How the U.S. Health System Is Preparing for the Demographic Cliff

(upbeat music) - Hi, this is Jim Nickman. - And this is Brian Elbowl, and you're listening to Conversations about Healthcare Delivery in the United States. A podcast series featuring our conversations with prominent experts, innovators, and leaders in the health sector. Our guest today are Ramsey Olin and Kathleen Cameron. Ramsey Olin is the president and CEO of the National Council on Aging, where she is renewing the organization's commitment to improving the lives of millions of older adults, especially those who are struggling. Kathleen Cameron is senior director at the National Council on Aging, where her work supports policy and advocacy efforts to improve healthcare and social service delivery for older adults. But first, a message from the National Council on Aging. Join the movement to help every person age well. Register for NCOA's 2024 Age+ Action Conference, May 6th through 8th in Arlington, Virginia. The first 50 listeners to use the discount code AgeAction24 will save on registration at ageaction.org. - So Ramsey and Kathleen, thank you so much for joining us. - Thanks for having us. - Thank you. - I was hoping we could start with a little bit about what is the National Council on Aging in COI? Could you just give us a little bit of sense of the organization? - Well, the National Council on Aging has been around for over 70 years, really serving as the nation's first national aging organization, advocating for the programs and policies we all need to age well. So Medicare, Social Security, Medicaid, and the Older Americans Act. We've also been working for over 70 years to provide services and supports to the most vulnerable older adults by helping them find jobs, enroll in programs that can help with food and medicine and other basic needs, better manage their chronic conditions like hypertension, diabetes and obesity and prevent falls. And we're really proud of our long history of working with the National Network of thousands of community-based organizations, including all of the senior centers across the country, to make sure those services and supports really help people age well, age in their home, age in their community, age on their terms. - Fantastic. So I think you all are very well situated in to have this conversation with us. And I wonder if we could start with just a little bit about the demographics. So, you know, anyone paying attention to the news, here's about this demographic shift, some call it a demographic cliff here. Like, what does this mean? What does this aging population in the United States look like? And what are the things that may be obvious to all Americans and the implications for that? - Well, I'll kick it off and welcome Cathy's thoughts as well. But I mean, it's an amazing illustration of the medical and technological advancements that we have the most centenarians living ever at this moment. And your average 10-year-old today is highly likely to live to be at least 100. So the longevity trends are incredible. And our demographics, we need to take note of the over 70 million baby boomers living longer than ever before. But that does mean we need to take a good hard look at the programs and the policies to ensure those are quality years, not just quantity years. We also need to reflect a bit about some of the continued disparities that demonstrate not everyone gets that gift of longevity. There are still considerable differences in terms of health span and life expectancy among demographic groups. One illustrative example is white women are more likely to live 10 to 15 years longer than African-American men. There's real work we need to do in this next chapter of advancing healthy longevity to ensure everyone gets that gift of quality and quantity of years. But Kathy, I welcome your thoughts as well. - Yeah, absolutely, thank you Ramsey. And I think I'd like to point out the diversity of the older adult population. As the general population is diverse, so is those over the age of 65. We're seeing more and more African-Americans, Asian-Americans, tribal elders, Hispanic older adults in particular. But unfortunately, many of those diverse older adults often are the underserved among us. And that's one area that we're certainly working on at NCOA to make sure that those population groups get the healthy aging services, benefits, that they need to age well. We want to equalize aging across the country. So I'm with the Center for Healthy Aging and we are working to scale health promotion and disease prevention programs all across the country that impact the way that older adults can manage their chronic illnesses, how they engage in physical activity, how we address their mental health like depression and anxiety, PTSD, and many other conditions, as well as getting them access to proper nutrition and understanding what proper nutrition is. So we're excited about this work. And the other piece that I think is important, we often hear in the media about the burden of older adults and the aging of society. You know, we like to think about the opportunities and we titled the book. It's, you know, the challenges, but the opportunities that we need to think about and how do we utilize the wisdom, the experience, the expertise at older adults bring to our society. - So I said, it's interesting. I think the whole issue of the demographic change is important. But the other demographic or semi-demographic thing that seems to be a challenge is the role of families. And, you know, families don't live