The Huge Cost of Health Care: Is America’S Viability As a Superpower Imperiled?

The Huge Cost of Health Care: Is America’s Viability as a Superpower Imperiled?

Victor Basiuk Huber Warner Consultant Former Professor Science, Technology, & Security University of Minnesota

Washington has been struggling with the issues of the deficit and the national debt for some time. In the short term, these issues can be addressed by conventional although not necessarily palatable means such as raising taxes, increasing the age for receiving Medicare and Social Security benefits, and implementing legal measures to reduce the pay for physicians. In the long term, however, there is no apparent solution. The reason for this is that the single most important factor in increasing deficits and calling for borrowing is the rising cost of health care, which affects the federal government because of Medicare and Medicaid. The cost of health care is rising because of the aging population 87 and the continual improvements in medicine that are increasingly expensive. The cost for the federal government will run into trillions of dollars per year, which it may not be able to afford. There is, however, a solution in sight, which at present is well outside of the realm of conventional wisdom. And yet, as we look at recent history, many schemes that once seemed mere utopian dreams are now accepted as parts of the policy fabric. This potential solution, which may be the single most important means to cut the cost of health care—including Medicare—is to increase human longevity for a number of years, while freeing it of age-related diseases such as cancer, cardiovascular illnesses, diabetes, and Alzheimer’s disease, thus extending Victor Basiuk is a consultant on Science, Technology, and National Security Policy based in Vienna, Virginia. Basiuk taught at the U.S. Naval War College, Columbia University, and Case Western Reserve University, and has been a consultant in the Washington area since 1973. He is the author of Technology, World Politics, and American Policy, a monograph on Technology and World Power, and of numerous articles, contributions to collective volumes, and expert testimonies before Congressional committees. At present, Basiuk is writing a book entitled After World Dominance, Whither America? Huber Warner is a former professor and former associate dean for research of the College of Biological Sciences at the University of Minnesota. He previously served as the associate director responsible for the extramural biology of aging program at the National Institutes on Aging. He has extensive experience in the field of gerontology research and is the author of numerous publications on aging.

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner human health span (the time of life free of diseases). While extension of health span is a compelling factor in upholding America’s fiscal viability, its impact is far-reaching. It affects the distribution of world power and the international system. It could revitalize some economies and would affect immigration policies of certain countries. We will address these and other issues in this article.

The Burden of Health Care on International Power

During the 2008 U.S. presidential campaigns, both parties conveniently swept the issue of Medicare under the rug—and for a good reason. In the coming years, the cost of Medicare will rival, if not dwarf, the cost of the recent financial and economic crises. It was not until the reform of the health care system and its accompanying debate that the full magnitude of the cost of Medicare was brought to the surface. This calls for a look at the specifics. The 2013 Report of the Trustees of Medicare and Social Security provided cost projections for the next 75 years. According to the Medicare Report’s projections under the current laws, the cost of Medicare will grow from the present $565 billion (3.6 percent of GDP, roughly equivalent to the share of the U.S. Defense budget) to $3.1 trillion (5.8 percent of projected GDP) in 2040. 88 From that point, the cost of Medicare will rise to $33.7 trillion (7.2 percent of GDP) by 2087. The reports, however, provide an important caveat to these figures. This year’s projections are based on the assumption that the cost-saving legislation of 2010—especially the Affordable Care Act—will be fully implemented. This is an optimistic assumption not likely to materialize because of entrenched vested interests and political opposition to some of its provisions. The report warns that if the cost-saving measures are not fully implemented, the projected Medicare costs will rise to $3.8 trillion (6.5 percent of GDP) in 2040 and a staggering $45.9 trillion (9.8 percent of GDP) per year by 2087. According to the projections of the reports, the Hospital Insurance (HI) Trust Fund component of Medicare, which comprises most of Medicare, will be exhausted in 2026, and from then on the federal general budget will have to cover Medicare’s deficit. 1 The burden of Medicare is especially troubling in the context of the changing distribution of world power. China’s GDP is growing at a rate of 7.5 to 9 percent annually and India’s at about 6 to 7 percent. The United States’ growth, in contrast, is 2.5 to 3 percent and that of the European Union is 1 to 1.5 percent.2 The recent financial and economic crisis has been more damaging to the United States than to China. The United States is very heavily in debt,

