The Longevity Imperative: Redefining the Way We Age

0:00You're keeping people alive, you're not keeping them healthy. The view that medicine starts with disease is part of the problem because it should start with health. One in five, four, one in six brits, and then to lift to a hundred, or go into the government. How do you finance that? Is your 401k set for you to lift to a hundred? People age really, really diverse, and you can be a hundred and literally running the hundred meters you can look at it on YouTube, or you can be 50 and in a wheelchair. And instead of this being a crisis, it could be the greatest accomplishment of humanity. Let's start this episode with a thought experiment.

0:37What would you do if you knew you were going to die today? And what would you do if it were impossible to die today? I'd bet that separate from the outcomes that those days would look pretty different. Because probabilities guide our decisions. And that is the premise of today's conversation. We as humans have extended the Asian curve, meaning we are probabilistically living longer, and a whole lot longer. In 1965, the most common age of death was in the first year of the UK. Now, that's flipped to 87. And contrary to popular belief, we are still extending lifespan. So what happens when the calculus is no longer avoiding dying young, but perhaps striving to live extremely old?

1:23Plus, what is life worth? And how does this impact our society? Not just in the health system, but the financial sector, career planning, and even direct sign. Joining us to discuss exactly this, or Dr. Andrew Scott, author of the Long Jebney Imperative, a book published earlier this year, alongside Founding General Partner of A16Z by Own Health Vijay Ponte. Let's get to it. As a reminder, the content here is for informational purposes only. should not be taken as legal, business, tax, or investment advice, or be used to evaluate any investment or security, and is not directed at any investors or potential investors in any A16z fund.

2:02Please note that A16z and its affiliates may also maintain investments in the company's disgust in this podcast. For more details including a link to our investments, please see A16z .com slash Disposures.

2:19You could have named the book Many Things. The longevity imperative is very specific and very telling, I think, of what message you're trying to get across. Let's start there. Why use the term imperative? Partly, I'm a macroeconomist and I think we've got to face the challenges we have in the world ahead of us. And this one just drops off the radar. We talk about AI and climate change now we have to adapt and adjust. But when it comes to this topic we tend to talk about an aging society and we rarely get beyond talking about adult diapers and ghettos. So I wanted to just sort of elevate this topic right up there.

2:56And the meaning of imperative is vital importance. And actually I think that's got to double play too because it's not just vitally important for society because we want to avoid a pension crisis and a health crisis. It's vitally important for of us because for the first time ever in human history the young can expect to become the very old. And so how are we ages now? An incredibly important thing. Let's quickly double click on that because you actually compare the criticality of longevity to things like let's say AI or climate change other areas or sectors where people widely address as really critical and widely impactful.

3:35Why do you position it there relative to those other areas. Good, I think it's right up there just as important. We fear getting old. We fear our crying, our skills, our health. And so that's why there's that longevity imperative. What are you going to do now to age? Well, but aging is not a sexy word. I know no one has says, yeah, great. We've got an aging society, which is sort of strange. It's one of the greatest achievements of the 20th century to get global life expectancy above 70 for not monol. Fewer children to mourn, few parents snatched away in midlife, more grandparents meeting their grandchildren, and we say, ship, they got an aging society.

4:12I mean, it's just a really weird way of frame it. And so people switch off with aging. Whereas when it comes to AI and climate change, it's like, oh, this is really important. If we don't do this, we're going to have a bad outcome. It's going to be crucial for humanity, crucial for my individual future. And all of those statements hold for how you deal with your long life. So that's why it's up And it's not just I think me being obsessed with this topic. I can give you very, very hard data about the welfare games, but also the economic consequences if we don't adapt. The pension crisis, the unsustainable health burden, it really is right out there.

4:47I don't think anyone really, other than people who look at the economics understand the impact this is having on us, not just as individuals, but as a country, and the amount of debt, the amount of expense that comes along with our current healthcare system, especially which is exacerbated with age. It's a very hidden and serious problem. And so I think imperative is spot on. Absolutely. And I'd love to dive into how we do need to refashion our economic system, our tax system, the way that people think about their careers because you talk about all of that Andrew. But before we get to that, let's maybe take stock of how lifespan and then also health span have changed since those are not the same thing.