next to each other anymore or multi-generational families. And so how does that play into what's going on in the aging field? - Well, Jim, it's such an important point. I mean, families have always had a significant role in caring for older adults, caring for loved ones in the United States. But we have changed our workforce patterns, our patterns around where we choose to live, our definition of family and community has also evolved. And we haven't necessarily updated our policies and our programs to better reflect that. So today with people living longer, which is such a wonderful miracle, we also have to really reflect on what is it required, what's required to ensure they can live well. And for so many families, when it comes to the role of older adults and the care for older adults, it's been assumed that the oldest daughter, that the women in the household will play a significant role in providing that care. But more women are working in the workforce, more women are choosing to maybe or go having a family with children that can care for them ultimately. So there are all these trends in terms of demographics and workforce that are absolutely coming into play in terms of the family's role in supporting older, frail or loved ones. And so I think as people are moving away and families are far more dispersed, women are increasingly in the workforce and not necessarily available in the same ways to provide care, we need to take a fresh look at the government's role at the role of community-based organizations and even the role of employers in helping provide supports and services to individuals that may be providing care. But Kathy, your thoughts? - Yeah, yeah, I absolutely agree. I think the family's role has changed so much over the past couple of decades and that has put a greater burden on our social support system to address the needs of those older adults who don't have family close by or don't have any family at all. And we do a lot of work at NCOA to support the aging network that provides those services that typically family members would provide like food and nutrition, transportation, housing, all of those sorts of things. So our focus is really to try to beef up and then increase support for public programs that support those interventions but also help people plan as early as possible. In their 40s, to think about what their needs are gonna be as they age and put structures in place to support them. Individually, as well as looking at their community and what their community can do for them. And that includes, I think a model that has developed over the last couple of decades. It's called the Neighbor to Neighbor or the Village Movement and that is neighbors helping neighbors. And it's an approach where older adults can kind of share services amongst themselves. It could be within a city, a county, or it could be even a high rise in a city where older adults can come together and like share services or help each other out in some of the needs that they might have, whether it be transportation to a doctor's appointment or food and nutrition or even just putting in a light bulb, those kinds of things. So there are lots of kind of neat innovations that are happening to address the growing needs of older adults. - Yeah, and as part of these demographic shifts and also shifts in the role of the family, Ramsey mentioned some policy changes that might need to happen or others actors that might want to step out. I want to kind of talk through a couple of those, you know. particularly in the light of us hearing a lot all the time, but a little bit lately about what is Medicare doing these days, what is Social Security doing these days? What about these other social safety net programs? Will they be their belong germ? Sort of what role do you think these like, you know, federal or even state level programs need to have here? And how do you think that needs to change, right? In light of some of these shifts? - Well, hands down our work at the National Council on Aging demonstrates that the bedrock of retirement security in America is Social Security. It is Medicare and it is Medicaid for the most vulnerable. We need to shore up, strengthen and expand those uphillers of retirement security in the United States. Social security was intended to be an anti-poverty program for older adults. It was created at a time where there was no guaranteed income in old age and the poverty numbers were atrocious. Well, lo and behold, last year census data demonstrated an increase in poverty among older adults. It was the only demographic group that saw an increase. So that's an alarm bell. That's indicating it's time to strengthen and expand that program to its intended purpose to provide that basic level of income security in old age. And so we are very, very supportive of taking that opportunity to strengthen and expand to better address contemporary realities such as changes in workforce patterns where more women are in the workforce, recognition that more individuals are playing a caregiving role men and women and that has implications for their ability to work and the way Social Security's currently structured, those hours, those weeks, those years of caregiving are not contributing to their Social Security record and there's a need to remedy that and get that caregiver credit so that it will really better illustrate their contribution and then ultimately ensure a greater level of economic security when it's time for them to drop on Social Security. Conversations around the program are bubbling up. They're