Inclusion: the elderly

Lane Kenworthy, The Good Society
December 2025

“Elderly” is commonly defined as age 65 or older. In 1960, the elderly were 9% of America’s population. Today they are 18%, and their share is expected to continue to rise in coming decades.1

We have an assortment of seemingly contradictory images of elderly life: relaxed, carefree, convivial but also fragile, decrepit, lonely. As these varied stereotypes suggest, old age is diverse and multifaceted.2

What challenges do the elderly face? How are we doing in addressing those challenges?

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HEALTH

For most people, health is in decline by the time they become elderly. But Americans live longer than ever before. And plenty of elderly persons are in fairly good shape in health terms.3

In the United States, a growing number of those years are spent with some kind of disease or disability. “Healthy life expectancy” in the US has increased only a very little bit since 1990, as we see in figure 1. That means a significant portion of elderly Americans are alive but not capable of living the kind of life they would prefer.

Figure 1. Healthy life expectancy
Years of life without disability or disease. At birth. The vertical axis doesn’t begin at zero. Data source: IMHE, Global Burden of Disease, via Our World in Data. Thick line: United States. “Asl” is Australia; “Aus” is Austria.

This owes partly to diet and other health behaviors.4 Improving them would make Americans healthier. And there are a number of assistive technologies that can facilitate better living among the elderly, and in the future there will be more, as the Stanford Center on Longevity notes5:

In the future, older adults will be able to remain mobile longer than they can now, with the help of thin, wearable exoskeletons that let them walk and run with enhanced strength, much as e-bike riders power uphill without huffing and puffing. Unlike wheelchairs, these devices can be tuned to provide enough support to maintain normal activities while still allowing muscles to exercise to their capacity, preserving muscle mass…. 3D-printed braces and pads, customized to the individual, will help prevent injury. Sleep may be enhanced by unobtrusive monitors that sense disturbances and adjust temperature and light. Later in life, remedies for age-related issues will be built into clothing, cars, and homes, much as driver-assist technologies are already making cars safer with blind spot indicators and automatic braking…. Combined, these opportunities have the potential to redefine old age from a period associated with illness, frailty, and dependence into yet another life stage with potential for vitality, independence, and continued contributions to society.

FINANCIAL SECURITY: INCOME

Central to inclusion of the elderly is economic security. A century ago, most older Americans had little or no economic security. Today, thanks to enhanced access to medical care, government services and income transfers, pension plans, and asset accumulation, their situation is much improved.

Indeed, by some measures the elderly now tend to enjoy as much economic security as many other groups. Consider the poverty rate. According to the US government’s official measure, shown in figure 2, in 1960 roughly 35% of elderly Americans were poor, compared to fewer than 20% of working-aged Americans. As of the mid-2020s, the poverty rate among the two groups was essentially identical, at around 10%.6

Figure 2. Poverty rate
Share of people living in a household with income below the poverty line. Working-age: household head aged 18 to 64. Elderly: household head aged 65 or over. Pretax income. Data source: Census Bureau, “Historical poverty tables: people and families,” table 3.

For most Americans, income security in old age rests on some combination of four pillars:

  • Social Security and SSI
  • Employer-based pension
  • Savings
  • Earnings from employment

Social Security has been key to the falling poverty rate among the elderly. Nearly one in three elderly Americans receives 90% or more of their income from Social Security.7 In 1960 the average recipient of Social Security old-age benefits got about $8,000 (in today’s dollars). That average has increased steadily, reaching $23,000 as of 2023. During this time the share of elderly Americans who receive Social Security expanded from 60% to around 90%.8

As figure 3 indicates, with Social Security alone, the income replacement rate for a typical American retiree is modest by the standards of the world’s rich countries.

Figure 3. Pension replacement rates
Share of prior income. For a person with average earnings. Net of taxes. 2018. In the United States there is no mandatory private pension, so the dark circle reflects Social Security only. Data source: OECD, Pensions at a Glance 2019, table 5.6.