5:27Groundless in how things have changed maybe over the last 100 years or so. Yeah, so if you look at the sort of high -income countries the last 100 years, life expectancy has increased up to three years every decade and in lower income countries even faster. And so global life expectancy is now over 73. I think it's worth just pausing at that point. Global life expectancy is over 73. Around the world, a child born today can now expect to live into an eighth decade. And actually that's based upon no further change. So it's probably a greater number than that because life expectancy is increasing in many countries.

6:04In the high income countries like the UK, the UK government says that 50 % of children born today will live to be about 91. That's extraordinary. And I start my book with a somewhat dramatic statistic, which is not about average life expectancy, but what is the most common age of death? And when I was writing the book, I wanted to sort of make it personal, illustrate these demographic trends with my own family. And I discovered my own family was stunningly average. They hit nearly every single demographic trend completely. But the most striking one was that when I was born, the most common age of death was children under one in the UK.

6:38And I was a twin and my twin died in the first few days of life. So I thought that was quite rare, but that was the most common age of death. And today the most common age of death, I think it's 87, 88, something like that. My lifetime, the modal age of death was shifted. I mean, it's complicated life expectancy. It's average, mean, and media. But wow, San Beckett, the Irish playwright says, we give birth, describe the gray of the life flickers instant, and then it goes out. Well, the lights flickering a lot longer now. And that's what we've got to prepare for. Yeah, I mean, you shared so many interesting statistics.

7:12I'll just share one more. That surprised me. Based on 2020 data, you said that a newborn girl in Japan has a 99 .6 % chance of living to 20, and 99 % chance of reaching 40 and a 96 % chance of making it to 60. I mean, those are just astounding numbers, which to your point, we're not millennia away from those statistics, like just the opposite of those a few decades ago. You said in 1965, we were looking at completely different numbers. And what's sort of happening is that there's a concept of the survival rate, the probability of a newborn reaching a certain age. And it's sort of rectangularizing, as you just said, the chances of a child, a female in Japan reaching 60, is there a bit higher now.

7:56And now the chance getting 70 is getting higher and higher and higher. So that's the real sort of shift. We've lowered infant mortality dramatically. We've made big steps in embryo and midlife mortality, although the US has got some problems there of late. And so, of course, now all the gains are coming up older ages. And so life expenses now have been driven by falls in mortality at older ages, is such that 80 % of life expectancy gains in the richer countries is coming from mortality rates coming down after 70. So it's just getting further and further along this reptile organization. Absolutely.

8:28And VJ, I'd love to bring you in here as you look at both the bio and health side of things. What gives you confidence that this trend might continue? Yeah, I think there's a lot of excitement about studying the biology of agent for a variety of reasons. I mean, first off, it's actually kind of shocking how poorly it has been studied and how little time has gone into it. But the other thing that maybe is at the heart of aging and disease is the fact that many diseases are exacerbated with age, like cancer, Alzheimer's, type 2 diabetes. And so given that there may actually be some common precursors that are interesting to go after, either from a therapeutic point of view, but obviously also from a lifestyle point of view.

9:09Even simple things like we know being overweight is a massive comorbidity for any of those things. And so part of the challenge will be is the society what we want to handle through the traditional healthcare model, which is basically a sick care model dealing with disease, or what can we do more broadly to actually get to longevity and never sort of engage with the medical model in that way. Yeah. And of course, you said it's through your whole life. I mean, for me, that's why I stress along the Jeopardy Society, not an aging society. An aging society says, what do we do with these old people?

9:40Where is the real change is the the young can expect to become old. When you've already got a 10 % chance of making it to 90, you really shouldn't say, think in your 430s and 40s, what can I do now to make sure I'm healthy in my 90s? But when there's a 50 % chance of making it, my goodness, you've got to start doing it. And we have this diseased focus model which doesn't work as we get older. Because as VJ says, chronic diseases have this common source. And I think that's really interesting. What is the X that affects all these later diseases and they could be aging, it could be obesity and GLP1, it could be through exercise.

