What comes after longevity?

Americans are living longer than ever: Life expectancy has risen by roughly 30 years over the past century. However, healthspan — the years spent in good health and functional independence — has not kept pace. The gap between healthspan and lifespan now exceeds a decade in the U.S., the widest of any country measured.

This challenge is compounded by America’s demographic imbalance. By 2034, for the first time in the nation’s history, older adults will outnumber children — a crossover that will hold for decades as a record-low birth rate pulls the median age steadily upward and the worker-to-beneficiary ratio keeps falling. Just like Social Security, America’s health system and broader economy were not built to absorb a growing older population. This isn’t only a problem to solve for older adults; extending healthspan benefits the generations that follow, both for their own health and by reducing the costs they inherit.

Increasing Americans’ healthspan is a central task of the 21st century — for individual quality of life, our health system capacity, and our economic productivity. It calls for a deliberate agenda that invests across the arc of a life: prevention that continues well past childhood, diagnostics that establish baselines and flag risk before decline sets in, novel vaccines and treatments, and the science of aging itself. Core to all of it is a reimbursement model that pays to keep people well (not just to treat them once they are sick) and a delivery system coordinated enough to act on what those diagnostics find.

The agenda

Measure vitality, not survival. Institute for Health Metrics and Evaluation’s 2023 Global Burden of Disease is explicit: progress on healthy aging should be judged by decline in years lived in poor health, not only increase in years lived. The Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) should adopt years-lived-in-poor-health (or perhaps years-lived-in-good-health) and functional-ability measures as standard reporting alongside life expectancy. You can’t fund what you don’t measure, and right now, the national scorecard rewards survival, not health. But a new metric needs a political, financial, and social commitment to wholesale change. America has done this before: The researchers behind the National Health Survey of 1935-1936 made use of pomp and circumstance to produce the largest morbidity survey of its time and demonstrate that despite falling mortality rates, America’s health was best understood using different measures.

Healthspan needs the same reframing today, and the same resolve behind it — not a campaign for the old or the young, but a whole-of-society commitment to valuing our years in health. America should build this campaign with ambition and optimism; instead of warning about decline, we can inspire with an invitation to vitality, at every age, all at once.

Make it local. We already know how to increase healthspan. Experts largely agree on what moves the needle most: movement, nutrition, avoiding smoking, limiting alcohol, sleep, preventative care, and social connection. But where you live still determines the choices available to you. Life expectancy gains over the past century varied enormously by state — women in some Southern states gained less than three years, while women in New York and California gained more than 20 — a divergence researchers trace to decades of cumulative differences in tobacco regulation, healthcare access, and public health investment. Without deliberate policy change, these gaps will persist or widen rather than close on their own.

There are global examples at the local level to build on. WHO’s Healthy Cities movement commits local governments in Europe to putting health and equity at the core of urban policy; Italy’s Wellness Valley has rebuilt an entire region around physical activity and accessible public space; the AARP Network of Age-Friendly States and Communities and WHO Age-Friendly Cities Framework redesign housing, transportation, and civic life for healthy aging; and the Blue Zones Project has cut health care costs and tobacco use in American towns that adopted its model. Building H advocates for companies to be accountable for how their products — food, transportation, housing — affect the health of the people who use them. State and local governments, working with employers, should proactively fund what these communities have done voluntarily: walkable streets, tobacco reduction, food access, and workplace health as infrastructure, not amenities.

Build the new checkup. Childhood comes with a built-in schedule — well-child visits, growth curves, and progress is tracked from birth to 18. That attention is a major reason lifespan rose so sharply last century. Adulthood gets no equivalent, just scattered, single-point screenings that often arrive too late. The first bone density scan isn’t recommended until age 65, long after loss begins. In one fracture clinic cohort, 61.9% of patients were younger than 65, yet only 34% met the criteria for bone density testing. There is no standard baseline for brain health at any age, but new research shows promise: A Harvard study found a blood biomarker predicts Alzheimer’s pathology years before symptoms appear.

Adulthood deserves the same care we provide childhood. Today’s checkups cover metabolic, cardiovascular, and cancer risk — and our aging population means that musculoskeletal and brain health checks are imperative to increasing healthspan. Ambitious as it might sound, we would benefit from reimagining the annual checkup to include a baseline analysis for future reference using diagnostics we already have: AI can already read fracture risk from CT scans taken for unrelated reasons, at no added cost. To be sure, more screening risks overdiagnosis and overtreatment. But that’s a system design problem, not an argument against screening. By looking at the whole person, at regular intervals, instead of one test at a time, we replace a system that rewards finding more with one that rewards understanding more. Furthermore, as the science of intrinsic capacity matures, what counts as a vital sign should expand to match it.

Treat vaccination as a healthspan strategy. Vaccines were largely responsible for our 20th century gains in lifespan. Now they’re extending healthspan. In Scotland, researchers studying women vaccinated against HPV at age 12 to 13 found the vaccine was 100% effective, with zero cases of invasive cervical cancer detected in that group since the program began — a cancer prevented decades downstream by a single shot in adolescence. The frontier is widening, as some vaccines’ benefits cascade beyond the disease they target. Four natural experiments now demonstrate that people who received the shingles vaccine are significantly less likely to develop dementia. And after Harvard researchers found that the risk of multiple sclerosis increased 32-fold after Epstein-Barr virus infection but was unchanged after infection with other viruses, Moderna moved an EBV vaccine into a new trial, testing whether it can help treat people with relapsing MS.

These findings call for large-scale investment in understanding why some vaccines deliver benefits beyond the disease they were designed for. Additional investment in the boosters and novel vaccines that match the immune demands of a much longer life — funding the research, running the trials, and updating vaccination schedules as the science evolves — could also yield benefits.

Fund the science of aging itself. Our medical system treats each age-related disease in isolation and rarely the process underneath. A growing body of research asks why cells break down at all. Two answers are driving the field: cells senescent — they stop dividing but refuse to die, lingering in the body and leaking signals that inflame the tissue around them — and mitochondria, the engines that power every cell, gradually lose their capacity to generate energy. By targeting these upstream mechanisms, researchers believe we have the potential to address multiple diseases at once.

The federal government has taken an interest in geroscience, and through PROSPR, ARPA-H is funding seven teams to treat aging as a tractable biological process. PROSPR is putting up to $144 million toward trials that measure health outcomes in one to three years instead of decades — including one awardee now building the regulatory path aging science still lacks. Yet PROSPR is a fraction of what disease-specific research spends fighting the same problem one symptom at a time: The National Cancer Institute alone spends $7.2 billion a year, and Alzheimer’s disease research draws another $3.6 billion. A cross-institute initiative that pools funds into the shared biology of aging would accelerate root-cause research and benefit every disease it currently funds separately. The stakes are enormous: Reversing biological age by a year nationally could create $38 trillion in economic value — and eventually close the gap between lifespan and healthspan for future generations.