bubbling up mostly around its solvency, which we also believe needs to be addressed sooner rather than later. We need to keep the promise that we've committed to today's workers, today's retirees and those in the future by balancing the books and making sure we can give people what they're owed in terms of the benefits we've committed to. But we also need to do that in a thoughtful way and not do it under the deras and urgency of a shrinking window of time to ensure the program's solvent. We need to do it sooner rather than later when we have more options on the table. And the same goes for Medicare. I mean, Medicare is just critical to the health security of older adults, but it still has gaping holes in it. We saw some great advancements last year with the Inflation Reduction Act to expand aspects of Medicare in particular around prescription drug costs and coverage. We're particularly proud of some of the components there that will better help make some of the benefits accessible and affordable for low income older adults around prescription drugs. But there are other frontiers for expansion that we need to address in terms of the needs of older adults as they age when it comes to hearing and dental and our eyes. So there's some unfinished business there as well as some solvency issues. And then Medicaid can never be forgotten. Also a critical component of retirement security being the only vehicle for home and community-based services as we age and yet the wait lists are in the six figures. And so we're absolutely supporters of the expansion of Medicaid and also creative conversations about other public health vehicles that can help provide home and community-based services for those who want a need to stay in their home in their community. But need a little support to do so. - Yeah, as we're having this conversation, we're also reading about what's going on in France where there's so much disarray about the idea of raising the retirement age. And so looking at their demographics, they have a lot fewer children who are going to be growing up to be able to support the people when they're retired. Do we have as big a potential challenge here on those regards of the number of people under 65 and number of people older and how's this effect going? - So Jimmy, make an interesting point. I mean, we have interesting demographics in the US where you've got a very substantial cohort of boomers, a pretty modest set of Gen X, but then millennials are 90 million and counting. So it's an interesting conversation about older adults of today and older adults in the future. Those millennials are highly likely to live to be at least 100. So there are real conversations about what that means. But at NCOA, we also see the most vulnerable, those who work in jobs, manual labor and otherwise that just cannot continue to work until the very end. And so our social insurance programs, including social security need to be reflective of ensuring the most vulnerable have the protections in place. And so one proposal that we are supportive, for instance, with social security, is not increasing, not increasing the early eligibility age because that age was chosen to protect those in jobs that can't work in perpetuity. But instead updating the name of those claiming terms. So right now in social security, your first milestone for claiming is called early eligibility at 62. And then there's a normal retirement age. And then at 70, there's the delayed retirement. Now, those are antiquated terms that don't really reflect the implications of claiming. The reality is when you claim at 62, you're claiming the minimum benefit. When you claim at 70, you're claiming the maximum benefit. And to put it into hard numbers, when you claim at 62, you're actually taking a 30% cut in your lifetime benefit. If you were to just wait until 70 and get that maximum, you would have considerably more from social security every month. So there's a bipartisan proposal that's been introduced in the Senate to update those terms of social security claiming to better reflect the true implications so people can be more informed about that are choices. And we think that'll go a long way in helping people better understand their options and making a decision that works for them. If you can delay, if you can wait out and get that maximum benefit, it's in your best interest. But there are lots of good reasons why people might have to take that minimum benefit at 62, which puts them in a category where they're not quite eligible for Medicare. They don't have insurance, perhaps, through the private market. And they're caught in between, they might not qualify for Medicaid. So that is a group of people that we care about as well. How do we meet their needs? They're really underinsured or uninsured completely. So how do we address that? And that's an area that we're working on as well. I wanted to touch upon a comment that Ramsay made about the millennials. And that's a growing population that's gonna be in need of services before we know it. And they're gonna have different expectations, I think, of the healthcare system. And I'm glad to see that I think the Centers for Medicare and Medicaid Services, they have been looking at new models of care for the aging population, some of which were described in the book chapter. But I'm hoping we're gonna see even more and more of that as time goes on. And both acute care, as well as long-term care, Medicare advantage is kind of new within the Medicare population. And that's a model that is growing significantly now