Transcript of Federal News Service (Continued)

Senator Carper.

SEN. CARPER: Thanks very much.

I just want to start off by asking is it Mr. Boettke or Dr. Boettke?

MR. BOETTKE: I'm Dr. Boettke.

SEN. CARPER: Dr. Boettke, okay.

Is it Dr. Hodes? Hodes, all right.

Dr. Gingrich? All right. (Laughter.) I --

SEN. STABENOW: I'm not Dr. Stabenow.

(Laughter.)

SEN. CARPER: It could be, Mr. Chairman.

Let me ask Dr. Boettke and Dr. Hodes to just respond to a couple of things that our former speaker has talked about. First of all, let's just take one of the issues that he raised, and that is the electronic prescribing of medication. Electronic prescribing of medication and your reaction to what he suggests: a good idea, a bad idea? Do you see any problems with it?

MR. BOETTKE: No. I mean, I think actually that Travelocity model is—seems to be a pretty interesting one. I haven't looked into it. I'd like to look into it more. I do think that the former speaker made an extremely important comment about trade and pricing and also competition, and I think he also made a very important comment --

SEN. CARPER: Let me stop you, Dr. Boettke. No, no, I want to—I'm taking a very narrow thing that he said—he was talking about.

MR. BOETTKE: Okay.

SEN. CARPER: And, Speaker Gingrich, just take a minute and tell us again what you were talking about.

MR. GINGRICH: Sure, the --

SEN. CARPER: The notion of prescribing medication electronically rather than --

MR. GINGRICH: Yeah, there are two powerful reasons you want to have electronic prescription. The first is accuracy. Doctors' handwriting is often not as clear as it could be and very small marginal changes can lead to people getting killed, which has happened last year in this city when a young lady was given 10 times the dose because they misread what the prescription should have said. So the first is an electronic prescription done on a PalmPilot or something else is very accurate.

The second is by being electronic it lends itself to measuring by an expert system to determine whether or not you're already taking a drug you shouldn't be taking. And the number of contraindications—if you go to two or three or four doctors, the chance of you getting two drugs—now, to give you an example, in Rhode Island a few years ago, 25 percent of all the emergency room visits by senior citizens was a function of being given the wrong medicine. So for both accuracy's sake in writing and for accuracy's sake in measuring against your own medical record, I think electronic prescriptions will dramatically improve the system.

And, finally, because 40 percent of all prescriptions currently require callbacks, you both save lives and save money because the pharmacist will not be calling you back and the doctor won't be wasting their time re-explaining what they'd already done.

SEN. CARPER: Dr. Hodes, your reaction to what he's suggesting?

DR. HODES: I think these are extremely good points. And, importantly, they're based not only on intuition, which would support them too, but on a good deal of testable hypothesis. And this actually is an important area of ongoing research as well, in particular with older individuals who even under best management are likely to have, as has been noted, a number of co-morbidities and face the challenge of needing medications for multiple conditions. It is a real challenge even to the most sophisticated of physicians of pharmacists to track appropriately the multiple potential interactions. And the database that is the underpinning to an electronic prescription system really allows one to address this.

But one could go still further I think on the same theme and talk about measurement of compliance, and the importance especially with older individuals with very complicated drug regimens. That can be used by providing electronic feedback not only for the prescription writing, but as well for the monitoring of prescription compliance as well. So these are important areas, important recommendations and also important areas of ongoing research to extend so further the possible application of information technology to the application of optimal therapies.

SEN. CARPER: Is there any role for the Congress with respect to this notion that Speaker Gingrich is suggesting? Is there something we ought to be doing or ought not to be doing?

MR. GINGRICH: If you'd—Senator, I think that—and here I'm a Theodore Roosevelt Republican. I believe the federal government has an absolute obligation to mandate safety and health standards. I like the idea if I go to McDonalds that the water is drinkable and the beef is actually beef. And I want the delivery system to be free market, but I want the rules of the game within which the delivery system competes to be established by the government, which was the Theodore Roosevelt breakthrough with the Food and Drug Act, for example.