Social Security is funded in a “pay as you go” fashion: money paid to current recipients comes directly from the payroll taxes paid by current working Americans.9 With the retirement of the large baby boom generation, increasing life expectancy, and low fertility, the number of working-age persons per elderly recipient is declining. But contrary to frequent assertions by political pundits and journalists, Social Security isn’t in crisis. As figure 4 indicates, the current projection is that its cost will rise by about 1% of GDP between now and 2060 and remain flat thereafter. This can be paid for via some relatively minor changes, such as an increase in the share of earnings subject to the payroll tax (as of 2025, earnings above $176,100 are exempt from the tax), a small increase in the payroll tax rate, a small increase in the retirement age, and/or a reduction in the rate of benefit increase over time.10

Figure 4. Social Security expenditures
Share of GDP. Social Security (OASI) plus Disability Insurance (SSDI). Data source: OASDI Trustees Report, “Table VI.G4. OASDI and HI Annual and Summarized Income, Cost, and Balance as a Percentage of GDP,” various years.

Around 5% of elderly Americans receive money from the Supplemental Security Income (SSI) program. SSI provides cash assistance to low-income, low-asset persons who are elderly, disabled, or blind. The program began in 1974. The average yearly benefit level is approximately $9,000. Nearly all of the states supplement these amounts. A significant limitation of SSI for the elderly is its low take-up rate; only slightly more than half of those who are eligible actually receive the benefit.11

The second retirement income security pillar is employment-based pensions. The share of workers who participate in an employer pension plan has remained steady in recent decades at around 45%,12 but the type of plan has changed significantly. In the late 1980s, 68% of Americans with an employer pension plan had a defined-benefit plan with their company. By 2022 that share had shrunk to 31%. These have been replaced by defined-contribution plans such as 401(k)s. Among those with a pension, defined-contribution plans jumped from 53% to 77%.13

Defined-contribution plans have some advantages: they’re portable across employers, the employee has some say in how the money is invested, and a person in financial difficulty prior to retirement age can withdraw some or all of the money, though there is a tax penalty for doing so.14 And pension wealth (as a share of wages and salaries) in defined-contribution plans has increased enough to offset the fall in pension wealth in defined-benefit plans.15 The problem is likely to be in the uneven distribution. Some employees and employers may not contribute enough to defined-contribution plans or keep the money in them long enough.16 If an employee doesn’t know about or understand her firm’s program, or if she feels she needs every dollar of her earnings to pay for current expenses, she may go a long time, perhaps even her entire working career, without putting any money into a defined-contribution plan. Because employer contributions usually take the form of matching funds, with the amount put in by the employer pegged to the amount put in by the employee, no employee contribution often means no employer contribution. Moreover, when a person switches employers she or he has a choice to keep the defined-contribution-plan money as is, roll it over into an individual retirement account (IRA), or withdraw it with a tax penalty subtracted. This creates a strong temptation to withdraw some or all of the money, leaving a lot less, and sometimes nothing at all, for the retirement years.

The third pillar of retirement income security is personal savings. As we see in figure 5, in the United States household saving as a share of household income declined steadily for several decades, from 12% in the 1970s to 10% in the 1980s to 7% in the 1990s to 4% in the 2000s. But then in the 2010s it increased to 6%.17

Figure 5. Household saving
Average household saving as a share of household net disposable income. Data source: OECD Data Explorer, “NAAG chapter 5: households.” Thick line: United States.

The fourth pillar is earnings from employment. Figure 6 shows the trend in the employment rate among Americans age 65-74. It decreased in the 1960s, 1970s, and 1980s, but then increased in subsequent decades, as was true in most of the rich democratic countries. America’s elderly employment rate is one of the highest, at around 25%. Many work part-time.18

Figure 6. Employment rate among the elderly
Employed persons age 65-74 as a share of the population age 65-74. Data source: OECD Data Explorer, “Employment and unemployment by five-year age group and sex – indicators.” Thick line: United States. “Asl” is Australia; “Aus” is Austria.

