Risking Old Age in America: The Coming Elder Care Crisis

Building Housing for the ‘Missing Middle’ with Amy Schectman of 2Life

Amy Schectman, CEO of 2Life Communities, explains 2Life’s mission to provide affordable, purpose-filled aging through deeply affordable housing and advocacy, and describes Opus Newton, a continuing care retirement community for the “missing middle” who earn too much for subsidies but can’t afford luxury options. She contrasts NewBridge’s high-income model with mixed-income Brown House and explains 2Life’s “optimal aging” components: lifetime affordability, social connection, and help navigating home and healthcare systems via care navigators and varied programming. Opus Newton keeps monthly fees low through a home-sale-funded upfront fee that eliminated construction debt, resident volunteerism (10 hours/month), shared overhead with adjacent affordable Coleman House and JCC partnerships, and flexible home care through Houseworks. Amy urges earlier moves, replicating the model, expanding supply, and shifting policy messaging from “aging in place” to “aging in community,” citing improved longevity and health outcomes and reduced public costs.
 
Topics
01:04 Meet Amy Schectman
02:00 Three Models Compared
04:42 What Optimal Aging Needs
07:13 Care Navigators Explained
08:19 Resident Led Culture
10:37 Making Opus Affordable
13:41 Shared Campus Partnerships
15:16 Home Care Without Waste
17:17 Why Size Matters
18:21 Demand And Waiting Lists
18:48 Finding Space to Grow
19:28 Community Gives Back
20:03 Scaling the Missing Middle
21:28 Market Model Requirements
22:48 Retirement and Next Steps
23:18 Move Before You Must
25:24 Louise and Bridge Club
28:22 Advice for Boomers
28:46 Policy Supply and Messaging
30:47 Longevity Proof Points
32:40 Efficiency and Cost Savings
33:38 Lessons from the Netherlands
34:40 Long Term Care Insurance
35:20 Closing and New Site

AgingIN CEO Susan Ryan

Harry talks with Susan Ryan, CEO of AgingIN, who pursued a “call to action” after seeing physical and chemical restraints used in nursing homes, including a case where a woman suffered a fractured hip and returned from the hospital with stage four decubitus ulcers. Susan moved into home care and geriatric education but found home care costly and sometimes isolating, leading her to culture-change efforts and ultimately the Green House model, developed by Dr. Bill Thomas to replace sterile institutions with small, home-like settings of 10–12 residents, private rooms, decentralized kitchens, and access outdoors. Susan says over 400 Green House homes have been built since 2003 across about 35 states, and the model can operate at similar cost to traditional nursing homes, including with substantial Medicaid populations, when paired with empowered, universal-worker staffing and shared decision-making. She explains how the Green House Project and Pioneer Network combined under AgingIN to catalyze person-directed living across the broader aging ecosystem, urges policy incentives like Medicaid reimbursement bumps, and advises individuals to be intentional about aging in community to reduce isolation.
 
Visit https://aginginnovation.org/
 
Topics
00:50 Susan’s Call to Reform
02:17 From Home Care to Culture Change
03:46 What Is Green House
05:36 Scale and Market Reality
07:09 Costs and Medicaid Viability
08:22 Renovate or Rebuild
09:23 Core Values Real Home
12:26 Assisted Living Home for Life
14:46 Community Dining and Opus
16:56 AgingIN Origin Story
20:30 Preparing for the Boomer Wave
23:34 State Plans and Policy Incentives
24:58 Advice for Policymakers and Boomers
27:27 Closing Thanks

Heidi Hartmann & Jeff Hayes on the Home Care Workforce and the Future of Elder Care

Heidi Hartmann and Jeff Hayes, both based in Washington, DC and formerly at the Institute for Women’s Policy Research, discuss their study on the shifting supply and demand of care work. They found immigrant workers are increasingly essential to direct care, with a growing share of workers being people of color and about three-quarters women, while pay remains low and many workers rely on public benefits; under-the-table work is hard to measure. They describe a shift away from nursing homes toward aging at home, increasing demand for home care, more medicalized and monitored work, and concerns that immigration restrictions are worsening worker shortages and raising costs. They note Medicaid both supports patients’ home-based care and indirectly subsidizes low wages, and suggest policy changes such as more public funding (potentially via Medicare or Medicaid asset-limit changes) and special visas for home care. They close with advice for baby boomers to save, plan for non-financial caregiving needs, and maintain friendships and support networks.
 
