The politics of healthy ageing: myths and realities

The economics of healthy and active ageing series The PoliTics of healThy ageing Myths and realities Scott L Greer Julia F Lynch Aaron Reeves Minakshi Raj Jane Gingrich Michelle Falkenbach Jonathan Cylus Clare Bambra Keywords: Aged Aged, 80 and over Aging Healthy Aging Health Care Costs – trends Health Services for the Aged – economics Health Policy – economics Long-Term Care – economics © World Health Organization 2022 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). All rights reserved. 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However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. 1Editors Jonathan Cylus Charles Normand Series Editor Jonathan Cylus Charles Normand Josep Figueras Managing Editors Jonathan North Lucie Jackson The authors and editors are grateful to the reviewers who commented on this publication and contributed their expertise. Authors Scott L Greer – University of Michigan* Julia F Lynch – University of Pennsylvania Aaron Reeves – University of Oxford Minakshi Raj – University of Illinois Jane Gingrich – University of Oxford Michelle Falkenbach – Cornell University Jonathan Cylus – European Observatory on Health Systems & Policies Clare Bambra – Newcastle University * corresponding author: slgreer@umich.edu The Politics of Healthy Ageing: Myths and realities Print ISSN 1997-8065 Web ISSN 1997-8073 Contents page About this brief / About the series 3 Figures and boxes / Acronyms 4 Key points 5 Executive summary 7 Policy brief 9 1. Introduction: why this brief? 9 2. Myths of ageing and health 11 3. Designing win–win policies and politics 20 4. Conclusion: Getting to win–win policies 25 References 27 2 The Economics of Healthy and Active Ageing About this brief Research from the European Observatory’s Economics of Health and Active Ageing series finds overwhelmingly that population ageing is not a major problem for the sustainability of health care systems or societies. So why is it so often treated as a threat? This brief draws on a book presenting and synthesizing the international evidence on this question. It first identifies three myths that are widely influential in debates about ageing. The myths are that ageing societies are fiscally unsustainable, that older people prefer better benefits for themselves at the expense of younger people, and that politicians give older people what they want – benefits for older people at the expense of younger generations. If these myths were true, there would indeed be a major crisis in the increasing number of ageing societies. The brief and research discussed in it find that none of these three myths is true. The brief then reviews evidence on the possibility of ‘win–win’ politics that produce good outcomes for people of all ages. In terms of policy design, this means focusing on life-course policies. Life-course approaches have extensive implications for policy because they suggest ways to make policies that invest for the future at every stage of people’s lives. They also have distinctive politics because they ask for political leaders, interests and advocates to form coalitions among different groups that mutually benefit from the same policies. The brief concludes with lessons on ways to develop political coalitions in support of life-course policies. About the series Population ageing is often perceived negatively from an economic standpoint. Yet taking a more balanced view, it becomes evident that a growing older population is not necessarily very costly to care for, and that older people provide significant economic and societal benefits – particularly if they are healthy and active. This is the broad perspective of the Economics of Healthy and Active Ageing series: to inspire a ‘rethink’ of the economic consequences of population ageing. In this series we investigate key policy questions associated with population ageing, bringing together findings from research and country experiences. We review what is known about the health and long-term care (LTC) costs of older people, and consider many of the economic and societal benefits of healthy ageing. We also explore policy options within the health and LTC sectors, as well as other areas beyond the care sector, which either minimize avoidable health and l LTC costs, support older people so that they can continue to contribute meaningfully to society, or otherwise contribute to the sustainability of care systems in the context of changing demographics. The outputs of this study series take a variety of brief formats that are accessible, policy-relevant and can be rapidly disseminated. 3The Politics of Healthy Ageing: Myths and realities Figures and boxes Figures Figure 1: The share of the population aged over 65 and 80 years in the OECD will increase significantly by 2050 9 Figure 2: Men and women in many countries spend their later years in poor health 12 Figure 3: People in many countries do not retire at the normal retirement age 13 Figure 4: The share of people aged 65+ who are not able to make ends meet is substantial in many countries 14 Figure 5: Countries with less income inequality tend to have more financially secure older people 15 Figure 6: Age is associated with some voting patterns 16 Figure 7: After controlling for other factors, the relationship between age and party voting disappears in many countries 17 Figure 8: There is a large cross-sectional variation in welfare spending across countries 18 Figure 9: Poverty rates from the late 1990s to the early 2010s often changed more for working-age compared to older people 19 Figure 10: Less educated people have lower predicted odds of reporting good health at all ages 20 Figure 11: Sustained investments in health closed the gap in life expectancy between the former East and West Germany 22 Figure 12: Many countries increased welfare spending for the young or working-age populations 23 Boxes Box 1: Life-course interventions recognize that all stages of life are important and interconnected 10 Box 2: COVID-19 clearly demonstrates that not only age but also other inequalities are important predictors of health outcomes 21 Box 3: Support for health of care partners: United States examples 24 Box 4: Dutch nurses provide support to family care partners in developing key competencies 24 Acronyms GDP gross domestic product IMF International Monetary Fund LTC long-term care OECD Organisation for Economic Co-operation and Development 4 The Economics of Healthy and Active Ageing Key points People living longer is seen as a societal triumph, while at the same time population ageing is perceived as problematic. There is a belief that ageing is fiscally unsustainable, and that old people have the power to hold politicians to ransom at the expense of younger generations. This narrative paints a picture of an intergenerational conflict that only one side can win. It is not true. This brief shows that: • The politics of health and ageing vary from country to country and there are few narratives that apply consistently across Europe. • Some of the beliefs associated with population ageing are popular myths that are simply false: o There is little empirical evidence to support the claim that ageing societies’ health care systems are unsustainable. o It is equally inaccurate that older voters consistently elect politicians that support policies benefiting them at the expense of younger people. o Politicians do not pander to older voters with additional government-funded benefits. If anything, overall public expenditure in European countries is tilting away from older people and towards younger people. o Older voters are not a homogeneous group agreed on common interests; within countries they are diverse and have many different political identities and commitments. o Voter preferences rarely explain policy choices; instead, the politics of ageing are shaped by coalitions of interested parties that can support policies with mutually beneficial objectives. • These myths are created and magnified by policies and political systems, and can obscure other kinds of conflicts in the society, such as those around gender, income, wealth, nationality, ethnicity and race. • It is possible to construct politically powerful coalitions for life-course policies that invest in people’s health and wellbeing at all stages of life. Creating win–win solutions such as promoting healthy ageing can enable older people to participate in work, caring and society and benefit all groups. 5The Politics of Healthy Ageing: Myths and realities 6 The Economics of Healthy and Active Ageing Executive summary Societal ageing is often portrayed as fiscally unsustainable, creating a narrative of an intergenerational conflict over public spending priorities Ageing societies are a triumph of economic growth, health care, public health and social policy. They also create new policy conversations about how and how much policies need to change in order to adapt to societies with a higher proportion of older people. Yet, many in politics and public debate see ageing as a fiscal problem, creating unsustainable burdens on health systems and governments which require drastic actions that older voters will oppose. This is despite the lack of evidence that ageing societies necessarily create an unsustainable fiscal burden, particularly within health and long-term care (LTC) systems. Why does so much policy and political debate assume intergenerational conflict that can only be won by one side? Can this narrative be changed and how? What ageing societies mean for politics changes from country to country The politics of ageing and health differ greatly between countries. Within Europe, there is enormous variation in everything from life expectancy to the health of older people to their ability to make ends meet to partisan trends in voting. Few narratives about the politics of ageing and health work in every country. Despite this nuanced picture, several popular myths promote a single narrative of intergenerational conflict that only one side can win. These myths are false: • The myth of unsustainability: There is little empirical evidence to support the claim that ageing societies’ health care systems are unsustainable. The health care costs associated with ageing societies are relatively small and can be made smaller with appropriately recalibrated policy. In addition, older people contribute to society in many ways, including by providing an enormous amount of unpaid labour in caring roles and civil society. • The myth of the selfish generation: The belief that older people support getting more benefits for themselves at the expense of younger people is also false. Like any other group of voters, older voters are divided in multiple ways by identity, ideology, income, and other factors – they do not vote as a monolithic block. People do not automatically change their political orientations as they age. In some countries, age predicts very little about voting behaviours. In particular, there is little evidence that older voters are particularly selfish. • The myth of pandering politicians: Politicians do not pander to older voters by offering additional government benefits. Voters are downstream of a complex policy development process. The policies that voters see reflect interest