The missing middle of aging in place
Medicaid catches families at the bottom. Money buys options at the top. In between sit millions of older adults who earn too much for help and too little for a facility. Their care falls to a daughter, son or spouse.
Sixteen million people with nowhere to go but home
NORC at the University of Chicago splits Americans 75+ into three groups by the money they can draw on each year, not counting their house. The middle group is the one public programs and the luxury market both skip.
Who covers long-term care, by financial resources
Americans 75+, grouped by annual income plus annuitized savings (percentiles)Inside the middle: can they afford assisted living?
The middle also carries the heaviest needs: 56% have mobility limits and 31% have cognitive impairment.
Source: NORC, The Forgotten Middle in 2033 (2022), modeled from the Health and Retirement Study. Middle = 41st–80th percentile. Splits computed from NORC's 72% and 39% figures on 16M.
Who actually pays for long-term care
Share of lifetime paid long-term care costs for Americans turning 65 (2020 dollars)Families pay more than a third of the bill, and Medicaid's share comes after they spend down. The middle doesn't stay put. Families spend down their savings, often the house, until they qualify.
Source: HHS ASPE, Long-Term Services and Supports for Older Americans: Risks and Financing (2022). 56% of people turning 65 will need long-term care; average need lasts 3.1 years.
Home looks cheaper until you count the family's time*
Facilities bundle housing, meals and supervision into one bill. Staying home splits the same costs across the household budget, a paid aide and hours of unpaid family care. Here are both sides using Pennsylvania medians.
*Annual costs only. Excludes one-time move-in costs such as continuing care entrance fees (see below).
Sources: CareScout 2025 Cost of Care, Pennsylvania; BLS Consumer Expenditure Survey 2024, households 65+; AARP Valuing the Invaluable; AARP/NAC Caregiving in the U.S. 2025.
Line by line, per year
| Cost | Home, moderate needs | Assisted living | Home, high needs | Nursing home (semi-private) |
|---|
- Paid aide at $34/hr: CareScout's PA non-medical home care median ($77,792 for 44 hrs/wk). Private pay rates run higher in high-cost states: about $40–45/hr for a non-medical aide (Massachusetts, Washington) and $105–120/hr for a private duty nurse (New Jersey, Massachusetts, California, New York), versus $35/hr and $90/hr nationally.
- Moderate needs at home: 20 paid hrs/wk plus 27 family hrs/wk, the average for family caregivers in 2025.
- High needs at home: 44 paid hrs/wk plus 40 family hrs/wk. 24% of family caregivers give 40+ hours a week. Overnights are still uncovered.
- Housing & food: BLS spending for households 65+ ($22,193 housing incl. utilities, taxes and upkeep; $7,940 food). Transportation ($9,538) is left out on both sides.
- Family time in a facility: 8 hrs/wk, an estimated assumption that could be higher or lower depending on a family's needs.
- Not counted: caregivers' own out-of-pocket spending (about $7,200/yr on average), lost wages, and the caregiver's health.
Rate sources: CareScout 2025 Cost of Care, national; Massachusetts; Washington; ranked state tables. CareScout publishes state, not metro, medians.
Medians leave out the cost of getting in
Continuing care retirement communities (CCRCs) usually charge a one-time entrance fee before monthly fees begin. Depending on the contract, some, all or none of it is refundable.
Sources: NIC MAP, CCRC Performance 3Q 2025 (asking rates across 1,049 CCRCs); Penn PASEF, Resource Guide to Living Options in Retirement: CCRCs (2023; mostly 2022 prices, single occupancy).