Providing Long-Term Supports and Services at Home for Our Nation’s Elders
March 2026, By Richard Frank, Sherry Glied, Jonathan Gruber, Vani Agarwal, and Wendell Primus
This twenty-page report proposes a fundamental shift in how the United States finances and delivers long-term supports and services (LTSS).
Scroll down to see responses by DignityMA participants.
The Crisis in Long-Term Care
The U.S. faces a rapidly aging population, with 43 states projected to have more than 20% of their residents over age 65 by 2050. Currently, the nation is ill-prepared to meet the associated demand for LTSS:
Underinsurance: 70% of individuals reaching age 65 will eventually have significant LTSS needs, yet private long-term care insurance (LTCI) has largely collapsed, covering only 3% of Americans over 50
Systemic Mismatch: Medicare currently only covers acute and post-acute care, excluding custodial assistance with “Activities of Daily Living” (ADLs) . Medicaid serves as the primary public payer but requires beneficiaries to spend down their assets to near-poverty levels and does not guarantee home-based care as an entitlement.
Workforce Shortage: There is a massive shortage of both formal caregivers and informal family caregivers, the latter of whom are often burdened by roles they are not qualified for.
Proposed Reform: A Universal Medicare Home Care Benefit
The authors propose establishing a new home care benefit under Medicare to provide universal eligibility and ensure older adults can age at home with dignity.
Eligibility: Benefits would be triggered by functional impairment standards (HIPAA triggers), defined as the inability to perform two or more ADLs (bathing, dressing, etc.) for at least 90 days or having severe cognitive impairment .
Services: The benefit includes home health aide assistance, personal care (ADL/IADL help), homemaker services, adult day services, and care coordination .
Administration: Third-party administrators (TPAs) would manage needs assessments and claims processing under population-based budgets to maintain cost control .
Financing and Economic Impact
The proposal moves away from “asset cliffs” toward a resource-based coinsurance model.
Contribution Model: Beneficiaries would contribute based on their ability to pay, using a formula that amortizes both income and assets (including housing wealth). Housing wealth would be liquidated gradually through “deferred payment agreements” similar to those used in the United Kingdom.
Cost and Savings: The program is estimated to cost $111.1 billion annually. After beneficiary contributions ($19.9 billion) and federal/state Medicaid savings ($50.2 billion), the net new direct financing required is approximately $41.1 billion.
Funding Sources: Dedicated funding could come from an expanded estate tax or an age-based income tax surcharge for filers over age 55.
Broader Benefits: The reform would create a significant expansion of the home care sector and could generate $0.8 to $1.55 billion in annual tax revenue by freeing informal caregivers to re-enter the labor market .
The authors conclude that universal home care is financially feasible and essential for a society where the dependency ratio is rising and middle-income households can no longer afford necessary care.
Aging with dignity shouldn’t mean paying with your home
By Richard T. Moore
The United States is finally beginning to confront one of its most predictable—and most neglected—challenges: how to care for an aging population that will increasingly need help with daily life.
A new white paper from the Brookings Institution, “Aging with Dignity,” makes an important contribution to that conversation. It proposes a universal home care benefit under Medicare, allowing older adults to receive long-term care services at home rather than being forced into poverty to qualify for Medicaid.
On its face, this is a breakthrough. For decades, the United States has treated long-term care not as a shared social responsibility, but as a personal financial failure. Millions of families have been forced to exhaust their savings just to access basic assistance with bathing, dressing, or eating. The Brookings proposal rightly recognizes that this system is both unjust and unsustainable. It also gets something else right: most people want to age at home. Home- and community-based care is not only more humane, but also often more cost-effective. And by acknowledging the growing shortage of caregivers, the report underscores a truth policymakers can no longer ignore—the system is already under strain, and the demographic wave has only begun.
Yet our current financing system tells a different story. Today, Medicare and Medicaid—the primary public payers for long-term care—still reflect a structural bias toward institutional care, particularly nursing homes. Access to robust home- and community-based services often depends on state waivers, waiting lists, or eligibility hurdles that do not apply to facility-based care. This imbalance persists despite overwhelming public preference: more than 90 percent of adults over age 60 say they want to remain in their homes or communities as long as possible. If dignity is the goal, public policy must catch up with that reality by rebalancing financing toward home-based care as the default, not the exception.