groups, partisan and coalitional politics, as well as policy-makers’ understanding of needs and constraints. Policies and political systems can shape the scale of intergenerational conflict and obscure other kinds of conflict It is possible to enact policies that treat different generations differently, and policies in health and other sectors can create intergenerational tradeoffs. But they can also reduce them, and in many countries recent decades have indeed seen increased expenditure on working-age and younger people. What looks like intergenerational conflict about wealth or pensions, upon investigation, is often a more complex conflict within generations. Public expenditure prioritizing older people can coexist with considerable poverty among older people. Discussing health and social policy in terms of the age of beneficiaries obscures all manner of inequalities, including gender, income, wealth, nationality, ethnicity and racial ones. A focus on intergenerational conflict can thus disguise more important kinds of conflict and distributional decisions. Policies built on the life-course approach can benefit all generations and be electorally attractive Still, it is also possible to develop life-course policies which focus on investments that promote health and, therefore, people’s contribution to society at every age. Rather than looking for pandering politicians catering to the demands of an older people’s block vote, this brief argues that it is better to develop a supply-side approach to health politics. It is possible to forge coalitions of interest groups, parties, activists and others that invest in people across generations while offering benefits that voters find electorally attractive. The broad policy framework for developing such policies is ‘life-course analysis’, which understands policies and interventions in terms of their contribution to people during their entire lives, capturing the value of intervention at each state, whether in early childhood or in support for the healthy ageing and caring of older adults. Policies such as support for at-home care or investment in the health and social care workforce can be electorally beneficial to governments while making investments with clear benefits across generations. 7The Politics of Healthy Ageing: Myths and realities 8 The Economics of Healthy and Active Ageing 1. Introduction: why this brief? Ageing societies, a novelty in human history, are more and more common. As a result of improvements in nutrition, sanitation, work, education, gender and racial equity, and medicine, people live longer, plus birth rates are dropping in many societies (Figure 1). Longer, healthier lives are a triumph in human history, but what are their implications for health systems, economies and societies? Many observers and policy-makers, rather than celebrating, regard societal ageing as a problem and view the demands of caring for older people as a burden on the informal and formal workforces. For these observers, the triumph of 20th-century public policy in expanding longevity contains the seeds of a crisis for 21st-century social policy. This belief in the inevitability of an age-related fiscal crisis often coincides with a belief in the inevitability of intergenerational conflict over public spending priorities. Fortunately, neither belief is correct. This policy brief summarizes the implications of a larger study we conducted (Greer et al., 2021) as part of a broader Observatory programme of work on the economics of healthy and active ageing. Our motivating question is simple: Why, given that there is not much evidence that ageing imperils the financing and provision of health care, do so many policy- makers act as if it does? We break the conventional wisdom down into three myths. A first myth is that ageing leads to unsustainable health care costs, which, in turn, creates intergenerational conflict over public policy. A second myth is that older people behave as a group that pursues policies which benefit themselves. The third and final myth is that policies are mainly determined by politicians who cater to that older voting bloc. We review the evidence, showing that these claims are unsubstantiated. They nevertheless risk becoming self-fulfilling prophecies if policy creates intergenerational conflict (as has happened in pensions policy and housing policy in some countries). We then turn to three realities. The first reality is that most of the societal problems ascribed to inequality between 9The Politics of Healthy Ageing: Myths and realities Policy brief Figure 1: The share of the population aged over 65 and 80 years in the OECD will increase significantly by 2050 1 Other publications from the Economics of Health and Active Ageing project can be found at: https://www.euro.who.int/en/about-us/partners/ observatory-old/activities/research-studies-and-projects/economics-of-healthy-and-active-ageing. Source: Colombo et al., 2011. % 80+ 2010 % 80+ 2050 Japan Germany Korea Italy Slovenia Finland Austria Switzerland Spain Greece Portugal Denmark France Czech Republic United Kingdom Poland Belgium Canada Netherlands Slovak Republic OECD New Zealand Hungary Sweden Luxembourg Norway Iceland Australia United States Ireland Mexico Chile Türkiye Japan Germany Korea Italy Slovenia Finland Austria Switzerland Spain Greece Portugal Denmark France Czech Republic United Kingdom Poland Belgium Canada Netherlands Slovak Republic OECD New Zealand Hungary Sweden Luxembourg Norway Iceland Australia United States Ireland Mexico Chile Türkiye % 65+ 2010 % 65+ 2050 0 5 10 15 20 0 10 20 30 40 50 % % generations are actually problems of inequality within each generation. What looks like a problem of intergenerational inequality is often a disguised problem of intragenerational inequality. The second reality is that policies which address these broader inequalities are also often the best for addressing the specific needs of all people, irrespective of age. These policies are built on the life-course perspective, which focuses on identifying the policies that can make people happier and healthier at all ages by drawing on the context and circumstances under which ageing occurs. The third reality is that it is possible to construct coalitions of politicians and interest groups which can develop and support sophisticated life-course policies that lessen the challenges associated with ageing and poor health for everybody. It is also, unfortunately, possible to adopt policies that do create intergenerational rivalries by allocating some resources disproportionately by age, whether directly (as can happen in pensions policy) (Walker, 1990), or indirectly (as with housing in some countries) (Phillipson, 1996; Emery, 2011; Naegele et al., 2020; Sandlie & Gulbrandsen, 2021). Rather than focusing on – or creating – conflict between generations over scarce resources, life-course policies that improve the health and productivity of people at all ages are more effective ways to support health, equity and economic sustainability. We conclude that intergenerational inequality is not, and need not be, a significant problem for rich countries. It is substantially a product of current and past intragenerational inequality and, in fact, inequality between generations often goes with inequality within generations. The deceptive notion that intergenerational conflict is inevitable is a distraction that inhibits systems from adopting life-course policies that promote greater equality within and between generations (Box 1). Talk of an ageing crisis is frequently just another version of longstanding arguments against public social investment from the cradle to the grave. 10 The Economics of Healthy and Active Ageing Box 1: Life-course interventions recognize that all stages of life are important and interconnected If the goal is healthy ageing, then policies and initiatives must encourage the healthy development of the individual across the course of one’s life (the ‘life course’) so that human capital can be accumulated and maintained. A life-course approach is a complex and multifaceted process. More importantly, it is being used as a theoretical platform to study the unfolding of life patterns over time (Kuh & Ben-Shlomo, 2004). Taking a life-course approach implies recognizing that all stages of life matter and are interconnected. Specifically, early developmental processes and environmental surroundings strongly impact an individual’s peak health capacity and overall wellbeing. Research has found that an individual’s rate of decline in capacity, specifically with age, is not solely dependent on current health status, rather on the peak capacity attained early in life (Kuh et al., 2014). Thus, interventions using a life-course approach aim to maintain peak capacity for as long as possible and, perhaps more importantly, to minimize the early decline of that capacity (Jacob et al., 2019). The key in creating policies based on a life-course approach is to help individuals maintain the highest possible level of functional capacity through all stages of their life while reducing inequalities not only amidst gender and classes, but also between generations. 2. Myths of ageing and health Societal ageing is often portrayed as unsustainable, creating a narrative of an intergenerational conflict over public spending priorities One influential school of thought sees the crisis of the welfare state as a product of its triumph. Advanced welfare states have made ageing societies possible, but at the cost of increasing pension and health care costs, which undermine the long-run sustainability of these same systems and the broader economy. According to this view, however, cutting public expenditures is politically difficult because older people mobilize to keep their public benefits and oblige politicians to keep providing them. The political theory is very simple: in 2004, the International Monetary Fund (IMF)’s World Economic Outlook listed the years in which older voters would make up more than half of the electorate in different countries and captioned it “The last train for pension reform leaves in…” (International Monetary Fund Research Department, 2004; Figure 3.12). After that, said the IMF, in “many countries the elderly may soon represent the majority of the voting public, making it harder to implement reforms that adversely affect them” (International Monetary Fund Research Department, 2004; 165). Arguments behind this intergenerational conflict are persuasive but they rest on assumptions that are unsubstantiated myths It seems persuasive enough. Arguments in this vein emphasize how rising health care costs, combined with a shrinking number of productive workers, will leave governments with less revenue generated through taxation and possibly without the workforce needed to care for older people. The feared result: a zero-sum game in the present where one generation’s gain is another one’s loss, and everybody is worse off in the long run. This thinking is common, but it is built on three wrong assumptions. To claim that supporting older people equitably today comes at a cost to our collective futures assumes: (1) there is a necessary tradeoff between age- related expenditure on health and expenditure on other priorities; (2) older voters vote based on homogeneous interests shaped by their age as opposed to other issues such as wealth, gender, race, education, ethnicity, religion, geography, or even diasporic ties; and (3) that politicians deliver policies in response to their interests. A considerable amount of work has gone into making this case, most of it in the politically tendentious ‘public choice’ or ‘intergenerational accounting’ schools (Cooper, 2021). The following section explains why each of these assumptions is flawed. 