As leaders gather in New York for the United Nations (UN) General Assembly this September, the world is also marking the midpoint of the UN’s Decade of Healthy Ageing (2021–2030). The initiative calls on nations to work together to support healthier aging for all by confronting ageism, creating supportive environments, integrating care, and ensuring access to long-term care (LTC). These goals are global, but the US faces a unique “gut check” moment. Despite being one of the wealthiest nations, America is faltering in providing dignified and equitable support for its rapidly aging population.

The central challenge: LTC. Without a reimagined approach, the nation risks failing millions of older adults, their families, and future generations.

The Scope of the Crisis

By 2030, one in five Americans will be over 65. Eighty percent of people turning 65 today will require some form of long-term services and supports (LTSS) during their lifetime. Yet the system is under severe strain.

• Costs: In 2024, the median private nursing home costs more than $10,000 per month, while round-the-clock home care can exceed $280,000 annually. For middle-income families, these expenses are catastrophic.
• Medicaid dependency: Medicaid covers about 61 percent of the $415 billion spent on LTSS annually. Institutional care is mandatory under statute, but home- and community-based services (HCBS) remain optional and waitlisted. In 2024, more than 700,000 eligible Americans could not access HCBS due to shortages.
• Workforce shortages: Direct care workers earn a median annual income of about $25,000. By 2032, there will be an estimated 8.9 million job openings in the sector, with too few workers to fill them. Families step in to fill the gap—63 million Americans already provide unpaid care to loved ones. For the first time, working adults in the US are more likely to care for an older adult (23 million) than a preschool child (21 million).
• Quality concerns: Nursing homes with serious deficiencies rose from 17 percent in 2015 to 28 percent in 2024, while reported deficiencies per facility have increased by 40 percent.

This is not just a policy gap. It is an ethical stress test for the nation’s commitments to dignity, justice, and intergenerational solidarity. 

Why It Matters Now

Experts across health and financial sectors agree that the US is far behind on the UN Decade’s long-term care goal. Many describe LTC as America’s “denial issue,” a looming crisis long recognized but still inadequately addressed.

The strain reverberates across families. Members of the “sandwich generation” juggle supporting aging parents and raising children, often at the expense of their own health, wealth, and careers. Even households with significant resources struggle to find appropriate care settings, whether because of specialized needs, cultural requirements, or simple supply shortages.

Without bold intervention, the future risks devolving into a two-tiered system: concierge aging for the wealthy and fragmented subsistence care for everyone else. 

A Path Forward: From “Illness Care” to Longevity Care

The TIAA Institute’s recent Health and Wealth Roundtable underscored that the US must shift from an “illness care system” to a genuine health system—one that integrates financial stability and healthy longevity. Several imperatives emerge:

1. Invest in prevention: Falls prevention, medication reviews, and nutrition programs reduce costly care needs while preserving independence.
2. Rebalance financing: Expand LTC insurance options and strengthen public-private risk pooling to protect household savings. Few families can absorb the unpredictability of six-figure annual expenses without structural reform.
3. Professionalize the workforce: Raising wages, training, and career ladders for direct care workers is essential to meet demand and ensure quality.
4. Leverage innovation: Home-based technologies, artificial intelligence–enabled monitoring, and community anchor strategies can extend capacity and build local resilience.
5. Confront ageism: Both in workplaces and in health care, ageism undermines policy momentum. A 2018 study estimated that ageism adds $63 billion annually to US health care costs.

The Moral Imperative

Behind the statistics lies a deeper truth. The LTC crisis threatens the foundational ethic of contributive justice—the idea that every individual deserves both the opportunity and the support to contribute to society and flourish throughout life. Catastrophic care costs drain assets, unpaid caregiving diminishes productivity, and systemic gaps amplify inequities.

Healthy longevity is not just about adding years to life but ensuring those years are lived with dignity, security, and purpose. Addressing long-term care is not only an economic necessity but a moral one. 

A Call to Action

The UN Decade of Healthy Ageing is halfway over. The second half must be an era of decisive US action. This means building financing models that protect middle-income families, scaling HCBS, investing in the direct care workforce, and embedding LTC into the nation’s broader health and financial systems.

As demographic shifts accelerate, delay is no longer an option. The world is watching in New York this week. For the United States, the question is stark: Will we continue to treat long-term care as the “denial issue” it has long been—or will we rise to the challenge and lead the way in shaping a more just and resilient longevity future?