the brown journal of world affairs The Huge Cost of Health Care while China’s foreign exchange reserves have been reported to be $3.4 trillion.3 In 2010, China’s GDP exceeded that of Japan, becoming the second largest in the world after the United States. By 2019, China’s GDP will likely surpass that of the United States.4 Moreover, the United States has suffered a serious setback in soft power.5 The American model of free-market capitalism spread across the globe as the ideal in the past 30 years is now being questioned in the context of the recent economic crisis. On the other hand, China’s quick recovery from the worldwide financial meltdown seems to have shown the strength of its brand of state-led capitalism.6 The extremely high cost of Medicare—and health care in general—will impose severe constraints on the U.S. budget. Such areas in the budget as armed forces, science and technology, foreign aid, public diplomacy, and education are not protected by entitlement legislation; they are discretionary. Therefore, they are likely to suffer more than others under budgetary constraints. America’s viability as a superpower could be seriously jeopardized, given that these areas are critical to strengthening U.S. influence abroad diplomatically, economically, and militarily. In the longer run, the growing cost of health care will slow down the United States’ economic growth. Perhaps even more important for the nation’s viability, it will modify the composition of U.S. GDP. Its health care component will be expanding at the expense of areas such as manufacturing, science and technol- 89 ogy, defense, the environment, and education.

A Powerful Remedy to Reduce the Cost of Health Care: Extension of Health Span

There are several ways to reduce the cost of health care: improving our health care system, cutting the cost of drugs, and reducing the charges of physicians are only some of them. While these and other cost-reducing measures need to be instituted, there is another more dramatic and potentially much more effec- tive policy that has not yet been discussed in the health care cost debate. This policy lies outside such conventional policy fields as economics, law, and political science; it comes from the realm of science, namely biogerontology. Extension of health span—by increasing human longevity for a number of years without age-related diseases such as diabetes, cardiovascular illnesses, cancer, Alzheimer’s disease, and others—is likely to produce a reduction of the cost of heath care much greater than all the other means of health care cost reduction combined. It would save society trillions of dollars in the coming years and add millions of healthy, vigorous individuals to the workforce, thus potentially invigorating

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner the economy. Likely, it will also be less complicated and cumbersome politically. Human longevity in the United States increased by 30 years in the past century and is now about 79 years.7 This was achieved by better nutrition, sani- tation, discovery of antibiotic drugs, and progress in conventional medicine, which ameliorated or virtually eliminated a number of diseases. But people are still aging, and the costs of supporting an aging population will grow. In recent years, biogerontologists have made major progress in elucidating the molecular basis of aging, and they have been able to increase the longevity of worms, fruit flies, and mice by 30–100 percent using a variety of strategies. If adequate funding for research Whether similar biological strategies will work in humans has not been clinically were available, within five to 10 proven. However, the scientific infra- years the human health span could structure for extending longevity and for corresponding delay in the onset of age- be extended by up to 20 years. related diseases has been built and clinically demonstrated on mice. Leading U.S. biogerontologists—such as Leonard Guarente (MIT), David A. Sinclair (Harvard), Cynthia Kenyon (University of California, San Francisco), Thomas E. Johnson (University of Colorado), and others—believe that if adequate funding for research were available, within five 90 to 10 years the human health span could be extended by up to 20 years.8 Hu- man appearance will likely not age. However, when the period of extension of health span expires, the aging process will resume and so will the risk of diseases.

How Can the Human Health Span Be Extended?

There are at least four leading methodologies for extension of health span. One is caloric restriction (CR), which has been known to work in mice. While the effect of CR on mice can be relatively easy to detect because of their short life, this is much more complicated in the case of humans; given human longevity, such studies would have to last many years. However, even in the absence of clinical evidence, the vast majority of biogerontologists believe in the viability of CR as an agent for extension of health span. Roy L. Walford, a prominent biogerontologist and a strong believer in CR, founded in 1994 with his daugh- ter Lisa Walford, Brian M. Delaney, and others, CR Society International, an organization of several thousand members practicing and conducting research on CR.9 At this point in time, the most definitive proof of the effectiveness of CR on humans is a 20-year longitudinal study completed in 2009, which revealed that CR significantly delays the onset of age-related diseases and mortality in