2.1 The myth of unsustainability: Are ageing societies facing a crisis? The common belief that population ageing is fiscally unsustainable is not supported by the evidence It is conventional wisdom that population ageing poses a substantial cost burden for health systems. The European Observatory on Health Systems and Policies initiated a study series on the Economics of Healthy and Active Ageing, which investigates key policy questions associated with population ageing. The series examines the evidence regarding older people’s health and long-term care (LTC) costs and many of the economic and societal benefits of healthy ageing. It also explores policy options within the health and LTC sectors, as well as other sectors, which look to minimize avoidable health and LTC costs, support older people so that they can continue to contribute meaningfully to society, and considers policies that contribute to the sustainability of care systems in the context of changing demographics. Collectively, this research shows that the costs of population ageing are not as great as commonly thought, and are manageable without reducing the availability of services to meet the needs of older people. Even in the case of LTC services, predominantly used by older people, current spending levels are low. Even with large relative increases in spending as populations age, these are likely to amount only to moderate increases in expenditures in absolute terms. Health and long-term care spending growth will not grow out of control due to population ageing It is true that per person health care spending in many countries increases on average as people age, although much of this increase in spending is driven by people near death; it just so happens that most deaths are typically at older ages. Health spending increases for people at all ages in the time period before they die, usually due to increased hospitalizations and care needs along with cultural tendencies towards services that aim to cure disease and extend life versus enhancing quality of life. However, more older people in society does not necessarily mean more costs. Often, the older people are when they die (e.g. the ‘older old’ who are 80+), the less they cost. This is due to the fact that less resource-intensive interventions may be used after a certain age, especially if the person has otherwise aged in good health (Normand, May & Cylus, 2021). These lower costs are further demonstrated by the increasing uptake of palliative care globally, which indicates a cultural shift towards emphasizing quality of life over lifespan (Reville & Foxwell, 2014). For example, for some cancers (e.g. slow-growing breast or prostate cancer), older people may not benefit significantly from invasive, often costly treatments (Trogdon et al., 2019; Shah et al., 2020). Nevertheless, poor health among older adults negatively influences health expenditure trends and so it is in societies’ best interests to invest in increasing the number of healthy life years older adults have so that they can become part of the older old in good health. 11The Politics of Healthy Ageing: Myths and realities Older people also do an enormous amount of unpaid labour in caring roles and civil society Older people contribute meaningfully to society in many ways. One clear example of this is among grandparents who look after grandchildren, enabling their working-age children to maintain employment (Hayslip Jr, Fruhauf & Dolbin-MacNab, 2019). In places where multigenerational households are common, it is clear how fluid and context- dependent notions of work and caring can be. The idea of the older person as necessarily dependent, encoded in statistics such as old-age dependency ratios as well as the politics of benefits for older people, is contingent on a particular political history rather than facts about how families operate (for an example of the historical roots of these assumptions, see Winant, 2021). In particular, simple accounts of dependency ratios or the costs of care can blur the work of informal care, which is a major part of activity in all societies. These caregivers can be young adults caring for an older family member or older adults caring for either grandchildren or other older people with care needs (Ali et al., 2021; Raj et al., 2021). The societal value in such unpaid work is substantial and generally goes unrecognized – including the value of productivity gains among those who can engage in paid employment. Further, these investments in informal caregiving can enable job and financial security among workers so that they can support themselves and their relatives in their own older adulthood. In addition, investments in training and integrating formal and informal carers could facilitate better health outcomes. Changing demographics pose different challenges in different countries There is no one narrative of demographics or health policy issues related to ageing. For example, the experience of old age depends substantially on one’s state of health. Good health enables paid and unpaid work as well as a good quality of life and engagement in society. Figure 2 shows the relationship between life expectancy and healthy life years. Ideally, these would be very close, meaning people are in good health almost until their deaths (a concept 12 The Economics of Healthy and Active Ageing (a) Men Figure 2: Men and women in many countries spend their later years in poor health Source: Eurostat. Note: All data are from 2018. (b) Women He al th y lif e ye ar s at a ge 6 5 He al th y lif e ye ar s at a ge 6 5 Life expectancy at age 65 Life expectancy at age 65 18 16 14 12 10 8 6 4 2 0 18 16 14 12 10 8 6 4 2 0 0 5 10 15 20 25 0 5 10 15 20 25 Sweden Bulgaria Poland Czechia Slovenia Estonia Croatia Slovakia Latvia Lithuania Romania Hungary Netherlands Finland Luxembourg Spain Switzerland France Italy Germany Denmark Norway Ireland Malta Belgium Portugal Cyprus Greece Austria Sweden Bulgaria Poland Czechia Slovenia EstoniaCroatia SlovakiaLatvia Lithuania Romania Hungary Netherlands Finland Luxembourg Spain Switzerland France Italy Germany Denmark Norway Ireland Malta Belgium Portugal Cyprus Greece Austria l ri l z c i l i st i r ti l i L t i Lit i i ry t rl s i l L x r i itz rl r c It ly r y r r y Ir l lt l i rt l y r s r c stri l ri l z c i l i st ir ti l iL t i Lit i i ry t rl s i l L x r i itz rl r c It ly r y r r y Ir l lt l i rt l y r s r c stri known as ‘morbidity compression’). In many countries, they are not though, meaning many people in those countries spend their later years in a state of poor health. If people experience better health throughout their old age, they can contribute more and enjoy a better quality of life. The differences in country experiences shown in Figure 2 demonstrate that some countries have a great deal of opportunity to improve the health of older people. Some of these efforts manifest in the built environment and neighbourhood structures that enable older adults to maintain social ties within their community. Likewise, formal retirement ages do not necessarily predict the actual age of retirement; Italians leave work before their country’s formal retirement age, and South Koreans much later (see Figure 3). This is in part a function of health status but also of labour market institutions and the entry and exit of women and migrants in the labour force, which substantially changes tax bases. In short, there are substantially different challenges from country to country. 13The Politics of Healthy Ageing: Myths and realities (a) Men Figure 3: People in many countries do not retire at the normal retirement age Source: OECD estimates derived from the European and national labour force surveys, OECD Pensions at a Glance (http://oe.cd/pag). Note: Data are for 2013–2018. The average effective age of retirement is defined as the average age of exit from the labour force during a 5-year period. Labour force (net) exits are estimated by taking the difference in the participation rate for each 5-year age group (40 and over) at the beginning of the period and the rate for the corresponding age group aged 5-years older at the end of the period. The official age corresponds to the age at which a pension can be received irrespective of whether a worker has a long insurance record of years of contributions. The normal retirement age is the age at which an individual could retire in 2018 without any reduction to their pension having had a full career from age 22. (b) Women % % 75 70 65 60 55 50 75 70 65 60 55 50 Ko re a M ex ico Ja pa n Ch ile N ew Z ea la nd Isr ae l Po rtu ga l Ic el an d Un ite d St at es Sw ed en Sw itz er la nd Tü rk iye N or w ay La tv ia Ire la nd Es to ni a Ca na da Au st ra lia N et he rla nd s De nm ar k Un ite d Ki ng do m Li th ua ni a Fi nl an d G er m an y Au st ria Hu ng ar y Ita ly Cz ec h Re pu bl ic Sl ov en ia Po la nd Sp ai n G re ec e Be lg iu m Sl ov ak R ep ub lic Fr an ce Lu xe m bo ur g O EC D Ko re a M ex ico Ja pa n Ch ile N ew Z ea la nd Isr ae l Po rtu ga l Ic el an d Un ite d St at es Sw ed en Sw itz er la nd Tü rk iye N or w ay La tv ia Ire la nd Es to ni a Ca na da Au st ra lia N et he rla nd s De nm ar k Un ite d Ki ng do m Li th ua ni a Fi nl an d G er m an y Au st ria Hu ng ar y Ita ly Cz ec h Re pu bl ic Sl ov en ia Po la nd Sp ai n G re ec e Be lg iu m Sl ov ak R ep ub lic Fr an ce Lu xe m bo ur g O EC D Effective Normal Effective Normal 2.2 The myth of the selfish generation: Are older people greedy? Another common myth is that older generations support policies that only favour them, preventing investments in policies that benefit younger people The myth of the selfish generation advances the idea that particular generations, such as the Baby Boomers, have used their sheer demographic weight to secure policies that benefit themselves at the expense of others. Proponents of this perspective point to issue after issue, from climate change to pensions policy, alleging that one selfish cohort has prioritized its own desires and timeframe at the expense of younger people and the future. There is some evidence in survey research that older people are marginally more supportive of pension and health expenditures than of education and other policies affecting the current needs of younger people (Busemeyer, Goerres & Weschle, 2009; Cattaneo & Wolter, 2009; Sorenson, Drummond & Khan, 2013; Mello et al., 2017). In Switzerland, which allows single policy referenda, there is further evidence that older voters have also pushed such outcomes electorally (Bonoli & Häusermann, 2009). While these findings seem powerful, we show below that they often have limited relevance beyond specific circumstances. Moreover, public support for these kinds of measures depends greatly on how survey researchers or, more importantly, politicians frame