What’s the bottom line on retirement income security? The best information on current and future income trends is from the Social Security Administration’s MINT (Modeling Income in the Near Term) projections.19 Figure 7 shows projected income for retirement-age households in the bottom fifth of incomes (“Q1”) and in the next fifth (“Q2”). Despite falling savings and the shift from defined-benefit to defined-contribution employer pensions, the incomes of elderly Americans at the low end aren’t likely to decline in absolute terms. Instead, they are projected to increase.20

Figure 7. Projected income at age 65 for households in the bottom 40%
Inflation-adjusted household income and GDP per capita. Household incomes are per person. Q1: bottom fifth of incomes. Q2: lower-middle fifth of incomes. GDP per capita is assumed to grow at an annual rate of 1.6%. Data source: Barbara A. Butrica, Karen E. Smith, and Howard M. Iams, “This Is Not Your Parents’ Retirement: Comparing Income Across Generations,” Social Security Bulletin, 2012, table 3, using MINT data.

On the other hand, figure 7 also shows that these income levels are projected to rise less rapidly than GDP per capita.21 Retirement incomes for many ordinary Americans will, in other words, fall farther and farther behind growth of the economy. Over the long run, that’s a potentially worrisome trend.

How can we do better? Social Security benefits could be increased.22 A modest, gradual rise over time is appropriate as the economy grows, and it surely is affordable. But this is only a partial solution. We need one or more of the other retirement income security pillars to increase as well.

We could try to encourage more saving. But previous attempts, such as offering tax advantages (IRAs), have had little impact on the savings behavior of most ordinary Americans.23

We need to shore up employment-based pensions. There is no going back to the defined-benefit past; for most Americans, a pension in the future will be a defined-contribution one. Rather than allow Americans to contribute to defined-contribution plans if they have a steady job and if their employer offers a plan and if they know about it and if they feel they can afford to put some of their earnings in it, we could make contributing the default option and make it available to everyone. Employers that have an existing plan could continue it, but they would have to automatically enroll all employees and deduct a portion of earnings unless the employee elects to opt out. Employees who lack access to an employer plan would be automatically enrolled in a new universal retirement fund, and those who lack an employer match would be eligible for matching contributions from the government.24

In the absence of federal government action along these lines, a few states have created their own programs.25 California’s Secure Choice Retirement Savings Program, the largest of these, requires firms with five or more employees to enroll them if it doesn’t offer a company-sponsored pension program. The program contributes 3% of each paycheck, unless an employee chooses to opt out. But there is no matching contribution from the employer or the state.

We also could facilitate greater employment among the elderly. Later retirement isn’t a good option for everyone, especially those who have spent most of their working lives in a stressful or physically taxing job. But for those who can manage it, it is doubly beneficial: it provides an additional source of income, and it allows people to delay receipt of Social Security, which in turn increases the benefit level they receive.

FINANCIAL SECURITY: EXPENSES FOR HOUSING AND MEDICAL CARE

Housing and medical care are among the largest life expenses for most people, and the elderly are no exception.

In an ideal scenario, a person or couple will purchase a home by age 35, taking out a 30-year mortgage loan, and by age 65 the loan will be paid off. Having no mortgage or rent payment sharply reduces expenses during the retirement years. Among America’s elderly, 79% live in a home they own, though not all have fully paid off their mortgage.26

A home you own can contribute not only to reduction of expenses in old age but also potentially to income, especially if its value increases over time. The sharp rise in home prices during the housing bubble from the mid-1990s to the mid-2000s boosted the assets of many middle-class homeowners in or near retirement. That bubble burst beginning in 2006, causing much or all of the gain to disappear for many.27 In the mid-2010s home prices once again began rising rapidly.

Medical care is another core expense. Health insurance is a must, as medical care is too expensive to be purchased out of pocket — particularly for the elderly, who tend to need more expensive care and have less income than working-aged adults. Nearly all elderly Americans are enrolled in Medicare.28 Most also have additional supplementary insurance for medical expenses that Medicare doesn’t cover.29 For most, the cost of Medicare enrollment is about $2,000 per year.30

For elderly Americans, Medicare pays, on average, about 65% of total medical expenses. Medicaid and supplemental health insurance plans pay about 20%. The remaining 15% comes from out-of-pocket payments.31 The elderly spend an average of 15% of their income on medical expenses.32

Medicare is a very popular program. And it has proven effective at helping to ensure economic security among older Americans. Indeed, it has largely eliminated financial hardship due to the cost of medical treatment among the elderly. However, Medicare also is expensive. Its cost has risen from 0.7% of GDP in 1970 to 3.9% in 2025, and as figure 8 shows, the cost is projected to continue increasing until it reaches about 6.7%. About half of this rise is a product of the same demographic development — the baby boom generation reaching retirement age — that is responsible for the coming increase in Social Security expenditures. The other half of the projected rise is a function of the increasing cost of healthcare in general.33

Figure 8. Medicare expenditures
Share of GDP. HI and SMI (including part D). Data source: Medicare Trustees Report, “Table V.B2. HI and SMI Incurred Expenditures as a Percentage of the Gross Domestic Product,” various years.