the brown journal of world affairs The Huge Cost of Health Care rhesus monkeys. Given the biological similarities between rhesus monkeys and humans, a similar effect would be likely in humans.10 CR requires a cut in the consumption of food by 30–40 percent, which activates the defensive mechanism of the body to protect DNA and thus extends health span (i.e., both longevity and freedom from age-related diseases) by about 30 percent. However, this near-starvation diet would not be acceptable to most humans and therefore can hardly be considered a viable method of extension of health span. Another method developed by Guarente and Sinclair uses sirtuin genes to activate the defensive mechanism of the body to protect DNA. Sirtuin activation, in effect, mimics CR without requiring dieting. This method has been explored in mice, although not in humans, and appears to be promising.11 It was also discovered that resveratrol, when used in conjunction with SIRT1 (a gene of the family of sirtuins) and the AMP-activated protein kinase (AMPK), also extends health span in mice.12 A related approach, developed by Cynthia Kenyon and known as hormonal control of aging, reduces the action of insulin and a related hormone, insulin-like growth factor (IGF-1). This activates a gene called FOXO, which in turn stimu- lates a number of responses that protect cells, including the strengthening of the immune system and an increase in antioxidants, thus extending health span.13 In 2010, Zelton D. Sharp and Randy Strong, researchers at the University 91 of Texas at San Antonio, elucidated the potential of rapamycin—a metabolite produced by a bacterium in the soil—for postponement of aging and age-related diseases. It works on mice and in some cancer patients it may result in tumor regression. Rapamycin produces its greatest benefits late in life by both delaying and reducing severity of age-related diseases, which would make it particularly useful for human applications.14 It has been known for some time that genetic manipulations of telomeres targeted at expanding telomere length increase health span in mice. Yet this also raises the risk of cancer. However, in 2012, Maria A. Blanco and her colleagues at the Spanish National Center For Cancer Investigation (CNIO) in Madrid discovered that a telomerase gene therapy in mice had a remarkably beneficial effect on health and fitness and increased health span without a greater risk of cancer.15 This discovery opens up new avenues for research on extending health span in humans. In short, biogerontology is now capable of extending health span in mice and, in some instances, in rhesus monkeys. What needs to be done is to expand this capability to humans. To minimize the risk of failure and resultant delays, a viable project for extending human health span should pursue research of more

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner than one of the most promising methodologies. However, at present, biogerontology research is starved for money. Esti- mates of the cost of research needed to significantly extend health span in humans are about $10 billion for five to ten years. Even though the U.S. National Institute on Aging (NIA) has funding of $1.13 billion (for fiscal year 2012), most of it is for research on age-related diseases, with one-tenth of it at most spent on extension of health span. Thus, what is needed is a Manhattan-like Project for Extension of Health Span (MPEHS),16 focused on life span free of age-related diseases. It would save money in research dealing with individual diseases and would go a long way towards reducing the trillions of dollars the United States will be spending on Medicare in the coming years.

Addiction to Individual Diseases

Preoccupation of the NIA with individual diseases—at the expense of a more fundamental and comprehensive approach, whereby a single drug would protect against a number of age-related diseases—is not solely a product of NIA’s leadership. It also reflects the traditional, deeply ingrained mentality of the United States’ scientific community and finds its way into the government and the 92 budgetary process. The National Institute of Health has at least nine institutes dealing with individual diseases or groups of diseases. Of these, the National Cancer Institute alone has a budget of $5.07 billion (fiscal year 2012)—more than four times that of the National Institute on Aging. In 2006, a group of prominent researchers in biogerontology—S. Jay Olshansky (University of Illinois, Chicago), Daniel P. Perry (Alliance for Aging Research, Washington, D.C.), Richard A. Miller (University of Michigan, Ann Arbor), and Robert N. Butler (International Longevity Center, New York)—at- tempted to change the way of thinking in the scientific community with regard to aging and diseases, and thus modify the system of allocation of funding. They published an article in The Scientist which pointed out that by extending longevity free of age-related diseases, a number of illnesses—not just one—could be deferred, thus saving a great deal of money presently allocated to individual diseases.17 Moreover, such an extension of health span would significantly cut the cost of health care and invigorate the economy by making available huge additional fiscal resources and manpower for the country. The researchers met with U.S. senators who served on the Senate committee overseeing the NIH budget, but their efforts failed to produce a greater allocation of funding to longevity research, and the present NIH system continues to place emphasis

the brown journal of world affairs The Huge Cost of Health Care on curing individual diseases.18 This is precisely why a Manhattan Project for Extension of Health Span, functioning outside of the NIH community and free of its mentality, is essential. If such a project achieved its objective, it would benefit society well beyond reducing the cost of Medicare. It would produce other savings for the public that are hard to estimate but the nature of which can be predicted. The first effect would be on Social Security. The likely rises in the cost of Social Security stemming from increased longevity would have significant offsets. We do not know how many people would choose to continue working and how many would retire. Those who would continue A Manhattan Project for Extension to work would pay Social Security taxes, thus not increasing its cost. An increase of Health Span, functioning out- of life span would prompt an increase in side of the NIH community and the retirement age. This would provide an offset to costs, but it would require a free of its mentality, is essential. political decision that cannot be predicted. Social Security would also benefit from extension of health span more directly by lowering the cost of disability insurance. At least 50 percent of the Disability Insurance (DI) component of Social Security (9 percent of the total cost in 2011) stems from age-related diseases, and this would reduce the cost of DI. When projected to 2086, the 93 potential reduction of the cost of DI would amount to about $2.3 trillion—in one year alone.19 The cost of private medical insurance would also significantly drop. The cost of Medicaid, amounting to about one-half of Medicare in federal outlays alone (fiscal year 2011), would materially decrease. The total savings to society would thus be huge but only a temporary reprieve. The reason for this is that after the 20 years of extension of health span, the risk of diseases would begin to increase again. However, in terms of costs, the temporary nature of this reprieve could be greatly reduced by what has become known in the world of science as “compression of morbidity.”