10:17And of course, that focuses on a really key issue, which is health. It just strikes me as stunning that we don't just say, how do we maintain health? We say, how do we prevent disease? It just shows you the orientation of the system. And there's a quote by WHO, which I used in the book, which is sort of, health is the concept that the medicine knows nothing about. And I said, But this other day is a cardiologist. He said, no, health is just an incomplete diagnosis. Something happens and then I'm in, but it is quite striking. Can we speak to that really quickly? Because something that you and many others have pointed out recently is this trend towards specialization in health care.

10:54And at face value, someone who's not involved in this world, actually, that sounds pretty great, right? The fact that for anything that I run into, there's going to be some specialist who's studied this much longer than the average doctor who can solve my problem. And so just as we're kind of addressing the state of affairs, can you speak to that specific trend in specialization and how maybe it's not as compelling as you might think if we're trying to achieve this idea of longevity? There's always a case you may have for everything. I don't want to sort of criticize specialization. I think when we come to drug development, we can say that there's some challenges there because we are seeing a lot of drugs being developed for very serious specific conditions where you can charge a lot, but only affect a small number of people, brilliant that you affect those people.

11:38But what about the crosscutting breakthroughs that we really need? But no, I think it's a consequence of this sort of disease specialization. And in particular, as you start to have an older population, I think the real problem with specialization is you'll be spending one morning with the cancer specialist, one morning with a cardiovascular specialist, one with a diabetic clinic. So you're gonna get massive polypharmacy, so you know, multiple description of drugs, where you've got no idea how they interact because we haven't got clinical trials to try and prove it. And then I think the other challenge we've got is that the trouble, as you get older, is you get all these aging related diseases and fantastic if you can reduce the risk of cancer.

12:18That's tremendous. But you've still got dementia out there. You've still got diabetes and cardio, ask all of which will lower the quality of your life. So if you could do something early that affected multiple diseases that are always greater than the sum of its parts, which specialization is not going to give you. I think Andrew Hittin that the view that medicine starts with disease is part of the problem because it should start with health and to maintain health rather than to fix disease. Like we all don't want our houses to be on fire so we have smoke alarms and if we wait until the house is on fire that's both unfortunate and also there's only so much you can do.

12:56In some ways, we ask a lot from acute care, and they can do reckless things. It's kind of amazing, but it would be a lot healthier, but also a lot cheaper to be able to address these issues early. But that has its own challenges, and part of it is just not the way the system is built to work. I think that is the problem, because what you've got then is you're keeping people alive, you know, keeping them healthy. And that's the real challenging, but I'm respectfully successful in keeping people alive. But as we're going beyond 70 into 80s and 90s, we slow down the diet process, but not the aging process.

13:31And that's a problem because you're going to spend ever more money on sensible things, but you're getting not better health outcomes. In as an economist, there's various tools where you can put dollar values on health gains, and you can add those to GDP and say, look, here are the welfare gains we've got. And Sunnier, the last decade, you've seen a really big slowdown in the rich countries is in terms of the health benefits they're getting. But health expenditure is still rising. In the United States, the health outcomes are being spits at least bad compared to other countries. This is a good point to really double -click on the fact that I think a lot of people don't realize the societal impact of just that spend.

14:10There's been a lot of talk we're in a election year about inequality between middle class and upper class that a lot of middle class gains and wages have been zero, they've been flat. But actually, if healthcare could have been kept at the same cost, let's say 30 years ago, then the middle class was seeing huge gains. Basically, healthcare and its rising cost is eating up these gains. And so it's not just about keeping us healthy, which would be great, it's about the health of the nation and the health of the economy. So it has really broad reaching impacts. It does. And there's also another link as well, which is something I'm particularly keen on at a moment, which is making a broader case of prevention, which is that if you could stop people in their 50s having heart attacks, they can carry on working.

