The U.S. has the most expensive healthcare system in the world but is not getting the best outcomes as a result -- particularly for U.S. seniors, whose health outcomes lag behind those of senior citizens in other industrialized countries. California's Master Plan for Aging provides a blueprint for other states on how to address this healthcare crisis for a diverse population that is both urban and rural. West Health's Shelley Lyford, president and chief executive officer, and Dr. Zia Agha, chief medical officer and executive vice president, join the podcast to discuss the master plan and how West Health's approach can address different needs and sectors that touch a senior citizen's life.
Below is a full transcript of the conversation, including time stamps. Full audio is posted above.
Mohamed Younis 00:07
I'm Mohamed Younis, and this is The Gallup Podcast. This week, in a country that spends more on healthcare than any other, we speak to two leaders focused on how to bring costs down -- particularly for seniors. Shelley Lyford is president and CEO of West Health, and Dr. Zia Agha is West Health's chief medical officer and senior vice president. Shelley, Zia, welcome to the podcast.
Shelley Lyford 00:30
Excellent. Thank you, Mohamed. It's great to be with you.
Zia Agha 00:33
Pleasure to be here, Mohamed.
Mohamed Younis 00:34
Shelley, last time we had you on the podcast, we talked about the high cost of healthcare in the U.S. I'm hoping that today we can dig deeper into particularly how uniquely this has been impacting senior citizens.
Shelley Lyford 00:47
Absolutely, Mohamed. Again, thank you for asking West Health to be part of your regular programming. We always want to shine a light on how hard it is to age in America, and particularly, let's take a look at the high cost of healthcare and the high cost of prescription drugs and the many choices that seniors need to make in order to afford healthcare and prescription drugs. So there is absolutely no doubt that America is entrenched in a healthcare cost crisis. To that end, Mohamed, every hour we spend approximately $420 million on healthcare, a number that is increasing by the minute. And that makes our healthcare system by far the most expensive in the world. Now, what are we getting for that and what are our seniors getting for that? We're not getting the best outcomes of the world at all. And I'll turn it over to Dr Agha right now to tell you a little bit about what seniors are getting for that very high cost.
Zia Agha 01:59
Thank, thank you Shelley. And, and Mohamed, thank you for raising this, this question. You know, from my vantage point, when I look at the cost of healthcare and the outcomes and where we rank, you know, in the OECD countries, we are not even in the top 10, yep, that's as a nation. But really what's important is the stories of individual seniors we get to talk to and work with -- in our PACE Clinic, for instance -- and how they are struggling to make choices between paying for their prescription drug versus paying for some other services like rent or electricity. And we'll talk about that in the Master Plan for Aging, which really addresses, you know, well beyond healthcare. But there are tough choices to be made, both at the individual level and at the state level when you have, you know, every dollar that goes towards healthcare could have been used toward social support, transportation, housing -- things that make seniors' lives so much more better if you provide those other services. In the European countries, approximately 50 cents to the dollar is spent on these social services and supports; not in our country. So we have to figure out a way to rein in the healthcare costs so we can then invest in these other areas that are so critical.
Shelley Lyford 03:13
Mohamed Younis 03:13
Shelley Lyford 03:15
I mean, just to add one, one thing to what Zia said, or Dr. Agha said, what we have found actually through research with you and with Gallup, health outcomes of low-income seniors are lagging well behind those of other industrialized countries, and their critical social-net safety programs that we all know about, such as Medicare and Medicaid, they are always squeezed and they are underfunded. And there's uncertainty with respect to their perpetuity. And so there's that segment of the population that worries about that. But then also there's the other segment, this middle segment, the middle-income folks who are really getting squeezed because they don't qualify for many of the programs, and their income is just enough -- sometimes just dollars more than a cutoff -- and it makes them not eligible for programs. And then these are the seniors that we're seeing who are really suffering.
