Here’s some news you probably don’t want to hear: if you are young, you should be planning for the care of your parents as they age. For that matter, maybe you should start thinking about how you’ll care for yourself. And while you’re at it, you should be concerned about the issue writ large: how will society meet the imperative of care for our rapidly aging population?

Every day some 10,000 baby boomers turn 65. And by 2030, the entire boomer generation (born 1946 to 1964) will have crossed that threshold. The Census Bureau projects that from 2022 to 2037 the 65 and over population will grow from 60.2 million to 80.9 million, an increase of 34 percent in just 15 years. In contrast, the under-65 population is expected to grow by just 5 percent over the same period.

This demographic shift, no surprise, carries with it profound changes to health care utilization. Health care spending increases with age – and rapidly so at older ages. This is not due solely to the fact that older Americans consume bigger-ticket care, they also need more regular care. Americans over 65 are just under 18 percent of the population, but they account for nearly half of all physician office visits, 43 percent of hospital admissions and approximately 37 percent of total health care costs.

The higher utilization highlights a critical concern: four out of five older adults believe the health care system is unprepared to meet the growing and evolving needs of America’s aging population. No wonder. Many older adults experience difficulty in accessing and navigating our fragmented, costly and inequitable health care system. The challenges are more pronounced – and dissatisfaction higher – among women, people of color, rural residents and the economically disadvantaged.

Aging is hardly a matter of one-size-fits-all. Some people show signs of frailty at 60, while many in their 90s remain functionally healthy. But, of course, many do not; aging is the leading risk factor for cardiovascular disease, type 2 diabetes, cancer, arthritis and dementia. Some 85 percent of adults age 65 and older have at least one chronic condition, while two-thirds have two or more.

These conditions often bring unique physical, social and psychological changes, leading to functional, sensory, mental and cognitive challenges. Consequently, most older adults will at some point in their lives require more frequent monitoring and care from providers with training in geriatrics who are capable of managing complex needs such as multimorbidity and polypharmacy interactions. And this surge in demand for specialized health care is colliding head-on with insufficient supply.

Too Few Hands

In 2022, 7,413 physicians were board-certified in geriatrics in the United States, adding up to just 1.3 geriatricians per 10,000 Americans age 65 or older. The Health Resources and Services Administration projects that from 2022 to 2037, the number of geriatricians will grow – but only by 16 percent, which is less than half the projected growth rate for the 65 and older population, meaning there will be even fewer providers per patient down the line.

It gets worse: many primary care physicians are not receiving adequate geriatrics education as part of their training, making it difficult for them to help cover the looming care deficit. Only 10 percent of medical schools require rotations in geriatrics – compared to 96 percent that require pediatric rotations.

One reason for the supply shortfall is that few students choose the specialty. In 2023 there were 419 residency slots in geriatrics. Of these only 174 were filled, a match rate of 41.5 percent. For comparison, the overall residency match rate for medical school graduates that year was 85.2 percent.

Compensation is part of the problem. Last year, geriatrics was among the 20 lowest-paid physician specialties. Moreover, geriatricians typically spend an additional one to two years in post-residency fellowship training, often earning less than if they began practicing without specialization. Why they earn less is pretty straightforward. On the one hand, most patients treated by geriatricians are insured by Medicare, which reimburses less on average than private health insurance. On the other, older adults generally need more complex care, meaning geriatricians spend more time with each patient and see fewer each hour.

Pay, however, is not the entire story. Internal medicine is also among the 20 lowest-paid specialties, yet it had a residency match rate of 88.4 percent in 2023. Studies of medical students show that in addition to being concerned by the lower pay for geriatricians, they are wary of the increased complexity and additional ambiguity of geriatric cases and may view the specialty as less prestigious compared to others. Some physicians-in-training also report having negative attitudes toward elder care, referring to the patient group as “frustrating” and “boring.” Yet, speak with almost any geriatrician, and you’ll hear from a physician who finds their work deeply rewarding.

