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E-news ExclusiveOut of Reach: Accessible, Affordable Aging in Place Remains Elusive
Three-quarters of Americans age 50 and older, and 85% age 65 and older, want to stay in their homes and communities as they age. The harsh reality is that, for most, their desire to age in place will be stymied by the triple barriers of housing readiness, affordability, and an insufficient workforce.1 The looming “gray tsunami” of aging Baby Boomers will see the nation’s 65+ age group climb to more than 82 million by 2050—a 47% increase over 2023—and those 85 and up will reach nearly 17.5 million.2 It will create a demand for aging-in-place services that the already-struggling long-term services and support (LTSS) industry is ill-equipped to manage. “I work with seniors on affording long term care, so LTSS is an issue I see up close every day. The biggest problem is that there are nowhere near enough LTSS workers, so many seniors just aren't getting the help they need,” says Yehuda Tropper, CEO at Beca Life Settlements. “Aging in place isn't just about medical care; it's about taking showers and brushing your teeth. Without filling that gap, the horror images people have in mind when they think of a nursing home will just happen to seniors at home instead.” By the Numbers Most homes aren’t equipped to handle the needs of their aging residents. According to the Census Bureau, only 10% of US homes are “aging-ready,” including features such as step-free entryways, a first-floor bedroom and full bathroom, and at least one bathroom accessibility feature. Making the necessary accommodations is costly, ranging from $10,000 to $100,000—out-of-pocket costs that are not typically covered by Medicare or commercial insurance.
Housing is not the only reason why 67% of seniors say rising living costs make it more difficult to age in place. Expenses related to in-home support, health care, transportation, home maintenance, insurance, and assistive technology can add thousands of dollars to the annual household budget.
“Closing the gaps in long-term service support is a shared responsibility among organizations that have a mission or mandate to serve our community’s most vulnerable populations of aging adults and people with disabilities,” says Corinne Eldridge, president and CEO of Center for Caregiver Advancement (CCA). She points to collaborations such as those between the state of California, the In-Home Supportive Services (IHSS) program, and organizations like CCA that serve senior populations as being best positioned to “close those gaps and strengthen our long term care system.” Critical Gaps in LTSS According to the lead researcher, Katherine Miller, PhD, an assistant professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, evidence indicates that individual LTSS requirements vary substantially and therefore require multifaceted support to facilitate aging in place, which is not widely available in the US. Nor does the US have a national long term care insurance system in place that could help facilitate aging in place. “If we really want to address these areas and make long-term services and supports accessible and affordable—and make sure that family caregivers have training, since they are part of our long term care delivery system—having more systemic and policy-level interventions is really, really important,” Miller says. She explains that there are several primary—and intertwined—challenges to affordable, accessible aging in place. Two are the high cost of long term care and the lack of a cohesive long term care insurance program to protect patients from those costs. “Those two issues alone are substantial barriers and addressing [them] requires federal policy or state-level policy changes,” Miller says. “But even if we do that, even if people pay out of pocket or purchase long term care insurance, we have significant workforce issues. It is very difficult to hire and retain the professional caregivers who will provide a large share of the care folks need to age in place.” She adds, “Technology absolutely plays an important role, 100%. But this hands-on care from the direct care workforce and others is important.” According to Caregiving in the US 2025, 59 million American adults provided ongoing care for an adult with a complex medical condition or disability, including seniors.10 While much of that care is considered unpaid, there are hidden costs related to caregivers’ absence from the workforce. “I would contend that the real question we need to be asking is what is the most efficient and sustainable way to structure these costs?” Miller says. The Johns Hopkins study stresses the need for a comprehensive and adequately financed LTSS infrastructure, as well as the importance of identifying innovative care models that can be scaled to meet the surge in demand for aging in place. For example, programs like the Program of All-Inclusive Care for the Elderly (PACE) and hospital-at-home initiatives, while promising, will require policy changes and funding support to reach more people. What “arguably makes these programs so special and so strong is [that they are] tailored to help meet individuals' needs. That can make scaling difficult,” Miller says. “Also, these programs tend to have large upfront investments that are required, and that can make it very hard to scale if [health care and payer organizations] don't have aligned financial incentives.” Tropper, of Beca Life Settlements, suggests that, in addition to increasing support for home and community-based services, higher pay rates for care workers, standardized training and oversight, and more support for family caregivers, “private providers can close part of the gap by creating small, staffed residential homes in regular neighborhoods, with predictable caregiver ratios and flat monthly pricing, so older adults with moderate needs can stay in their communities without entering large facilities.” Caring for the Caregiver She points to CCA research on the impact of training in essential skills, which found that training for IHSS workers reduces unnecessary emergency department visits by 25% and hospitalization readmissions among consumers in their care by 30%.11 “Training helps caregivers build the skills and confidence they need to deliver higher quality care. Training improves the quality of life for both caregivers and the consumers they serve,” says Eldridge. Nonetheless, many states have minimal training requirements or funding for caregiver training. “Caregivers have historically been invisible workers who are undervalued and underpaid or not paid at all. This work is often done by women in families or by hired care workers who don’t earn enough to support their own families,” says Eldridge, noting that in California alone there are more than 700,000 IHSS providers who are typically immigrant women and women of color who lack access to quality training and career pathways. “We desperately need these workers, yet we are not doing enough to train and support them,” she adds. “Training for caregivers must be free, available in multiple languages, available online and in-person for greater flexibility, and designed with input from caregivers themselves.” Averting a Public Health Crisis Miller says a delicate balance is required. Providers and payers may have to choose between meeting some needs for everyone or all needs for some. “The COVID-19 pandemic really brought the failings of how we finance and deliver long term care in the United States to the forefront of policy discussions. Our long term care system is not currently set up to provide affordable and dignified care for the aging population with care needs,” she says. “Reforming the financing of our long term care system is one critical step to addressing these systemic and structural challenges.”
—Elizabeth S. Goar is a health care writer based in Wisconsin. |
