The commitment of ACCESS Health International to elder care and optimal aging is fueled by the global change in demographics. The population over 60 is expected to double to 22 percent, reaching 2.1 billion from 2000 to 2050.Footnote 1 The demographic shift is attributed to increased life span, lower mortality rates, declining immigration rates, and lower fertility rates. Figure 1.1 is an example of the rectangularization process from 1970 to 2060.

Fig. 1.1
figure 1

Rectangularization of the global aging pyramid from 1970 to 2060

The 100-year shift that began in 1950 is only 17 years past its midpoint.Footnote 2 By 2060, the pyramid will resemble a dome shape. Some predict that it will morph into the shape of a rectangleFootnote 3 because, in many countries, the oldest old (85+) population is growing the fastest.Footnote 4 The global population of those 85–99 is projected to increase by 151 percent from 2005 to 2050, while the population of those 100+ is expected to increase by more than 400 percentFootnote 5 (Table 1.1).

Table 1.1 Projected global population increase by age group 2005–2050

The demographic shift is occurring at varying rates throughout the world (Fig. 1.2). The United Nations reported that, in 2015, almost 25 percent of the world’s population 60 and over lived in China and that only four other countries account for another 25 percent including the United States, Japan, India, and the Russian Federation.Footnote 6 The projected growth rate for the over 60 population also varies from country to country, but is expected to continue to grow globally until 2060.

Fig. 1.2
figure 2

Global distribution of population 65 and over in 2015 and 2050. Source: U.S. Census Bureau, 2013, 2014a, 2014b; International Data Base, U.S. population estimates, and U.S. population projections

Potential Support Ratio

One result of the demographic shift is that there will be substantially more older people who need care and fewer younger people to provide the care. This care conundrum is reflected in the potential support ratio—the number of workers (age 15–65) to the number of retirees (65+). The potential support ratio has been declining substantially from 2000 to 2050 (Fig. 1.3).

Fig. 1.3
figure 3

Potential support ratios by region, 2015, 2030, and 2050. Source: UN Department of Economic and Social Affairs

With the shrinking potential support ratio, who will care for the growing number of older adults? Immigration is one answer, but the overarching response should be that healthcare and social support systems become more efficient to meet the significant needs of this cohort. Informal caregivers make invaluable contributions, but they cannot meet the complex care needs of the growing older population. This care gap is further magnified when considering the rates of comorbidity and cognitive and functional limitations of the older population.

We will begin with some facts about healthcare in the United States and then describe solutions to the challenges we have laid out.