The projected increase in Medicare costs is affordable. Continued reduction in the cost of food and manufactured goods will free up money we as a society can use to pay for medical care.34

There also are grounds for optimism about our ability to reduce the rate of growth of Medicare expenditures, and to do so in a way that maintains or improves economic security for recipients. (Proposals for Medicare reform that don’t meet this criterion include increasing the age of Medicare eligibility and shifting to “premium support.”35) Healthcare experts largely agree that the problem owes to excessive treatment and overpricing by medical care providers, and we have begun to address this.36 Since the late 1990s Medicare costs per recipient have risen less rapidly than costs for those with private insurance. And the 2010 Affordable Care Act created some mechanisms to slow the growth of Medicare costs.37

LIVING ARRANGEMENTS AND CARE

Many older persons want independence but also social connections and community. Quite a few need help with daily activities. What type of living arrangement best promotes these goals?38

Historically, the most common arrangement has been for elderly persons to live with their children or other members of their extended family. This remains the norm in Japan and some southern European countries.

In many countries a majority of elderly people say they would prefer to to live in their own home or apartment, and many do so.39 Spouses, partners, children, or other family members can help older persons who need assistance with day-to-day activities. But scheduling obstacles or partner frailties mean some will need additional help.

Paid in-home assistance and elderly “daycare” can help to increase care and community for those living in their own home or with extended family. Nurses can come to the home to provide assistance for several hours, throughout the day, or round-the-clock if needed. And elderly persons can be transported occasionally or every day to centers or other places where they are able to meet and socialize with others.

A third option is an elderly institutional facility. There are three main types. Independent living communities are groups of elderly persons who need little or no help. Assisted living facilities provide help with everyday tasks, including eating, dressing, bathing, and using the bathroom, but they don’t offer full-time nursing care. Nursing homes provide full care. Some facilities combine these.

How does Sweden do this?40 Elderly Swedes who need assistance may get help from family members, but they can instead or in addition receive publicly-funded services. About 17% do so: 5% live in an elderly institution, and another 12% receive “home-help services” in their home. Decisions about types and levels of provision are made by counties and municipalities. Providers of institutional care and in-home help are both public and private. There is a co-payment, but it is capped at about $300 per month. Sweden spends about 3.5% of its GDP on long-term care.

In the United States, government support for elder care is more limited.41 Approximately 25% of America’s 65-and-over population are limited in one or more everyday activity.42 The average yearly cost is about $37,500 for a home-health aide (30 hours per week, 50 weeks per year, $25 per hour), $50,000 for a room in an assisted living center, and $100,000 for a room in a nursing home. Medicare doesn’t cover long-term care, though it does pay for 20 days in a nursing home after hospitalization. Medicaid is the principal government provider of funding for long-term elder care. It funds mainly nursing home care and in-home care, though some money is available for care in assisted-living facilities. Medicaid has a stiff asset limit, which often forces recipients to spend down most of their assets in order to qualify. And Medicaid covers a comparatively small share of those who need support. As figures 9 and 10 show, fewer elderly persons in the US receive paid long-term care, either in their home or in an institution, than in quite a few other rich nations. Total expenditure on long-term care in the US is about 1% of GDP.

Figure 9. Elderly recipients of long-term care in their home
Share of elderly persons receiving paid medical care, personal care, and assistance services in their home. These are services provided to people with a degree of long-term dependency to assist with daily living, alleviate pain, and manage deterioration in health status. Includes both publicly- and privately-funded care. Data source: OECD Data Explorer, “Long-term care resources and utilisation – recipients.” Thick line: United States. “Asl” is Australia.

