Tiffany Robinson (00:04.184)
Today, we're joined by Nora Super, a national expert on aging and long-term care policy. Nora has served as executive director of the White House Conference on Aging and now advises the Reframing Aging Initiative. She brings both professional expertise and personal perspective as someone who has navigated the care system firsthand. Today, we'll explore the changing demographics of aging, the rising demand for long-term care,

and what it means for caregivers and families alike. Nora, welcome to the podcast.

Nora Super (00:38.22)
Well, thank you. I'm happy to be here.

Tiffany Robinson (00:41.304)
Can you share a little about your background and how you became involved in aging policy?

Nora Super (00:48.066)
Sure. I had the great privilege to serve as the executive director of the White House Conference on Aging for President Obama after years working as an advocate for AARP and as an expert on Medicare and Medicaid. At the White House, we focused on four challenges facing older Americans, retirement security, healthy aging, elder justice, and long-term care.

Unfortunately, since 2015, when the White House conference took place, our nation's long-term care crisis has only worsened. We're seeing an unprecedented number of people in need of long-term care, but the costs keep going up and the number of workers providing it keep going down.

According to estimates, about 70 % of older adults will need some form of long-term care, with the need often arising from chronic illness, mobility issues, or cognitive decline.

Individuals typically need assistance with at least two activities of daily living or ADLs such as bathing, dressing or eating for an extended period. Home care costs differ significantly based on the skill set necessary to deliver the type of service needed. But to give you a starting point, the national average for eight hours of home care aid services each day of the year is about $90,000 annually. And if you wanted to have that same level of

around-the-clock skilled care in the home, it could cost nearly twice as much as nursing home care.

Nora Super (02:21.942)
Two years ago, all of this data became much more personally relevant. I suffered a spinal cord injury and am now a paraplegic. I also need long-term services and supports and have grown very aware of the huge demand for services and the lack of supply of workers. In addition, my father and his three siblings all suffered from Alzheimer's disease. So my family knows firsthand how important long-term care is, how it can be the difference between never getting a break from the demands

of full-time caregiving and how expensive it can be to maintain. I also was instrumental in starting a new government pilot program for people living with dementia and their caregivers. It's the first Medicare program to pay for family caregiver support services, recognizing how important a caregiver's health is to the overall health of their loved one.

Finally, as a public policy expert on aging, I know that the availability of and access to home care is critical for the future of our country.

Tiffany Robinson (03:26.136)
Thank you for sharing your background with us. So not only do you have experience with family members that have needed services, you also have this personal perspective that has come into play as well. I really think taking an experience like yours where now you need some of these care services, I really think it's inspiring because you've still continued to be a voice on aging. You haven't slowed down at all in that aspect.

Nora Super (03:37.697)
That's right.

Tiffany Robinson (03:54.998)
And now you bring that perspective of, you I've gone through this process now myself, not just with family.

Nora Super (04:01.686)
That's absolutely true. know firsthand really these issues that I've been working on throughout my career. Now I really have experienced and know firsthand how important long-term care is.

Tiffany Robinson (04:14.894)
So let's kind of jump in and talk a little bit about the population. So we know the population is growing. What do you think the US population, the aging population will look like in these coming decades?

Nora Super (04:28.642)
Well, our world is aging rapidly and here in the US, in the United States, while not as fast as some parts of the world, we are experiencing a huge increase in the number of people over the age of 65. Today, nearly 11,000 people a day turn 65.

and with increased restrictions on immigration and a fertility decline, we expect to see older adults outnumber children for the first time in U.S. history in 2034, according to the U.S. Census Bureau.

As people age, their need for long-term care increases. The average duration of long-term care is longer for women than for men, with women averaging 3.7 years and men 2.2 years. Additionally, the percentage of people who will require paid long-term care services is higher for those turning age 65, with 48 % of this age group needing some type of paid long-term care services in their lifetimes. This trend is particularly

particularly pronounced among the 85 and older age group who rely the most on long-term care and are our fastest growing demographic. One third of those over age 80 suffer from dementia, which is a leading cause of needing paid long-term care.