more than I think half or close to half of Medicare beneficiaries are enrolled in a Medicare advantage plan. And CMS is allowing Medicare advantage plans to offer services that better address some of the social determinants of health that are so critical to the lives of older adults. And that includes things like home delivered meals, medical nutrition therapy, even home modifications so that older adults can age in place. So we're learning more and more about how these benefits are being used by the Medicare advantage population, what the uptake is, the impact that these social determinants health services are having, to make sure that people in fee for service Medicare in the future will have access to those benefits too. So I think that's an area of growth for sure within Medicare is how we address those social care needs. And CMS is even talking about having healthcare providers who are getting Medicare reimbursement, actually screening for social determinants of health. [BLANK_AUDIO] assess and refer to services that are needed in the community to address those really critical issues that underserved populations don't have access to. So, very interesting. One of the other things that you mentioned, I think it was Ramsey, was about the role of employers. And that's when you don't often hear it quite as much about in this debate, relative to things like Medicare and Medicaid. And I wonder if you could talk a little bit more about that. Is that employers taking care of their employees as they age? Is that allowing for their employers to take care of their potentially aging parents? Like, what does that look like from an employer perspective? Also, what we're hearing increasingly as employers, especially in light of the pandemic, and recognize that their workforce increasingly self-identify as caregivers. So there's that piece of the puzzle that as individuals are experiencing the need to help older, frill, or family members navigate these key life moments as we age, there's an impact to productivity if they aren't getting the right support. So there are some innovations around employee assistance programs and other interventions through employee resource groups where they're bringing together people who self-identify as caregivers to have conversations about the supports and the experience that they're having. And they're recognizing that employers there's a value to investing in providing better support for those caregivers. So there's an opportunity there. And then we're also hearing from employers that are looking to better support their employees that are looking to say enroll in Medicare and maximize that enrollment experience. We're also hearing from the financial services sector of financial advisors that were a long focus just on your investments, recognizing that they need to play a role in helping their clients think about that key life moment of enrolling in Medicare as well and optimizing the resources they have available to truly ensure their health security ultimately. So it's very promising to see just additional stakeholders get involved in recognizing the need to get up to speed on the demographic trends and all the supports and resources that can be brought to bear to help people really get that health and economic security. And Kathy brought up an important point. There's a vast network of community-based organizations and resources and innovations. And it's so important to get to know the resources available in your community whether it's a council on aging, an area agency on aging, a senior center, a community action agency. These organizations have resources and professionals that can help support individuals that are navigating these important decisions. Now a message from the National Council on Aging. Benefitscheckup.org has information on thousands of programs that can help eligible older adults afford health care utilities and more, so they can age well. Learn more at Benefitscheckup.org today. And now back to the episode. That also leads me to something that Kathy mentioned as well, which is that, and I wonder if we can get gem thoughts on this also. People often think of the burden of aging, but Kathy mentioned the opportunities with aging as well. And I wonder if we can talk a little bit about that. What does that look like? How should we be reframing how we think about that, particularly as the society just as it is? Yeah, I think we're seeing it in pockets across the country where older adults are volunteering, you know, in schools and in hospitals, you know, wherever they're needed. You know, people who retire at 65, they could have 30 more years of their life, 20 of which they could be quite healthy and functional and really can contribute in significant ways. I think there are, you know, mentoring programs that older adults are involved with for young professionals to help them, you know, get into the workforce and be successful. So I think there's just a myriad of examples in which older adults can play a role. You know, I think it's really important because we know that meaning and purpose is really key to longevity. And being able to give back is a way in which older adults can have that meaning and purpose in their life. We also know that being connected to others is helps us age well and those connections are really important. And I believe an intergenerational connections for older adults. It's important for older adults to be connected to younger folks and younger folks can also learn so much from our older adults. You know, I always like to, you know, bring