Figure 10. Elderly recipients of long-term care in an institution
Share of elderly persons receiving paid medical care, personal care, and assistance services in an institution other than a hospital. These are services provided to people with a degree of long-term dependency to assist with daily living, alleviate pain, and manage deterioration in health status. Includes both publicly- and privately-funded care. Data source: OECD Data Explorer, “Long-term care resources and utilisation.” Thick line: United States. “Asl” is Australia.

LIFELONG LEARNING

Our standard model of education is that it occurs during the first two or three decades of life and then ends. But there is no need for that to be the case. Many elderly persons, particularly those who are retired from paid employment, are likely to be interested in additional education, perhaps through formal schooling.43

Indeed, some will want to be in or near an active learning environment.44 This suggests that colleges ought to pursue the integration of “nontraditional” students. Some have begun to do so, often through “extension” programs, but this process is only in its infancy.

SOCIAL CONNECTEDNESS

According to one study, 20% of elderly in OECD countries report having no contact with friends, a higher share than among other age groups.45 This suggests loneliness may be a problem of concern among the elderly.

In the United States, Gallup asks a variety of questions about relationships with friends and family, personal time, and receipt of encouragement and support. They use the responses to create a composite indicator of “social wellbeing.” They then classify respondents as either thriving (wellbeing that is strong and consistent), struggling (wellbeing that is moderate or inconsistent), or suffering (wellbeing that is low and inconsistent). As of 2017, the share of Americans age 18-29, 30-44, and 45-64 who are thriving on social wellbeing was 54-62%. Among the elderly, the share was slightly lower, at 48%.46

HAPPINESS

Since the early 1970s, the General Social Survey (GSS) has asked American adults “Taken all together, how would you say things are these days — would you say that you are very happy, pretty happy, or not too happy?” Figure 11 shows that the share of elderly Americans who say they are “not too happy” has been virtually identical to the share among the nonelderly throughout this period.

Figure 11. Unhappiness among the elderly and the nonelderly
Share who say they are “not too happy.” Question: “Taken all together, how would you say things are these days — would you say that you are very happy, pretty happy, or not too happy?” Data source: General Social Survey, sda.berkeley.edu, series happy. The lines are loess curves. The lines stop prior to the sharp jump in unhappiness caused by the Covid pandemic.

Other indicators point to a similar conclusion. Responses to surveys suggest that elderly Americans tend to be no more likely than their nonelderly counterparts to be struggling along various dimensions of subjective wellbeing — having a purpose, feeling involved, not feeling stressed or worried.47

On the other hand, although it’s too early to be certain, the survey data suggest that the Covid pandemic may have worsened subjective wellbeing more among the elderly than for others.

SUMMARY

Economic security and inclusion have improved immensely for America’s elderly over the past century. Three significant challenges loom: ensuring that the incomes of elderly Americans in the bottom half don’t fall farther and farther behind the growth of the economy, slowing the rise in Medicare costs, and transitioning to living arrangements that combine affordability, independence, and community.