The geriatrician workforce shortfall is not limited to physicians. A shortage of nearly 338,000 registered nurses is projected for 2036. Over 95 percent of today’s nursing homes and assisted living facilities report staff shortages across all nursing levels, with over half of nursing homes and over a quarter of assisted living facilities saying they had to limit admissions due to insufficient staffing. Home health care, which primarily serves older adults, has parallel staffing difficulties: the annual rate of attrition for home health nurses is just over 30 percent, an astronomical number compared to the job turnover rate in the overall economy of 3.3 percent. Moreover, the long-standing shortage of hands-on care workers will become worse, with a projected 4.6 million unfilled positions by 2032.

As gloomy as the numbers are, they look worse when one considers the reality that the number of older adults with Alzheimer’s disease and related dementias, who need more than average amounts of care, is expected to grow disproportionately. Today, nearly 7 million people in the U.S. are living with Alzheimer’s, and that number is likely to nearly double by 2050.

The Family Caregiver Crunch

With the demand for geriatric-capable care rising, and the supply of practitioners falling short, a second labor force is stepping up (out of necessity and heartfelt duty) to fill the care gap: family members and friends. Research from the AARP and the National Alliance for Caregiving concludes that there are approximately 53 million unpaid family caregivers in the United States. Of these, some 42 million, or over 16 percent of American adults, are caring for someone over 50, and more than 13 million are part of the sandwich generation, caring for a minor in addition to an adult.

Over half of these caregivers say they did not have a choice. And the impact is cascading toward younger generations. In 2020, 6 percent of unpaid caregivers were part of Generation Y (born in 1997 or later), implying that care obligations are interrupting educational and early-career pursuits.

Caregiving is both time- and labor-intensive. The average unpaid caregiver for an adult provides 23.7 hours of care weekly, with 21 percent providing over 40 hours, the equivalent of a full-time job. This is on top of the hours that the 61 percent of unpaid caregivers who are part of the paid workforce must spend on making a living.

Unpaid caregivers meet their responsibilities at the expense of their own physical and emotional needs. Some 36 percent caring for an adult report high levels of emotional stress, and disproportionate numbers detail chronic illnesses of their own, including arthritis, chronic obstructive pulmonary disease and obesity.

The financial toll is also significant. The average annual out-of-pocket expenses incurred by family caregivers is $7,200, with dementia caregivers reporting outlays exceeding $9,000. All told, 45 percent of caregivers report a negative financial impact such as needing to dip into savings, taking on additional debt, paying bills late or borrowing money from family or friends.

This should not be surprising in light of the finding from a 2023 survey that over a quarter of unpaid caregivers shifted from full- to parttime work or took reduced hours, and over 16 percent turned down promotions. The most complete accounting of the drag of these costs on the economy comes from a 2016 study based on 2012 data. The authors estimate that the wages lost by unpaid elder-caregivers exceeded half a trillion (!) dollars, a number that has certainly grown over the past decade due to the increasing size of the unpaid caregiver workforce.

Caregiving responsibilities disproportionately impact women’s progress and financial lives since the obligations most often fall on their shoulders. On average, women sacrifice $295,000 in lost earnings and related retirement income across a lifetime as they juggle caregiving duties.

Bringing Care to the Home

Increased reliance on unpaid caregivers coincides with a shift toward care delivered at home. In 2022, the U.S. market for home health care services was estimated at $94 billion and is expected to grow to $153 billion by 2029. Those numbers are on the conservative end of estimates. McKinsey predicted that $265 billion in care services for Medicare enrollees could be delivered in the home by 2025. The reasons for the shift range from patient preferences and advancements in technology to cost-minded policies permitting telehealth, remote patient monitoring and hospital-at-home care models.

Initiatives such as the Acute Hospital Care at Home waiver program launched by the Centers for Medicare & Medicaid Services in November 2020 have enabled hospitals to provide inpatient-level care at home. As of 2024, over 300 hospitals across 37 states were on board.

The approach is catching on because hospital-at-home programs are associated with lower mortality rates and reduced post-discharge spending compared to traditional inpatient care, along with generally positive feedback from patients and caregivers.

The increasing prevalence of chronic conditions among older adults requires longitudinal, rather than episodic care, with monitoring and management that often do not require in-person visits. Technologies that augment the human presence, monitor patients remotely and improve communication and social connections will need to be scaled in the care ecosystem.

Four Strategies (Pick Four)

The facts on the ground are clear: the population of over-65s is surging, the growth in geriatric- capable care professionals is lagging, and unpaid – often undertrained – caregivers are being crushed by responsibilities they did not plan for but cannot avoid. There are paths forward that can improve this outlook. We outline four of them – but to be clear, our preferred option is for “all of them.”