out that diagram once more and say, there are actually three stages of aging. Also, there's a healthy active stage where, you know, you're fine, right? And you're enjoying retirement. And then there's a slightly slowing down phase, you know, where you need some help. You might need some help being driven around stuff like that, shopping. And then there's, you know, the end of life phase where you really need a lot of care. And to me, the best model is to say the healthy elders should be helping out the medium level elders who need some things. And then we should have a safety net that is probably government programs that really take care of the people who are most in need at the end of life. And if you have that sort of quint pro quo of sort of, you know, volunteerism and community activities and then have the federal government play a role at the end, maybe that's one way to look at how we should be thinking of this. Yeah, and that relates to another issue that we hear a lot about, which is socialized social isolation, right? And obviously, this is something that could help us some of that. But how big of an issue is that for many older Americans and what can we do to really help with that at a broader societal level or doubt to the individual? We should know. Capitalism is an expert, both on social isolation, walls and falls, which are two of the key challenges. So we should. Yeah, yeah. Well, you know, even before the pandemic, social isolation was an issue with the older adult population, there are estimates that as many as 20% of the population experience social isolation or loneliness. And that increased to more than 50% during the pandemic. So it's a really significant problem. And why do we care about it? Because there have been tremendous number of studies and shown that social isolation and loneliness leads to negative outcomes for older adults and really in terms of heart disease, stroke, mental health, and really all cause mortality is increased with high rates of social isolation and loneliness. So it's really, really important for older adults' quality of life, their physical and their mental health. During the pandemic, certainly technology played a role in connecting older adults to their family, their friends, as well as to their healthcare providers. Telehealth really took off during the pandemic. It had to. And which was great. That was a lifeline for many older adults to get connected to their doctors. So many older adults got up to speed very quickly on how to use Zoom and FaceTime and other platforms so that they could connect to those that they needed to connect with. But there was also disparities there because there were many parts of the country that didn't have that still don't have broadband. That's something we're working on. I really think access to technology is a social determinant of health now. We need to better address that. So it's in access to broadband access to the technology itself and to help older adults use the technology effectively. So really increasing the technology literacy among the older adult population. And that has been a role for the aging network. Senior centers played are a really large role in educating older adults how to how to use technology as well as getting them access to technology during during the pandemic. But there have been a number of programs that have been developed over the last several years to connect older adults to one another to reduce social isolation and loneliness as well as identify those who are at risk. And those, you know, there are new tools to do that that now some healthcare providers are using, you know, in the doctor's office to identify those who are at risk and get them access to to services and programs that they need. But one area is certainly senior centers. Ramsey has mentioned them already, but they are about 10,000 senior centers across the country. And they are hubs in the community where older adults can go and get access to a broad range of services and programs. From any older adults, most importantly, a warm meal every day is really critical. But there are, you know, physical activity programs, there are games, clubs, you know, social engagement opportunities are available at senior centers and we're working at NCOA to kind of modernize as we say senior centers to get more older adults to to go to senior centers. They're going through a transformation right now. and we're hoping to reimagine what they're going to look like so that world or adults can take advantage of the great services that they can really benefit from. It's interesting the you know the communities that I spend a lot of my time in they have all these active programs for older adults but they're in most of the towns I watch you know their resources are not enough to handle the growth that's happening and and so you know we need that type of an investment probably that these councils on aging are going to get overwhelmed with their current budgets and and you talk a lot about Medicare Medicaid and Social Security but there's also the money that comes from the federal government to support those community-based things and in my sense is those are really small investments compared to what we invest in other areas at the federal level. Yeah very very small investments compared to Medicare and Medicaid and the Older Americans Act was was passed at the same time as the Medicare and Medicaid. But yeah we've seen small increases over the years and that that's an area of policy and advocacy and COA that we we continue to to work on. I