Are We Missing an Elder Care Problem?

Exponential Elder Care Demand. Shrinking Support. Rising Reliance on Families.

Clinical innovators already know the pressure is real and growing. An aging population is living longer, often with multiple chronic conditions, functional decline, and cognitive impairment. Institutional capacity is constrained. Workforce shortages persist. Expectations to improve outcomes while reducing costs never ease. Under these conditions, ignoring the system’s reliance on family caregivers is no longer neutral. It is a performance risk.

The Scale of the Hidden Dependency at Home

Today, an estimated 59 million adults (18-64 years old) support approximately 77 million older adults (65+ years old) with chronic conditions, serious illness, or disability (1) (2). Prevalence among American adults has climbed from 17 percent in 2015 (2) to roughly 23 percent in 2025. Family and friends now provide 75 to 80 percent of all long-term service and support hours delivered in the community (3).

Family caregivers function as the primary performance layer. On average, they spend more than 27 hours per week providing support. For one in five, support exceeds 40 hours per week—the equivalent of a full-time job. And it is often sustained over five to six years or more (1).

Collectively, informal caregivers provide roughly 84 billion hours of long-term services and supports each year. Even valued conservatively, this equates to more than $2.5 trillion annually in value—dwarfing public investment in nursing homes, home health, and caregiver support combined.

Nearly all older adults—94 percent (4)—want to age in place for personal and financial reasons, and that preference is reflected in practice, with about 90 percent residing in community rather than institutional settings (5). While the share living in their own homes with family support has declined [48 to 44 percent], the proportion moving into a relative’s household has increased [35 to 40 percent] (1). At the same time, nursing home use contracted from 5 to 2 percent, accelerated by pandemic-era disruptions, static supply, and ongoing staffing shortages. Taken together, long-term services and support happen principally at home, and families are the ones making it work.

A Policy and Funding Mismatch

Public policy has long reinforced this shift, though rarely in explicit terms. As the IOM observed, caregiving has been treated primarily as a personal or moral obligation—not an extension of the workforce. Policymakers, accustomed to receiving this labor at no cost, have designed systems that assume its continued availability (6).

Recent efforts to control public spending have focused on reducing Medicaid nursing home expenditures and limiting the duration and scope of home health services. Despite rising demand, nursing home bed supply has remained essentially flat at about 1.6 million beds, and home health episodes have shortened from 60 to 30 days (7).

The funding imbalance is striking. In 2024, Medicaid spent approximately $220 billion on nursing homes, and Medicare spent about $169 billion on home health services (8). By contrast, federal investment in the National Family Caregiver Support Program totaled only $209 million in 2025 (9)—roughly $3.54 per caregiver annually.

Simultaneously, the structural capacity of families themselves is eroding. Declining birth rates, increased geographic dispersion, higher workforce participation among women, and longer periods of disability late in life have thinned informal networks. Many spouses who once would have filled the role, now require support themselves. Sandwich generation caregivers balance aging parent demands while raising children, often providing more intense support to keep older adults in the community (4).

An Unsustainable Equation

From a systems perspective, the equation is clear. Demand for older adult aid is growing exponentially. Formal resources—workforce, institutional capacity, and funding—are shrinking. Responsibility has shifted to families and communities. This arrangement holds only as long as caregivers can continue. If they cannot—due to burnout, illness, financial strain, or sheer exhaustion—the consequences are immediate and costly. Older adults move into institutional settings, often at public expense, and frequently after preventable crises (10). The reliance on family is not a temporary workaround. It is a permanent feature of how senior support functions in the U.S.

Works Cited

1. AARP and National Alliance for Caregiving. Caregiving in the U.S. 2025. 2025.

2. AARP andNational Alliance for Caregiving. Caregiving in the United States 2015. 2015.

3. Providing Physical Assistance for Family or Friends: An Overview for the Home Health Care Professional–Part 1. Weir, Rodney L and Donald L Hoover. 2021, Home Health Care Management & Practice.

4. Informal Caregiver Supply and Demographic Changes: Review of Literature. Spillman, Brenda C., Eva H. Allen, and Melissa Favreault,. https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//198051/ICSupplyLR.pdf, 2020, U.S. Department of HHS.

5. Hisle, Rachel. Aging in Place with Assistive Technology. [Online] U.S. News and World Reports, July 8, 2025. https://www.usnews.com/360-reviews/services/senior-tech-aging-in-place-survey.

6. Institute of Medicine (US) Committee on the Future Health Care Workforce for Older Americans. Retooling for an Aging America: Building the Health Care Workforce. Washington DC : National Academies Press, 2008.

7. Medicare Payment Advisory Commission. MedPac Report to Congress. [Online] March 2025. https://www.medpac.gov/wp-content/uploads/2025/03/Mar25_MedPAC_Report_To_Congress_SEC.pdf.

8. CMS. NHE Fact Sheet. [Online] 2024. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet.

9. ARCH National Respite Network and Resource Center. Senate Appropriations Committee Takes Action on FY 2026 Funding. [Online] August 01, 2025. https://archrespite.org/senate-appropriations-committee-takes-action-on-fy-2026-funding/.

10. Bridging Troubled Waters: Family Caregivers, Transitions, and Long-Term Care. Levine, Carol, Deborah Halper, Ariella Peist, and David Gould. 10.1377/hlthaff.2009.0520, 2010, Health Affairs.