Tiffany Robinson (05:49.644)
What do you contribute? know we always hear about baby boomers, right? The baby boomers are now getting to the age where they may need to start utilizing care or are utilizing care. Are we also thinking about maybe increased longevity? You what are some of the other things that are kind of contributing to this?

Nora Super (06:07.168)
That's right. As the baby boomers age, we're seeing an increase in longevity and many people living to their 80s and 90s and beyond. This didn't used to be the case as many people died from natural causes of cancer or heart disease, but now because of medical advances and then just people taking better care of themselves, people are living longer than ever before.

Tiffany Robinson (06:36.888)
So when I hear about a growing population and being in the home care industry myself, I right away go to the idea that we hear about shortages for these very vital jobs. We're hearing about it for nursing, for caregiving. How do we prepare for this population need in the near future? What should we be doing to kind of get ready for this?

Nora Super (07:01.568)
Well, as you noted, I mean, we already have a lack of supply of

care, paid caregivers in the workforce. And this is only going to get worse as the demand for home-based care continues to increase. I think professionals need to prepare for this fact that this demand is going to continue increasing, especially for home care. The vast majority, over 95 % of older adults, express their desire to stay at home as long as possible. And professionals should prepare by keeping their skills up to date and recognizing that the needs are likely to continue

becoming even more complex.

Tiffany Robinson (07:46.72)
also kind of think about that from a perspective of someone who works for a home care agency about even potential solutions being that we're creating a culture where nurses and caregivers want to be doing the services that they're providing. So, you know, are we providing them an environment? Are we creating a culture where they want to work for us? Are we, you know, for example, utilizing technology that can help boost efficiency and support them with

know, continued education. What are some of your ideas on how we can, you know, combat this shortage, but, you know, try to build, you know, maybe even build a stronger group of, you know, specifically in home care caregivers.

Nora Super (08:32.744)
Well, absolutely. Caregiving is one of the most critical jobs in the future. Not only because it will be in such demand, but because the skills that are required.

to do home care include trustworthiness, kindness, and efficiency. And moreover, because some of the services provided are quite intimate, caregiving requires professionals to maintain their clients' dignity throughout some of the most difficult challenges of aging. And while it can be a very difficult job, I think it can also be very rewarding because people see the difference that they're making and the people that they're caring for on a day-to-day basis and what a critical importance

it has for the families that they care for. I know this from personal experience. Nothing is more personal than having someone help you with bathing and toileting. And I greatly appreciate those caregivers who could do so while still maintaining my dignity and independence.

Tiffany Robinson (09:33.534)
Absolutely. Professional caregivers, like you said, they're providing dignity and independence at home. They're also supporting that feeling of aging on your own terms. That's something that I've always kind of thought is that they're allowing you to age on your own terms. If you want to do that at home, it can be done at home. If you want to do that, you know, in a facility, that's also something that can happen. But these professional caregivers really have such a critical role. So as we're

Nora Super (10:00.649)
Absolutely.

Tiffany Robinson (10:02.228)
we're talking about how a lot of people do want to remain at home as long as possible, let's take a little bit of a closer look on what that really entails. Can you talk a little bit about the cost and coverage challenges that people experience?

Nora Super (10:18.892)
Sure, survey after survey shows that people want to age at home. And when people look to have services provided at home, they find that the cost can sometimes be prohibitive.

For example, right now to get care in assisted living is we're seeing some interest and some ability for affordability to go down, but it's still quite high to live in assisted living. It's about $5,000 a month close to, but to get round the clock care at home for five days a week,

for eight hours a day is over $5,000 a month. And if you wanted it to be skilled services 24 hours a day, it could cost twice as much as it costs to be in a nursing home.

Tiffany Robinson (11:24.672)
Wow, those numbers are those are big numbers. And so when I think about people who are coping with aging, they're, you know, coping with the physical and mental demands and changes that they're experiencing. They're also coping with the cost that is associated with aging. When you found yourself in a spot to need services and equipment, were you surprised about the limited coverage that that maybe you had?

with insurance and so forth.

Nora Super (11:55.991)
Well, Tiffany, I probably wasn't as surprised as most folks because I've been studying Medicare and Medicaid my whole career. But I think many, many people are very surprised that Medicare doesn't cover long-term care at all. Once they need long-term care, they think this is an essential need. It's something that I need to stay healthy and independent. surely my insurance covers it.