think Kathy's point about how devastating social isolation can be just really punctuates the importance of elevating connectedness and socialization to that level of a public health issue. I mean sometimes we use the talking point that social isolation is as lethal as smoking a pack of cigarettes a day and so if we're really going to take that knowledge seriously we do need to invest in the programs and services that can cultivate that connection and to Kathy's point I mean older the older Americans act should rival the investments of Medicare and Medicaid given the demographic trends. However it's pennies on the dollar and so as as I think about this incredible audience that's listening as those that are interested in public health policy I think there's a real opportunity for the next generation to elevate this social connectedness issue in the conversations and they get into the financing systems to ensure that those organizations can have the resources needed to meet the demand. Yeah so you mentioned at the outset the shift in demographics right and the fact that we have different age different racial ethic groups that are that are aging at different rates and that leads to a key discussions about disparities and inequities. Now what I forget spent a little bit of time on that you know particularly as it relates to things like long-term care services or even just sort of medical services right. Or could I add the idea that we might have a world where the wealthy people live to be 120 and non-wealthy people live to be 80 and you know does that work? Well Jim let me just say we're already there right we're already there in many ways when you look at demographics around life expectancy some of the key drivers are income, education and zip code. And then of course race and ethnicity and gender comes into play but when you look at the stark realities of life expectancy today you already have considerable disparities based on those core components that are key drivers and so I think some of the medical and technological advancements will only drive that which further if we're not intentional about the public policies that may regulate them especially the vast amount of venture capital resources going into radical life extension initiatives that are just sci-fi in nature but really happening in terms of creative ways to push the limits on human life expectancy but those will absolutely be left behind though there will be people that will be left behind and it will drive those disparities to be even deeper. And just maybe to highlight a study that we conducted at NCOA I think really points to some of your comments Brian and that is women more than half of those who lose wages because of chronic conditions are women. Women have the highest financial yearly burden caused by chronic conditions but they have the lowest household incomes and the highest so it's again a tremendous disparity but also black and Latino people 60 and over spend $4,000 per year or more on average due to inequities and that's often related to the fact that those two populations get later diagnoses for diseases including cancer diabetes heart disease therefore they tend to have greater severity of diseases requiring more intensive treatment and more more expensive treatments and they have to pay a significant heart of those costs so really tremendous inequities there. Do we have solutions for that? I mean is this about strengthening the social safety net here like policy solutions I mean is that what we're talking about or is it something bigger or better difference in that? Good question because I'd say that maybe some of our existing social insurance programs don't account for the unique life experiences and challenges that the different demographic groups experience so I think that there's a need to be a little bit more targeted about what the needs of different demographic groups are to get them on track as opposed to just a universal strengthening. So for instance looking at say the needs of those that are more likely to experience that cost burden of chronic conditions and looking for upstream interventions that could allow the diagnosis to happen sooner so there'd be more options on the table. I think it's access to care oftentimes and there are segments of the population that don't trust the healthcare system don't want to access it I think we need to have healthcare providers that reflect the communities in which they work and that's an area that I'd like to see more work in getting community people of color in more in the healthcare professions to work with with those populations that are underserved. So I want to shift to career at the end here and you know we you've mentioned lots of ways I think that that one who wants to engage in improving the lives of older Americans can do so but maybe you could just highlight it right like one of the various possibilities that that you know a student coming out or someone even made career that was to shift can can think about doing so. I think the beauty in this field is there's so many potential career paths from entry level to middle management to executive and so it's really a matter of thinking about what you're most passionate about is it the public policy is it the advocacy is it the administration is it the direct service is it the clinical is it the research what are you most passionate about because in the field of aging there are a range of opportunities that are available to individuals improving the overall systems or working with the older adults themselves on the