When I ask my patients about their long-term health goals, they seldom say they want to live to be 100. Instead they talk about aging with independence and dignity, being free from aches and pains or having the strength to play with their grandchildren. “I’d just like to blow out the candles on my birthday cake without coughing,” a 60-something patient suffering from emphysema told me.
Yet our national dialogue around aging doesn’t reflect this basic reality about what people value in their lives.
Our country is long overdue for an audacious health goal. The average life span in the United States is about 1.5 times what it was a century ago, a stunning achievement. Equally stunning is that life expectancy is now stagnating, a revelation that has mostly been met with a collective shrug.
The Census Bureau predicts that by 2034, there will be more people in the United States age 65 or older than under 18, for the first time in history. Increasingly people are suffering from addiction, other chronic diseases and injuries, even at younger ages. Our current state of politics, mired in narrow debates about who does and does not deserve health insurance, is not up to meeting these challenges. We need a fresh approach to talking about health before we can improve it.
A new health moonshot should not just be oriented around increasing life spans but should focus, too, on what’s referred to as health span — the years people can expect to live in good health. As President John F. Kennedy said decades ago: “It is not enough for a great nation merely to have added new years to life. Our objective must also be to add new life to those years.”
Let’s start with what already matters to each of us: healthy birthdays. When we are younger, many of us take for granted having our faculties intact with the passing years. But as we age, every birthday spent flourishing versus feeling frail becomes an increasingly precious experience.
Peer nations have already taken steps to center health span in their policies. Singapore, with a longer average life span and an even more rapidly aging society than the United States, committed in its national health reforms last year “to prevent or delay the onset of ill health.” Britain has set an explicit goal of increasing healthy life expectancy by five years by 2035. And in Japan, local programs already invest in initiatives to help older adults share their skills and wisdom across generations, such as teaching youths how to cook, make art and garden, with benefits for young and old alike.
Yet in the United States, we do not rigorously measure and report health span as we do life expectancy. Best estimates indicate that the average American can expect to celebrate only a single birthday in good health after the traditional retirement age of 65. Meanwhile, Singapore, Britain and Japan (along with Canada, Costa Rica and Chile) already report average health spans of at least 70 years.
A bold but common-sense national goal would be to add a decade of healthy birthdays after retirement age. Achieving a target health span of 75 years would push us to think about health equity, given the lower healthy life expectancies for certain groups, such as Native Americans, Black Americans and low-income Americans.
Measuring health span, however, must go hand in hand with re-engineering our health and social systems. Doubling our national investment in primary care — to at least 10 cents of every dollar spent on health services — would make our medical infrastructure more proactive. We would be more effective at catching and treating diseases earlier and centering patient care on trusted relationships built over time. Increased access to primary care would mean that medical innovations offering hope for reversing diabetes or curing hepatitis could be made more available to those who would benefit from them.
Rebalancing national health expenditures toward primary care should be part of a broader shift toward disease prevention. For instance, President Biden’s cancer moonshot has emphasized the importance of reducing tobacco use and getting more people vaccinated against human papillomavirus to prevent new diagnoses of cancer. The National Institutes of Health could build on these efforts by advancing the science of healthy longevity and developing better ways to stall cognitive and physical decline, particularly by facilitating behavioral changes like reducing sedentary time.
The quest to improve health span should integrate mental and emotional health. Health departments have tackled smoking, infectious diseases and blood pressure — often resulting in remarkable gains in life expectancy. Extending health span would require taking on other major causes of morbidity, too, such as anxiety and loneliness. A lack of social connection can increase the risk of depression and dementia, often leading to a vicious cycle of illness and isolation. The role of public health must be to interrupt those vicious cycles and seed virtuous ones, particularly for emotional support and connection.
Adding a decade of healthy birthdays to Americans’ lives would also require us to reckon with issues beyond health care. When I take care of patients experiencing homelessness, who have a markedly lower healthy life expectancy than average, I measure their blood pressure and check their bloodwork as I do for any other patient. But the most definitive treatment for any issues they may be experiencing is not medicine or surgery; it’s housing. One of my patients who struggled for years to give up cigarettes quit smoking the day he moved into his new apartment. When I asked him what changed, he had a laconic answer: “Less stress and more sleep.” It was a recipe for better health I wish I could prescribe to everyone.
Housing costs money, of course, as do other basic needs, such as healthy food and quality education. But they should be seen as investments for the economic benefits of extending health span. One study published in the journal Nature Aging in 2021 estimated that improving health spans and increasing the average life span by one year would be worth $725 billion annually.
A better quality of life in older age could provide cascading returns for society. “As we age, we gain knowledge and expertise, along with the intellectual and cognitive abilities to decide if something matters,” Linda P. Fried, a geriatrician and the dean of the Columbia Mailman School of Public Health, has said.
But unlocking this longevity dividend would require new narratives about healthy aging. Older Americans already contribute to society through working, caring for grandchildren, volunteering and civic participation. Social infrastructure could be further adapted around older age as a latent natural resource, waiting for us to tap it in ways that build purpose and connection. Schools could host youth mentoring programs. Employers could create additional part-time or flexible work opportunities. Even smaller campaigns that combat ageist stereotypes, like reimagining birthday cards to ditch denigrating jokes in favor of celebratory pride, could change these narratives. “Great stories take time,” reads one, depicting a stylish woman in sunglasses with flowing white hair.
In Spanish, the word for retirement is “jubilación.” Its English cognate matches what I most wish for my parents after a half-century of working: that their birthdays are not just healthy but jubilant, too. For my patient with emphysema, a dockworker originally from South America, our primary care team has painstakingly helped get his symptoms under better control. But to truly thrive, he would also need a more dignified place to live, larger public investments in indoor air quality and stronger social connections to supplant screen time. All of these seem like tall orders until I reflect on the boldness it took for him to immigrate across a continent and carve out a life for his family in the United States, like so many of our forebears. It’s that boldness our nation would have to channel to make a moonshot for health span a reality. It wouldn’t happen in weeks, months or even the next couple of years — but then again, great stories take time.
Dave A. Chokshi (@davechokshi) is a physician at Bellevue Hospital and a professor of leadership at the City College of New York. He previously served as the 43rd health commissioner of New York City.
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