14:53And that then generates huge benefits in GDP and taxes and benefits. And this, of course, is the key thing because you've got more and more older people. If you want to make them work for Lunga, you've got to keep them healthy and productive for Lunga. You can't just say, hey, I raised the Social Security age. Good luck. So we think about these incentives and how these healthcare systems really need to think about where they allocate their resources. It really is a very multibaryed equation. And I'd love for you to break down how these systems actually do decide where to invest. I know there's different metrics whether it's VSL or QALE quality adjusted life year that different groups use.

15:29But then in addition to that, I just wanted to call out one other metric from your book, which is about this idea of action versus prevention. In 2020, total US healthcare expenditure was $4 .1 trillion, dollars, which is around 12 .5 ,000 per person, but of that only around $363 was spent on prevention. I think that really highlights exactly what both of you just spoke to, which is the idea that we're not investing in prevention at least compared to the action when something goes wrong. Could you just speak to how these healthcare systems choose to divvy up the resources? So what's interesting, globally we've got the same problem.

16:06We've got a pensions problem and a health problem. And then of course if you look within the details of the pension health, there's no big country, it's wildly different. They're all going wrong in different ways, but in a lot of them, basically, broadly speaking, the Ministry of Finance had over a check to the Ministry of Health. The Ministry of Health got that stock of money, it has to side out, allocated. And it will look at some health measures. Again, your varies. In my country, the UK, one of the big targets is waiting this for operations, which is just a crazy metric because I can't rethink how that links into health measures very well, but that's a big measure.

16:41But there's also this medical concept of a quality, which is a quality adjusted life here. And so if you have a treatment that saves a child's life and they go live to 80, you've saved 80 years, but you quality adjust the years for the sort of level of health that you get. And so broadly speaking, you can calculate that. And might 30 ,000 pounds, so it's about $40 ,000. And say if this treatment comes in less than that price, it's worth it if it's not down to it. In the US, the budget's a much bigger and it's more of a commercial decision, I would say that happens. And of course, that's that question of how much you can pass on to the insurer.

17:24But there's all sort of value -based pricing in that as well. Most of the measures are all very internal to the health system. I think that's a for me a really big issue because with budgets under constraint, take the UK where the health system actually they spent a lot more money but they're not getting better outcomes. You've got more and more older people who need operations, need the health replacement etc and you can't say to them, no, I'm not going to do it. So you haven't got the money to finance prevention and you're just stuck forever doing hit replacement operations. So the case for prevention at the moment is sort of made, will it save me money within in the health system.

18:01If I spend this now, would it reduce more operating costs now? And the problem with that is prevention tends to take a bit of time to come through. The other problem you've got in the US health system is that with multiple health providers, one person's expenditure could be someone else's benefit rather than them. In the UK it's not easier because we have one health system, the Ministry of Finance pays for everything so they can see the savings. But this is why I'm very keen to sort of say, Oh, hold on a minute, though, there's another game to prevention, which is the spillover benefits in the UK I'm sure it's similar in the US if you're 15 you have a heart attack your six times more likely to leave the labor market And once you're out the labor market it's very hard to get back in the game So you can stop that person leaving you've got this knock on effect in terms of income GDP and revenue And that's not currently taking into account Very little time is discussed on prevention and nutrition and also those fields are complex and highly debated.

19:01So there's the education part, which I think there's huge room for improvement, but then at least in the US, the big question is, who's gonna pay for it? And with existing payers, they unfortunately have to deal with a reality where people may switch payers every two or three years, and prevention is a long -term game. There's a big push for value -based care, and I think there's new models for that, and exciting things happening, especially in areas like Medicare Advantage. But in the end, I think what we're going to see is high deductible plans and choices like IKRA that will allow actually consumers to be the ultimate payer.

19:36And in the end, we kind of are the ultimate payer in dollars and we are obviously the ultimate payer in healthcare results. And so we care about value. I care about my children's health and my wife's health and so on in a way that no insurance company would. And I think that shift for who's going to pay at me choosing how my dollars are spent could also facilitate more prevention Yeah, and it's a really interesting point too because of course once you move away from the disease model The health system and now everything it's the air that you breathe It's the British state that you live in it's the food that you buy and I think you're gonna see a Retail in a very big way of course not everyone is gonna spend an invest in health But I do think that's the logical consequence of prevention if the health providers won't provide it sufficiently I thought people will, whether that be wearable devices or whatever.