Compression of Morbidity

What is compression of morbidity? As a human begins to age, he or she starts to accumulate age-related pathologies, which cause actual or potential disability. The process begins at about the age of 55 and worsens until the time of death, which usually occurs in the late seventies. The aggregate of such disabilities (morbidity) can be compressed to the years close to the end of life. If morbid-

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner ity is compressed, the cost of health care will significantly decrease. Instead of persisting throughout a couple of decades, the incidence of morbities will fall mainly into the few years before death.20 Indeed, with the help of compression of morbidity, extension of health span will come fairly close to eliminating those costs of health care that arise from age-related diseases, and thus virtually lose its attribute as merely a temporary reprieve. There are two causes of compression of morbidity that have been clinically identified. The first consists of the efforts and willpower of individuals. If human beings exercise, eat healthy food, do not become obese, do not smoke, use preventive medicine, and have healthy lifestyles, they push morbidity towards the end of their lives. First advanced as a hypothesis by James F. Fries of Stanford University School of Medicine in 1980, compression of morbidity was subjected to longitudinal studies of aging and eventually was accepted as a viable concept.21 The second is genetic characteristics. Studies of centenarians revealed that for most of their lives they experience few hospitalizations, consume little medication, and have few diseases. They enjoy excellent health well into their mid-nineties, after which they experience a fairly rapid decline. In other words, they seem to have genes that promote compression of morbidity and thus help extend their lives.22 94 The problem with compression of morbidity by willpower of individuals is that it is difficult to make it widespread. However, if the genes involved in the compression of morbidity in centenarians could be identified and translated into drug treatments, then compression of morbidity might be available for the population as a whole, thus further cutting the cost of health care. It would therefore be appropriate for a MPEHS to undertake a concerted effort to discover such morbidity-compressing genes.23 Such an effort would be consistent with its overall mission as well as complementary to the scientific activity it would be pursuing. For the purpose of maximizing the reduction of the cost of health care by extension of health span, it will not be essential to discover morbidity-compressing genes within the span of the five- to ten-year duration of the Manhattan Project. Compression of morbidity will be highly important after the expiration of the period of the extension of health span, that is 25 to 30 years from the launching of a Manhattan Project. Having the luxury of 25 to 30 years, there is a strong likelihood that the research to discover morbidity-compressing genes will produce results. Some progress in this area has already been made. The New England Cen- tenarian Study, an ongoing project headed by Paola Sebastiani and Thomas T.

the brown journal of world affairs The Huge Cost of Health Care Perls of Boston University, discovered some 30 morbidity-compressing genes. Individually, they produce modest effects; however, as a group they can have a strong influence. To translate a number of genes into a morbidity-compressing drug would be extremely difficult, if possible. What is needed is to discover one or two morbidity-compressing genes powerful enough to produce results that could be used in drug development. Research along these lines continues.24

Extension of Health Span and Fiscal Viability of the Nation

How is the extension of health span relevant to the ongoing effort to reform the health care system? If a program for the extension of health span is launched soon, it will only be relevant if the solution for the extension of health span is developed before the end of this decade. However, in the next decade it might stimulate modifications in the health care reform act, such as an expansion of coverage and a lesser allocation of resources to selected programs because of lower costs. Overall, this will help reduce the budget deficit. The reduction of the cost of health care could be critical for the fiscal health of the nation in the next few decades, especially with regard to the national debt. In The 2013 Long-Term Budget Outlook, the Congressional Budget Office (CBO) projects the federal debt until 2038. According to the extended baseline 95 scenario, which adheres closely to current laws, the national debt in 2038 would amount to 100 percent of GDP, or $53.1 trillion (in 2013, it was 73 percent of GDP or $12.2 trillion). The CBO also computed figures for an alternative fiscal scenario, in which certain policies now in place but scheduled to change under the current law would instead continue, and some provisions of current law that might be difficult to sustain for a long period would be modified. Under this scenario, which is considered to be more realistic, the federal debt would reach about 190 percent of GDP in 2038, or $100.9 trillion. The importance of these numbers is clear in a historical perspective: the highest debt to GDP level for the United States was shortly after World War II when, in 1946, it reached 106 percent.25 Washington is realizing the implications of a potential fiscal crisis in the coming years. In the spring and summer of 2011, a fierce debate about this threat effectively generated a political crisis in Washington. In this debate, Medicare was a key target. A highly sensitive and political topic, the discussion on Medicare often leads to deadlock. The Medicare issue has not been resolved, and while the program can be modified, it cannot be abolished. More borrowing is thus unavoidable.