the issues at hand and how salient these issues are. The answers to specific questions asked in specific situations do not easily translate to broad propositions about politics. More broadly, the narrative of a ‘selfish generation’ imposing their political will and preventing investments in social policies that benefit younger groups is largely a figment of the collective political imagination. There are three distinct reasons why the selfish generation narrative is a myth. Most people do not focus solely on their own situation at their given age First, we all age. Older people are simply younger people a bit further along in life. This means age is difficult to mobilize as a stable political cleavage. It is why pensioners’ political parties are usually marginal and short-lived. Meanwhile, families redistribute resources across generations, in big and small ways. Grandparents help their children and grandchildren, and children and grandchildren help their grandparents. Family life creates intergenerational transfers of money and labour (caregiving, inheritances, gifts), while also changing time horizons. Private within-family financial transfers rival public ones but are far less visible or politicized. The logic of social insurance, in health care and pensions, is not the logic of a transfer but rather shared provision against misfortune. That logic is politically powerful for a reason; making individual provisions for the future in a way that collectively insures against risk fits the moral economy many people inhabit. Older voters might well try to vote in the best interests of not only their own grandchildren, but grandchildren in general. As a result, most people of a given age do not focus on their own situation at their age; they have a broader perspective on time and social obligation that influences their public as well as private activity. Even people without living parents or children need not choose to vote egotistically; economic interests narrowly defined by age are only one of the many motivations for voting decisions. Older people are not a monolithic group – the financial situation of older people can differ dramatically between countries Secondly, older people are heterogeneous between countries. The folk narrative of greedy pensioners sunning themselves in the Mediterranean is very much a western European one. It is incongruous for much of central and eastern Europe, where poverty among older people is a serious issue (Figure 4). The scale of unmet health needs suggests that health services are not disproportionately catering to them. Life expectancies and healthy life expectancies paint the same picture, showing both shorter lives and many impaired life years in the poorer European countries compared to the richer ones. This divergence is not diminishing (Makszin, 2020). The experience of older people, their health status and use of health care, and their financial situation are all quite different from country to country. However influential they may be in English- language debates, the relatively inflamed intergenerational politics of the UK and the United States are outliers. Large inequalities among older people can also exist within individual countries Third, and perhaps most politically importantly, there is also heterogeneity among older people within countries. Marketers might be able to sell advertising campaigns based on generalizations about Boomers or Millennials as a group, but it is not clear that such generalizations hold or usefully predict behaviour (Duffy, 2021a, 2021b). Older people, in general, experience the same kinds of inequalities and heterogeneity that we see at other ages. One of our most alarming findings is, in fact, that inequality between generations goes hand in hand with inequality within generations. Figure 4 shows the number of older people who cannot make ends meet – many of them live in countries with high-income inequality overall. Figure 5 shows the connection between inter- and intra-generational inequality. A broad measure of inequality across the society – the Gini coefficient – correlates with a higher percentage of older people who report having trouble making ends meet. In economies where many people have trouble making ends meet during their working lives, they can also have trouble after retirement. These inequalities can manifest in many ways, from food security to isolation and vulnerability to crime. Some of those countries direct a large share of their social expenditures to older people (e.g. the United States, Japan and Italy), but that does not mean that expenditures on older people can undo the effects of a life spent at the bottom end of an unequal society or that expenditures directed at older people remedy inequalities among older people. Hence, a substantial flow of resources to older people is quite compatible with poverty and inequality among older, or in fact any, generation. Even the likelihood of surviving to old age at all is substantially predicted by other well-known inequalities, such as income, place and race. 14 The Economics of Healthy and Active Ageing 15The Politics of Healthy Ageing: Myths and realities Figure 4: The share of people aged 65+ who are able to make ends meet is low in many countries Figure 5: Countries with less income inequality tend to have more financially secure older people G re ec e Bu lg ar ia La tv ia Hu ng ar y Ro m an ia Cr oa tia Cy pr us Li th ua ni a Sl ov ak ia Po la nd Sl ov en ia Ita ly Es to ni a M al ta Po rtu ga l Sp ai n Isr ae l Cz ec hi a Fr an ce Be lg iu m Fi nl an d G er m an y Sw ed en Sw itz er la nd Au st ria Lu xe m bo ur g De nm ar k Source: Authors’ analysis of SHARE data. Note: Bars show the share of 65+ people who say they can make ends meet. Source: OECD Income Inequality Data (https://data.oecd.org/inequality/income-inequality.htm). Note: Y-axis shows Gini index for entire population. % 100 90 80 70 60 50 40 30 20 10 0 0.45 0.40 0.35 0.30 0.25 0.20 % reporting easy or fairly easy to make ends meet (65+) G in i c oe ffi cie nt (0 = c om pl et e eq ua lit y; 1 = c om pl et e in eq ua lit y) 0 10 20 30 40 50 60 70 80 90 100 R² = 0.2149 Greece Bulgaria Austria Belgium Czech Republic Denmark Estonia Finland France Germany Hungary Israel Italy Latvia Lithuania Luxembourg Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland 2.3 The myth of pandering politicians: Do politicians do what older people want? Many people also believe that politicians cater to the needs of the older electorate at the cost of younger people The third myth about ageing is that politicians pander to older people at the expense of efficient and equitable policy. This myth rests on a model of politics that is not supported by evidence. While politicians often look to respond to the issues and preferences of voters, they are also active in constructing political debate. Politicians help voters to make connections among policy areas, structure the alternatives under consideration, and shape what kinds of policies are taken seriously in political debate. Perhaps the best way to understand this is to consider differences in party vote by age. Age is associated with patterns of voting for one party versus another in many European party systems, as well as at the European level. For example, exit polling during the 2019 European Parliament elections showed that as compared to voters under the age of 35, older voters were markedly less likely to vote for a Green Party candidate and more likely to vote for a centre-right (EPP) or conservative (ECR) candidate (see Figure 6).  While older people form a large voting group, their voting preferences vary from country to country However, the role of calendar age as a consistent predictor of voting behaviours across countries is easily overstated. In addition to being confounded by a range of other variables that are well-established predictors of vote choice such as income and gender, belonging to an older age group does not necessarily translate into distinctive voting patterns. Analysis of European Social Survey data shows that even after controlling for factors such as gender, household income, social class, religiosity, rural residence and ideological orientation, older people are not a homogenous voting block. For example, in places like Austria or Germany older people tend to prefer mainstream parties, while the young tend to vote more for the Green Party or populist radical right. In other countries, such as Spain or the UK, older people tend to be more conservative, but not always. Even in those cases where differential voting by age group does occur, it is not always clear that the consolidation of support among older voters has an effect on the policy outputs of governments. This is a consequence of older people’s demographic diversity; while they may form a large voting group, they do not necessarily act as a group. Hence, they may have difficulty translating even those policy preferences that they share into effective political pressure. 16 The Economics of Healthy and Active Ageing Figure 6: Age is associated with some voting patterns Source: Schminke, 2019. Note: The figure shows vote shares of party groups by age, 2019 European Parliament elections. Right-wing ENF/I 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 Conservative EC Age Centre-right EP Liberal ALDE/REU Centre-left S&D Greens/EFA Left-wing GUE/NGL 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Right-wing ENF/I 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 Conservative EC Age Centre-right EP Liberal ALD /REU Centre-left S&D Greens/EFA Left-wing GUE/NGL 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Voters, young or old, do not formulate their policy demands but rather choose from among what is offered by the politicians Still more important for understanding politics: there is little reason to believe in the underlying demand-side model of politics in which politicians identify the preferences of the electorate and then cater to them (Gilens, 2012; Mair, 2013; Hacker & Pierson, 2014).2 Emphasizing the demand side of politics understates the role of the supply side, which in politics refers to the formulation of policy alternatives by politicians, governments, policy entrepreneurs and others in the political system. Voters do not formulate their own lists of policy demands and ask politicians to deliver them; rather, politicians develop policy ‘offerings’ that balance their electoral interests against other issues such as coalitional politics amongst elites, and constraints such as fiscal pressure. This process occurs in much the same way that consumers choose items from a menu in a restaurant and can choose between restaurants. Still, restaurant managers and chefs determine what is on those menus, not the customers. Age divides emerge when politicians offer them. When they do not, we see a remarkable ability for voters from different groups to opt for collectively supportive policies. From this perspective, creating and mobilizing intergenerational conflict is a political and policy strategy. Consider the most obvious example of creating intergenerational conflict through policy, much discussed in the pensions literature (also seen in higher education or housing finance in some countries) (Sandlie & Gulbrandsen, 2021): cutting pension expenditure by reducing future pensions while leaving pension entitlements alone for current pensioners. As a result of this strategy, younger generations will have higher retirement ages, lower benefits and more exposure to the risks of individual private pensions, all of which can stir up intergenerational conflict by asking people in younger cohorts to finance a state pension system at benefit levels that they will not experience. It may also create other kinds of distributional conflict, in often complex ways, because it changes the ability of people at different levels of income and wealth to plan their futures. Pension reform politics are often the politics of blame avoidance, with projections about the impact of demographic change and the institutional characteristics of pension systems creating the likely blame and possibilities for avoiding it (Bonoli & Shinkawa, 2005; Weaver, 2010). Much political effort is used in designing blame avoidance strategies (Pierson, 1996) by disguising the extent to which working-age people might be asked to accept worse terms than today’s older people. 