I believe that the Medicare bill absolutely should have a very powerful section on patient safety, and I believe that from the Administration for Health Research and Quality, from the National Institutes of Health, from the Institute of Medicine, from the Food and Drug Administration you can pull together a set of recommendations. And I also believe that institutions like AARP would be very supportive of establishing a higher standard for the country on computerized order entry of drugs which will save a substantial number of lives, on electronic prescriptions, on a number of other steps that could be done so that you could require, for example, that within three to five years every hospital in the country would either have an intensivist onsite or an electronic intensive care unit. There is no question this saves lives.

And these are things that are not going to happen for a practical reason inside the current system. No hospital administrator can take on their doctors when their doctors are the primary source of the patients for their hospital. And so the system is just grid locked today. And in some cases we ought to have federal funding, different topic.

Some day I would argue that the biological threat to this country is four time as great as the nuclear threat and that we should have the equivalent of Eisenhower's interstate highway system as an investment in Internet technology for biological survival in a real threat. So some places I'd have the federal government involved. In rural areas I'd look at some things that need to be done differently. But on balance, this bill should not leave the House and Senate without a very strong patient safety component that includes these kind of breakthroughs.

And, by the way, the best people I talk to believe this bill will actually cost less than the current system if you do it right, and that it will not cost more. Now, whether we get CBO to score that is an argument I've having with CBO. But if you look at the scale of the breakthroughs with co-morbidity management, with electronic prescriptions, with computer order entry, with an electronic health record, this should be a less—a substantially less expensive system than it is today.

SEN. CARPER: I'm just wondering, Mr. Chairman, if we've got a patient—and one of our witnesses talked about an elderly person who may be seeing a variety of doctors, taking a multitude of prescription medicines or non-prescription medicines, whose job is it to oversee the entire regimen, the entire medical—medication, if you will, that a person is taking? If you're seeing, again, a variety of physicians and taking a variety of medicines, whose job is it? I think—Newt, I think you said if you deal with—talking about co- morbidity, if you deal with the person in the totality, who is the "you?" Who is the "you?"

MR. GINGRICH: Well, Lois Quam, who is the head of a major subsidiary of United Health and one of the smartest health managers in the country, has testified and has worked with staffs on the Hill on co-morbidity management and absolutely believes—and she helped to develop the Evercare model I described earlier, which literally currently saves the federal government money, improves the quality of life for senior citizens and is stunningly effective. Now, she absolutely believes you can build a system.

In the end you want doctors and patients to be in charge, not bureaucrats. But you want to build systems that make that easy, and you want to build incentive that make that easy. And I think there's a growing belief that you could have an intelligent co-morbidity management system that would, again, be part of an electronic health record, because if you don't have that you can't make it work at a practical level.

I mean, I was—when my mother first went into long-term care I was stunned to realize that she was taking at one point 17 different medications from three different doctors, none of whom looked at her total record. I mean, it was breathtaking and these are—but CMS today, it does not design the incentive system, doesn't design the payments, doesn't design the structure. And I think that there is some obligation on the government to think through how you design the structure to empower the doctor and the patient to have this kind of intelligent capability.

SEN. CARPER: Mr. Chairman, I'll just say one other thing. I'm reminded a little bit in this discussion with respect to co-morbidity management of an earlier witness that we had before us on a similar subject—a closely related subject, and I'm reminded of some work that's being done within the Democratic Leadership Council on this issue, I think some very good work. And one of the things—I look for issues and ways that we can work together to face our challenges and, God knows, we've got a huge one with respect to healthcare costs and healthcare cost containment and better outcomes.

And I think that with issues like co-morbidity management, electronic prescribing of drugs, electronic patient records, that's a minefield that's well worth mining. And we've not been able to get into issues of privacy concerns, but I've heard some of those raised. And I can't stay any longer but I just would note for the record that I'm encouraged by the conversation we've had here, Mr. Chairman, and somewhere along the line we need to have a further discussion on privacy. Thank you. Nice to see you all.

SEN. CRAIG: Dr. Boettke, I have I guess one last question to ask of you. I could ask many more, but we're running out of time this morning. But when we talk about longevity we're not just concerned about making sure people live longer lives. In this country it's longer lives and a better life in that longer life. And you talked about the comparatives you've looked at in a market-driven system or a—if you will, a free system, open free enterprise system that tends to do that. How does—what are the conclusions you draw? Why is this happening where it is not happening elsewhere?

