

69.1

72.6

63.5

68.2

1965

70.0

73.9

64.0

70.4

1975

70.6

75.1

65.1

71.9

1985

72.3

76.5

67.4

73.7

1995

74.5

78.6

69.7

75.7

2005

76.2

80.5

72.0

77.8

2015

78.0

81.8

74.7

79.5

Disability-free life expectancy

12With the increase in life expectancy at 65, it has become of crucial importance for public health and healthcare planning to know to what extent the years gained are years of good health (Cambois and Robine, 2014; Berger et al., 2015). It has also become a social and economic issue due to the growing expectation for social participation by the elderly. How many years are lived in good functional health?

13To answer this question at a European level, it was decided in 2004 to organise a yearly survey asking people how they felt. The GALI (Global Activity Limitation Indicator) asks people: ‘For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do? Would you say you have been ... 1. Severely limited, 2. Limited but not severely, or 3. Not limited at all?’

14In France, the sample consists of around 21,000 persons. It means that the statistical confidence interval is ± 0.6 year, which is more than the changes observed each year. The consequence is that any change has to be appreciated over one or two decades. But here we have two difficulties: firstly, nothing guarantees that people will have the same appreciation of their disabilities in 2005 and in 2020, because expectations will necessarily have changed. Secondly, it was shown back in the 1990s that the social milieu has a direct influence on what people declare. From a series of indicators intended to measure biological age, it was observed that a manual worker aged 35 was biologically 4.5 years older than an executive of the same chronological age. Survivors from the working class – fewer than from the other social categories – are also less healthy than survivors from other categories. A CREDES study confirms those differences. Relative ageing, put forward as a combined indicator of life expectancy and disablement, enables us to estimate that, among survivors, persons who left school early age prematurely by more than three years compared to those who went on to study at university (Mizrahi and Mizrahi, 1994). The difference is over five years when active executives and unqualified or unemployed manual workers are considered. However, the differences observed between self-reporting and the results of medical examinations show there are different norms for assessing state of health: while the working classes overestimate the state of their health compared to the results of medical examinations, the opposite is true among the more fortunate social classes, who expect more from medical progress and science, possibly because they have a less resigned attitude to the traditional course of life. It really means that these GALI statistics, based on self-reporting, are not very robust. They simply give an idea of what people’s declared feelings are (Robine and Cambois, 2017). That is important, but they can vary from one country to another, from one decade to the next and from one social class to another (Herr et al., 2014).

Table 3 - Comparisons between life expectancy (LE), disability-free life expectancy (DFLE) and life expectancy with activity limitation (LEAL), at age 65, France, 2014

Men

Women

LE

DFLE

LEAL

LE

DFLE

LEAL

19.1

10.2

8.9

23.0

10.4

12.6

15According to these self-reporting results, the combined indicator I propose would be fine for men (74.7 compared with 65+10.2 = 75.2) but too optimistic for women (79.5 compared with 65+10.4= 75.4). The survey trends in France seem to indicate some compression in morbidity. After some stabilisation in the 1990s, the 2000s saw a slight increase in disability but, curiously, especially before age 65. How do we interpret that? Either the changing demands and expectations of the interviewees led to more negative statements than previously, or they correspond, at least partially, to a lived reality. It has been observed that women's more frequent involvement in housekeeping and daily chores necessarily tends to make them perceive minor disabilities that men, who are often less involved, neglect as embarrassing. The sharing of roles may be at the origin of the differences highlighted in the surveys.

16The rise in unemployment and the marginalisation of a growing proportion of the population from the 1980s onwards may very well have readable effects in aggregate statistics for the years 2000-2010, especially before the age of 65. If the state of health of part of the adult population has deteriorated over the past 30 years, it is likely that this trend will weigh on life expectancy at age 65 and especially on disability-free life expectancy. We could then observe the beginning of a decline in life expectancy gain curves at age 65 (which is not the case at the moment) and especially a decrease in the average number of years lived without disabilities.

Conclusion

17We would like to reiterate here that economic growth and the ensuing improvement in the standard of living have made possible this completely unprecedented recent rise in life expectancy at age 65, which is undoubtedly today a better indicator of a country's level of development than the infant mortality rate, once the usual indicator (Falkingham, 2017). A triple illustration has been given. The effects of strong growth in Japan and South Korea have had dramatic effects on increasing life expectancy since 1980. On the other hand, an aggravation of economic conditions not compensated for by decisive public policies has led to the deteriorating situation in the USA, which today has fallen behind the leading countries in life expectancy at 65 years. Finally, the situation in the Scandinavian countries is also striking. These former models of public health management and mortality decline are now somewhat less well placed. The abandonment of the social model put in place by social democratic governments between the two World Wars and during the glorious Thirties may have led to choices that have dampened further progress in this life expectancy, which is demanding in terms of long-term investment (Lubitz et al. 2003).

