A new report from the Brookings Institution underscores what home care providers across Florida already know: the nation’s long-term care system is not built to meet the needs of an aging population — and the consequences are growing more visible each year.

The report, Aging With Dignity: Providing Long-Term Supports and Services at Home for Our Nation’s Elders, lays out a stark reality. Demand for long-term services and supports (LTSS) is accelerating rapidly, while the systems designed to finance and deliver that care remain fragmented, under-resourced, and heavily dependent on unpaid caregivers.

A System Under Strain

The demographic trends alone are striking. By 2050, more than one in five residents will be age 65 or older in the vast majority of states. Today, one in five seniors already needs assistance with basic activities of daily living such as bathing, dressing, or eating — and among those over age 85, that figure approaches 40%.

At the same time, most Americans are financially unprepared for the cost of care. Roughly 70% of individuals turning 65 will require long-term services and supports at some point, with average lifetime costs exceeding $120,000. Yet median financial assets for older adults fall short of that threshold, leaving many without a viable path to pay for care.

Private long-term care insurance has not filled the gap. Coverage rates remain extremely low, and underwriting practices exclude a significant portion of the population. The report concludes that the private market is unlikely to serve as a meaningful solution at scale.

Medicaid as the Default — But Not the Answer

In the absence of comprehensive coverage, Medicaid has become the nation’s primary payer for long-term care, accounting for nearly half of all LTSS spending.

However, the program’s structure presents well-known challenges:

• Eligibility is limited to individuals with very low income and assets
• Many must “spend down” to qualify
• Access to home and community-based services (HCBS) varies significantly by state
• Unlike nursing home care, HCBS is not guaranteed and often subject to waiting lists

This creates a system that frequently steers individuals toward institutional care — even when they would prefer to remain at home.

The Hidden Backbone: Unpaid Caregivers

Perhaps most striking is the system’s reliance on informal care. More than 53 million Americans provide unpaid care to family members and loved ones, and over 80% of older adults receiving assistance rely exclusively on this informal support.

While essential, this model is increasingly unsustainable. Demographic shifts, workforce participation, and family structures are all reducing the availability of informal caregivers — placing additional pressure on formal providers and public programs.

A Growing Workforce Crisis

The report also highlights a critical constraint: the workforce. Nearly three million direct care workers currently support individuals in homes and facilities, yet wages remain low and turnover high.

As demand grows, the gap between need and workforce capacity is expected to widen. Without targeted investment in wages, training, and career pathways, expanding access to care will remain a challenge.

A Policy Shift Toward Home-Based Care

In response to these challenges, the report proposes a significant structural reform: a universal home care benefit under Medicare for individuals with functional impairments.

The proposed model would:

• Expand access to home-based services based on need, not income alone
• Replace sharp eligibility cutoffs with income- and asset-based cost sharing
• Integrate home care into the broader continuum of medical care
• Reduce reliance on institutional settings

The scale of the proposal is notable. The report estimates that more than 8 million individuals would qualify for services, with total program costs offset in part by reductions in Medicaid spending and broader system efficiencies.

Implications for Home Care Providers

While the proposal is federal in scope, its implications are immediate and relevant for providers at the state level.

First, it reinforces the continued shift toward home- and community-based care as the preferred setting for long-term services. Consumer preference is clear, and policymakers are increasingly aligning with that reality.

Second, it underscores the importance of workforce investment. Expanding access without addressing recruitment and retention challenges will not be sustainable.

Third, it highlights the need for greater alignment across payers and programs. The current division between Medicare and Medicaid continues to create inefficiencies and gaps in care delivery.

Finally, the report provides strong, data-driven support for ongoing advocacy efforts to expand access, improve reimbursement, and strengthen the home care infrastructure.

Looking Ahead

The report’s central conclusion is straightforward: the current system is not equipped to meet the needs of an aging population, but reform is both necessary and achievable.

For home care providers, this moment represents both a challenge and an opportunity. As demand continues to grow, providers will play an increasingly central role in delivering care that is not only cost-effective, but aligned with patient preferences and quality outcomes.

The policy conversation is evolving. The question is no longer whether the system must change — but how quickly it can adapt to meet the needs of the millions of Americans who prefer to age with dignity at home.

Related News: Nonprofit Proposes Medicare Home Care Benefit for Older Americans (HomeCare, 4/6/26)