MR. BOETTKE: Well, as our economic wealth increases we end up by having more array of choices in our life. We can live different types of life, each to our own in some sense. Our wealth enables us to engage in more leisure. If we look at how much leisure we can enjoy today versus how much leisure our ancestors, our grandparents or whatnot could enjoy, look at various different technological innovations that have been driven by market.

Say, for example the—even the invention of the electric light, which enabled people now to enjoy a personal life at home, work hours and whatnot, how much time we have to spend in order to generate a house. Even given the rise in housing prices, the real amount of work that we have to expend now in order to purchase a house versus what our grandparents did. The market society has generated tremendous amounts of wealth, which enable us to enjoy the fruits of a productive life. So as we get older we also want to have more fruitful lives, more meaningful lives that we can live out. And the wealth that's generated by a market society actually provides that for us.

And what I was going to say before was that I thought that a point that Mr. Gingrich raised before in his original comments about the Europeanization of America in certain public policy issues—that is, when you go around the world you see problems with pensions, problems with healthcare, problems with unemployment, I would also add problems of environment in the transition economies and the developing economies. The very policies that a lot of these countries pursue are the things that don't allow them to fix those problems. And the last thing that we should engage in is trying to engage in the Europeanization of the American system, which would in fact generate our problems with—or exacerbate our problems with our healthcare system and our unemployment problem.

And so, I mean, to conclude I just think that what we need to do is make sure that we follow smart public policies which generate or free up individuals to bet on ideas, find the financing to bring those bets to life and to allow our economy to grow. And with that you'll end up by having people being able to expend more of their money on leisure, on the environment, on living better lives as we extend our lives through these benefits of innovation.

SEN. CRAIG: We think that's probably a pretty good thought to end this panel on. So thank you, gentlemen, all very much for your participation today.

Newt, I'll look forward to getting a copy of that book. Ah, there it is. Okay. Hand delivered, that's even better. Gentlemen, thank you.

Thank you all much. We would ask our second panel to come forward please.

Newt, if we could get you to move to the back of the room, thank you, we'll get our next two panelists up.

Well, gentlemen, thank you very much for being with us today. You can see by the tone of our first panel some of the energy and the excitement that's going on out there. And, of course, our great concern that as we craft public policy in these areas that we do it right, so that we don't stifle any of that which is moving in the market today, and at the same time accomplishes something that our society can afford. So with this second panel, Stephen Goss, chief actuary at the Social Security Administration. Stephen, we thank you for being with us.

And Dr. James Vaupel. Dr. Vaupel is director of the Max Planck—I'll let you pronounce that, Doctor—Institute of Demography in Germany and senior researcher with the Terry Sanford Institute of Public Policy at Duke University. Doctor, thank you very much.

Steve, we'll turn to you first for your testimony. Thank you.

MR. STEPHEN C. GOSS: Thank you very much, Mr. Chairman. It's a pleasure to be with you today. During the last century, human longevity has literally exploded as much of the world has become industrialized. Productivity and income rose to unprecedented levels, permitting vast improvements in the standard of living. Innovation in agriculture permitted adequate nutrition for whole populations. Innovation in engineering resulted in sanitary and safe living and working conditions, and innovation in medicine has resulted in immunizations and antibiotics that could be provided through primary medical care to all within these populations.

In recent decades Europe, North America and Japan have experienced great increases in life expectancy at age 65, averaging nearly one year of increase per decade. Some countries have risen faster, most notably Japan, and some slower. The United States has been about average in this group, as you can see in the first chart. The average increase for the United States over the last three decades has been a little bit less than one year per decade.

Each year the Social Security trustees report to the Congress on the actuarial status of the Social Security Trust Fund. This assessment depends critically on assumptions about the future course of longevity in the United States, among other variables. How good have these projections been in recent years? The second chart indicates that the period life expectancies projected as of 1983 and 1992 in these reports for the year 2000 were pretty accurate. If anything, projections in 1983 were a little bit optimistic, slightly overstating the life expectancy for 2000, particularly for women. This is true both for life expectancy at birth and life expectancy at 65.

