Let me tell you about a math problem most American families don’t see coming. The median American household headed by someone 75 or older has $50,000 in total financial assets. A private nursing home room costs $127,750 per year.
That’s not a gap—that’s a cliff.
And here’s the part that makes it worse: 58% of Americans believe Medicare will cover their long-term care costs. It won’t. Not one dollar of custodial care: no assisted living, no nursing home stays beyond 100 days, no home health aide helping your mom get dressed in the morning. Medicare was never designed to cover that, and nobody’s bothered to tell the public.
So where does that leave us? With a system that requires you to go broke, down to your last $2,000 in assets, before Medicaid kicks in. A 2025 study tracking nearly 200,000 first-time nursing home residents found that 61.8% of those who entered as private-pay patients had transitioned to Medicaid within four years. The average time to spend down their life savings? Six months.
This is not a crisis that snuck up on us. It was designed this way or more accurately, it was never designed at all.
The Tab Nobody Wants to Pick Up
Medicare won’t pay. Private insurance has collapsed and we’ve gone from over 100 carriers offering long-term care policies to fewer than a dozen, with only about 3-4% of adults over 50 holding a policy today. Medicaid requires impoverishment. And somewhere in that gap, 63 million Americans have stepped in to fill the void; all of them unpaid, undertrained, and increasingly burned out.
These are the family caregivers.
Three in five are women. Their average age is 51. Together, they provide an estimated 36 billion hours of unpaid care each year, valued at $600 billion which is more than the entire out-of-pocket healthcare spending in this country. And in exchange, they lose an average of $237,000 to $295,000 in lifetime earnings. For college-educated mothers, that number climbs to $420,000. One study found caregivers face up to a 90% reduction in retirement savings compared to non-caregivers.
Think about what that means: the people quietly keeping our elder care system from total collapse are doing it at the cost of their own financial futures. They’re sacrificing the retirement security they’re supposed to have to care for a generation that was also never given a real plan.
We are passing the crisis forward.
And the people who do get paid? Not much.
The direct care workforce—home health aides, nursing assistants, personal care workers—is 5.4 million people strong, making it the single largest occupation in the United States. The median wage is $17.36 an hour. Nearly half rely on public assistance programs like Medicaid and SNAP just to get by.
We are asking the people responsible for the dignity and safety of our most vulnerable citizens to do it for poverty wages, with minimal training. Federal law requires just 75 hours to become a certified nursing assistant, which has been unchanged since 1987, and turnover is so catastrophic that the average nursing home loses more than half its staff every single year.
In May 2024, the federal government finally enacted the first-ever minimum staffing standard for nursing homes. It was repealed by December 2025. University of Pennsylvania researchers estimated it would have saved 13,000 lives annually. Gone.
This is Structural, Not Accidental
I want to be direct about something: this is not a story about individual bad actors, though there are plenty. Private equity firms that buy nursing homes see short-term mortality increase 10% among residents, a staggering finding from a landmark study published in 2024. One major chain went through a leveraged buyout, sold its own buildings in a sale-leaseback deal, then paid $472 million a year in rent while health code violations rose 26%. It filed for bankruptcy in 2018. The residents were still there.
But even setting aside the predatory operators, the structural reality is damning: the United States is the only developed country with no universal financing mechanism for long-term care. We have Medicare for acute care. We have Medicaid for the impoverished. We have nothing for the vast middle class—the working families, the middle-class retirees, the sandwich generation trying to raise kids and care for parents simultaneously—who make too much for Medicaid and have nowhere near enough to pay out of pocket.
The population of Americans 85 and older is projected to nearly triple by 2060. The workforce needed to care for them doesn’t exist yet, the housing isn’t built, the financing mechanism isn’t funded, and the regulatory framework just lost its only federal staffing floor.
What Comes Next
I’m not going to pretend there’s a single policy lever that fixes this. There isn’t. But there are real choices being made right now about who gets coverage and who doesn’t, who gets funded and who doesn’t, whose labor gets valued and whose doesn’t.
Those choices have answers. Universal long-term care financing. A direct care workforce that earns a living wage. Serious federal oversight with actual teeth. Investment in home and community-based care so people can age where they want to. Reimbursement rates that don’t force facilities to cut staff just to keep the lights on.
None of this is cheap. None of it is politically easy. But all of it is less expensive than the alternative, which is what we’re living through right now.
America doesn’t have a plan for getting old. It’s time we built one.