20:23So I think the health economy just starts to get even bigger. And I think something that a lot of people don't realize is that if you look at the determinants of health and especially mortality, genetics is a large part, like 30 % or 40%. All of medicine is basically 10%. And then a large fraction, like 40 % is social determinants. So if you're spouse smokes, guess what? You'll either be smoking or you'll have secondhand smoke where your zip code predicts your health to a large degree. Those social determinants are a huge part and addressing that should be part of health care, but right now the health care really is that 10 % are providing disease -focused care and you're missing that 40%.

21:01I completely agree. I mean the socio -economic determinants are huge, so behaviour and environment explain the majority. One thing is about interesting is people kind of resistently idea that aging is malleable, but you just look at inequality and you say we found a way to speed up aging. It's a social account of your terminus. So it's proof positive that we can really affect how we age. And it somehow just doesn't get into the consciousness. Yeah. And I think examples that you gave in the book are that on a very small scale, you are seeing some insurance companies incentivize people who exercise or have healthy habits or get discounts on healthy food.

21:35I'm surprised we're not seeing that more candidly, but maybe this is a good transition for us to talk about social implications and the major parts of society that do need to be restructured as some of this is somewhat inevitable, right? There's things like the health system, the financial sector, taxes and career planning, drug design. Yeah, and let me just reiterate that the very simple idea of the book, which is for the first time ever, you can now expect to become old. So you've got to make sure that you're healthy and engaged for longer. You've got to invest more in your human capital. And of course, if you don't invest in your future, then actually your future isn't very good.

22:09You run out of money. You run out of skills. You run out of purpose. You run out of health. But we had never set up our institutions to say, how does Andrew live a life to his 90, that remained healthy and engaged? So nothing is sort of untouched, including culture and psychology. But where are the main things? Well, obviously, the health system, huge. I mean, a shift to a focus on delivering health rather than treating disease. work clearly has to change. And in an early book, The Hundred Year Life, I told her talked about how we created a three -stage life in the 20th century of education, work, retirement.

22:45But if you just stretch that out to 90, it looks pretty unappealing, pretty miserable. And I think for me, the very simple notion here is longevity is about having more time. So the question is, what do you want to do with that time? And how do you in particular distribute leisure across your life. And in the 20th century, we fixed retirement age, lived for longer and just took more and more leisure at the end of life. Governments around the world saying, no, that doesn't stack up. You're going to have to work for longer. So I think we may take less leisure at the end of life, but we're spread more leisure across life.

23:16We might start work later. We might take mid -career breaks. Your last job might be part time or you might go part time, sometimes, I'm in the middle. But your career's going to have, I think, a lot more transition, some chosen by you, some forced upon you. And that I think has big implications for all sorts of different people. So if you're a manual worker, age 50, you can't carry on working in a physical job, how'd you transition into something different? If you're an investment banker working all those hours, you can't carry on doing this. Beyond the age of 45, 50, do you take a break, retrain and do something?

23:50Or wrapped into this is education, identity, and so many things. But finance comes into it as well because the simple pension industry says, accumulate money away, working, run it down when you retire. But if you've got this sort of multi -stage life, accumulation, de -cumulation becomes much more complicated. So I think finance has to probably do three things. One is do long -run saving products that have a much more flexible pattern, totally tie financing into health. And then the other big challenge is that, you know, in the 1920s and we developed a life insurance industry that paid out if you died young.

24:29But sort of the risk now is not that you die at the average, but most people die above the average. And there's now a small chance of going above 100, one in five, for one in six brits and then to live to 100 or go into the government. How do you finance that? So that living insurance, how do I provide you a steady stream of income in case you sort of live a really long life is a huge financial one. Yeah, I think there's a crisis also that either those who have anticipated it see it, but I don't think every day people think about this way, which is the shift at least in the United States from pensions, which have defined payouts to 401K's, which have defined contributions.