For the future, mortality at higher ages is what we pay most attention to. Three-fourths of all deaths now occur in the United States at ages 65 and above. Chart three shows that in 1900 less than one-fifth of all deaths were at age 65 and over. Advances in infant mortality and reduction in mortality rates at ages below 65 have been dramatic during the past century. Rates of improvement in mortality for the total population, men and women combined, is shown in chart six. In the interests of time I won't talk much about charts four and above for men and women separately. The average annual decline between 1900 and 2000 for the age group 65 and over of a little over seven-tenths of 1 percent is about twice as large as experienced during the most recent 18 years of this period in the United States.

Going forward, we believe that achieving mortality improvement for the aged at about the same rate as we averaged for the entirety of the last century is reasonable, and this will be no small assumption to achieve. Matching the accomplishments of the last century with the pure positive effects of improved sanitation, nutrition, medical accessibility for all will not be easy. AIDS, SARS, antibiotic- resistant microbes, along with increasing obesity and declining levels of exercise in the United States remind us that mortality improvement will not be automatic. There are forces that operate in the opposite direction.

For ages under 65 there is some agreement that mortality declines will diminish—the rate of decline will diminish from the level of the last century. The 1999 technical panel appointed by the Social Security Advisory Board endorsed the trustees' pattern of relative rates of improvement by age group. Moreover, the rate of improvement has diminished for this age group under 65 through the last century with slower average rates for the last 50 years and for the last 18- year period.

Implications for the cost of social insurance. Social Security, as well as Medicare, but Social Security benefits are indexed to reflect the average wage growth and price inflation, and thus are relatively insensitive to variation in these parameters. However, there are no automatic adjustments in the Social Security program for changes in demographic parameters. The drop in the United States birth rate that started in the 1960s will increase the age of dependency ratio shown in chart seven between 2010 and 2030. Continued increase in this ratio after 2030 reflect the more subtle but steady effects of increasing longevity.

Increases in this ratio of aged population to working age population translate directly to increases in the number of Social Security beneficiaries per worker covered under the system, shown in charge eight, and the program cost expressed as a percentage of the taxable payroll, shown in chart nine. Continued increases in human longevity will require change for the Social Security program. We've known this truth for many decades. It was even evident in the projections developed and presented in the 1983 trustees' report to Congress that was produced right after enactment of the last major Social Security reform legislation.

How quickly longevity will increase is the subject we will continue to debate and observe. The trustees' track record over the last 20 years has been pretty good. We believe that the current assumption of a return to the remarkable rate of longevity increase experienced during the 20th century as a whole for aged Americans provides a sound basis for assessing the actuarial status of the Social Security program. Thank you again for the opportunity to come today and I look forward to your comments and questions.

SEN. CRAIG: Steve, thank you. And it is Goss. Is that correct?

MR. GOSS: That's correct.

SEN. CRAIG: I apologize.

MR. GOSS: It's okay.

SEN. CRAIG: Doctor, welcome.

MR. JAMES VAUPEL: Thank you. Mr. Chairman, is life expectancy approaching its limit? Many believe it is, but the evidence suggests otherwise. Consider an astonishing fact: life expectancy in the record holding country has risen from 160 years at a steady pace of three months per year. In 1840 the record was held by Swedish women, who lived 45 years on average. Today among nations, the longest expectation of life, just over 85 years, is enjoyed by Japanese women. There is no evidence of any slowing of this long-term rise in best practice life expectancy.

From 1900 to 1950 life expectancy increased rapidly in the United States, as Steve mentioned, and mid-century U.S. life expectancy was only a few months less than the highest life expectancy anywhere in the world. As recently as 1979 the U.S. disadvantage was only two years. Among people 80 years old and older, survival was better in the United States than anywhere else, a lead the United States held until 1992. But health progress in the United States has slowed, especially over the past decade or two. Other countries have caught up and surpassed us. Today, U.S. life expectancy at birth is six years behind the record. In many countries, including Japan and France, people of all ages, from the very young to the very old, enjoy better survival chances than in the United States. The United States is the world's leader in so many things that it is surprising and disturbing that the U.S. has fallen so far behind in the matter of life itself.

