Aging with dignity: Providing long-term supports and services at home for our nation’s elders

As the U.S. population is forecast to age rapidly during the next few decades, a central public policy challenge is how to address the needs of a growing pool of older Americans who cannot fully care for themselves. Already, one in five U.S. residents over age 65 is unable to carry out at least one of their “Activities of Daily Living,” such as bathing, dressing, and toileting.¹ For people older than 85, the population’s fastest-growing age group, that ratio is nearly two in five.² This escalating need for help as the population ages will lead to a large increase in the demand for what are known as Long-term Services and Supports (LTSS).

The United States is ill-prepared to meet this demand. The rapid aging of America means that the availability of family members and friends to care for impaired older adults is declining. Yet seven in 10 individuals who reach the age of 65 will, at some point, have a significant need for long-term services and supports.³ Roughly half will need to pay for those services, but the typical cost of home care exceeds the average amounts that older Americans have available to spend on it, putting services out of reach for most middle-income households.⁴ There is virtually no private sector option: despite many efforts, the market for private long-term care insurance has collapsed. Among public insurance programs, Medicaid covers nursing home costs, but only for those whose incomes are extremely low or who have spent all their assets. Moreover, the quality of nursing homes is often inadequate, and people generally prefer to continue living at home. Medicaid does offer some home and community-based services, but these services are not uniformly available even for the low-income and asset group eligible for Medicaid.⁵ On top of all these financial hurdles, the nation—especially amid changing immigration policies—faces a massive shortage of workers to provide long-term supports and services.⁶

We outline an approach to a more dignified path that would provide financial protection for older Americans who develop functional impairments. It would allow them to continue living at home with the resources they need. Specifically, we propose a new home care benefit within Medicare, the federal insurance system for older Americans, as an entitlement for those who require LTSS.

Read the white paper

Read the appendix