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner The growth of spending on health care programs would be the single most important factor in the rise of the national debt. According to projections by the CBO, if current laws remain in place, spending on the major federal health care programs will grow from 4.6 percent of GDP in 2013 to 8 percent in 2038, or $4.2 trillion per year.26 The IMPEHS could materially help resolve the situation by eliminating the need to treat age-related diseases for an extended period of time. The United States is the leading nation in longevity research, and it could undertake the IMPEHS unilaterally. Private donors could ameliorate the cost of research. In addition to reducing the cost of health care, extension of health span would strengthen national vitality and viability because the most talented and competent people—vibrant and active, free of age-related diseases—would likely continue working for much longer. The lower cost of health care would alleviate constraints on the U.S. budget and would make it possible for the U.S. government to avoid curtailment of the essential social services, including Social Security; perhaps it might even be possible to increase them.

An International Program for Extension of Health Span?

96 The cost of health care, however, is not only a problem for the United States. It is a global problem. Its principal drivers are the expanding capabilities of medical technology and the aging of populations. The enhanced capabilities of medical technology account for 50 percent of the cost increase, while populations aging accounts for 20 percent. However, the share of the cost of population aging is likely to grow in coming years. According to the OECD, over the past 50 years health care spending has increased, on average, by 2 percentage points more than GDP growth.27 Because of differences in policies and local conditions, different nations are affected differently. In the United Kingdom, the cost of health care is about 8 percent of GDP, which is about a half of that of the United States, but it is growing and beginning to alarm British authorities. The population is aging, and fertility is at 1.7 per woman, which is below the replacement level of 2.1. Due to immigration, however, the population is still projected to grow from 63 million in 2012 to 71.2 million in 2050. By contrast, the population of Japan is projected to dwindle from 127 million in 2012 to 107.2 million by 2050, and Russia’s present population of 143 million may shrink to as low as 99 million in the same period. China’s fertility rate has dropped to 1.82, the cost of health care in the country is high, and its population is also aging; by 2050, there will

the brown journal of world affairs The Huge Cost of Health Care be 334 million elderly in China.28 The above data suggest that it would be in the interest not only of the United States but also of other developed and developing nations to fund the extension of health span. Therefore, it would be advisable for the United States to undertake the IMPEHS jointly with the European Union (EU), Japan, China, Russia, and perhaps other nations. An international approach would lower the cost of research for the United States because other nations would share the cost. All nations would benefit from the lower cost of health care, but those with dwindling populations—like Japan, Russia, and Ukraine—would be additionally advantaged because the decrease in their populations will be at least slowed down, more likely stopped, by the increase of healthy longevity. For countries like the United States, the United Kingdom, and Germany, where the demographics and economic growth are becoming increasingly dependent on immigration, extension of health span would decrease the need for immigration and alleviate problems associated with it. To work toward the extension of health span on an international basis would also have an important symbolic value for the United States. The two previous major scientific projects of the United States—the Manhattan Project, which produced the first nuclear weapon, and the Apollo Program, which led to the landing on the moon—were strictly unilateral endeavors. The first was 97 part of the war effort in which America’s survival was at stake. The second was mainly a product of the Cold War, and it reflected the bipolarity of the previous international system. An IMPEHS would symbolize the recognition by Washington that we live in a different, increasingly multipolar world, where objectives of a major scientific project need not be zero-sum, but positive-sum, with global benefits. The full benefits for the United States of an international approach to extension of health span are easily recognized when such a project is viewed in the context of recent history. The United States’ soft power—its image in the world, world leadership (including that in science), public diplomacy, relation- ship with its allies as well as with less friendly nations—suffered significantly and unnecessarily under the George W. Bush administration. Given that the United States’ hard power—the economy and the military—is relatively declin- ing and will decline further in coming years, it would be critical for the United States to attempt to compensate for its relative losses in hard power by gains in soft power. In this category, U.S. world leadership would be perhaps the most important. IMPEHS could be a powerful instrument of soft power for the United States, especially if Washington policymakers effectively capitalize on

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner it and, wherever possible, skillfully translate its soft power potential into hard power. For example, if extension of health span stops the decline of Japan’s population, revives its economy, and generates a great deal of good will for the United States in Japan, the United States could perhaps take advantage of this good will (soft power) to conclude a favorable trade treaty (hard power) with Japan, or win other concessions in the area of hard power. In sum, biogerontology, through its prospective capability to extend human health span, would help the United States cope with the two major challenges the nation is facing in the twenty-first century: the relative decline of U.S. power in world affairs and U.S. fiscal viability. With regard to the relative decline of U.S. power, the contribution of biogerontology will be both direct and indirect. Extension of health span would Biogerontology would help the free up vast resources by decreasing the cost of health care. Those resources could United States cope with two be used for areas essential for America’s major challenges: the relative status as a superpower, such as science decline of U.S. power in world and technology, education, armed forces, foreign affairs, space exploration, and affairs and U.S. fiscal viability. economic growth. If extension of health 98 span is put on an international basis by establishing the IMPEHS, biogerontology will enhance America’s role in the world indirectly through the soft power that such a project would generate. Indeed, it is not likely that the United States will be able to do both—to maintain its superpower status and provide the essential services to its population—for very long without resorting to biogerontology. However, if it effectively combines its revitalized hard power with IMPEHS and other instruments of soft power, this goal could arguably be achieved.