The Social Security Administration forecasts that improvements in U.S. life expectancy will continue to be very slow. This implies that the life expectancy gap between the United States and Japan, between the United States and France, between the United States and almost all other advanced countries in the world, will continue to widen by one or two months per year. Consider the situation in 2050. A half century may sound distant, but a majority of the people currently living in the United States will still be alive

The Social Security Administration's latest forecast, the 2003 forecast, is that female life expectancy in the United States will gradually rise from 79.5 years today to 83.4 years in 2050. This level, half a century from today, is less than current female life expectancy in Japan and in France and in many other countries, and it is 13 or 14 years less than likely Japanese and French female life expectancy in 2050.

The prediction for France and Japan and other countries is uncertain, but most of the uncertainty is on the upside. Breakthroughs in biomedical research could lead to even higher life expectancies, as the speakers in the previous panel emphasized. There's an enormous contrast between the optimism of the previous panel and the pessimism of the Social Security Administration.

Is it realistic to assume that the United States will fail to catch up in half a century with expectations of life already exceeded in Japan and France? Is it realistic to assume that the United States will fall more than a decade behind Japan and France? Market economies around the world are tightly interconnected. Research, ideas and innovations quickly spring across national boundaries by the Internet, as discussed earlier. The United States will, I am confident, reduce the health disparities, implement the healthcare and health promoting innovations and make the research investments needed to halt the widening life expectancy gap and then to reduce it.

A crucial first step is to figure out why the United States is falling further and further behind. There are guesses, there are assertions, but there are no persuasive findings. This is something that the Social Security Administration should be worrying about. This is something that the National Institute on Aging should be funding more research on. A larger concerted, more focused effort is needed on why the United States is falling further and further behind other countries in life expectancy. Many people believe that little or nothing can be done about health at older ages. This is nonsense. Mortality and many kinds of morbidity in older ages have declined remarkably over the past half century.

East Germany, where I now live, offers a dramatic example of how much can be done to improve the health of the elderly. Under Communist rule, older East Germans suffered poor health and short lives. Today, a mere decade after the fall of Communism, older East Germans enjoy the same high level of health and longevity as West Germans. In one decade. The number of centenarians over this decade has tripled. These people were around 90-years-old when Communism fell, but even at their advanced age they were able to benefit from a Western economy and healthcare system.

In sum, given intelligent economic and social policy and continued investment in research, longevity and healthy longevity will dramatically increase in coming decades. This is not a problem, it is a great achievement, but it will result in challenges for policymakers, especially concerning Social Security. Thank you.

SEN. CRAIG: Well, thank you, Doctor. Gentlemen, thank you. What do I say? Well, maybe I say it this way: both of you have two substantially different points of view as it relates to protection of U.S. longevity. So at the risk of starting a gentlemanly argument, let me ask each of you to identify the limitations of your colleagues' evaluations.

Steve?

MR. GOSS: Thank you very much. Well, first of all I guess I'd like to just suggest that I would like to characterize the difference in our views as not being one of optimistic versus pessimistic, but of being optimistic and more optimistic. I think clearly --

SEN. CRAIG: (Laughs.) Right.

MR. GOSS: -- that a --

SEN. CRAIG: A better way of putting it, yes.

MR. GOSS: That a continuation of the rate of improvement in mortality at age 65 and over into the next century at rates that were experienced on average during the past century is perhaps even bold. It's dramatic and --

SEN. CRAIG: Yeah, I'm fairly optimistic about those rates on behalf of myself.

MR. GOSS: And we all want --

SEN. CRAIG: I don't want to move to Japan.

MR. GOSS: -- that to happen.

SEN. CRAIG: Or change gender.

MR. GOSS: But I think it's important to keep in mind the kinds of changes that occurred during the past century, the pure positive effects that they had. The optimism that we had on the prior panel about some of the science and technological changes that we will have in the future is real. The real question on those changes is the rapidity and the speed with which those will be realized, they will be developed and they will be able to be brought to the population as a whole, and the extent to which they will be pure positive effects on our population and its longevity versus effects that will have some good points and some bad points. Improved nutrition, improved public safety, better drinking water, better sanitary conditions have no downsides. Many technological breakthroughs may have some downsides and it may take us decades to really bring them to the population as a whole.