17The Politics of Healthy Ageing: Myths and realities 2 These demand-side models are median voter models, akin to representative agent thinking in economics, in which politicians are assumed to cater to the interests of the median voter, a fictitious creature whose existence depends on the assumption that voters are neatly aligned on a single axis with a median. The attraction of this model is not in its realism or usefulness, but rather that it can model the entire electorate like a single agent (the median voter) and posit a gravitational pull towards centrist policy. Figure 7: After controlling for other factors, the relationship between age and party voting disappears in many countries Source: Authors’ compilation from European Social Survey. Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Over 65 = 1 Austria Belgium Denmark Finland France Germany Italy Netherlands Norway Spain Sweden Switzerland UK Other left – age only Main SD – age only Mainstream right – age only Radical right – age only Other left – controls Main SD – controls Mainstream right – controls Radical right – controls -.2 -.1 0 .1 .2 -.2 -.1 0 .1 .2 -.1 -.05 0 .05 .1 -.2 -.1 0 .1 .2 -.2 -.1 0 .1 .2 -.2 -.1 0 .1 .2 -.2 -.1 0 .1 .2 -.2 -.1 0 .1 .2 -.15 -.1 -.05 0 .05 .1 -.2 -.1 0 .1 .2 -.1 -.05 0 .05 .1 .15 -.2 -.1 0 .1 .2 -.1 0 .1 .2 Policies that create asset bubbles in housing can similarly create intergenerational inequality by pricing younger people out of the market while also exacerbating intragenerational inequality by punishing older and middle-aged people who do not own houses. Unsurprisingly, in countries with high and unequal levels of asset-based wealth (mostly in private housing stock, the supply of which is often restricted by policy), property owners are less supportive of redistributive policies in general, including universal health coverage (Ansell, 2014; Ansell & Cansunar, 2021). This is in large part, Ansell (2014) argues, because owners of housing assets view their housing wealth as cushioning them from the need for social insurance against risks such as ill health or the need for LTC. Political parties that believe in a small state and are not committed to universalism, he further argues, will find an elective affinity with these housing owners, creating a reinforcing loop of housing wealth bubbles and weaker welfare states that increases intra- and inter-generational inequity. The evidence that politicians consistently cater to the interests of their older electorates is weak Figure 8 shows the relationship between spending on older people (age 65+) and younger people (under age 65) as a percentage of gross domestic product (GDP), excluding health (updating measures from Lynch (2006); health is excluded because it cannot be attributed to any given age group in the way that pensions or education expenditure are). It shows that countries have quite distinct approaches, including: those that spend relatively little on either younger or older people (e.g. the US and Canada, whose different age-related spending profiles are less important than their generally low spending); countries with high expenditure on both groups (e.g. Austria, Denmark, France); countries with a focus on expenditure for younger people and more limited spending on older people, such as Iceland and Ireland; and countries with high spending on older people and limited expenditure on younger people (another oddly assorted group including Italy, Japan and Australia). There is no inevitable relationship between age-related expenditure outside health; if there is a crowding-out effect from high expenditures on older people, it has not influenced France, Austria or Denmark. While diversity among countries is once again extremely important, Figure 9 shows a tendency to cut back investment in under-65s (right panel) relative to benefits for older people (left panel) when developing policies for new social risks outside the traditional breadwinner model. Put differently, it seems that benefits for the working-age adults are less politically robust than those of older adults in times of fiscal pressure. 18 The Economics of Healthy and Active Ageing Figure 8: There is a large cross-sectional variation in welfare spending across countries Source: Building on Lynch, 2006. Non-elderly spending as % of GDP El de rly s pe nd in g as % o f G DP 0 2 4 6 8 Spending as a % of GDP, 2015 20 15 10 5 0 UK USA Switzerland Sweden Spain Australia Austria Belgium Canada Czechia Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Japan Luxembourg Netherlands New Zealand Norway Portugal Slovakia Slovenia The policy trends resulting from Figure 9 are complex in that some of the cuts to benefits targeted at older people, e.g. pension replacement rates for people who are not yet retired, are slow to take effect (Huber & Stephens, 2015). Meanwhile, in many cases, the composition and structure of benefits to working-age populations have changed more than they have for older people. The working-age population, in many cases, has experienced an expansion of transfers to low-income families (Morgan, 2013; Hills, de Agostini & Sutherland, 2016), and simultaneous cuts to income replacement programmes increasing use of conditional workfare benefits (Rueda, 2015). The result is a shift in the distributive structure of benefits within working-age populations. In short, there is weak evidence for the proposition that politicians consistently cater to the interests of older people. At most we can make heavily qualified propositions that emphasize the diversity of policies and country experience. In doing this, we can note that benefits targeted at older people are somewhat less likely to change than benefits targeted at working-age people, and that there has been a gentle shift towards greater expenditure on younger people relative to expenditure on older people. It is important to underscore that while we can estimate the direct beneficiaries of certain policies, the indirect ones are often very important. Maintaining older people’s quality of life is very valuable to younger people who would otherwise have to care for them (Schoppa, 2011), good health enables informal caring at all ages, and reducing passive benefits to younger people is in some cases compatible with investment in their human capital. 19The Politics of Healthy Ageing: Myths and realities Figure 9: Poverty rates from the late 1990s to the early 2010s often changed more for working-age compared to older people Source: Fiscal Redistribution Database. Working age poverty – 60% of median incomeElderly poverty – 60% of median income Australia Austria Canada Czech DenmarkFinland Germany Greece Hungary Italy Luxembourg Norway Poland Spain Switzerland UK USA 20 40 60 80 100 Re la tiv e re du ct io n in p ov er ty 10 20 30 40 50 60 % poor after redistribution Australia Austria Canada Czech Denmark Finland Germany Greece Hungary Italy LuxembourgNorway Poland Spain Switzerland UK USA 20 40 60 80 100 Re la tiv e re du ct io n in p ov er ty 10 20 30 40 50 60 % poor after redistribution 3. Designing win–win policies and politics Focusing on intergenerational inequity can distract from other inequities that cut through all generations To make healthy and sustainable policies, one must first understand the real causes of the problems often ascribed to ageing or selfish generations. The real political issue in health and most other policy is usually not inequity between generations (intergenerational inequity) but rather inequality within generations (intragenerational inequity). The price of focusing on inequalities between generations is that we might overlook inequalities within generations. Focusing narrowly on inequalities between generations distracts us from how social inequalities across the life course produce health inequalities in later life. It stops us from seeing inequalities in who gets to be ‘old’, who lives longer and who gets to enjoy good health in retirement. In this respect, the politics of ageing is more properly framed as the politics of inequality – and this cuts across generations. Consider Figure 10. What if we do not listen to the myths, and instead ask what other kinds of inequality are at work, shaping everyone’s life chances and politics of ageing? There are many. Income inequalities structure the ageing process, so that inequalities in mortality and morbidity are forged through our exposure to poverty and income insecurity in childhood, adolescence, and during our working lives. In all countries, people in lower-income groups have worse health than those in higher-income groups at all ages. This is not inevitable. The stronger and more universal the public provision, the less it matters how much money a family has, and the less likely it is that costs associated with providing for the wellbeing of older adults will fall upon relatives. Wealth inequalities do not always track income inequalities, and LTC costs can affect wealth and its intergenerational transfer. In particular, housing markets in several countries have recently exacerbated wealth inequalities, by creating a massive appreciation for incumbent homeowners (and their heirs), which seems to induce them to vote for parties of the right (Ansell, 2014) while making it difficult or impossible for younger and poorer people to live in dynamic urban areas (Bohle & Seabrooke, 2020). These socioeconomic inequalities often overlap with inequalities in race or ethnicity, gender and geography, with some groups being systematically excluded from opportunity and security, and even being systematically subject to unfair conditions (e.g. practices that discriminate based on neighbourhood, known as redlining in the US). But these other dimensions of inequality are independently associated with life chances. Racial, religious and ethnic discrimination shapes access to caring assistance as well as the makeup of the caring workforce. Citizenship, too, represents institutional and structural forms of inequality that exacerbate inequalities in ageing. One way to reduce the cost of care is to exploit undocumented people or others with precarious citizenship and exclude them from publicly funded care. Gender