Will Science and the Flow of History Save the United States from Potential Adversity?

On the previous pages, we have pointed out that biogerontologists have in recent years made major progress towards the capability of increasing human health span. Extension of health span will most likely result in a massive reduction of the cost of health care. A Manhattan-like Project for Extension of Health Span, focused on life span free of age-related diseases, would reduce the trillions of dollars the United States will be spending on Medicare and Medicaid in the coming years. It is very likely that the United States will be able to maintain its

the brown journal of world affairs The Huge Cost of Health Care superpower status and provide the essential services to its population—perhaps even improve them—with the help of biogerontology and a skillful use of soft power in coming years. The cost of health care, however, is a global problem. An international approach would not only benefit all nations through lower costs of health care, but would also lower the cost of research for the United States because of cost sharing. Moreover, the United States would make soft power gains if it were to lead such a program. Now we would like to raise more general and abstract questions. What will be the regional and global consequences of the IMPEHS? How does extension of health span affect trends in foreign affairs? How does it fit in history? Although science has extended human longevity, it has done so at a high cost. We have reached the point where the combination of the extension of human longevity by traditional means and the aging of populations is bringing us to a dead end—it constrains resources so much that the United States will be increasingly less capable of accomplishing other important objectives, including those of national security and foreign policy. But now science offers a different solution—extension of health span—that would release huge resources for other purposes. The upward trend of evolutionary history suggests that extension of human health span will happen anyway, with IMPEHS or without it. IMPEHS is merely intended to accelerate the process and steer it toward specific objectives. 99 Extension of health span introduces a major discontinuity into trends in foreign affairs. Unlike the most recent major discontinuity—the collapse of the Soviet Union—it will not be sudden but gradual. Trends in demography are a looming force in changing the distribution of world power in the twenty-first century. As mentioned earlier, extension of health span will at least slow down the population decline—if not revert the trend—in those nations where population dwindles, thus enhancing their viability and preventing potential instability. If extension of health span is successful, current projections of the distribution of power in the world, as measured by demographic trends, will not materialize. The decline of Japan’s population to 107 million by 2050 will not happen. With extension of health span, Japan’s economy is likely to be revived and Japan could emerge again as a viable world power. Russia’s population is conservatively projected to dwindle from the present (2012) 142.2 million to 129.9 million (by some estimates, to as low as 99 million) in the next 37 years.29 Extension of health span would probably help reduce the decline. However, it is not clear if it would solve the problem entirely, since Russia’s severe population crisis has multiple causes, including poor health conditions and excessive consumption of alcohol.30 To optimize the benefits of extension of health span

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner for Russia, substantial improvements must be made in these and other areas. Ukraine’s population instead would remain at a much better level than the projected 33.6 million for 2050 (from the present 44.9 million).31 If it solves or at least alleviates its multiple political problems, then better demographics, a substantial industrial base, rich natural resources, and a well-educated population could help the country evolve into an influential European nation.32 China’s population has been aging and its size will be shrinking. By 2050, it is projected to reach 1.304 billion, 39 million fewer than in 2012.33 Exten- sion of health span would stop the population decline, is likely to improve the economy, and could possibly prevent the potential instability arising from the huge number of elderly people devoid of a social safety net. In contrast, India’s fertility rate is at 2.8, its population growth has been rising rapidly, and the government’s efforts to stem it have not been successful. By 2050, it is projected to reach 1.659 billion people, which is 355 million more than China’s.34 Extension of health span would reduce the cost of health care—which is important for India, because its population is aging and is increasingly encumbered by age- related diseases, while the country does not have a social safety net—and would be beneficial for the Indian economy. However, it is likely to aggravate India’s rampant population growth. It is not clear how the size of India’s population 100 translates into international power because of the huge numbers of impoverished and illiterate people in India (as of 2012, the illiteracy rate in India was 37.2 percent, while in China it was 7.7 percent).35 The picture is clearer for the European Union, which will significantly benefit from extension of health span. According to present projections, the EU will lose only 12 million in population (to a total of 492.4 million from the present 504 million, nearly all of them—9.8 million—in Germany) by 2050, which is less than Russia’s loss and about a half of China’s.36 Extension of health span would be important for the EU because it would help increase its population numbers and revive its economy. Additionally, health span extension could potentially reduce immigration if there is a decrease in job availability due to larger numbers of healthy Europeans able to work for longer periods of time. Given that Western Europe has been known for difficulties in assimilating im- migrants, a reduction in immigration could potentially limit this destabilizing problem. Improvements in economic conditions would likely stimulate European integration, possibly nudging the EU toward a superpower status. Current demographic projections are favorable for the United States. At present, the United States is the only major developed nation that has a fertility rate at or above the replacement level of 2.1 per woman.37 With the help of im-