18If we look at the postponement of the age of onset of the first disabilities affecting daily activities, the comparison between a statistical method based on calculations made from mortality tables and a survey method among the elderly reveals a notable difference on the female side. The interpretation of self-reporting surveys is always difficult because the context in which the responses are obtained is so important, as expectations regarding life and the sharing of roles in daily life weigh heavily on the statements. Conversely, the statistical method assumes a strong correlation between mortality levels, health status and disabilities, the robustness of which may change over time. The emergence in France of a slight increase in the number of years lived with disability before the age of 65, which can be linked to the rise in mass unemployment and the economic and social marginalisation of a significant proportion of the population, does not bode well for the future trend of life expectancy at 65 and the average number of years lived beyond that age without disabilities. Indeed, we can predict that these people will reach this age in a more fragile state of health than today's 60-year-olds, and this is likely to contribute to limiting future progress in both overall life expectancy at 65 years and disability-free life expectancy. The policies to be implemented before this deterioration occurs will have to try to limit its extent and the consequent costs of medical and hospital care.

Bibliographie

Berger, N., Van Oyen, H., Cambois, E., Fouweather, T., Jagger, C., Nusselder, W. and Robine, J.-M. (2015). Assessing the validity of the Global Activity Limitation Indicator in fourteen European countries. BMC Medical Research Methodology, 15(1):1-8.

Bourdelais, P. (1994). L’âge de la vieillesse, histoire du vieillissement de la population. Paperback edition 1997. Paris: Odile Jacob.

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Cambois, E. and Robine J.-M. (2014). Les espérances de vie sans incapacité : un outil de prospective en santé publique. Informations sociales, 3(183), 106-114.

Case, A. and Deaton, A. (2015). Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS, 112(49), 15078-15083

Crimmins, E. M., Zhang, Y. and Saito Y. (2016). Trends over 4 decades in disability-free life expectancy in the United States. American Journal of Public Health, 106(7), 1287-1293.

Drefahl, S., Ahlbom, A. and Modig, K (2014). Losing ground – Swedish life expectancy in a comparative perspective. PLoS One 9(2), e88357.

Falkingham, J. (2017). Rising life expectancy and why we need to rethink the meaning of old age. The Conversation, 23 Feb.

Herr, M., Arvieu, J. J., Aegerter, P., Robine, J.-M. and Ankri, J. (2014). Unmet health care needs of older people: prevalence and predictors in a French cross-sectional survey. European Journal of Public Health. 24(5), 808-813.

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Lubitz, J. Cai L., Kranarow E. and Lentzner, H. (2003). Health, life expectancy and health care spending among the elderly. The New England Journal of Medicine, 349, 1048-1055.

Mizrahi A. and Mizrahi A. (1994). Etat de santé, vieillissement relatif et variables socio-démographiques. Enquête sur la Santé et la Protection Sociale 1988-1991. Paris: CREDES, nº 999.

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Robine, J.-M. and Cambois, E. (2017). Estimation de l’espérance de vie sans incapacité en France en 2015 et évolution depuis 2004 : impact de la diminution de l’espérance de vie en 2015. Bulletin Epidémiologique Hebdomadaire (16-17), 294-300.

Sauvy, A. (1928). La population française jusqu’en 1956, essai de prévision démographique. Journal de la Société de statistique de Paris, 1928(12), 318-331.

Table des illustrations

Titre Figure 1 - Life expectancy at age 65 (women). Comparisons 1980-2014/15
Crédits OECD Data
URL http://books.openedition.org/cidehus/docannexe/image/8378/img-1.png
Fichier image/, 7,6k
Titre Figure 2 - Increase in life expectancy at age 65 (women, %)
Crédits OECD Data
URL http://books.openedition.org/cidehus/docannexe/image/8378/img-2.png
Fichier image/, 6,0k
Titre Figure 3 - Changes in the threshold of old age (France)
URL http://books.openedition.org/cidehus/docannexe/image/8378/img-3.png
Fichier image/, 6,0k

Auteur

Ecole des hautes études en sciences sociales (EHESS), Paris

Patrice.Bourdelais@ehess.fr

© Publicações do Cidehus, 2019

Conditions d’utilisation : http://www.openedition.org/6540