But if the goal is dignity, we also need to be clear about what dignity requires. The Brookings plan would ask many older Americans to help finance their care by drawing on their assets—including, most notably, their homes. Through mechanisms similar to deferred payment agreements, individuals could be required to tap home equity to cover costs over time. That may sound reasonable in a policy model. In practice, it risks recreating the very insecurity the proposal aims to solve. For millions of middle-class Americans, a home is not just an asset—it is the foundation of financial stability and the primary means of passing opportunity to the next generation. Conditioning access to care on the gradual liquidation of that asset is not a neutral policy choice. It is a shift in burden, one that falls hardest on those who have the least margin for error.
We have seen this story before. Medicaid forces people to “spend down” into poverty before qualifying for long-term care. Replacing that system with one that effectively says “pay with your house instead” is not a transformation—it is a rebranding. There are other concerns as well. The proposal relies on private third-party administrators to determine eligibility and manage services, echoing elements of Medicare Advantage. Experience suggests that when private entities are paid to manage costs, access can become more difficult, not less. And while the report acknowledges the severe shortage of caregivers, it stops short of offering the kind of robust workforce strategy that would make a universal benefit real. Without better wages, training, and career pathways, expanded coverage may exist on paper but remain out of reach in practice.
Still, these concerns should not obscure the central achievement of the Brookings proposal. It moves the country closer to recognizing a fundamental truth: needing help with daily life is not an exception. It is part of the human condition. The question now is whether we are willing to meet that reality with policies that truly reflect our values.
That also means recognizing that the Brookings framework is not the only path forward. Other models deserve serious consideration if we are to build a system that truly supports dignity. State-based social insurance programs such as the WA Cares Fund show that modest, universal benefits can be financed broadly and delivered without requiring individuals to first lose everything. These approaches could be strengthened by pairing them with catastrophic public insurance to protect against the most devastating, long-duration needs. Public–private “wraparound” models could make supplemental coverage affordable and automatic, while reforms to Medicaid—such as pre-funding options or buy-in pathways—could allow middle-class families to plan ahead rather than wait for crisis. Employer-based benefits, long-term care savings mechanisms, and even carefully designed home equity tools that preserve—not strip—family stability could all play a role. The lesson is clear: dignity is not created by a single program, but by a layered system that spreads risk, expands choice, and protects people from financial ruin.
Dignity in aging should not depend on how much equity you have in your home. It should not be mediated by private gatekeepers whose incentives may not align with patient needs. And it should not arrive only after a person’s condition has deteriorated to the point of crisis. If we are serious about reform, we should build on the best of this proposal—universal access, a commitment to home-based care, and a recognition of shared responsibility—while rejecting approaches that shift risk back onto individuals and families. We have an opportunity to get this right. To create a system that ensures people can age with dignity, security, and independence.
But dignity, in the end, is not just about where care is delivered. It is about whether that care comes at the cost of everything people have worked their lives to build.
On Labels, Lawrence, and Who Dignity Is Actually For
By James Lomastro
Someone suggested recently that my critique of the Brookings proposal makes me a Marxist. I want to respond to that — not defensively, but because it points to something worth naming.
My grandfather was an anarchist. He was nearly deported. What kept him in this country was enlisting in the U.S. Army for World War I — after which he became a citizen and never spoke of any of it again. I didn’t know that history until I wrote a research paper on the 1912 Lawrence textile strike and found him in it. The family had buried it, the way working-class families often bury the parts of their story that made survival uncertain.
My family is not an abstraction. Most of them are working class — modest savings, some equity in the house, not much else. Almost all of them have been caregivers at some point: for a parent, a sibling, a child. They are exactly the people this proposal claims to serve. And I am not confident it does anything meaningful for them. Not because the financing architecture is wrong in every detail, but because it was designed by people who do not share their exposure — people who experience long-term care as a policy problem rather than as a crisis that arrives without warning and strips everything a family has built.
They believe the system is rigged. As I have written, they are right about that diagnosis even when they are wrong about the remedy.
What I want us to be careful about — and this connects to the broader work we are doing on dignity — is that the word applies to all of them. Not only to the people in facilities. Not only to people with disabilities. But to the daughter who has been driving her mother to appointments for three years, the son who quit his job to provide care, the home health aide earning fifteen dollars an hour to do work that makes everything else possible. Dignity is not a word for the people the system has already identified as deserving. It is a prior claim that every person carries — and a standard against which every institution, including this proposal, must be measured.
NYT: Working Americans Knew the Money Wouldn’t Reach Them. They Were Right.