But, if I could, what I would like to do in answer to your question is address a couple of technical points about Jim's very, very creative and very insightful sort of description which he included in the chart included in his handout. This idea of looking at best nations practice over about the last 150 years is very intriguing, and I'd suggest there are a couple of technical points that are worthy of consideration on that. During a fairly substantial portion of this period between 1880 and just short of 1940 the points on the curve which are shown in Jim's more expanded technical article were the result of data from one particular area of the world, which in fact was not even really a complete nation—it was a portion of New Zealand, if I recall correctly—and there's a very long period of almost 60 years in which maintaining this linear pattern is dependent upon the data from that area.

Some demographers we've talked to have suggested that if you did not have that portion of New Zealand supporting the linear trend during that fairly long period and you had some lower numbers for some of the other countries, you would in fact uncover a trend that in fact showed relatively slower improvement in best nation mortality in the latter portion of the last century and the very early portion of the century, than with the sudden explosion in the rate of improvement in mortality during the first portion to the middle portion of this century. It would also suggest that this curve, rather than being a line that might extend indefinitely, would be a line that had a more gradual slope for a while, then went up very rapidly in the middle portion of the century, and maybe moving towards the shape of what we sometimes call sort of an "S" curve, with a little bit of a flattening. I think this is a very possible scenario and many demographers believe that that may be really where we're headed.

The other technical aspect that I would suggest on this, and Jim is right in saying that we're, in a sense, grasping at straws and dealing with impressions and views on this. But I would like to suggest sort of a different sort of possible interpretation, which I think has just as much chance as validity, and that is that there is differentiation amongst nations on the basis of lifestyle, diet, the nature of populations, in terms of the potential longevity that they might have given access to what is currently available in medical technology and other technologies. I think this is probably fairly evident. Right now the United States, many European countries and Japan have reasonably well accessed most of what is available in terms of technologies, and yet we have quite a large difference in longevity. So there really are some sort of differences that are not immutable, but some fairly strong differences amongst nations based on lifestyle and diet and other aspects of the population.

That being the case, when we look at this progression of best nation achievement of mortality, the sequencing through time of which nations have availed themselves of the current state of technology is really critical. Japan, it might be argued—and people from Japan believe that this is perhaps the case because of the nature of their lifestyle, multigenerational families instead of people going to nursing homes, for example—believe that there are probably some inherent advantages that Japan has over some of the other countries listed in this progression. The fact that Japan post World War II, only in that timeframe, began to avail itself of many of the technologies that other countries had availed themselves of earlier may explain why Japan has simply risen to the level it's at later on. The data we've seen suggests that in the last 10 or 20 years, and I think Jim would concur with this, there has been some deceleration in Japan and likely there will be some more in the future.

So I guess our suggestion is that we should be cautious in over interpreting this progression of a sequence of nations. This is not a single population or a single nation we're looking at a trajectory, but really just a growth rate that has occurred by piecing together a number of nations which have very different characteristics.

SEN. CRAIG: Doctor?

MR. VAUPEL: Well, let me respond to that. First of all let me say that I have the highest respect for Steve Goss, who's a really excellent actuary, but I disagree with him and I think some of his facts are incorrect. First of all, matching the accomplishments of the last century is not what the previous panel talked about. The previous panel talked about the accomplishments of the last century being matched in 20 to 25 years. I think that's much more realistic.

Secondly, matching the accomplishments of the past century is not a very high aspiration when it comes to reducing death rates for elderly people. The mortality fell in the first part of the last century because of a reduction in infant and child mortality, and only in the last part of the last century, in fact only in the last 30 years, have death rates started to fall for older people, in part because of the research that's being done on aging. So matching the accomplishments of the last century in terms of older people is not a high aspiration. It's certainly not a high aspiration compared with the 20 to 25 years of the last panel.

Secondly, Steve is factually incorrect about the straight line that I show of life expectancy increase. In this Science magazine article we point out, and have in the appendix a diagram saying that if you look to the second best country you have the same pattern, if you look at the third best country you have the same pattern. If New Zealand never existed you have the same pattern. In fact, if Japan never existed you'd have a very similar pattern in recent years. This is not some outlier that's driving the whole curve. This is the rate of improvement in the countries that are doing best.