the brown journal of world affairs The Huge Cost of Health Care migration, its population is expected to grow and reach the size of 423 million by 2050 from 109 million in 2012.38 The United States will remain the third most populous country after India and China. With extension of health span, the total number would likely be larger. The vast majority of the population will be healthy and potentially much more productive. These demographic trends, therefore, suggest that a program for extension of health span may help other participant nations more than the United States in terms of benefits derived from population expansion and viability; however, an increased population boost to the United States coupled with soft power gains provides a huge incentive for the United States to start such a program. As mentioned earlier, extension of human health span will inevitably happen, although not necessarily as soon Nearly all Western countries as proposed here. By 2050, the United States and the European Union—the would benefit from the two ma- two regions comprising the hub of jor advantages of extending Western civilization—will have a total health span—population ex- population of over one billion well educated, vigorous, and productive people. pansion and economic growth. Extension of health span enhances the vitality and viability of societies not only in the economic sphere, but also in other areas of human endeavor—such as 101 music, science, technology, the environment, education, foreign affairs, and literature—all of which are important elements of civilization. The most talented individuals in each of these fields will live healthy and vibrant lives for some 20 additional years, thus not only enriching theirs respective fields but, in their aggregate, enhancing and accelerating the evolution of Western civilization. Accordingly, to speak of the twenty-first century as “an Asian century”—which is fashionable now—may be shortsighted. True, extension of health span will also benefit Asian nations, but the impact will be differential, and it will favor the West. The reasons for the differential impact vary from country to country, but perhaps the single most important reason is that nearly all Western countries would benefit from the two major advantages of extending health span—population expansion and economic growth—while this is not so for Asian countries. Populations of most Asian countries are growing rapidly, and for some of these countries accelerated growth could be damaging to society. A significant excep- tion is Japan, but given that Japan is the major industrialized Asian country, its economic revival would be in the interest of the West. The favorable impact of extension of health span for the West opens up new opportunities for the United

Fall/Winter 2013 • volume xx, issue 1 Victor Basiuk & Huber Warner States and for its leadership in the world. In this context, a close cooperation W between the United Sates and the European Union will be essential. A

Notes

1. The 2013 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supple- mentary Medical Insurance Trust Fund (Washington, D.C.: U.S. GPO, 2013) and data provided by the Center for Medicare and Medicaid Services. The dollar figures were computed by the authors. 2. “Indicators,” World Bank. 3. Simon Rabinovitch, “China’s Forex Reserves Reach 3.4 Trillion,” Financial Times, April 11, 2013. 4. The World Almanac and Book of Facts (New York: World Almanac Books, 2013), 764 and 850. In 2012 GDP of the United States was $15.3 trillion and that of China, $11.4 trillion, in purchasing power parity. Projected annually at 3.0 percent for the United States and at 7.5 percent for China, in 2019 it will be $18.8 trillion for the United States and $18.9 trillion for China. 5. In this article the term “soft power” is used more broadly than the concept of soft power as originally developed by Joseph S. Nye, Jr. in his book Soft Power: The Means of Success in World Politics (New York: Public Affairs, 2004). Nye’s notion of soft power focuses on the aspect of attractiveness; here any actual or potential influence of a nation in foreign affairs other than by coercive use of hard power—military and economic might—is soft power. 6. Roger C. Altman, “The Great Crash, 2008: A Geopolitical Setback for the West,”Foreign Affairs88 (January/February 2009): 1–10. 7. As of 2010, human longevity in the United States was 78.7 years. The World Almanac and the Book of Facts 2013 (New York: World Almanac Books, 2013), 209. 8. Personal communications of Victor Basiuk with these and other researchers in August to September 102 2013. 9. In his widely read book on CR, Walford proposed a dietary program to live 120 years or longer. See: Roy L. Walford, Maximum Life Span (New York: Norton, 1983). 10. Ricki J. Colman, et al., “Caloric Restriction Delays Disease Onset and Mortality in Rhesus Mon- keys,” Science 325 (July 2009): 201–04. 11. David A. Sinclair and Lenny Guarente, “Unlocking the Secrets of Longevity Genes,” Scientific American 294 (March 2006): 48–56; Basil P. Hubbards, et al., “Evidence for Common Mechanism of SIRT1 Regulation by Allosteric Activators,” Science 339 (March 2013): 1216–19. This study, whose principal researcher was David A. Sinclair, confirmed the viability of sirtuin activation as a strategy for extending health span. GlaxoSmithKline, a major phamaceutical company, is using this methodology to develop a drug for extension of health span. 12. Nathan Price, et al., “SIRT1 Is Required for AMPK Activation and the Beneficial Effects of Resve- ratrol on Metachondrial Function,” Cell Metabolism 15 (May 2012): 1–9. 13. Cynthia Kenyon, telephone interview with Victor Basiuk, June 19, 2012. 14. Zelton D. Sharp and Randy Strong, “The role of mTOR signaling in controlling mammalian lifes- pan: what a fungicide teaches us about longevity,” The Journal of Gerontology, Series A: Biological Sciences and Medical Sciences 65 (2010): 580–89. 15. Maria A. Blasco, et al., “Telemarase Gene Therapy in Adult and Old Mice Delays Aging and Increases Longevity Without Increasing Cancer,” EMBO Molecular Medicine 4 (2012): 1–14. 16. This is not to suggest that a project for extension of health span should duplicate the organization of the Manhattan Project, which produced the first nuclear weapon, but that it should have its principal characteristics—a single focus, intensity of pursuit of its objective, and independence from other scientific institutions. The specifics of its organization and activity will have to be decided by a group of biogerontologists and other appropriately qualified individuals after the decision to establish such a project is made. 17. S. Jay Olshansky, et al., “In Pursuit of the Longevity Dividend: What Should We Be Doing to Prepare for the Unprecedented Aging of Humanity?” The Scientist20 (March 2006): 28. 18. Kronos Longevity Research Institute, Grey Is the New Gold; State of the Science Two Thousand Nine

