A healthy future: A demographic snapshot

The future will offer, as the past did and the present does, significant opportunities and robust challenges for the practice of medicine. These will, to a large extent, stem from the achievement of medicine: long and healthy lives for Canadians, with expectations of continued increases in both health and life expectancy.

A simple, dramatic indicator of the achievement of medical practice is the continual increase in the percentage of people who live to reach “old age”: over the past century, the 65-plus population has increased from 5% of Canada’s population to its record of 12% today (see Table 1). This aging of our population is largely the result of a 30-year increase in life expectancies at birth, from an average of 49 years in 1901 to 79 years in 1998.

The accompanying reduction in mortality in younger age groups has been dramatic. There were 8329 fewer deaths of people under the age of 65 in Canada in 1998 than there were in 1921, even though the total number of deaths more than doubled. The achievement of medical practice has meant that death now most often comes with age rather than with youth.

Birth control has also contributed to the aging of the population, resulting in both fewer and older parents. The current average of 1.6 children born per woman during her lifetime (less than half of the 3.9 children of 1961) means that every generation the population gets older since, effectively, 2 older people contribute 1.6 younger people to the population.

Below the replacement level birth rates, long generation spans, and long life expectancies mean that in the future, as in the past, the country’s population will age. In the years to come the number of people 65 and older will double from today’s 12% of Canada’s population to 25%, with most rapid growth occurring between 2010 and 2030.

The increase in the 65-plus age group’s share will be accelerated by the aging of the Second World War and post-war babies, the 35 to 60 year olds who make up 37% of Canada’s population. Considering only the biological processes of birth, aging, and death related to today’s population, the 65-plus age group’s share would increase to 25% of the population by 2030 and 29% by 2050.

International migration will slow the rate at which Canada’s population ages: the age profiles of the immigrant, emigrant, and returning Canadian populations are all significantly younger than that of the resident population. Net annual population change due to international migration is small, currently in the range of 140 000 additional people per year, contributing only a 0.5% increase to a population of 30 million. If Canada can gradually increase net international migration to the 270 000 persons per year range over the next four decades, only 22% of the population will be 65 or older in 2030, and the 25% share will not be reached until 2050.

Demographic change will ensure that in less than three decades, between one in four and one in five people in Canada will be 65 or older, compared to one in eight today, a change that will shape the future practice of medicine. Internally, medicine will be asked to continue to meet the expectations of not only maintaining, but of increasing, health and life expectancy. Externally, society will be dealing with the economic consequences of these expectations.

An aging population means increasing per capita health costs. Average annual spending on health increases steadily with age from one’s fifth birthday: two-thirds of the health expenditures that occur during a lifetime are made after a person’s 65th birthday. This age-related pattern of health expenditure combined with the coming doubling of the 65-plus age group’s share of the population will increase health expenditures at twice the rate of population growth over the next three decades.

During the past 40 years, Canada has been blessed with a demographic situation in which the beneficiary population of intergenerational transfers (education for the young, health care and income support for the old) has been relatively small in number compared to the contributory population. With the aging of the baby boom generation into the 65-plus age group, the beneficiary population will increase much faster than the contributory population. In 1961, there were 131 people 65 years of age and older per 1000 people of working age in Canada, today there are 181, and by 2030 there will be 347.

We must come to terms with the value and the cost of health, and the fact that the health system will, and must, change. Maintenance of today’s level of health and life span will mean much larger per capita health expenditure in the future because so many more of us will be in the age group where health expenditures are the highest; health-care funding must acknowledge this inevitable consequence of aging. It must also acknowledge that only through real economic growth will society have sufficient resources to meet the increasing demand for health care, education, income support, and all of the other social transfers that demographic change will bring.

A healthy future is in store for medical practice and for Canadians if the health-care system is permitted to evolve in response the dramatic increase in demand it will experience and if our economy grows fast enough to ensure that society has sufficient resources to meet this demand. The process of change, specifically in health care and generally in the economy, must be encouraged to meet the opportunities and challenges that the future will bring.