Americans are unprepared for the expensive and complex process of aging – a geriatrician explains how they can start planning
- Written by Kahli Zietlow, Physician and Clinical Associate Professor of Geriatrics & Internal Medicine, University of Michigan
Hollywood legend Gene Hackman and his wife, Betsy Arakawa, were found dead in their home[1] in February 2025. Hackman had been living with Alzheimer’s[2] and depended on Arakawa as his full-time caregiver.
Disturbingly, postmortem data suggests that Arakawa died of complications from pulmonary Hantavirus[3] several days before her husband passed. The discordant times of death point to a grim scenario: Hackman was left alone and helpless, trapped in his home after his wife’s death.
The couple’s story, while shocking, is not unique. It serves as a warning for our rapidly aging society[4]. The U.S. population is aging[5], but most Americans are not adequately planning to meet the needs of older adulthood[6].
As a geriatric physician and medical educator[7], I care for older adults in both inpatient and outpatient settings. My research and clinical work focus on dementia and surrogate decision-making.
In my experience, regardless of race, education or socioeconomic status, there are some universal challenges that all people face with aging and there are steps everyone can take to prepare.
Aging is inevitable but unpredictable
Aging is an unpredictable, highly individualized process that varies depending on a person’s genetics, medical history, cognitive status and socioeconomic factors.
The majority of older Americans report a strong sense of purpose and self-worth[8]. Many maintain a positive view of their overall health[9] well into their 70s and 80s.
But at some point, the body starts to slow down. Older adults experience gradual sensory impairment, loss of muscle mass and changes in their memory[10]. Chronic diseases[11] are more likely with advancing age.
According to the U.S. Census Bureau, 46% of adults over age 75[12] live with at least one physical disability, and this proportion grows with age. Even those without major health issues may find that routine tasks like yard work, housekeeping and home repairs become insurmountable as they enter their 80s and 90s.
Some may find that subtle changes in memory make it difficult to manage household finances or keep track of their medications. Others may find that vision loss and slowed reaction time make it harder to safely drive. Still others may struggle with basic activities needed to live independently, such as bathing or using a toilet. All of these changes threaten older adults’ ability to remain independent.
The costs of aging
Nearly 70% of older Americans[13] will require long-term care in their lifetime, whether through paid, in-home help or residence in an assisted living facility or nursing home.
But long-term care is expensive. In 2021, the Federal Long Term Care Insurance Program reported that the average hourly rate[14] for in-home care was US$27. An assisted living apartment averaged $4,800 per month, and a nursing home bed cost nearly double that, at a rate of $276 per day.
Many Americans may be shocked to discover that these costs are not covered by Medicare or other traditional medical insurance. Long-term care insurance covers the cost of long-term care, such as in-home care or nursing home placement. However, what is covered varies from plan to plan. Currently, only a small minority of Americans have long-term care insurance due to high premiums and complex activation rules[15].
I am not aware of any high-quality, peer-reviewed studies that have demonstrated the cost effectiveness of long-term care insurance. Yet, for many Americans, paying for care out of pocket is simply not an option[16].
Medicaid can provide[17] financial support for long-term care but only for older adults with very low income and minimal assets[18] – criteria most Americans don’t meet until they have nearly exhausted their savings.
Those receiving Medicaid to cover the costs of long-term care have essentially no funds for anything other than medical care, room and board. And proposed federal financial cuts may further erode the limited support services available[19]. In Michigan, for example, Medicaid-covered nursing home residents[20] keep only $60 per month for personal needs. If individuals receive monthly income greater than $60 – for instance, from Social Security or a pension – the extra money would go toward the cost of nursing home care.
Those who don’t qualify for Medicaid or cannot afford private care often rely on family and friends for unpaid assistance, but not everyone has such support systems.
Planning for the care you want
Beyond financial planning, older adults can make an advance directive[22]. This is a set of legal documents that outlines preferences for medical care and asset management if a person becomes incapacitated. However, only about 25% of Americans over 50[23] have completed such documentation.
Without medical and financial powers of attorney in place, state laws determine who makes critical decisions, which may or may not align with a person’s wishes. For instance, an estranged child may have more legal authority over an incapacitated parent than their long-term but unmarried partner. Seniors without clear advocates risk being placed under court-appointed guardianship[24] – a restrictive and often irreversible process.
In addition to completing advance directives, it is important that older adults talk about their wishes with their loved ones. Conversations about disability, serious illness and loss of independence can be difficult, but these discussions allow your loved ones to advocate for you in the event of a health crisis.