Topics
00:00 Meet Heidi and Jeff
01:47 Care Work Study Findings
03:00 Who Does Care Work
03:43 Low Wages and Benefits Gaps
05:39 Medicaid and Under the Table Work
06:25 Post Pandemic Care Shift
10:45 Why Care Is So Expensive
13:14 Personal Elder Care Stories
19:47 Immigration Crunch Ahead
21:10 Policy Fixes for Long Term Care
23:43 Immigration Reform Ideas
26:19 Advice for Baby Boomers

Inside a $110 Million Verdict: Private Equity, Assisted Living, and the Hidden Risks of Rehab

Sacramento attorney Ed Dudensing joins Harry to discuss nursing home and assisted living litigation, including his $110 million verdict against corporate owners Colony Capital and Formation Capital after a cognitively impaired 100-year-old resident with dementia wandered out an unalarmed second-floor door, was locked outside, fell, and died of exposure on a 38–39° February night. Dudensing describes how assisted living is less regulated yet increasingly houses higher-acuity residents, and how layered holding-company structures can leave licensees assetless while top entities control budgets. He explains why private equity and REITs invest despite claims that Medicaid rates are inadequate, citing higher Medicare reimbursement and profit strategies including high-acuity “short-stay rehab” marketing and related-party transactions that shift costs. He supports staffing minimums, notes studies linking private equity ownership to worse outcomes, urges hospital accountability for discharge placements and ownership transparency, and advises families to visit unannounced and trust their instincts.
 
Topics
00:24 Meet Ed Dudensing
01:11 Why He Sued Facilities
02:23 110 Million Verdict
03:32 How Neglect Happened
04:56 Following the Money
08:11 Private Equity Playbook
10:27 Medicaid Myth Explained
16:07 Staffing and Outcomes
18:09 Nonprofit vs For Profit
19:48 What States Can Do
22:15 Rehab Marketing Trap
24:12 Policy Fixes
25:48 Advice for Families
27:00 Closing Thoughts

Rep. Tom Stanley on Long-Term Care Reform & a Universal Care Financing Plan

Harry is joined by Massachusetts State Representative Tom Stanley, chair of the legislature’s Aging and Independence Committee, to discuss major elder-care initiatives, including the 2024 long-term care reform law (Chapter 197), the first major update in over 25 years. The law strengthens transparency and oversight of nursing homes and assisted living through expanded suitability reviews of owners, operators, management companies, and 5% stakeholders; gives the Department of Public Health earlier intervention tools such as increased fees and temporary management; and creates a long-term care workforce and capital fund for training and facility upgrades, partly supported by increased fines for serious infractions. It also permanently allows assisted living to provide basic health services like wound care and injections. Stanley describes proposed legislation for a family caregiver commission to evaluate a payroll-tax-funded public long-term care insurance model based on Washington Cares, and a home care licensure bill to standardize provider quality and worker protections. He urges voters to engage legislators and advises baby boomers to plan early, secure proxies, and use local aging resources.
 
Topics
01:10 Why Rename the Committee
01:34 Long Term Care Reform Bill
03:55 Assisted Living Health Services
07:30 Stronger Nursing Home Enforcement
09:14 Facilities Ownership and Upgrades
12:50 Family Caregiver Commission Plan
17:22 Designing Universal LTC Insurance
22:00 Home Care Licensing Bill
26:25 Advice for Voters and Boomers
31:09 Aging Preparedness Statistics
33:12 Closing Thanks and Wrap Up

Neal Shah, Co-Founder & CEO of CareYaya

Harry talks with Neal Shah, co-founder and CEO of CareYaya, a digital platform matching healthcare students with seniors for affordable companion care (~$20/hr). He critiques costly home-care agencies, underfunded social care, and looming workforce shortages, and discusses impact funding, policy changes, and planning for elder-care expenses.
Visit https://www.careyaya.org/
Topics
00:00 Why Getting Care Help Is So Frustrating (Caregiver Reality Check)
00:26 Meet Neal Shah & the Mission Behind CareYaya
01:01 How CareYaya Works: Healthcare Students, Digital Booking, Lower Cost
02:19 What Kind of Care They Provide (Home Care vs. Home Health)
03:29 Why Home Care Is So Expensive: Middlemen, Markups, and Bad Experiences
06:02 CareYaya’s “Costco Model”: Tech Efficiency, Reliability, and Better Pay
08:03 Employer Paperwork & the Gray Market: Taxes, Workers’ Comp, and DIY Tradeoffs
09:56 Neal’s Origin Story: From Hedge Funds to Family Caregiving
12:48 Funding & Business Model: For-Profit, No Fees (Yet)
13:54 What Are Impact Funds? Patient Capital for Long-Term Social Change
16:23 Switching Gears: The U.S. Is Great at Healthcare, Bad at Social Care
16:45 Why the U.S. Underspends on Social Care (Dementia & Cancer at Home)
18:02 The Hidden Army of Family Caregivers—and the Trillion-Dollar Burden
18:36 Boomers Turning 80: The Coming Care Crunch & Workforce Dropout Risk
19:34 Who Should Pay? Private Sector, Tax Breaks, and Employer Elder-Care Benefits
21:42 Preventing Hospitalizations: Loneliness, Home Support, and Medicare’s Incentives
23:17 Medicare Advantage Critique and the Fragmented Payer Problem
24:21 The “Longevity Grift”: Why Anti-Aging Hype Misses the Real Crisis
28:37 Policy Advice: Invest in Home-Based Care and Build the Care Workforce
30:29 Advice for Boomers: Plan Early, Save More, and Rethink HSAs
33:05 Closing Thoughts and Farewell