Tiffany Robinson (12:01.73)
Right.

Nora Super (12:20.396)
But what they find out is Medicare doesn't cover it. Medicaid, on the other hand, is the largest payer of nursing home and long-term care services in the US. But that is a program that people only qualify for if they have very low incomes or high levels of disability. And so many people are surprised to find that their insurance doesn't cover long-term care.

Tiffany Robinson (12:48.926)
What are some other options that are gaining traction? Different types of communities and situations beyond kind of bringing care into the home or nursing home. What are some other options that you've seen available?

Nora Super (13:04.62)
Sure, we're seeing some promising new housing and community models. For those who wish to stay at home, we're seeing an increase in what are called PACE models or the Program for All-Inclusive Care of the Elderly. Today, 33 states and the District of Columbia have implemented 180 PACE programs, accounting for more than 79,000 enrollees. And the 25 programs that were added in 2024 quadrupled the model's average growth since 2015.

So we're seeing this model really increasing across the United States. This model is an adult daycare model where eligible participants who must be duly eligible for both Medicare and Medicaid go five days a week or less to receive health and long-term care services. What we're also seeing, Tiffany, is a significant growth in senior living communities. The baby boom generation, as you noted, is reaching retirement age, leading to a surge in the number of seniors seeking housing.

housing. And senior living communities offer a range of options from independent living to assisted living to memory care, catering to different needs and preferences. And many senior living communities, as I mentioned, are becoming more affordable with medium rates between $2,500 to $3,500 per month. But today, the national average cost is $4,774 per month.

But we'll see in the future an increasing demand for middle income market products. So we will see pressure on the industry to bring costs down. It's important to remember that the median retirement savings of boomers is only $202,000. And almost half of 55 to 64 year olds have no retirement savings at all.

Other models that are coming up in the private sector are co-housing and tiny homes. Another interesting trend I found is that almost 20 % of baby boom women did not have children. Combined with increased rates of divorce, 40 % of divorcing persons are 50 and older.

Nora Super (15:12.928)
we end up with a very large population of what we call solo agers. Even in the senior living industry, also home and community services are growing because of the desire of so many to age in place.

Tiffany Robinson (15:29.719)
So when you talk about these solo agers, these individuals who maybe they didn't have children, maybe they don't have a spouse. And so they're doing a lot of this aging really on their own. And so I actually read an article a couple of weeks ago that I thought was interesting. And what they were doing is it was a local senior center and they were doing a co-housing. So they were trying to match families to seniors. So seniors and families, right, housing costs are

very high and this provided an option for those people who can't necessarily afford to maybe stay in a community instead. The way that they can get community is by being matched with a family who's willing to rent out a room, offer them a little bit of community and they have a room and also that person is going to be paying for that room. So it provides that family with some help as well on housing. So that's kind of just an interesting thing that I saw for those people who aren't in that price point where they can make it make sense.

Nora Super (16:28.864)
Right, those types of models are increasingly important and I think we'll see more and more innovation as people find that the cost of getting long-term care is prohibitively expensive, but they'll be looking to non-traditional ways to age. For example, as I mentioned, you're talking about co-housing is a growing trend. This can be intergenerational, as you discussed. It can also be older people living with older people. Think of the golden girl.

of many people getting together and saying, makes more sense for us to share the cost of housing. And we can also be there as supports to each other as we age. Others are moving towards what we call tiny houses. We're starting to see some changes in the housing zoning laws to allow people to build a small house on their property where their loved one can live. Or as you mentioned, you could run it out to someone who may need it at a more affordable cost.

Tiffany Robinson (16:59.341)
Right?

Nora Super (17:28.708)
cost.

Tiffany Robinson (17:30.657)
Yeah, I absolutely think that the tiny house movement is something that can really provide another option, whether it's a family member that's living there or like you said, we're renting it out, we're giving them another option. So let's talk for a moment about nursing homes. It seems that most people kind of want to avoid a nursing home. They kind of have this almost stigma about a nursing home. Can you talk a little bit about that?