Mohamed Younis 04:17
I just recently had the pleasure of speaking to a roundtable for The Atlantic and an opportunity to share some of the work we've been doing with West Health and, in particular, just the millions of Americans who have trouble paying for prescription drugs and the impact, the disparity on minority groups, but also particularly on those who are dealing with three or more prescriptions. The difficulty in paying just goes, skyrockets in correlation to how much medication somebody is being prescribed and needing. You all are based in what I think is the greatest state on earth. At Gallup, we're nonpartisan and neutral on all things partisanship. But I'm never shy of saying, I love California. One of the things that's happening in California, and one of the reasons I wanted to speak to both of you today, is this new initiative called California's Master Plan for Aging. Tell us about it, and tell us about what role you all played in bringing it to fruition.
Shelley Lyford 05:21
Well, this is a program and really a movement that the Gary and Mary West Foundation and West Health is so, so delighted and privileged to play a leadership role in. In 2018, the Gary and Mary West Foundation actually began a program called, We Stand With Seniors. And we worked with the SCAN Foundation, and together at that point in time, we went to the candidates running for governor, John Cox and Gavin Newsom, and said, "If you are elected, will you stand with seniors? Will you take bold steps to assure that California is setting the pace in the nation to become the best state to grow old in? Will you break down ageist barriers? Will you create better programs for seniors to have access so they may age in place and age with dignity and with the resources that they need?" And both of those gentlemen signed on and said, "Yes, we will make that pledge to you as candidates."
Shelley Lyford 06:28
And then Gov. Newsom became the governor; Gavin Newsom became the governor. And in his inauguration speech, he said, "I stand with seniors, and I pledge to the seniors in this state and to their families that we will create a plan that will make aging easier." And he has lived up to that promise, and we are so proud to have been a pivotal member of pushing his, him and his administration to create the Master Plan for Aging. So we worked alongside other foundations and other key stakeholders. We were members of an advisory committee to create a Master Plan for Aging -- there were about 30 of us in this state -- and we created a plan that has five primary parts.
Shelley Lyford 07:19
And the pledge that we made as we were going through -- pre- COVID times and then during COVID times, when there was a bright light shining on the criticality of having programs for seniors -- we pledged, we're going to create a plan that we will execute that will indeed be implemented into communities, into cities, into counties. We're not going to create a textbook and then put it on a shelf and let it create, and let it collect dust. And to that end, Dr. Agha and his team and many others across the state have taken the five main components, which Dr. Agha will go into, and have started to implement them.
Mohamed Younis 08:05
Zia, so tell us more about these five components.
Zia Agha 08:08
Yes, Mohamed. So as, as the stakeholder group that Shelley was part of and I was part of came together, we had a really broad-based discussion to really define, what is the aging experience in California and how can we improve it? It included areas beyond healthcare. At the end of the day, there are five areas that we all aligned on and that the governor approved. And those five areas are of course housing for all ages and stages; healthcare reimagined for seniors; inclusion and equity, not isolation -- and that was really made visible during the pandemic, the whole isolation issue; caregiving that works for our families and our seniors; and affordable aging, which, of course, is so critical.
Zia Agha 08:56
And we started our discussion today to talk about healthcare costs. And within these five bold areas, there are already in the first two years, 130 initiatives that have been sort of proposed and have funding and are now being sort of developed to be fully implemented. We can go where some of these that we are involved with, but I do agree with Shelley that the focus from Day One has been on a practical master plan that is going to serve as a blueprint, blueprint to really guide us in doing these types of programs that are gonna touch seniors today and improve healthcare and social services and supports for them.
Mohamed Younis 09:38
One of the things that I was shocked to learn as I was just reading up on this and what you all have been up to is that this is really the first plan the state of California really has ever had to comprehensively address the aging population in this sort of multidimensional way. I bring that up because one of the reasons, as a Californian, I'm so enamored by the state is despite all of its challenges -- politically, economically, it's really led the nation on a lot of really critical issues: environmental standards, recycling before anybody even knew what that was, alternative energy and alternative fuels. Talk to us about the reality that a state that big doesn't have this kind of a plan. Why is it important that it has one now?