  1. OECD, “Elderly population.” ↩︎
  2. Corey M. Abramson, The End Game: How Inequality Shapes Our Final Years, Harvard University Press, 2015. ↩︎
  3. National Institute on Aging, Growing Older in America: The Health and Retirement Study, 2015, ch. 1. ↩︎
  4. Lane Kenworthy, “Weight Moderation,” The Good Society. ↩︎
  5. Stanford Center on Longevity, “The New Map of Life,” 2021, pp. 8-9. ↩︎
  6. The official poverty rate measure has an assortment of deficiencies. But it’s not a bad measure, and it has the significant advantage of being available over a long stretch of time. ↩︎
  7. Center on Budget and Policy Priorities, “Top Ten Facts about Social Security,” 2016. ↩︎
  8. Lane Kenworthy, “Social Policy,” The Good Society. ↩︎
  9. Half the payroll tax is paid by employers. ↩︎
  10. Peter A. Diamond and Peter Orszag, Saving Social Security: A Balanced Approach, Brookings Institution Press, 2004; Kathy A. Ruffing, “What the 2011 Trustees’ Report Shows About Social Security,” Center on Budget and Policy Priorities, 2011; Henry Aaron, “Progressives and the Safety Net,” Democracy, 2013. ↩︎
  11. Kenworthy, “Social Policy,” The Good Society. ↩︎
  12. Center for Retirement Research, “Pension Participation of All Workers, by Type of Plan, 1989-2022,” using data from the Survey of Consumer Finances. ↩︎
  13. Center for Retirement Research, “Pension Participation of All Workers, by Type of Plan, 1989-2022.” The numbers sum to more than 100% because some people are enrolled in both types of plan. ↩︎
  14. Another potential advantage is that a defined-contribution plan isn’t vulnerable to a firm going out of business or declaring bankruptcy. Such an occurrence can leave those in a traditional company pension plan out in the cold, though most such pensions are guaranteed by the federal government-backed Pension Guarantee Benefit Corporation. ↩︎
  15. Alicia H. Munnell, Jean-Pierre Aubry, and Caroline V. Crawford, “How Has Has Shift to Defined Contribution Plans Affected Saving?,” Center for Retirement Research, 2015, figure 7. ↩︎
  16. “The Trouble with Pensions,” The Economist, 2008; Teresa Ghilarducci, When I’m Sixty-Four, Princeton University Press, 2008; Edward N. Wolff, The Transformation of the American Pension System, Upjohn Institute, 2011; Michael A. Fletcher, “401(k) Breaches Undermining Retirement Security for Millions,” Washington Post, 2013. ↩︎
  17. These decade averages are my calculations using OECD data. ↩︎
  18. The average weekly hours of employment is 30. See Steven Greenhouse, “At Leisure, or Still at Work,” New York Times, 2013, using data from the American Time Use Survey. ↩︎
  19. Barbara A. Butrica, Karen E. Smith, and Howard M. Iams, “This Is Not Your Parents’ Retirement: Comparing Income Across Generations,” Social Security Bulletin, 2012. ↩︎
  20. See also Kevin Drum, “My Social Security Reform Plan,” Mother Jones, 2016. ↩︎
  21. Between 2007 and 2037, according to these projections, GDP per capita will increase by 60%, bottom-fifth household incomes for age-65ers will increase by 27%, and lower-middle-fifth household incomes will increase by 16%. ↩︎
  22. Thomas Geoghegan, “Get Radical: Raise Social Security,” New York Times, 2011; Michael Lind, Steven Hill, Robert Hiltonsmith, and Joshua Freedman, “Expanded Social Security,” New America Foundation, 2013. ↩︎
  23. Ghilarducci, When I’m Sixty-Four. ↩︎
  24. Michael J. Graetz and Jerry L. Mashaw, True Security: Rethinking American Social Insurance, Yale University Press, 1999; Alicia H. Munnell, “Bigger and Better: Redesigning Our Retirement System in the Wake of the Financial Collapse,” in Shared Responsibility, Shared Risk, edited by Jacob S. Hacker and Ann O’Leary, Oxford University Press, 2012; U.S. Senate Committee on Health, Education, Labor, and Pensions, “The Retirement Crisis and a Plan to Solve It,” 2012. ↩︎
  25. Lane Kenworthy, “What the States Can Do,”* The Good Society. ↩︎
  26. Joint Center for Housing Studies of Harvard University, “Housing America’s Older Adults,” 2023. ↩︎
  27. Edward N. Wolff, “The Asset Price Meltdown and the Wealth of the Middle Class,” New York University, 2012. ↩︎