Nora Super (17:58.497)
Yes, as I mentioned, the vast majority of people really want to age at home. And survey after survey shows that. I think for a lot of people, it's because they don't want to give up their autonomy and independence. They're really fearful of what it may mean to live in a nursing home. There have been some horror stories, especially during the COVID epidemic, when people

died because they were exposed to COVID and they weren't allowed to visit with their loved ones. I think that really increased sort of the stigma against nursing home care. And even with assisted living, some people don't want to give up their autonomy. For example, my husband and I have discussed assisted living, but he's afraid of giving up his ability to grill. He loves to grill his own food and it's one of his favorite ways to cook and to eat.

And I think, you know, he fears living in assisted living where he wouldn't have control over what meals he has. I think that's some of the reason why people really want to age at home.

Tiffany Robinson (19:06.477)
also think that our culture in America really has this high value on independence. And so I think that also kind of comes into play here where sometimes nursing homes will be seen in a more negative light because it's perceived as you've lost your independence. I think that's a big reason too.

Nora Super (19:25.192)
Absolutely, absolutely. People want to maintain their independence for as long as possible and they see losing that when they move to a nursing home.

Tiffany Robinson (19:35.337)
Let's turn to the policy side. Because the way we fund and support long-term care has a huge impact on what's possible for families and caregivers. You did extensive research and published a paper called The Three Trends Shaping the Politics of Aging in America. Can you share with us a little bit about your findings?

Nora Super (19:54.371)
Sure. First, I just want to note that Medicaid was the primary payer for 63 % of nursing home residents in 2024. In five states, Alaska, Georgia, Louisiana, Mississippi, and West Virginia, and the District of Columbia, Medicaid paid for more than 70 % of nursing home care. So it's critically important for paying for nursing home care.

But as a component of long-term services and support, Medicaid spending on home and community-based services surpassed spending on institutional care beginning in fiscal year 2013. However, this might change in coming years because of enactment of the one big beautiful bill, which I call the one big ugly bill because of its sharp reduction in the safety net. As you mentioned, I wrote a paper in 2020 that looked at the three trends shaping

the politics of aging. So let's take a look at the three trends that I noted and see how they may have changed. First, I noted that the federal government will spend over two thirds of its budget on those aged 65 and older over the next decade. This is still true and has been exacerbated by the one big ugly bill because that legislation increased the deficit by trillions of dollars, putting renewed pressure on how much debt burden the US Treasury can withstand. At the same

time, the legislation includes an estimated $880 billion in cuts to Medicaid over 10 years, which as I've stated will take away coverage for millions of adults. And the long-term care sector will see diminished government support for home and community-based coverage because under Medicaid home and community-based coverage is considered to be optional while nursing home coverage is considered to be mandatory.

The second trend that I noted said that the number of caregivers is shrinking as the need for care explodes. Now,

Nora Super (21:53.033)
As we've been talking, we haven't spent much time talking about family caregivers, that is those who provide unpaid care to their loved ones. A new report by AARP and the National Alliance on Caregiving found that the number of family caregivers has jumped to 63 million Americans, representing a 45 % increase or nearly 20 million more caregivers over the past decade.

Meanwhile, in the paid caregiving workforce, there were approximately 8.9 million direct care workers in the US with an estimated 9.7 million projected job openings from 2024 to 2020 to 2034. So let me say that again, we have right now about 8.9 million direct care workers, but we're estimating that we're going to need an estimated 9.7 million more. And this work

workforce includes home care workers, residential care aides, and nursing assistants. These numbers will be exacerbated by the recent crackdown on immigration. Hopefully, we may see some waivers or government-sponsored visas for home care workers as policy solutions to a deepening crisis.

As you know, direct care workers are hard to find because they generally experience low pay, high turnover, and few advancement and training opportunities. So I see that we'll have to see positive changes in this direction in order to meet the demand for direct care workers. The final trend that I noted was that older people are becoming more concentrated in certain geographic areas. This is still true. We see the highest percentage of older adults living in Maine, Vermont, and Florida.

The three states with the lowest percentage of seniors include Utah, Texas, and Alaska.