Shelley Lyford 10:22
So you are so right: California leads the way in our nation in so many aspects of our life. In fact, California is the fifth biggest economy in the world, and as California goes, so goes the nation. And so at this juncture, we have 35 million people in our state. We have an incredibly diverse state. We've got rural areas and urban areas. There is such a great opportunity for us to demonstrate in such a big, diverse state that you can implement a plan, no matter if it's in a rural setting like our Central Valley or in metropolises like Los Angeles or San Francisco. So why, why after all these years and after this big, growing population and the fact that we're just a booming economy, why are we not paying attention to seniors? Why haven't we implemented a plan that will allow seniors to age with dignity and grace and access to the services they need? And I think the concept for this plan, for a master plan in aging, has truly been in California for some time -- the concept.
Shelley Lyford 11:27
There are a lot of really great people doing great work who have thought about this and considered this. But I really feel like our momentum in 2018 during the election cycle of putting the candidates' feet to the fire, saying, "Pledge. Pledge that you're going to do this and do it," and then, and then holding them accountable. That was the first time in our history that we've ever done that and that we had an administration that said, "Hold us accountable. Do it. Let's get this done." So, but really, for the past 20 years we've had a lot of great people working in aging, rallying and clamoring for such a plan. Listen, you know, aging is changing all over the state of California. The over 60, 60 population in the state is projected to diversify and grow faster than any other age group. And by 2030 there will, there will be, for the very first time in this state, more seniors than kids under the age of 18.
Shelley Lyford 12:35
So just looking at the demographics, just the demographics of them, we, we can't go into this with our eyes closed. It is right in front of us, and it is an opportunity. You know, so many people say, you know, "the, the silver tsunami of aging." Well, I mean we, we really take great offense to that term, silver tsunami -- "tsunami" is not a pleasant thing. We look at this more -- some people say, like "the golden wave." There is an opportunity as we grow older and we are 60 and 70 and 80, we have got wisdom; we've got opportunities; we have got skills to impart. We've got good ideas, and we're really working to break down those ageist barriers and create a plan that is replicable, that is implementable. And the demographic shift, if it didn't before, it's going to make us and push us move forward.
Mohamed Younis 13:33
Zia, how is it going so far? So this was started in January -- correct me if I'm wrong. And how has it been progressing?
Zia Agha 13:41
Yeah. So I will just add to what Shelley said, in the sense that there's always been a realization about the needs of this population, but you need a movement. And I think that is what the SCAN Foundation and West Health and Shelley really have created, that brought together not just sort of private organizations and stakeholders, but the government and public, you know, leaders. As a result of that, if you think about success, you know, for any kind of master plan like this, it's one thing to put together your priorities -- and it was a big document, but, you know, hundreds of priorities put together very thoughtfully. But then to help prioritize those for funding, yep.
Zia Agha 14:25
And I would say that was our first measure of success when in, in initial budgets, the Mary Wise, and then through the legislature, the state government, the governor and the legislature have committed over $10 billion over a period of 10 years to impact this change. That's a historic level of funding that's going directly to improving care for seniors. And that number is divided across big initiatives, you know, over $500 million in housing, you know. IHSS, which is essentially the in-home services and support network that takes care of people in their homes, keeping them out of nursing homes, $300 million-plus. You know, $150 million on digital health and telehealth to really break some of the gaps between our rural communities and seniors who live there. So these are big investments by any measure. And these investments are of course gonna, you know, hopefully bring outcomes, but we're also holding their feet to the fire by saying we need evidence and data that will show us that these outcomes are being achieved.
Mohamed Younis 15:34
I was just going to say, I work at Gallup, so I'd get fired if I don't say, "How are you going to measure progress?"
Zia Agha 15:41
Exactly. And so, so we'll measure progress along three axes. Yeah. We already saw some progress on sort of implementation of a budget that's gonna put life into this master plan, really, literally. We are going to have stakeholder advisory committee and other committees from the nonprofit sector and other stakeholders that are gonna work with the state to monitor and advise. And we're going to have a very data-driven approach, which West Health partnered with our state agency, the California Department of Public Health, to create a data dashboard, which is over 50 metrics that span anywhere from healthcare to housing to transportation and cost of healthcare. And we're establishing baselines right now and the dashboard is live, you can go to the CDA's website and look at it. And then of course, we're gonna have targets that we're gonna measure our progress against. Are we moving in the right direction? Are we not moving in the right direction? And this is a 10-year plan, so you better have a target, yep, that you can follow as a North Star, otherwise you could easily get lost. So I think that three-pronged approach of providing the resources, having the stakeholder engagement to implement the plan, and having targets that are measurable is really going to serve us well.