Invest in Healthier Aging

The first strategy is to invest in increasing individual “health spans,” the portion of a person’s life that consists of healthy (or at least independent) years. Delaying the onset of chronic conditions that often increase with age or preventing them altogether would alleviate the tremendous strains on both providers and family caregivers. If one thinks of the underlying problem as one of too much demand and too little supply, this strategy focuses on tamping down demand.

One way of getting from here to there is to move away from what Peter Attia has termed “Medicine 2.0,” which focuses on treating the “four horsemen” of chronic disease – cardiovascular disease, metabolic disease (Type 2 diabetes), cancer and neurodegenerative disease – to “Medicine 3.0,” which emphasizes prevention. Lifestyle improvements such as a balanced diet, limited alcohol intake, regular exercise and adequate sleep as well as regular medical screenings are all part of a prevention focus. There is also evidence that less tangible attributes such as a strong sense of purpose in life and a network of high-quality personal relationships reduce the risk of chronic disease and serious illness.

Even modest advances in prevention could save tremendous sums. For example, a mere one-year delay in dementia onset would save $113 billion annually by 2030, of which $43 billion represents the implicit costs of informal home care. A three- or five-year delay could save $415 billion and $599 billion, respectively, by 2050.

This is not pie-in-the-sky. A 2024 Lancet Commission Report highlights 14 evidence-based, modifiable risk factors that could reduce dementia risk by up to 45 percent. And some of these preventive actions could piggyback on existing public policies. Dementia risk is decreased with lower exposure to air pollution and by addressing hearing loss. Strengthening existing anti-pollution policies and ensuring access to assistive hearing devices would carry the additional benefit of a long-run increase in health span due to decreased or delayed dementia diagnoses. Investing in healthy aging also entails investing in the promise of “geroscience,” which moves away from disease-specific treatments to address the underlying aging process – the biological mechanisms of aging such as telomere shortening, cellular senescence, mitochondrial dysfunction and more. Interventions aimed at eradicating or slowing the biological mechanisms of aging could reduce, delay or eliminate chronic diseases associated with aging and extend health span.

Build Out Geriatric Care Capability

The second strategy is to build workforce capacity and capability. This includes actions that increase the supply of geriatricians as well as initiatives that enable (and encourage) providers and facilities to make geriatric care tenets integral to their care practices.

The most obvious place to start is with the workforce shortage. There is a long history of policy interventions aimed at expanding part or all of the health care workforce, and now is the time to pull out that playbook. A classic example is the National Health Services Corps, which provides loan forgiveness for physicians who practice in underserved areas. Expanding the NHSC to cover underprovided specialties such as geriatrics as well as underserved regions would provide a sizable incentive to go into the specialty.

Note, too, that this approach would likely perform better than the base NHSC program in terms of provider retention. When young physicians have completed their obligation to the NHSC, it is simple for them to move to localities with more amenities and better compensation. It is far more difficult to switch specialties.

Another approach would be to increase Medicare and Medicaid reimbursements for geriatric services. This could be done by increasing payments for common geriatric procedures, or by adding an additional bump to the pay for select services if the provider is a certified practicing geriatrician. A payment adjustment for Medicare would be especially influential as Medicare payments tend to pull private insurance payments along with them.

We could also make changes to the immigration system to entice foreign geriatricians to join the U.S. workforce. For example, geriatricians could be exempted from (i.e., not count toward) the cap on the number of H-1B visas issued each year for skilled labor. Similar exemptions could be made as appropriate for other relevant health workers, provided that they maintain activity within the specialty workforce.

It is also clear that geriatrics needs a rebrand with medical students. The negative perceptions of the specialty do not match up with what is reported in physician career satisfaction surveys. Indeed, geriatricians have one of the highest levels of career satisfaction among all medical specialties. Students need more exposure to the specialty. The simplest path forward: medical schools could include geriatrics as a core rotation in training.

We also need to assure funding for those seeking innovative ways to expand and improve the geriatric-capable workforce. There have been two lines of federal funding from HRSA with this aim: the Geriatrics Academic Career Awards and the Geriatrics Workforce Enhancement Program. There have also been private sources of funding with similar goals. The Geriatrics for Specialists Initiative aims to increase surgical and specialty physicians’ competence in geriatrics.