Who’s going to care for you?
Finding a caregiver is an important step in making arrangements for aging. If you are planning to rely on family or friends for some care, it helps to discuss this with them ahead of time and to have contingency plans in place. As the Hackman case demonstrates, if a caregiver is suddenly incapacitated, the older adult may be left in immediate danger.
Caregivers experience higher rates of stress, depression and physical illness[25] compared with their peers. This is often exacerbated by financial strain and a lack of support. It helps if the people you will be relying on have expectations in place about their role.
For instance, some people may prefer placement in a facility rather than relying on a loved one if they can no longer use the bathroom independently. Others may wish to remain in their homes as long as this is a feasible option.
Connecting with available resources
There are local and federal initiatives designed to help aging adults find and get the help they need. The Centers for Medicare & Medicaid Services recently launched the GUIDE Model[26] to improve care and quality of life for both those suffering from dementia and their caregivers.
This program connects caregivers with local resources and provides a 24-hour support line for crises. While GUIDE, which stands for Guiding an Improved Dementia Experience, is currently in the pilot stage, it is slowly expanding[27], and I am hopeful that it will eventually expand to provide enhanced coverage for those suffering from dementia nationwide.
The Program for All-Inclusive Care of the Elderly[28] helps dual-eligible Medicare and Medicaid recipients remain at home as they age. This program provides comprehensive services including medical care, a day center[29] and home health services.
Area agencies on aging[30] are regionally located and can connect older adults with local resources, based on availability and income, such as meals, transportation and home modifications that help maintain independence.
Unfortunately, all of these programs and others that support older adults are threatened by recent federal budget cuts. The tax breaks and spending cuts bill, which was signed into law in July 2025, will result in progressive reductions to Medicaid funding over the next 10 years[31]. These cuts will decrease the number of individuals eligible for Medicaid and negatively affect how nursing homes are reimbursed.
The government funding bill passed on Nov. 13 extends current Medicare funding[32] through Jan. 30, 2026, at which point Medicare funding may be reduced[33].
Even as the future of these programs remains uncertain, it’s important for older adults and their caregivers to be intentional in making plans and to familiarize themselves with the resources available to them.
References
- ^ were found dead in their home (www.bbc.com)
- ^ Alzheimer’s (my.clevelandclinic.org)
- ^ pulmonary Hantavirus (www.mayoclinic.org)
- ^ a warning for our rapidly aging society (doi.org)
- ^ is aging (www.census.gov)
- ^ not adequately planning to meet the needs of older adulthood (www.johnhancock.com)
- ^ geriatric physician and medical educator (experts.umich.edu)
- ^ a strong sense of purpose and self-worth (ihpi.umich.edu)
- ^ positive view of their overall health (kffhealthnews.org)
- ^ changes in their memory (med.stanford.edu)
- ^ Chronic diseases (www.aarp.org)
- ^ 46% of adults over age 75 (data.census.gov)
- ^ Nearly 70% of older Americans (aspe.hhs.gov)
- ^ reported that the average hourly rate (www.ltcfeds.gov)
- ^ high premiums and complex activation rules (www.ncoa.org)
- ^ paying for care out of pocket is simply not an option (www.kff.org)
- ^ Medicaid can provide (www.medicaid.gov)
- ^ with very low income and minimal assets (www.hhs.gov)
- ^ may further erode the limited support services available (www.aarp.org)
- ^ Medicaid-covered nursing home residents (www.medicaidplanningassistance.org)
- ^ Klaus Vedfelt/DigitalVision via Getty Images (www.gettyimages.com)
- ^ advance directive (www.nia.nih.gov)
- ^ only about 25% of Americans over 50 (ihpi.umich.edu)
- ^ under court-appointed guardianship (doi.org)
- ^ stress, depression and physical illness (doi.org)
- ^ GUIDE Model (www.cms.gov)
- ^ it is slowly expanding (www.aarp.org)
- ^ Program for All-Inclusive Care of the Elderly (www.npaonline.org)
- ^ day center (www.aarp.org)
- ^ Area agencies on aging (eldercare.acl.gov)
- ^ progressive reductions to Medicaid funding over the next 10 years (www.maynardnexsen.com)
- ^ extends current Medicare funding (www.pbs.org)
- ^ Medicare funding may be reduced (www.investopedia.com)
Authors: Kahli Zietlow, Physician and Clinical Associate Professor of Geriatrics & Internal Medicine, University of Michigan