inequalities are enormous in the context of ageing. The devaluation of care work and the fact that women deliver the preponderance of both paid and unpaid care are manifestations of structural sexism, with consequences for the health and wellbeing of women. In the US, for example, women’s participation in the workforce grew steadily in the years following the Great Depression. It is suspected that this rise, especially among married women, may have resulted from unemployment or the loss of their 20 The Economics of Healthy and Active Ageing Figure 10: Less educated people have lower predicted odds of reporting good health at all ages Source: Authors’ analysis of SHARE data. O dd s ra tio s 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 65–69 70–74 75–79 80–84 Age Low Middle High husbands (Bellou & Cardia, 2021). However, their informal care responsibilities likely persisted alongside increasing employment responsibilities. Thus, for example, the caring workforce, which is often female, migrant, not of the dominant ethnicity or race, and unorganized by labour unions, will frequently be hard-pressed to push its political views. The LTC sector, particularly dependent on migrant carers and women, has largely been overlooked in public health and health workforce research (Kuhlmann et al., 2020). With around 6.3 million people working in the LTC sector in the EU, four-fifths are female (Dubois et al., 2020). The operation of the care sector itself, which is growing in most countries (Martinelli, Anttonen & Mätzke, 2017) and in most cases depends on low wages, contributes to labour market polarization and inequalities while probably also building up health problems among its workforce (Dwyer, 2013). It is important to keep our eye on the much larger issues obscured by a focus on ageing, namely the politics of inequality. We are not talking about the chimera of intergenerational inequity, but rather the inequalities that scholars of politics, social policy and health have long studied and understood. Of particular importance are the inequalities that cut across generations, reproducing unhealthy ageing for each new cohort. Political identities, politics and policies are not driven by ageing alone; other inequalities are equally important. A prime example of this is the COVID-19 pandemic (Box 2). COVID-19 is clearly more dangerous to older people. Still, the odds of catching it and having comorbidities that make it more dangerous are all reflective of deeper social inequalities from which age is mostly a distraction. COVID-19 belies simple narratives of win–lose intergenerational politics and policies. Not only did the deaths in care homes for older people remind us of how poorly treated many older people are, with care homes a focus of infection and death in country after country (and limited or no vaccine prioritization for family caregivers); it also showed that younger people were willing to stay home and wait for their vaccines in order to protect older people. 3.1 Policies: Life-course approaches and win–win solutions It is possible to design welfare policies that benefit both the old and the young The conventional narrative of intergenerational conflict posits a zero-sum game between generations. It assumes that money spent on older people is money not spent on younger people – that health care for older people crowds out expenditures on education or other policies of interest to younger people. Policy options developed within this framework often undermine universalism even as they purport to address the fiscal consequences of ageing populations. Means-testing services for older people or relying on private finance for them has fairly predictable effects: the wealthiest will be mostly unaffected, while others can see a blow to their wealth and people with unpaid caring responsibilities will leave the labour force or not invest in their human capital; and poorer or less resilient households face particularly significant risks if the costs of caring exceed what they can provide. In other words, it is a conventional question of distributional politics: Who should get how much support from the government? Many of the policies that are justified by appeals to a fiscal crisis caused by ageing are more usefully understood as being a normal part of arguments about the priorities and extent of public action – the extent to which it is the state’s role to insure people against risk through the mobilization of funds when they are needed whilst 21The Politics of Healthy Ageing: Myths and realities Box 2: COVID-19 clearly demonstrates that not only age but also other inequalities are important predictors of health outcomes The COVID-19 pandemic showed just how political systems decide how to value the lives of older people. In rich countries such as western Europe, pandemic mortality had an extremely pronounced age bias, with older people much more likely to become very sick and die (Hradsky & Komarek, 2021). While other health inequalities exposed by the pandemic were startling, none was so dramatic as its impact on older people. This difference was in part due to characteristics of the virus, which was particularly harmful to people of advanced biological age (which only partly correlates with chronological age; Polidori et al., 2021). It also reflected the structure of social, health and LTC in many countries. In country after country, homes for older people were centres of infection and had alarming mortality. It was immediately apparent that there would be predictable variation in the mortality of different care homes, with more expensive and better-run ones occupied by majority populations generally safer (Shippee et al., 2020). Given these differences, it is safe to attribute some of the disproportionate spread and mortality of the virus to the state of care for older people. If a greedy generation were really obliging politicians to pamper them, would that have happened? Instead, it is notable that many of the countries with the worst problems in older person care were those with both the worst inter- and intragenerational inequality (Spain, Italy and the United States, for example – see Figure 5). Even relatively equal Sweden had a series of serious outbreaks in homes for older people, which contributed to its high mortality. It is worth noting that, unlike its Nordic neighbours, Sweden relies on privatized and much cheaper nursing homes with fewer skilled staff, all of which seemingly led to poor control of the virus by organizations that were too lean to be resilient. In short, the dismal performance of unequal countries in the pandemic suggests that their eye-catching intergenerational inequality is actually a by-product of intragenerational inequality that left many older people in dangerous situations. The COVID-19 pandemic also showed the importance of politics and governance in deciding who suffered the worst effects of the pandemic in Europe (Greer et al. 2020, 2021; Bambra, Lynch & Smith, 2021). On the one hand, younger people showed themselves willing to sacrifice a great deal to shield older people from the pandemic. On the other hand, it showed how many decisions were made in ways that did not value the lives of older people, and in particular, the lives of people whose class, race or other ascriptive groups led to discrimination against them (which, in turn, has physiological ‘weathering’ effects that probably reduce their ability to fight the virus; Muennig et al., 2018; Millet et al., 2020). Weighing lives differently extended to the politics of public health measures, which were often biased by the preferences and ideas of those who could safely self-isolate, and which did not take into account the health and economic risks faced by ‘key workers’ (Bambra et al., 2021). also compensating for differences in income and wealth, enabling workforce participation, regulating employers, or investing in skills and capacities. Fortunately, there is considerable evidence that there are win–win policies that are politically feasible and make programmes for people of all ages more fiscally sustainable. Win–win policies create outcomes that are better for all the people involved. Consider, for example, the impact on life expectancy of the sustained programme of expenditure that the Federal Republic of Germany undertook after reunification (Figure 11). It was expensive and the economy of the former German Democratic Republic is still weaker than that of the west. The tradeoff was clear, in that the costs of reconstruction in the east affected the German economy and fiscal balance for more than a decade. Still, its peoples’ health and productivity have nearly caught up, with female life expectancy the same as in the west, and male life expectancy much closer than at reunification. Frankfurt-am-Oder is still not as wealthy and healthy as Frankfurt-am-Main, but the counterfactual of the east without those integrated investments would be a far poorer and unhealthier population than we see today. Investing in the health of the young and middle aged, as well as the healthiness of their communities, in the 1990s and 2000s pays off now in their health and ability to engage in paid and unpaid work as well as society. Likewise, in recent decades, England has given us examples of the positive impact on health that sustained welfare investments can make and the negative impact on life expectancy and healthy life years that major and targeted austerity programmes have produced (Bambra, Smith & Pearce, 2019). Taking the life-course approach to public investments supports developing policies that can benefit all generations Investment in health across the lifespan increases the odds that people contribute to the economy while employed and build up personal social networks that benefit them, and then enjoy as healthy an old age as possible, which in turn means they can enjoy life, help raise children, suffer fewer chronic health problems and require less care. In the caring sector, investment training and support for informal carers can be beneficial for the carers, the people they care for, and society as a whole, including by reducing the need for institutional care. Investment in better trained and paid staff for care homes and in-home care will pay off for older people (as the COVID-19 pandemic showed) and will also pay off for society, since the caring workforce is often female, immigrant, victimized by ethnic or racial discrimination, and generally blocked from upward mobility. The thread running through all of these ideas is known as a life-course approach (Box 1). In public health, life-course approaches are the route to policies that can be genuine win–win policies for multiple groups. They take into account the ways in which policies aimed at different stages of life – from before birth until death – interact, including: how good prenatal care can reduce health challenges later; how better social networks and opportunities in working- age years can improve health after retirement; and how better social opportunities after retirement can extend healthy life years. Life ends only at death, and so should life-course interventions. If we consider that older people are just younger people a bit later in their life course, then an important way in which life-course policies are good 22 The Economics of Healthy and Active Ageing Figure 11: Sustained investments in health closed the gap in life expectancy between the former East and West Germany Source: Reproduced from (Bambra, 2016) with permission of Policy Press. (b) Women(a) Men for people is that they help in the difficult task of shifting access to resources across the life course from times of plenty to times of famine. Life-course thinking also turns our attention to policies that look for ways in which one policy (such as better pay for carers) can serve multiple ends (such as gender equity, healthier old age, higher labour force participation, and better upward mobility). 