the brown journal of world affairs The Huge Cost of Health Care (Phoenix, AZ: 2009), 5. 19. For the source of the projections used in these computations, see: The Annual Report of the Board of Trustees of the Federal Old Age and Survivors Insurance and Federal Disability Insurance Trust Funds (Washington, D.C.: U.S. GPO, 2012): 197. The computations were made on the assumption that the ratio of disability insurance to the total amount of Social Security will remain at nine percent. This is a conservative assumption, because in 2086 there will be more people of advanced age. Therefore, the cost of disability insurance in 2086 is likely to be greater than $2.3 trillion. 20. James F. Fries, “Compression of Morbidity,” Encyclopedia of Aging (2002): 257–59. 21. Aimee Swartz, “James Fries: Healthy Aging Pioneer,” American Journal of Public Health 98 (July 2008): 1163–66. 22. Thomas T. Pearls, “Centenarians Prove the Compression of Morbidity Hypothesis; But What About the Rest of Us Who Are Genetically Less Fortunate?” Medical Hypotheses 49 (1997): 405–07; Rachel Hitt, et al., “Centenarians: The Older You Get, the Healthier You Have Been,”Lancet 354 (August 1999): 652. 23. Thomas T. Perls, “The Different Paths to 100,” American Journal of Clinical Nutrition 83 (February 2006): 484S–87S. 24. Paola Sebastiani and Thomas T. Perls, “The Genetics of Extreme Longevity: Lessons From the New England Centenarian Study,” Frontiers of Genetics of Aging 3 (November 2012) and telephone interviews of Paola Sebastiani by Victor Basiuk in May 2013. 25. Congressional Budget Office, The 2013 Long-Term Budget Outlook (Washington, D.C.: 2013), 1, 3, 8, 11. The dollar figures have been computed by the authors. 26. Ibid., 42. The dollar figure has been computed by the authors. 27. Peter M. Jackson, “Debate: Health Care Expenditure Trends,” Public Money & Management 29 (January 2009): 1–4. 28. Richard Jackson and Neil Howe, The Greying of the Great Powers: Demography and Geopolitics in the 21st Century (Washington, D.C.: Center for Strategic and International Studies, 2008); The World Almanac (2013), 733–34. 103 29. Richard Jackson and Neil Howe, The Greying of the Great Powers, 180. 30. Nicholas Eberstadt, “Drunken Nation: Russia’s Depopulation Bomb,” World Affairs (Spring 2009): 51–62. 31. World Almanac (2013), 733–34; Neil Howe and Richard Jackson, “Global Aging and the Crisis of the 2020s,” Current History 110 (January 2011): 20–25. 32. For some of the enduring political problems of Ukraine, see: Sharon L. Wolchik and Volodymyr Zviglyanich, Ukraine: The Search for a National Identity (Lanham, MD: Rowman & Littlefield, 2000). 33. World Almanac (2013), 733. 34. Ibid., 733–34. 35. World Almanac (2013), 764, 782. For a more extensive discussion of India’s population problems and how to capitalize on opportunities available for a prudent policy, see: David E. Bloom, “India’s Baby Boomers: Dividend or Disaster?” Current History (April 2011): 143–49. 36. The World Almanac (2013), 733–34. 37. Neil Howe and Richard Jackson, “Global Aging,” 22. 38. The World Almanac (2013), 734.

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