Eighty million people in the U.S. will be 65 or older within a few decades, compared with around 50 million today, and, according to surveys conducted by AARP Inc., the desire to grow old at home is almost universal. Most who do so will need help with daily tasks and will exhaust the ability of family and friends to cook and clean, bathe and dress, and run errands. When Americans look for paid help, they’ll find their national infrastructure convoluted and wanting. It’s a problem the world over, but one compounded in the U.S. by the fragility of the welfare state.
A typical home-based care plan of six or eight hours a day is less costly, and more salutary, than a nursing-home stay, but it’s still expensive enough to bankrupt a middle-class American family. Medicare, the public benefit plan for those 65 and older, pays only for strictly medical forms of home care, such as dressing wounds and physical therapy, or for short post-hospital stints in nursing homes. Private long-term care insurance can be prohibitively expensive (annual premiums run into the thousands) and unavailable to those with preexisting conditions. Most seniors who need help with daily tasks first exhaust their savings, then apply for Medicaid, the public health insurance program for the poor.
In states with strict limits, many patients who would prefer to stay at home are placed instead in a nursing facility, at significant cost to the public—in 2015, about $55 billion. In states that do approve substantial home-based care, Medicaid budgets are underfunded to the point of crisis. As a result the nation’s 2.9 million home-care workers—who, according to the Bureau of Labor Statistics, earn a median annual income of $22,200—are routinely pressed to donate their labor, pushing through required breaks, staying well beyond the hours set by their agency, or, like Valia, enduring long, uncompensated nights.
New York, one of the nation’s largest long-term-care markets and the only state whose Medicaid program covers around-the-clock help, comes closest to the future Americans say they want. But New York also demonstrates the system’s central problem: It’s untenable, given current funding levels, to pay workers for anywhere close to the number of hours they actually work.