The United States has no coherent system for financing long-term care. Medicare does not cover it in any meaningful way. Private long-term care insurance collapsed as a viable market because the actuarial math made it unprofitable. What remains is a patchwork: Medicaid for those who have spent down their assets to near poverty, unpaid family labor for those whose families can provide it, and paid care workers who are among the most poorly compensated in the American economy.
This is not a gap that emerged from neglect. It is the predictable result of a system built around acute care and employer-sponsored insurance that was never designed to address sustained long-term needs. The demographic pressure arriving over the next two decades — the aging of the baby boom generation — will make what is already a quiet crisis impossible to ignore.
This hub documents how the current non-system works, who bears its costs, and what serious reform proposals exist. It does not advocate for a specific financing path. It provides the foundation that informed deliberation about long-term care requires.
Who Does the Work: The Direct Care Workforce and Why It’s Failing — The home health aides, nursing assistants, and personal care attendants who provide the most hands-on care to the most vulnerable Americans are among the lowest-paid workers in the economy. This article documents who does this work, why chronic underpayment and high turnover are structural rather than accidental, and why there is no workforce solution that does not require a financing solution.