3.2 Politics: From intergenerational conflict to productive policy Life-course policies can be electorally attractive If ageing societies need not be fiscally unsustainable, then the question is how best to arrive at win–win, life-course policies rather than ones that create or exacerbate intra- and intergenerational inequality. What kinds of political coalitions can do this? A focus on assembling coalitions favouring win–win solutions changes the kinds of political thinking required, specifically the role of women. Consider, for example, the intersection of caring, work and gender. At this intersection we find a number of interests and interest groups that can advocate for a more equitable life-course social policy: unions (representing workers, in many contexts, a majority of which are women), women’s organizations, and organizations representing older people and pensioners. Each has an interest that can be combined with the others in support of better care for older people. All of this means that organizations concerned with women in society have multiple interests in the definition of ageing, the ageing policy agenda, and the policies adopted. It is possible to imagine narrowly class-based definitions of women’s interests, in which the interest of well-off working women in having cheap child care and caregiving for dependent adults is prioritized. Still, it is also possible to imagine, and in some countries see, much more encompassing approaches that align the interests of working women (in support for their family and work roles), paid carers (in salary and good conditions), and older people (in good support). The class-based approach simply offloads duties from overburdened working women onto less well-off working women, many of them migrants or racial and ethnic minorities (Ehrenreich & Hochschild, 2003). Women, like older people, are a heterogeneous group, both in terms of their economic and political behaviours. However, attention to women’s historic exclusion from the welfare state, particularly where benefits ran through ‘male breadwinners’, and the labour market, has brought the possibility of new political and interest group coalitions around expansionary life-cycle policies without an immediate erosion of benefits for older people.  Increasing public spending on younger or working-age people often reflects the adoption of life-course policies As Figure 12 shows, most European countries have shifted away from expenditure directed at older people – even as those countries’ populations have aged – with increasing expenditure on programmes for the young or working-age populations, including informal carers. This change, in many cases, reflects the adoption of life-course policies that recognize the benefits of investing in people when they are younger precisely to enhance their health and wellbeing when they are older. Policies that support informal carers, in fact, are investing in the health of both carers themselves and the older individuals they support (Boxes 3 and 4). Greater professionalization and pay for carers would be an investment not just in the care that they provide but also in their futures and equality within the whole society.3 If the goal is to achieve a future world that is better, more equitable and costs less, then the investments must be made now. If we want successful reductions in morbidity and more productive older people, we must be prepared to pay for it. 23The Politics of Healthy Ageing: Myths and realities 3 Besides the critical gender imbalance in the caring workforce, there is also significant cross-country variation due to data issues in comparability as well as critical differences in policy and organization (Fujisawa & Colombo, 2009). For example, in 2019, Ireland reported 3.9 formal LTC workers per 100 population aged 65 and older, while Norway reported 12.4 per 100 in that same year (OECD.stat, 2021). Source: Building on Lynch, 2006. Figure 12: Many countries increased welfare spending for the young or working-age populations 0 10 % of GDP 20 30 40 Sweden Netherlands Norway Ireland UK Belgium Finland Denmark Australia Germany Canada Iceland France Austria New Zealand Spain Luxembourg Portugal Switzerland USA Italy Japan Greece Elderly/Non−Elderly Spending Pre-2000 Post-2000 Furthermore, better and more professional caring can lift the burden of unpaid care, which is stressful and tends to drive carers, particularly women, out of the workforce entirely when they could be in prime earning years (Navaie- Waliser, Spriggs & Feldman, 2002). Ideally, people would be supported if they chose to leave the workforce for caring roles or stay in the workforce and rely on formal care. While the effects on the labour market have been historically minimal (Bauer & Sousa-Poza, 2015), it is nevertheless worthwhile that the informal care workforce is refocused on doing things that can best be done by informal carers, i.e., mental health or spiritual support, rather than doing the tasks considered to be formal care. This refocusing will decrease the need for informal carers to give up paid work as evidence suggests that a time ‘budget’ for informal care is upheld. 24 The Economics of Healthy and Active Ageing Box 3: Support for health of care partners: United States examples In the US alone, more than 40 million family members (e.g. spouse/ partner, adult child) support a relative age 50 and older with daily activities, health care, and other tasks (National Alliance on Caregiving, 2020). Nearly two-thirds of these care partners are employed full time; others may resign or even lose their job due to competing responsibilities from caregiving (Feinberg, 2016). While care partners may be responsible for financially supporting their relatives, they may also bear financial burdens associated with caregiving (e.g. unexpected health care costs, home modifications, requiring additional daily resources such as groceries). To support care partners in this situation, in 15 US states, if the family member is financially sound, they can pay their relative to provide caregiving support. The manner in which this funding is provided varies by state. For example, some states use LTC insurance to compensate a family care partner and, of those, some states only compensate family members other than a spouse (AARP, 2021). In addition, caregivers may be responsible for tasks that they are not fully equipped to do. For instance, family caregivers may be changing wounds, administering medications, or may require skills to manage their relative’s health needs. Some US states provide training programmes for caregivers within or outside of the health care system to support these needs. For example, the Caregiver Advise, Record, Enable Act encourages clinicians to enter discharge instructions for care partners once their relative designates them as a caregiver. Notably, these policies not only support adults that require assistance, but also support the care partners so that they can be productive whilst caregiving and in the future, thereby investing in their health through their life course. Box 4: Dutch nurses provide support to family care partners in developing key competencies About 70% of patients prefer to be cared for and to die at home at the end of life (Higginson et al., 2013). This often requires family care partners, who are able to provide care in the home rather than in an institutional setting, to support psychological needs, activity of daily living assistance, and care coordination (Lund, Stansfield & de Silva, 2014). This care, in the Netherlands, amounts to an average of 26 hours per week and this number is greater – reportedly 69 hours per week – in the UK (Rowland et al., 2017). Family care partners may experience significant physical, mental and emotional distress when supporting a relative through end-of-life care. In the Netherlands, recent interventions have sought to use the skills of nursing professionals to support family care partners (Becqué et al., 2019). These interventions emphasize nurses supporting care partners in developing four primary competencies (needs assessment, psychoeducation, practical support with caregiving, and peer support) in an effort to improve caregiving preparedness, competence, rewards, mental wellbeing, optimism, satisfaction, self-efficacy and social support, and to reduce distress and workload (Becqué et al., 2019). While the formal and informal workforces are often distinguished based on training, skills and professional boundaries, these interventions demonstrate the potential for drawing upon the formal workforce (nurses) to train and support the informal workforce (family care partners), rather than functioning as siloed resources working towards the same goal of improving patient care and quality of life. In other words, in the Netherlands, investments in the formal workforce translate into resources for family care partners to extend and enhance the health care system’s efforts. 