front line every day what would get you out of bed but you name it it's available in the field of aging there are so many different career paths and I and it's not always linear for individuals there opportunities to move across different aspects of the field from policy to direct care to administration and so it's just a fabulous sandbox to play in and there's so much need so much demand for workforce I just encourage anyone considering it to to explore the options possible and in the chapter we have a nice list of different types of occupations that are just a sample because new new jobs are getting created every day given the evolving needs of older adults yeah I would add to that I think there are so many fields that people might not even think about that impact lives of older adults technology you know creating new and better technologies that are more accessible for for older adults and people with disabilities is is one example I was an architecture you know building making sure we have accessible homes for the aging population certainly pharmaceuticals is an area I'm actually a pharmacist by training I never thought I'd be working in the field of aging actually when I first started my career three decades ago but had the good fortune to go to a school of public health that had a great aging focus program and the first project that I worked on was developing a long-term care system for the United States we've come a little we've made some progress in that regard since since those days but we still have a long ways to go but yeah I think I would would recommend, you know, for anyone who is, you know, exploring what they want to do, go out and volunteer, or like the neighborhood village that I talked about earlier, or find out what opportunities there might be at the local senior center, or area agency on agent, or nursing home, like, you know, Jim Nickman's experience with working at a local nursing home when he was growing up, and, you know, understanding how rewarding a career in aging can be, no matter what aspect of aging, and again, it's very broad. It can be. That's great. I'm going to turn it to you. Final thoughts, sir. Yeah, go for it, Jim. I just want to say we really do need a complete rethinking of the long-term care, you know, nursing home, assisted living, all those things, and, you know, I think there are lots of really interesting careers and, and sort of figuring out that whole issue. Yeah. Well, Ramsey and Kathy, thank you so much for joining us and such an interesting and insightful conversation. Thank you. Thank you. Now a message from Springer Publishing. Variety flexibility, accessibility, and the freedom to choose what works for your busy life. That's the Springer Publishing way. Does it Springer pub dot com slash public health or content and tools to move forward in your career? Use code podcast for 25% off your next purchase. So Brian, I thought it was really enlightening to really talk to them and hear what they had to say relative to where they sit in the long-term care and aging field. But what are your reactions to what we learn? I agree. I thought it was interesting to start with the scale and scope of what we're talking about in terms of demographic shift. You know, I think they put that in a nice perspective. And obviously that is real on there. But also interesting to think about what agents that will look like in the future. One, for example, millennials become the older group. So I thought that was like a nice way to think about it. And I think it also really gave you a scope, a sense of a huge scope of possibility for acturing or interacting with this field, right? I mean, I think there's so many possibilities on the clinical care side on the service side, on the policy side, you know, so many various things that are influencing aging. And that is just really a wide scope for being able to engage. Right. And I think a lot of the opportunities are in organizational types of things that are very different than you would have thought of in the aging field 20 years ago, whether it's a startup creating new technologies or it's some of the long-term care facility changes and other housing changes that they talked about. So it really is a diverse set of opportunities for the next generation. I hope those millennials, though, keep working for as long as possible because they have to still take care of the baby boomers, you know? Yeah. And I thought the point you brought in about thinking with respect to how the conversation in France is going right now, or the lack of conversation, you know, it was also really relevant in a contrast to kind of how things are going here, where maybe we're not paying attention to quite as much, but it's happening in a very real way. Yeah. And I thought the other thing I learned a lot and I really care about is that part of the solution is at the community level and at the volunteer level. And that's that's by good for our country and financially good too. We just have to get everybody out there and involved. For sure. They're a really great conversation, though. This concludes another great episode of Conversations about Healthcare Delivery in the United States. Thanks for listening and stay tuned for more episodes and additional resources related to the text book. Conversations about Healthcare Delivery in the United States have been brought to you Restbringer Publishing Company LLC. All rates reserved. No part of this podcast may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior permission of Springer Publishing Company LLC.