Mohamed Younis 16:57
Zia, can you tell us about some specific programs with regards to this master plan that are new or, or particularly impactful you've noticed?
Zia Agha 17:05
Mohamed, I'm glad that you asked that question. You know, as you think about the aging experience and the healthcare services that seniors receive, one area that we are very concerned about and have put a lot of effort into is emergency services. It's a time of need which, you know, any of us who've had to go to an ER recognize that the type of services and care you receive can have a big, big impact on your outcomes. As part of the Master Plan for Aging, and even before that, with our county, we have been working in a public-private partnership that allows us to develop these geriatric emergency departments, which are essentially a specialized place within a regular ER with protocols and services and specially trained clinicians to meet the need of the 65-and-above population.
Zia Agha 17:59
As part of this initiative, we started working with the county of San Diego to create the first sort of county in the nation where every emergency room is certified to provide that level of care as a GED. And this was not just done by West Health; of course, we had all the major healthcare systems who signed up and made a pledge that they will deliver this type of care within one year: our national partners; the American College of Emergency Physicians; and then our county leadership. That example resonated with us and the state and other partners, and as part of this Master Plan for Aging, we're thinking of an even more bold vision: to make California the first state in the nation to have access to geriatric emergency services across all counties, all cities. And to do that, we have launched an initiative working with our state partners, working with the hospital associations in California, and then hospital partners (all the major healthcare systems) to sort of start to develop these emergency rooms with those capabilities.
Zia Agha 19:09
What's really interesting is when you think about the state like, well, yes the GED and the ER is an important initiative for them, but what really excites them is that it touches so many other aspects of this larger master plan. We think about housing. We think about transportation. We think about transitions in care. During the pandemic, we had to take, take care of people in the ER, outside of the ER, in nursing homes. This initiative really helps us touch many of these areas. Workforce is a big emphasis for the Master Plan for Aging. This initiative exemplifies how you can take an existing workforce and train them to raise their level so they can take care of seniors appropriately. And it's of course a great initiative in the sense that it's a true public-private partnership. It's not just run by the state. The state is helping us, but it's really run by nonprofit organization West Health and the healthcare system partners. And I think that's a good example of other initiatives that we hope to achieve through this master plan.
Shelley Lyford 20:12
And I'd just like to add here, Mohamed, that what is so great is that we had a host of stakeholders from diverse communities come together, put forth over 800 ideas. Those 800 ideas were refined into a two-year plan for implementation, and they were really focused on 130 things. And the governor and the administration and the state put their money where their mouth was. We have funding opportunities for these initiatives, so we are truly implementing. And West Health not only is leading the way with geriatric emergency medicine initiatives, but also Zia and his team, along with the state, are holding us accountable to implementation with those data dashboards. And that is really exciting. Because you've got a nice loop here: You've got people who want to do the right thing and implement programs; you've got funding for programs; and then you've got the accountability of the data dashboards. So I mean this is really, and in other states we have seen plans be created and initiated to a degree, but here we are holding our feet to the fire, and it is really exciting.
Mohamed Younis 21:27
One of the things Zia mentioned earlier was isolation -- of course, the, this first year for the plan has been unfolding in the context of a pandemic that is particularly dangerous for seniors. What's, what has that been like and what impact has that had on this plan?
Shelley Lyford 21:44
So I would say, listen, we're trying to make lemonade out of lemons, and COVID shined a light on the fragility of our system. It shined a light on where we have many obstacles to overcome. Obviously, seniors had to face a very harsh reality during COVID and, you know, were at home; were alone; were dependent upon nutrition being delivered to their doors. They weren't able to socialize. One thing that we've noticed right here in our own San Diego County: We, in collaboration with Serving Seniors, run the Gary and Mary West Senior Wellness Center, a center that is a bubbling hub of activity in normal days, with 900 seniors going to one location to receive nutrition and services from about 24 different nonprofits under a single roof.