A significant initiative to develop and implement Age-Friendly Health Systems led by The John A. Hartford Foundation and the Institute for Healthcare Improvement is underway, based on spreading the “4Ms” – what matters, medication, mentation and mobility – as foundational elements of care for older adults. At the end of 2024, over 4,800 hospitals and health care practices were part of the Age- Friendly Health Systems. The John A. Hartford Foundation and West Health also fund the Geriatric Emergency Department Accreditation Program, another effective program to meet the care needs of older adults. Today, nearly 30 percent of older Americans have access to emergency care provided by physicians, nurses, pharmacists, social workers and physical therapists trained in geriatric care.

All of these public and privately funded initiatives should continue and be scaled.

Improve Support for Family Caregivers

The third strategy is to pursue interventions that make family caregiving more sustainable. The most direct way: compensate currently unpaid caregivers.

The federal government recently added new billing codes to Medicare that allow payment for training home caregivers. Under some circumstances, Medicare will also pay for respite care, allowing home caregivers to take a short break from their responsibilities. Programs are available to help family caregivers become Medicare-certified home health aides and be eligible to be paid for the care they provide to a loved one.

There has also been some legislative movement toward broader compensation. House Resolution 3632 of 2021 (which did not make it out of committee) proposed counting time spent caregiving toward Social Security wage calculations, which would help defray the opportunity cost of providing care.

These policies all fall short of directly compensating unpaid caregivers, who generally do not undergo additional training. But that need not be the end of the story. For example, there are many ways to use tax incentives to indirectly compensate caregivers, either by creating new tax credits or deductions for providing care for others or by expanding existing dependent care credits to be more generous or to cover a wider array of care relationships. In a similar vein, Congress could change the rules around tax-advantaged savings accounts such as health savings accounts and dependent care accounts to increase contribution limits and to expand qualified expenses and eligibility to include caregiving for older adults.

Employers of unpaid caregivers can help, too. They can offer flexible work arrangements – remote work options, job sharing, part-time or adjustable hours. And they could extend paid leave now given to care for newborns to include caregiving for other family members.

Many employers include assistance with financial planning for retirement. This sort of assistance could be expanded with caregivers in mind, offering advice on long-term care insurance and navigating Medicare.

Accelerate Tech-Enabled Care at Home

Innovations in technology such as wearable devices, smart home systems, telehealth platforms and remote patient monitoring tools are transforming how health care is delivered, and not just for scenarios that demand high acuity. For example, falls, which are often costly and sometimes deadly to older adults, have typically been addressed through home safety modifications, assistance with high-risk activities like bathing, and personal emergency response devices. New passive monitoring technologies and AI could take prevention upstream, analyzing a multitude of data to flag when the risk of falls rises. AI could also track movement patterns to detect falls, supporting faster response.

Yet currently, there are several barriers to scaling tech-enabled home care that must be tackled to realize its full potential. Issues of digital literacy, ease of use, trust and affordability hinder older adults’ adoption of technology for care at home. Data fragmentation across provider- and consumer-facing technologies obscures a holistic view of older adults’ health at home, limiting the accessibility, flow and usefulness of the data. Disconnected point solutions, gaps in the evidence base and insurance coverage, and market access bottlenecks faced by tech innovators all hinder wider adoption and sustained expansion.

Public and private investment in the digital health ecosystem – for example, expanding regulatory and payment models, incenting health systems and providers, and stimulating innovation and interest within the venture capital and private equity communities – are steps in the right direction. Rapid tech advancements, especially within AI, will accelerate the development of digital health tools that are predictive, personalized, preventative and participatory, making data more meaningful for older adults and their care teams.

Policy That's Proactive

The unprecedented demographic shift in the United States is already in motion, and the needs of an aging population are guaranteed to grow. Yet the health care system is underprepared for the escalating demand that will flood a system already suffering from fragmentation, inefficiency, uneven quality, uneven access and high costs.

The die isn’t cast, though. A future where people live longer, healthier lives, where care is easily accessible, where the health care workforce is trained in geriatrics, and where family caregivers shoulder a lighter burden with an assist from technology is – indeed, must be – attainable.