Thirdly, we don't have to make any forecasts to be concerned, we can look at historical facts. And the historical facts are the United States is falling behind. There's no argument about that. In 1979 the U.S. life expectancy --

SEN. CRAIG: Do you both agree on that point?

MR. VAUPEL: Yeah, right? There's no argument.

SEN. CRAIG: I saw your head --

MR. VAUPEL: The United States is falling behind.

MR. GOSS: That's true. But I would suggest that, of course, the United States is not alone in that regard and it may be a question not so much of the --

SEN. CRAIG: I'll let you pursue that when you complete your thought there, because --

MR. VAUPEL: The United States is falling behind. We were two years behind the record in 1979. We were close to the record in 1950, two years behind in 1979, and we're six years behind today. And this is not because of—I mean, life expectancy in the United States is partly due to mortality at younger ages, but our falling behind is largely due to the fact that we're making very little progress at older ages.

And, in fact, I'll give you an amazing fact: native-born white females, you don't ordinarily think of them as a disadvantaged group. But native-born white females, there's been no improvement in mortality for this group in 20 years. Life expectancy—at older ages. Life expectancy at age 80, for example, for this group is identical to what it was in 1982, 20 years ago. So the United States is falling behind at older ages. The Social Security Administration assumes the United States is not going to catch up, the gap is going to continue, and I just don't—I don't see any logic behind that.

SEN. CRAIG: Okay.

MR. GOSS: I guess I'd like to suggest that one way of looking at this is that the United States has been falling behind, and it certainly has. But another way of looking at this is that many other nations, for instance Japan, that may have certain advantages in terms of the lifestyle and diet have simply been asserting themselves and moving ahead to positions in terms of life expectancy which perhaps are appropriate and should be expected. I don't think that we can expect homogeneity across all nations in terms of life expectancy.

I could not agree more with Jim that the last 20 years have been very, very bad. In fact, shown right on our charts—which are not up there now but you have in the handout. On our chart number five you will see exactly what Jim was talking about: mortality improvement for females over the past 18 years has been zero, and this is why we have, in fact, really rejected the rate of improvement in mortality over the last 20 years and have looked at much longer periods, as has been suggested by a number of other demographers like Ron Lee (ph), that we should be looking at longer periods. Is it possible that we will, in fact, have much faster rates of improvement than suggested in the trustees' intermediate assumptions? Absolutely. We have alternative assumptions that incorporate this.

But I would just suggest one other point, and that is the prior panel was talking about having perhaps in the next 25 years the possibility of having technological and medical advances that would rival what we had for the entire past century. That certainly is possible. It's also possible that we will not have the ability to bring these breakthroughs fully to the whole population and be able to afford bringing them to the whole population.

And the other point I think to keep very much in mind is that technological breakthroughs and medicine are not the whole story of the last century. Even if we do achieve the impact of medical technology breakthroughs that we had in the last century entirely in the next 25 years, there are so many other things like the improvements in nutrition and sanitary conditions that had major impacts in the last century, especially in the first half of the last century, for the United States that would also need to be duplicated in order to even match the rate of improvement during the next century.

We are optimistic. Some are more optimistic, obviously. But I think the numbers that the trustees have, which have actually been increased fairly substantially in the last five years in their projections, are reasonable. I'm not sure Jim would contend that, and I would also not contend with him that there is a very distinct possibility that improvement might be substantially faster.

SEN. CRAIG: Well, Dr. Vaupel suggests that officials responsible for health and social policies believe that life expectancy is approaching its limit. Do the folks over at the Social Security agree? I mean, do the trustees—are they one of those institutions that agrees with that figure?

MR. GOSS: Absolutely not. And fortunately Jim clarified that point for me when we were talking before the hearing started. I think he was referring perhaps to officials in some other countries. But as Jim is well aware, and a lot of people are in this room, the trustees have now for decades been projecting continued mortality improvement indefinitely into the future. We've never ever assumed or projected that there is a limit to the maximum life expectancy that would be --

SEN. CRAIG: Did I misstate your comment in relation to that question?

MR. VAUPEL: Yeah.

SEN. CRAIG: Would you like to clarify that, please?