Shelley Lyford 22:39
That has been transformed. Our senior center has been transformed into a nutrition center now. And we have to, that is the only way for us to be able to touch the lives of seniors, because seniors aren't coming back; seniors are nervous. Unfortunately, our numbers there are down to 175 people a day, because seniors are still nervous and still feeling the effects of this pandemic. And so the plan has really shined a light on the opportunities. We need to take care of seniors, and we can't let a senior's best friend be a TV. And when seniors are lonely and depressed, it affects their body the same way if you smoked 19 cigarettes a day. We have to do better. We're seeing opportunities to do better. And, and really this plan is blossoming into something that's much more holistic -- as Zia said, five different areas focusing on all aspects of life.
Mohamed Younis 23:34
As we close, I want to ask both of you a question. If you could wave a magic wand, would you rather see other states implementing similar master plans for their seniors, or do you think the solutions for seniors across the country are more along the lines of a federal act by Congress that really attempts to tackle the problem at the national level. Which, in your view, would be more impactful for seniors today?
Zia Agha 23:58
Sure. That's a great question. And we've put a lot of thought into this, Mohamed. Clearly there are other states that are developing master plans. There are four states -- Colorado, Massachusetts, Minnesota and Texas -- that have master plans (and California, of course). So that's five of us. I think it's a combination. Yeah. If you think about the federal government's role in this space, clearly, you know, they can provide direction and resources, as they have. They can expand certain federal programs that, touch seniors like Medicare, Medi-Cal expansion. Even the infrastructure bill that is coming down is going to provide resources and dollars that could be used for improving infrastructure that touches seniors. So from that perspective, yes, there's an important role that our federal government can play in supporting, incentivizing and creating the right sort of, I would say, you know, the soil for us to really plant the master plan.
Zia Agha 24:54
Now, the states really have the responsibility, and they have the stakeholders and have an understanding of what is best for their populations. And they, like California has done, really -- if given the resources from the feds and the direction -- are able to really have a master plan and implement it. I'll use the example of our master plan. When we started down this path, the funding was initially coming only from the state. But earlier this year, we got a home and community-based benefit for $3.5 billion. Now, if we did not have a Master Plan for Aging, we don't know how that $3.5 billion would have been spent. But because we had gone through, like Shelley said, we had 800 really good ideas down to 130, we could take those $3.5 billion of federal dollars and immediately deploy them in the right direction. So it's a combination of states taking leadership and the federal government providing the framework and the resources.
Shelley Lyford 25:56
Exactly. The hybrid approach is exactly the approach that, you know, West Health is going to advocate for going forward. I will say we've had this really wonderful opportunity, Mohamed, to be part of this group of stakeholders and learn about the different needs and the different sectors of everything that touches a senior's life. In that, we have become better advocates. We have been much better about going to state government and saying like, "Listen, we should rally behind this. We need to have better funding here or there," and that has been taken to the federal level, and that, a reallocation of dollars. So it really makes sense. And listen, I am, of course I realize, what's good in Vermont or what's good in Arkansas isn't exactly what is good in San Diego County or L.A. per se, but there are elements of every single state plan that span across the nation. And, and I'm really excited to be able to demonstrate it, as we said earlier, in the fifth-biggest economy in the world. And, and, and I'm excited to be a leader in this space to really improve aging across all of America, not just the great state of California.
Mohamed Younis 27:09
That's Shelley Lyford and Zia Agha from West Health. Folks, thank you for joining us and enlightening us, as always.
Shelley Lyford 27:15
Zia Agha 27:16
Thank you so much, Mohamed.
Mohamed Younis 27:18
That's our show. Thank you for tuning in. To subscribe and stay up to date with our latest conversations, just search for "The Gallup Podcast" wherever you podcast. And for more key findings from Gallup News, go to news.gallup.com, or follow us on twitter @gallupnews. If you have suggestions for the show, email firstname.lastname@example.org. The Gallup Podcast is directed by Curtis Grubb and produced by Justin McCarthy. I'm Mohamed Younis, and this is Gallup: reporting on the will of the people since the 1930s.