  28. Medicare Part A covers hospital costs. Part B covers other medical costs, including outpatient medical services at hospitals (including emergency-room visits), observed-status services at hospitals even if confined to the hospital overnight or longer, surgical center procedures, doctor services (including most doctor services performed during the admitted hospital stays covered under Part A as well as office visits), a limited number of drugs, and some durable medical equipment. Part C is “Medicare Advantage,” private plans run through Medicare. Part D covers prescription drugs. ↩︎
  29. Medicare has no annual or lifetime limit on out-of-pocket costs, there is a 20% co-pay for most Medicare Part B services, and there is a deductible of approximately $1200 for a hospital stay. Sources of supplementary insurance vary: some have employer health insurance that continues in retirement, others have Medicaid, and others purchase private supplemental insurance (“Medigap”). ↩︎
  30. Most elderly receive Medicare Part A coverage at no cost and pay about $185 per month for Medicare Part B. ↩︎
  31. Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey, 2008, “Table 4.1. Personal Health Care Expenditures for Medicare Beneficiaries, by Source of Payment and Type of Medical Service.” ↩︎
  32. This compares to 5% for people under 65. See Paul Starr, “The Medicare Bind,” The American Prospect, 2011. ↩︎
  33. 2013 Medicare Trustees Report. ↩︎
  34. William J. Baumol, The Cost Disease, Yale University Press, 2012. ↩︎
  35. See Ezekiel J. Emanuel, “For Medicare, We Must Cut Costs, Not Shift Them,” New York Times: Opinionator, 2011; Paul Starr, “The Medicare Bind.” ↩︎
  36. Jonathan Cohn, “What Really Ails Medicare,” The American Prospect, 2008; Emanuel, “For Medicare, We Must Cut Costs, Not Shift Them”; Sarah Kliff, “Should the Doc Fix Get Fixed?,” Wonkblog: Washington Post, 2011; Starr, “The Medicare Bind”; Peter Orszag, “Healthcare Goal Should Be Quality, Not Quantity,” Bloomberg, 2012; Michael Levine and Melinda Buntin, “Why Has Growth in Spending for Fee-for-Service Medicare Slowed?,” Working Paper 2013-06, Congressional Budget Office, 2013; Eduardo Porter, “Medicare Needs Fixing, but Not Right Now,” New York Times, 2013. ↩︎
  37. It reduced Medicare “overpayments” (certain types of payments to providers and subsidies to private insurers that offer Medicare Advantage Plans). It encouraged a switch in payment from “fee-for-service” to “accountable care,” whereby physicians and hospitals are paid according to their effectiveness in delivering successful outcomes while controlling costs. It penalized hospitals if too many of their patients end up being readmitted soon after release. ↩︎
  38. See American Association of Retired Persons (AARP), “A Report to the Nation on Livable Communities: Creating Environments for Successful Aging,” 2012; National Institute on Aging, Growing Older in America, ch. 4; Anu Partanen, The Nordic Theory of Everything, HarperCollins, 2016; The Economist, “The Pandemic Shows the Urgency of Reforming Care for the Elderly,” 2020. ↩︎
  39. Jonathan Gruber and Kathleen McGarry, eds., Long-Term Care Around the World, University of Chicago Press, 2025, table I.5. ↩︎
  40. OECD, A Good Life in Old Age? Monitoring and Improving Quality in Long-Term Care, 2013; HelpAge International, “Global AgeWatch Index 2015,” 2015; OECD, Health at a Glance 2025, ch. 10; Swedish Institute, “Elderly Care in Sweden,” 2025. ↩︎
  41. Jonathan Gruber and Kathleen McGarry, “Long-Term Care in the United States,” in Long-Term Care Around the World, edited by Gruber and McGarry, University of Chicago Press, 2025. ↩︎
  42. OECD, Health at a Glance 2025, OECD Publishing, 2025, figure 10.5; Gruber and McGarry, eds., Long-Term Care Around the World, figure I.2. ↩︎
  43. Stanford Center on Longevity, “The New Map of Life.” ↩︎
  44. Anemona Hartocollis, “At Colleges, What’s Old Is New: Retirees Living on Campus,” New York Times, 2019. ↩︎
  45. Justin Dupre-Harbord, “How’s Life in Old Age?,” OECD Insights blog, 2014. ↩︎
  46. Gallup, “Life Evaluation Index,” Gallup Analytics. ↩︎
  47. Brown and Sharpe, “Americans’ Financial Well-Being Is Lowest, Social Highest”; Gallup, “2015 State Well-Being Rankings for Older Americans.”; National Institute on Aging, Growing Older in America; Susan T. Charles, Jonathan Rush, Jennifer R. Piazza, Eric S. Cerino, Jaqueline Mogle, and David M. Almeida, “Growing Old and Being Old: Emotional Well-Being Across Adulthood,” Journal of Personality and Social Psychology, 2023. ↩︎