MR. VAUPEL: Steve Goss is absolutely correct that many countries and many agencies that do forecasting, including the United Nations, assume some limit, but the Social Security Administration does not. But the Social Security Administration assumes a very slow increase. No limit, but a slow increase.

SEN. CRAIG: You talk about the United States falling behind based on your observations. There's been some comment about why this gap might exist. Are there any other conclusions drawn as to what attributes to the gap?

MR. VAUPEL: You know, Mr. Chairman, I'm—as a demographer I'm very embarrassed to tell you that I don't know what is causing this gap. And I'm actually deeply grateful to have been invited by you to testify today, because it started me to think about this. I previously hadn't—I'd know about this but I hadn't thought about it. I was afraid that you might ask me what is the cause of this increasing gap, so I tried to do some research to find out if anybody had done any persuasive fact finding about this, and there's really very little information.

The fact that I gave you before just astonished me that native- born white females have made no progress in 20 years, despite the fact that we have a very good medical care system in this country, a very expensive medical care system, because—as you mentioned before, because of Medicare and because of Medicaid and other federal programs and state programs, there's universal access. We should be doing very well. And you can think of reasons why—you might think of reasons why immigrants or males or minority groups might not be doing so well, but they're actually doing better than native-white born white females, so it's a real mystery.

And the National Institute on Aging, the Social Security Administration, the community of demographers should really start worrying about this. What's going on? What's happening when the United States is doing so well on so many fronts but is falling further and further behind on this critically important—you know, life itself they're falling critically—falling further and further behind.

SEN. CRAIG: Do you wish to make any comment on that?

MR. GOSS: I agree with Jim completely that we absolutely wish we knew more about this and had definitive answers. There have been suggestions of the possibility that female mortality has improved more slowly over the last 20 years perhaps because women have increased the extent to which they're smoking in absolute terms and relative to men, that women have been getting involved in behaviors in the workplace more to the extent that men have and have perhaps have been exposing themselves to --

SEN. CRAIG: I've read articles on that --

MR. GOSS: -- more and more stress.

SEN. CRAIG: -- and that argument is placed.

MR. GOSS: And there may be validity to that and there may not. We really don't have definitive answers as yet.

SEN. CRAIG: Okay. Doctor, you made observation living in East Germany that East Germans had rapidly caught up with West Germans as it relates to longevity. This is a little outside where this committee is going, but I'm curious because looking at the other panel and some of their work, and we look at market and marketplace and free market and wealth and you heard one of our first panelists talk about those relationships, the Soviet Union moving into a more market- oriented economy, and yet it has not improved the longevity of its citizenry. I guess—I think the answer is obvious to me, but I'd like to hear it from you. Is it because the East Germans had the opportunity to immediately associate with the healthcare system from West Germany and incorporate that into a whole government, if you will, and a whole system and a whole healthcare delivery program, whereas Russia has not?

MR. VAUPEL: You know, I think both factors have played a role. Following reunification, the West German healthcare system was extended to East Germany, nursing homes were established. There had not been nursing homes before, there had been hospital wards for older people.

SEN. CRAIG: Right.

MR. VAUPEL: This made a big difference. Modern medicine was available and the system whereby the government helped pay for medical care and medicine was implemented. But in addition, the older people in East Germany started to receive West German pensions, and older people in East Germany started to be able to buy fresh fruits and vegetables. You know --

SEN. CRAIG: It was a matter of income?

MR. VAUPEL: There was a higher income, there was a market --

SEN. CRAIG: Good supply.

MR. VAUPEL: -- economy established that let older people buy the things that they wanted and needed that made life better for them, that let them eat better, that let them live better, let them heat their houses better and so on. So I think it is a mixture of both economic progress and a better medical system.

SEN. CRAIG: Okay. Well, thank you.

Gentlemen, thank you very much for your testimony this morning. I think it is extremely valuable for the record and for what we are attempting to build here in this committee for Congress to look at. We do appreciate it. It is a fascinating topic that we better understand reasonably well, based on how we're trying to shape public policy and public programs at this moment. Failure to recognize it or misjudge it can be either expensive or certainly troublesome and a problem for our country. We thank you very much and the committee will stand adjourned.