4. Conclusion: Getting to win–win policies It is often argued that population ageing is fiscally unsustainable, but this is not supported by the evidence We asked at the start: given that there is not much evidence that ageing imperils the finance and provision of health care, why do so many policy-makers act as if it does? We first reviewed the evidence on ageing and expenditure priorities. You cannot infer a country’s politics, let alone its policies, from its demographics. Ageing societies need not have more costly health systems. People do not have clear interests shaped by demography, and electoral demand does not shape the supply of policy ideas. But it is still common to hear arguments that ageing is creating a fiscal crisis for health, that cutbacks will be necessary, or that selfish generations are at war for the public budget. This policy brief has argued that these ideas are erroneous, that what are ostensibly arguments about the policy consequences of ageing are actually usually about much more common distributional issues in public policy, and that coalitions built around the pursuit of life-course based policies can provide the political basis for win–win policy solutions. Policies and politics can set generations against each other, but designing electorally attractive win–win solutions is also possible Ageing societies can lead to intergenerational political conflict, and some do. The United Kingdom and the United States stand out for the relative salience of that conflict. But the fact that the scale of such conflict is highly variable suggests that it is often created by policy and politics. It is a policy, and therefore a political decision, to create LTC or pension politics (or housing policies) which directly or indirectly tax one generation for another’s welfare, with the effects cushioned by compensating flows of income within families that exacerbate inequality. It is possible to adopt win–lose or lose–lose policies that set generations against each other, or to polarize politics around issues where generations differ; but it is not necessary. Even the basic link between intergenerational political polarization and intergenerational distributive conflict cannot be assumed; it is possible to polarize voters around cultural issues with little economic base, it is possible to make big distributional decisions with little political conflict, and it is possible that intergenerational polarization is actually about something else, such as racial, immigration or educational politics. In other words, policy can create needless tradeoffs and conflict between generational interests, which should be avoided; and win–win policies can limit such tradeoffs. Win–win solutions are positive-sum solutions to problems. For example, replacing policies that create inequality within and between generations with ones that invest in people’s health and wellbeing over the life course can pay off in many ways, from longer time in paid employment, to greater investment in human capital, to more intergenerational wealth building when savings are not depleted by care costs, to stronger families in which older and younger people can reciprocally care for each other. There will always be some kind of tradeoff, and what that tradeoff might be will look different when viewed through the life-course perspective. The goal is to develop politically feasible policies that identifiably pay off for a strong coalition of interests and benefit ageing societies as a whole. Politicians still act as if ageing imperils the welfare state, partly because it is not immediately obvious that the narrative of the selfish generation is wrong. It is backed by the superficially plausible and well-resourced arguments that carry labels such as ‘intergenerational accounting’, backed up by marketing narratives about the characteristics of whole generations, and underpinned by real differences between cohorts, such as in educational attainment or income over their life courses. But this is not simply a problem of missing information. Intergenerational inequality often obscures other forms of inequality that afflict all generations The explanation of why the narrative of the selfish generation persists, we found, lies precisely in the nexus of inter- and intragenerational inequality. Putative intergenerational inequality is not just a distraction from the inequalities that actually structure the courses of our lives; it also comes from intragenerational inequalities. Some countries have such apparently wealthy and well-protected older people because those countries are generally less equal, and some beneficiaries of that inequality are wealthy and older. That is why it is possible for Italy or the United States to both favour older people in their public expenditure while also having high levels of poverty and inequality among older people. Their welfare states encode political preferences for less egalitarian policy, and the intergenerational inequality is primarily a by-product of those preferences for less economic equality. That the intergenerational inequality in their expenditure has then been weaponized as an argument for still less intragenerational and overall equality is rich in irony and politically dangerous. What are the steps to getting from the weaponized myths of intergenerational conflict to a more constructive focus on win–win solutions? One step is policy ideas: A focus on policy ideas includes a focus on policy debate, which often means, once again, disputing facile generational arguments. Myth busting is a valuable activity because a widely accepted myth can be the basis for destructive public policy. Policy ideas come with an understanding of the policy problems and efforts to think through how one policy could solve many people’s problems. Thus, for example, efforts to redevelop urban built environments to be more pedestrian-friendly contribute to the health of older people by making it easier for them to exercise and socialize, but also make life easier for many others, from people without cars to recreational exercisers to businesses that depend on foot traffic. Supporting carers can improve their lives and those of everybody in their families (Boxes 3 and 4). Efforts to build nursery schools near nursing homes contribute both to the wellbeing of older adults and the growth and social wellbeing of young children. 25The Politics of Healthy Ageing: Myths and realities Policies that solve problems for many different groups enable coalitions to support them in politics Groups that look to solve problems for many different groups will often have organizations with policy analysis capacities and political skills, making a coalition more powerful than an individual appeal. A second step, therefore, is coalitional politics. What are some organized groups interested in positive-sum approaches to health policy, including policies relevant to ageing? When thinking not just about approaches to health policy, but also approaches that consist of policies relevant to ageing, we consider organized groups. This includes groups with a commitment to a sustainable approach to ageing and LTC based on a formulated understanding of their interests. Organized groups can do two things that disorganized voters, focused on other issues, cannot: formulate and debate complex policy options; and identify longer-term sustainability threats and possibilities. A number of these organized groups stand out from our analysis. One is providers of health care and LTC. These are often highly problematic employers, but it is possible to design policy arrangements that assure them adequate profit while improving quality. Another is the formal caring workforce. This workforce is typically organized, if organized at all, by public-sector unions. Likewise, they have an incentive to promote a fiscally sustainable, high-quality model of care – and to undercut insider/outsider divides that unions in other sectors can often promote. The formal caring workforce, like the informal caring workforce, is predominantly female, and women are at the centre of any likely sustainable policy solution. Women’s movements can opt for many different definitions of women’s problems, and their internal politics are complex and filled with their own representational inequalities. This makes their decisions particularly interesting and shows the importance of highlighting the gender dimensions of this issue, on the level of individuals as well as society. Such an understanding has changed politics to a surprising degree, e.g. in Japan (Schoppa, 2011). Policy-makers themselves can be important members of coalitions – health ministry officials, for example, will often be aware of good and plausible policy options and skills to promote them within coalitions. Finally, organizations representing older people, especially the better established, have an interest in solutions that reflect the unselfishness of many older voters (who can care about their society and children as much as anybody) and in policy solutions that will be fiscally and politically sustainable over time. Policies that produce immediate gains are harder to dismantle and can help embed the life-course approach A third step is to focus on time horizons. Policy-makers often wish to make policies that will stay after they have left, but they also face pressure to make short-term decisions, in particular when their re-election and tenure in office is particularly uncertain (Jacobs, 2011; Tuohy, 2018). Policies that are supported by organized interests, such as women’s or pensioners’ organizations, will have a better chance of surviving because they will have advocates in the political system. Policy design that starts to produce gains immediately will also benefit from the well-documented difficulty of rolling back existing provisions. Once a beneficial policy is in place, it might be undermined or weakened but it is typically very hard to actually eliminate it (Pierson, 1996; Falkenbach, Bekker & Greer, 2020). Thus, provision of immediate benefits and a strong supporting coalition in civil society and interest group politics greatly enhance the likelihood that a policy is implemented and becomes entrenched. It is no accident that in most public pension and health systems, universal health care access came about very quickly even if the logic of insurance would have suggested a long period of vesting and resource accumulation, and neither is it an accident that LTC schemes which depend on years of contributions before anybody gets any benefits are extremely politically vulnerable.4 The life-course approach offers an opportunity to replace the negative rhetoric around population ageing with a positive one that unifies all generations around solutions that benefit all This is a message of optimism. Instead of deterministic theories that infer inexorable conflict and policy change from demographics, we have a world of complex coalitions and debates about policy ideas and agendas. The supply of ideas can be shaped by a small number of people with policy skills, and the development of coalitions is flexible and can always offer new opportunities and ideas. Life-course thinking helps us identify win–win policy solutions and the coalitions which might make them possible. Instead of trying to infer inevitable policy from demographic patterns, we can embrace the complexity of politics and the possibilities that it brings. Instead of assuming, or creating, a zero- sum struggle between the generations, we can push for positive-sum outcomes. Instead of a world of winners and losers, we can make win–win policies. But it takes getting the politics right. 26 The Economics of Healthy and Active Ageing 4 Literature on this topic is best developed in the United States. US studies with clear broad applicability include Patashnik (2008) in general. On the problems of developing a fiscally and politically viable LTC insurance system, see Saldin (2017). References AARP (2021). 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Toronto, University of Toronto Press. Walker A (1990). The economic ‘burden’ of ageing and the prospect of intergenerational conflict. Ageing & Society, 10(4):377–396 (doi.org/10.1017/S0144686X00007376, accessed 11 May 2022). Weaver K (2010). Paths and forks or chutes and ladders?: Negative feedbacks and policy regime change. Journal of Public Policy, 30(2):137–162 (doi.org/10.1017/S0143814 X10000061, accessed 11 May 2022). Winant G (2021). The natural profits of their years of labor: Mass production, family, and the politics of old age. Radical History Review, 139:75–102 (doi.org/10.1215/01636545- 8822614, accessed 11 May 2022). 29The Politics of Healthy Ageing: Myths and realities The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its web site (https://eurohealthobservatory.who.int). Print ISSN 1997-8065 Web ISSN 1997-8073 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: postmaster@euro.who.int Website: www.euro.who.int