Navigating long-term health care for older adults is an agonizing challenge faced by millions of people across the U.S. The emotional, physical and financial costs can be overwhelming for older adults who need care and for those who provide it—whether they are professional caregivers or family members. Earlier this month Vice President Kamala Harris announced a future expansion of government health benefits that would tackle these issues head-on if she’s elected president.
“I took care of my mother when she was sick. She was diagnosed with cancer. And so it is a personal experience for me as well as something I care deeply about,” Harris said during a recent interview on the talk show The View. “There are so many people in our country who are right in the middle. They’re taking care of their kids, and they’re taking care of their aging parents, and it’s just almost impossible to do it all, especially if they work.”
Harris’s new proposal, called the Medicare at Home plan, emphasizes supporting these members in the so-called sandwich generation—people who care for both young and aging family members. If it passes, at-home aides who provide support for day-to-day activities, such as bathing, cooking and using the bathroom, would be covered for the first time ever by Medicare, the federal health insurance program for adults aged 65 and older and some people with disabilities. The proposal also maps out avenues to improve wages for professional care workers, expand access to remote technologies and telehealth services and cover hearing and vision needs, including hearing aids and eyeglasses. Based on the eligibility criteria of similar proposals, Harris’s plan could potentially help more than 14.7 million of the 67 million people enrolled in Medicare, as well as countless caregivers—but it rides on the results of the upcoming U.S. presidential election and on crucial negotiations across branches of the federal government.
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“I think anyone who has gone through an aging parent situation has a really visceral sense of how important this is and how much people fall through the cracks,” says Sarah Szanton, a nurse practitioner and dean of Johns Hopkins School of Nursing, who specializes in aging. “What Vice President Harris has put her finger on is the vast need that so many of us have lived through or are living through.”
Research suggests that the need for long-term care services and programs is only going to become more demanding. Demographic studies have found that human population growth is slowing down and family sizes are getting smaller—people have fewer cousins and siblings close in age to them and more relatives who are older. This means people will need to care for aging loved ones with decreasing family support.
“The world as a whole is aging, but we’re at a real tipping point,” Szanton says. In the U.S., there are “10,000 people who turn 65 every day right now, so 300,000 new people a month—and that means that many more people are on Medicare each month.”
Medicare currently pays for home assistance and rehabilitation services for a limited time after hospitalization (for a medical stay involving issues such as a broken hip, cancer treatment or heart surgery). People in very low income brackets can apply to continue at-home nursing support through federal-state Medicaid insurance programs. Some state Medicaid programs offer self-directed care, which allows people to hire informal caregivers, such as friends or family members, who may have to quit their job to care for their loved one.
But many people wind up paying out-of-pocket; one 2024 survey estimates that the median cost of 40-hour-per-week at-home health care in the U.S. is $5,892 a month. Some at-home aides and services require payment for a set minimum number of hours per day, Szanton explains. So if someone only requires an hour of help to cook, clean or grab the mail, they may have to pay more for a longer shift of four hours. Sometimes older adults and their families “essentially impoverish themselves and then get onto Medicaid,” Szanton says.
“There’s nothing for you, unless you spend your entire life savings and stop working and somehow become eligible for Medicaid,” says Carrie Graham, a gerontologist and health policy analyst at Georgetown University’s Center on Health Insurance Reforms. Graham also points out that the majority of family caregiving falls on women; on any given day, nearly 24 percent of women aged 55 and older in the U.S. provide unpaid family care.
“A lot of caregivers are older adults themselves,” Graham says. “It takes a major toll on being able to take care of your own health.” According to a Centers for Disease Control and Prevention survey conducted from 2015 to 2017, 41 percent of caregivers reported having two or more chronic diseases. More than half also said a decline in their own health had affected their ability to provide care.
Covering costs of at-home care workers through Harris’s plan could help alleviate some of these burdens. The day-to-day services wouldn’t fit those who require higher level medical care or skilled nursing facilities but would help older adults who can live independently with some support. “If we don’t have the ability to support people to age at home, both Medicaid and Medicare will balloon in cost,” Szanton says.
Szanton notes how much the government spends just on older adult injuries from falls, for example. A CDC study published in July found that nonfatal falls among people aged 65 and older accounted for $80 billion in health care costs in 2020—with the majority of those costs paid by Medicare. “Daily activities like getting dressed or bathing or toileting are the most common reasons someone does fall,” Szanton says. “Being able to have more direct care workers or helpers through Medicare could help prevent some of these falls and some of these expenditures.”
Harris’s plan isn’t exactly cheap, however. Similar proposals have been estimated to cost about $40 billion per year, before any potential savings from lower Medicare spending on hospitalizations or facility care. Harris’s team is hoping that savings from the Inflation Reduction Act’s Medicare drug price negotiations will help fund the plan. Price negotiations for an initial list of drugs are expected to take effect in 2026, though Harris has pushed for expanding this coverage. The Centers for Medicare & Medicaid Services projects that negotiations for the selected drugs would have saved $6 billion in 2023, and the Congressional Budget Office estimates $98.5 billion in Medicare savings from price negotiations by 2031.
Under Harris’s proposal, coverage and cost-sharing would be decided on a sliding scale based on income. Graham says more information is needed on exactly what this would look like and who would be eligible for certain services. “When would it kick in?” she asks. “What would a co-pay be? Would there be a waiting period? Would it be needs tested?” The plan does specify that aides would assist those with cognitive issues—a service gap that desperately needs to be addressed, she says. “We’re seeing a major increase in people who have dementia and cognitive impairment,” says Graham, who is herself navigating care for her father, who has dementia. “What’s offered in the Medicaid program often focuses on physical impairment, but it’s really, really important that this proposal talks about cognitive impairment.”
And Szanton says health aides cover just one section in a broad spectrum of long-term care needs. In a program she co-developed called CAPABLE (Community Aging in Place—Advancing Better Living for Elders), a nurse, an occupational therapist and a handyperson spend four to five months with older adults to help with health needs, as well as home modifications and repairs, such as lowering cabinets, removing trip hazards or putting accessibility railings in the bathroom. The program, active in 25 states, has not only helped keep older adults in their community but has also reduced hospitalizations, nursing home admissions and overall Medicaid and Medicare spending.
“We definitely need what Vice President Harris has proposed,” Szanton says. “I think there are other things around edges that could also help, where people could become more independent at the same time.”
Harris’s plan hasn’t been fully detailed or finalized—and it would very likely undergo many changes in the legislative process, Graham says. “Whatever is in the proposal now will need to be negotiated, but I think the focus really needs to be [that] this is a bipartisan issue,” Graham says. “Harris is a Democrat, but the people who realize that there’s no care they’re getting from Medicare are Republicans and Democrats and lots of different people. And so I do think that this is an issue for everybody, and I hope that we can keep this [going] and really work together.”