James A. Lomastro, PhD
I grew up in a tenement building in Lawrence, Massachusetts. My parents had a small Social Security check, a little equity in the house, and not much else. I went on to earn a doctorate from Brandeis and spent 40 years as a nursing home administrator, surveyor, and long-term care advocate. I have spent my career inside the progressive policy world. And I am going to say something that world does not want to hear on the most important diagnostic question in American politics right now, MAGA voters are not wrong.
The system is extractive. The people who design the reforms are often insulated from what the system does to everyone else. And the working- and middle-class Americans who have concluded that government programs do not reach them — that the money flows in and disappears before it arrives — are describing their actual experience with precision.
What the Movement Got Right
MAGA did not invent the grievance. It named it. Working Americans did not arrive at their distrust of government through ignorance or manipulation alone. They arrived at it through experience. They watched Medicare flow into nursing home chains. They watched Medicaid reform get absorbed by ownership structures that extracted the benefit before it reached their parent. And then they watched credentialed, well-intentioned people explain why the solution was more money, better program design, and improved messaging.
MAGA named the betrayal even if it misidentified the betrayers. It said: the system does not work for you, the people running it do not share your life, and the reforms they propose will not reach you. On those three diagnostic points — not on the solutions, not on the scapegoating, not on the authoritarian response — the movement was telling a recognizable truth to people whose experience confirmed it every day. My neighbors in Conway, Massachusetts — farmers, tradespeople, retired mill workers — are not unsophisticated. They are paying attention with their whole lives because they have no other choice.
The Elite Trap
The Brookings Institution recently released a serious proposal on aging with dignity. I do not question its authors’ intentions. I question their position. They have defined benefit pensions and investment portfolios. Their universities hold endowments managed by the same financial institutions that own nursing home REITs. They experience long-term care as a policy problem. Working Americans experience it as a crisis that strips everything they built. That positional difference determines what you can see.
Brookings has company. In late 2025, the Harvard Business Review published an article recommending private equity operational tactics — clean-sheet labor, elimination of low-value revenue, relentless execution — as universal management wisdom. The authors, several of them McKinsey partners advising PE firms, wrote with the confidence of people who have never stood on the receiving end of the model they were recommending. The most catastrophic recent application of that model in healthcare occurred in neighborhoods adjacent to the HBR offices in Brighton, Massachusetts. The collapse closed hospitals, stranded patients, and left communities without emergency care. It was not an aberration of the private equity playbook. It was the playbook, executed as designed. The authors had not thought to ask the people who worked in those facilities what they had seen. One wonders whether that conversation might have complicated their conclusions.
The same blindness shapes long-term care policy. In Massachusetts, for-profit nursing facilities account for 92% of staffing standard violations. Nationally, 63% of nursing home profits flow through related-party arrangements — management fees, consulting contracts, and rent paid to affiliated real estate companies — each transaction siphoning resources before they reach a resident. Bear Mountain at Worcester paid nearly $1.4 million to affiliated entities in a single year while residents experienced documented neglect, then closed in 2023, scattering 120 people. The extraction continued until there was nothing left to extract. The Brookings proposal would send new federal dollars into this architecture without touching it.
This is the elite trap: policy designed by people whose security insulates them from its failures, using frameworks that are structurally blind to the governance and ownership questions that determine whether policy works at ground level. It asks working people to capitalize a system that transfers their contributions upward. Labor pays in. Private equity takes out. The people who need care get something — but not what the policy promised.
The Right Diagnostic
Acknowledging what MAGA got right does not mean accepting what MAGA prescribes. The movement identified the betrayal and directed the rage at immigrants, at government itself, at anyone but the ownership structures doing the extracting. That misdirection is not an accident. It is the service the movement renders to the capital it claims to oppose.
The answer is not less government. It is accountable government. The system is extractive, the extraction is structural, and financing without governance reform does not fix extraction — it funds it. That means mandatory ownership disclosure that follows the money through every LLC layer, workforce standards with real enforcement, and accountability structures that reach beneficial owners, not just the operating entities they dissolve when citations accumulate. These are not left-wing demands. They are transparency and accountability demands that a fiscal conservative, a union member, and a family caregiver can all support — because they describe what actually happened to someone they know.
My parents had a Social Security check, a little equity in the house, and the reasonable expectation that the system would treat them fairly. What they could not have known is that the system had been engineered to route their contributions somewhere else before it ever reached them. MAGA voters felt that. They named it badly and aimed the anger in the wrong direction. But the feeling was not manufactured. It was real. And until progressive policy is willing to say out loud that the system extracts from the people it claims to serve and that new financing without governance reform will accelerate that extraction, the distrust will continue.
It will continue because it is deserved.