Inside Home Healthcare with Wendy Adlerstein

Wendy Adlerstein, co-owner of First Light Home Care of West Suburban Boston, shares her journey and experiences running a private, non-medical home healthcare agency. Wendy discusses the benefits of being part of a larger franchise, the challenges faced in recruiting qualified caregivers, and the impact of immigration policies on staffing. She also highlights the importance of licensure and regulation in the home healthcare industry and shares her thoughts on the need for specialized caregiver visas. Wendy emphasizes the value of planning ahead for families seeking care for their loved ones and advocates for early preparation and research to avoid crisis situations.
 
Topics
00:29 Overview of the Home Healthcare Agency
01:13 Benefits of Being Part of a Franchise
01:52 Wendy's Background and Journey
02:54 Differences Between Private and Nonprofit Home Care
03:38 Typical Clients and Home Health Aides
04:59 Recruitment and Vetting Process
06:15 Impact of Immigration Policies
08:46 Employee Compensation and Client Costs
14:09 Regulation and Licensing in Home Care
20:12 Challenges and Recommendations
24:50 Conclusion and Final Thoughts

Understanding the Challenges of Caregivers with NAC Research Director George Kueppers

George Kueppers, the research director of the National Alliance for Caregiving (NAC), discusses the organization's role and mission. Founded in 1996, NAC focuses on public policy needs and understanding the impact of family caregiving in the United States. George highlights the extensive work of NAC and its members to improve the health and wellbeing of family caregivers who provide care for loved ones with complex medical needs. The conversation covers the demographics of caregivers, financial burdens, and the diverse types of assistance provided based on gender and racial differences. Additionally, the episode delves into the survey findings on the prevalence of paid caregivers, the financial impact on caregivers, and policy recommendations to support them, including expanding paid family leave and respite care programs. George also emphasizes the importance of caregivers prioritizing their own health and wellbeing to prevent burnout.
 
Topics
00:32 Overview of the National Alliance for Caregiving
01:55 Statistics on Family Caregivers in the U.S.
03:39 Financial Impacts of Caregiving
05:42 Gender Differences in Caregiving
07:16 State-by-State Analysis of Caregiving
10:21 Racial and Ethnic Differences in Caregiving
12:04 Policy Recommendations for Supporting Caregivers
17:51 Advice for Family Caregivers
19:05 Conclusion and Final Thoughts

Navigating ‘Solo Aging’ with Dr. Sara Zeff Geber

Harry interviews Dr. Sara Zeff Geber, who coined the term 'solo agers' to describe individuals without reliable family support as they age. They discuss the growing population of solo agers, particularly among baby boomers, and explore the challenges and opportunities in planning for later life. Key topics include the importance of having a robust estate plan, the role of licensed professional fiduciaries, the emergence of the Child Free Trust, and alternative living arrangements such as senior living communities. Sarah emphasizes the need for solo agers to proactively plan for their future to ensure they are supported and comfortable in their later years.
 
More on Sara: https://sarazeffgeber.com/
More on Harry Margolis: https://margolisbloom.com/harry-s-margolis/ 
Harry on Substack:  https://okayboomer.substack.com/ 
 
Topics
00:37 Defining ‘Solo Agers’
02:18 Statistics and Trends of Solo Agers
05:06 Personal Journey into Solo Aging
06:42 Solutions for Solo Agers
14:21 Living Arrangements for Solo Agers
22:32 Policy Recommendations and Final Thoughts

Ensuring Financial Longevity with Dr. Dawn Carpenter

Harry speaks with Dr. Dawn Carpenter of the Milken Institute about the concept of financial longevity and the importance of maintaining financial security and dignity as people age. They discuss the definitions and implications of financial longevity, the psychological aspects of personal finance, and the role of uncertainty in financial planning. Dr. Carpenter shares insights from her personal experiences and professional perspectives, highlighting the importance of flexibility and pre-planning. The conversation also covers the broader societal issues of inequality, the role of government and employers, and the Milken Institute's initiatives in promoting financial health. Dr. Carpenter stresses the importance of engaging actively in one’s longevity and offers practical advice for individuals, families, employers, and policymakers.
 
More on Dawn: https://milkeninstitute.org/experts/dawn-m-carpenter-dls
 
Topics
00:41 Defining Financial Longevity
02:25 Psychology vs. Math in Personal Finance
03:06 Personal Anecdotes and Long-Term Care
06:04 Planning for College Education
09:00 Flexibility in Financial Planning
10:05 Dignity in Aging
11:47 Obstacles to Financial Longevity
15:36 Role of Government and Employers
17:59 Milken Institute's Role
21:42 Recommendations for Policymakers and Baby Boomers
25:40 Conclusion and Contact Information