Risking Old Age in America: The Coming Elder Care Crisis

Inside PACE with Anthony Zizza

Anthony Zizza, a geriatrician and chief medical officer at Element Care PACE, describes his career from Beth Israel Deaconess and Harvard to Landmark Health, a mobile interdisciplinary house-calls group serving the top 5% of complex Medicare Advantage patients, and why PACE was a natural next step. He explains PACE (Program of All-Inclusive Care for the Elderly) as a Medicare/Medicaid model for adults 55+ who are nursing-home eligible but can live safely in the community with support, offering an integrated package including primary care, transportation, therapies, social work, adult day health, home services, palliative and urgent care, and even long-term care when needed, with examples like providing an air conditioner to prevent COPD exacerbations. The conversation covers eligibility (service area, ADL dependence, dual eligibility, asset limits and look-back), Medicare-only/private pay options, limited geographic availability and heavy regulation, overlap and for-profit expansion, and policy recommendations to expand access earlier and simplify enrollment.   Topics 02:06 Landmark Health House Calls 03:58 Why Landmark Ended 05:20 PACE Explained Basics 06:42 PACE Services and Team 08:04 Outside the Box Care 09:34 Costs and Long Term Care 12:35 Eligibility and Enrollment 16:43 Coverage Areas and Red Tape 18:56 For Profit Growth Debate 20:08 Element Care Mission Stories 23:24 Finding a Local PACE 28:26 Policy and Family Advice 30:43 Criticisms and Risk Adjustment 34:47 Closing Thoughts

Retirement, Inequality, and Social Connection with Daniel Horowitz

Harry talks with historian Daniel Horowitz, author of “On Retirement: How Aging Is Transforming American Lives [https://a.co/d/07sy46s8].” He discusses his wide-ranging prior work and his move with his historian wife to a continuing care retirement community near their daughter. He describes major changes in aging and retirement since midcentury: longer lifespan and healthspan, key policy supports (Social Security, Medicare, Medicaid), and a shift from defined-benefit to defined-contribution retirement risk. He outlines expanding housing and care arrangements (NORCs, supplemented NORCs, 55+ communities) alongside problems like nursing-home conditions and under-studied elderly homelessness, emphasizing how race, class, gender, and geography shape wealth, access, and even a nine-year longevity gap by income. He explains “successful aging” and critiques its optimism amid inequality, pandemics, and climate threats, stressing luck and fall risks. His personal advice centers on sustaining social connections, not comparing oneself to the past, protecting public programs, and skepticism toward costly longevity clinics and promises of living to 120.   Get Daniel’s book: https://a.co/d/07sy46s8 [https://a.co/d/07sy46s8]   Topics 00:00 Meet Dan Horowitz 01:02 Books and Background 02:08 Moving to a CCRC 03:32 Retirement Then and Now 05:50 Housing Options and Risks 06:50 Inequality in Aging 10:18 Successful Aging Debate 13:36 Renewal Retirement 16:07 Isolation and Community Design 18:38 Personal Keys to Aging Well 22:02 Policy Advice for Boomers 23:19 Longevity Hype and 120 26:18 Public Health Over Biohacks

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/ [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