Nora Super (23:43.331)
And the top five states where retirees moved in 2023 include Florida, South Carolina, New Jersey, Texas, and Washington. So we're continuing to see older adults either staying in place because they're unable to move, or those that can move tend to move to less expensive, more warmer climates.

Tiffany Robinson (24:09.421)
those numbers that you were providing are just shocking. mean, if we sit down and think about how many people that is, I 63 million family caregivers. And the thought that my mind goes to right away is how can we support those people? Right? Because we all know what if you're in the industry, you know what it's like for these family caregivers. There's they burn out. There's a lot on their shoulders. It's not always just caring for their loved one. They might still be

maintaining full-time jobs. They might also have children that they're still raising. So my mind quickly goes to, know, how are we going to be able to also support them, but also increase the amount of caregivers that we have because we're also in that shortage for these caregivers and just projected a need even more. I know for us, we work hand in hand a lot of times with family caregivers because of the they also need a break, but

I just can't help but think of not only do we have to find these caregivers additional ones, but we also have to support these family caregivers on this journey as well.

Nora Super (25:15.202)
Absolutely, and we'll continue to see this pressure mounting. We're moving from a place where we used to see about seven to one family caregivers to the person who needed it. Now it's about four to one. And as you mentioned, people are working full time. They live far away from their loved ones. They have other responsibilities for children and other people that they care for as well.

So there's a strong likelihood that these family caregivers will burn out. And paid caregiving really helps provide a break for these people so that they can care for their loved ones when they're able and don't have to feel like it's a burden. And as we're seeing, because the demand continues to grow, this demand for family caregivers is going to go up. And we'll see more and more focus on trying to find some paid caregivers to provide

relief.

Tiffany Robinson (26:18.658)
We're starting to come towards the end of our podcast today, but I have a few more questions. If you could make one policy change tomorrow, what would it be?

Nora Super (26:31.34)
The one thing I would change is I would make home care a benefit paid for by Medicare and integrate it into overall health care. mean, as I mentioned, Medicaid makes it difficult. You have to be low income to qualify. And what we see are millions of Americans need this benefit. And it's a central part of health care that should be provided by Medicare.

Tiffany Robinson (26:36.311)
Right.

Tiffany Robinson (26:54.798)
I absolutely agree with you. What's one word you would use to describe the future of long-term care?

Nora Super (27:01.77)
growing.

Tiffany Robinson (27:03.313)
Yes, I think that is the perfect word for what's going on and what the future looks like. Do you have a book, paper or resource that you would recommend to caregivers who want to understand the big picture of aging policy?

Nora Super (27:20.834)
Yes, I'd recommend the new report that came out in July 2025 by AARP and the National Alliance for Caregiving on caregiving in the U.S. While the report focuses on family caregivers, it also provides important insights about who's paying for caregiving and under what circumstances.

Tiffany Robinson (27:41.313)
Thank you, I think that's great. We'll make sure that we include that in our show notes so that people can look at that and see that information. What's the most surprising thing you've learned in your career about how Americans age?

Nora Super (27:56.151)
That's an interesting question. I think the most surprising thing I've learned is that we're all very different. While we look for trends and similarities, in truth, we all age very differently. I have an 80 year old brother-in-law that is much healthier than my 69 year old brother, for example. And lifestyle factors greatly influence how we age. Where you live makes a big difference in how you age. For example, research indicates that 80 % of life expectancy is influenced by zip code.

For example, in New York City, life expectancy in Midtown Manhattan can be 10 years younger than in the Bronx.

Tiffany Robinson (28:35.757)
Wow, I mean, it's just all of these different things that are contributing to what your aging process may look like. Very, very interesting. If you could leave caregivers and professionals with one message about the future of long-term care, what would it be?

Nora Super (28:55.2)
Long-term care is a growing field, as we've said. As demand continues to surpass the supply of workers, I'm hopeful that we'll see some positive changes. Wages should go up and the stability of the workforce should strengthen. We'll possibly see special work visas for immigrants to work in the long-term care sector. And I see it as a very, very promising field for the future.

Tiffany Robinson (29:22.389)
Nora, thank you for your time today and the insights that you shared with us. We appreciate your time.

Nora Super (29:28.098)
Thank you. I appreciate you having me on.