Aging in America offers plenty of opportunities…and plenty of challenges. Medicare helps pay health-care bills, but the health-care system doesn’t always serve people over age 65 well. A range of long-term-care options, including in-home care, assisted living and nursing home care, are available to those who can afford them, but each of these has hidden problems beyond their staggeringly high costs.

MT Connolly, founding head of the Department of Justice’s Elder Justice Initiative and architect of the Elder Justice Act, explains just a few of the health-care and long-term-care challenges we all could face during our later years…

Challenge #1: Few doctors specialize in treating older patients. Children are treated by pediatricians rather than general practitioners—that’s because kids have different health needs than adults, so they see doctors who specialize in those needs. But much the way children aren’t just tiny adults, people of advanced age aren’t just wrinkly adults—they have different health needs, and some of their health issues present in different ways. Example: An older person experiencing a heart attack might not have severe chest pain.

But unlike kids, older adults often are cared for by doctors who don’t specialize in treating their demographic—and that is one reason why older people are more likely to be over- or underdiagnosed with a range of medical conditions, according to a study published in International Journal of General Medicine.

What to do: Obtain health care from professionals with specialized knowledge about older patients—geriatricians or geriatrics teams. A study by University of Minnesota researchers found that older patients who did this were 25% less likely to become disabled…40% less likely to require home health services…and 50% less likely to develop depression, among other benefits.

To find a geriatrician or geriatric team: Most major health systems have geriatrics experts on staff…or your local Area Agency on Aging might be able to provide a list of geriatricians in your area (to find your Agency on Aging, go to…or contact the Program of All-Inclusive Care for the Elderly (

Challenge #2: Many nursing homes are badly understaffed. The ratio of caregivers to residents is the most important factor in nursing home quality. When there isn’t sufficient staff, corners get cut, residents’ basic needs get overlooked and access to activities that help make life interesting declines sharply. Yet staffing is kept at a minimum at many nursing homes to control costs, and labor shortages make it difficult to fill these low-paying jobs—in one survey by The American Health Care Association and National Center for Assisted Living (AHCA/NCAL), 94% of nursing home providers admitted to being short-staffed.

What to do: If you are considering a nursing home for a loved one, check the staffing levels. Start on the website of the Centers for Medicare and Medicaid Services (—select a nursing home then click “View Staffing Information.” A report commissioned by CMS recommended a minimum of 4.1 staff hours per resident per day (HPRD), but this is a bare minimum—4.1 HRPD might be sufficient to provide basic care, but it doesn’t support residents’ quality of life. Also: Those staffing numbers do not tell the whole story—many nursing homes rely on an ever-changing lineup of poorly trained temporary employees who lack familiarity with residents…and there’s reason to suspect that some nursing homes provide inflated staffing figures to CMS.

Visit the nursing home multiple times. Don’t just take a tour or look at the lobby—watch how residents and staff members interact. Ask residents and their visitors whether they think the facility has enough staff—and what they think about the quality of that staff.

Your state’s long-term-care ombudsman program might provide insight about nursing homes in your area (go to, enter the state and “long-term-care ombudsman” into a search engine). A private geriatric care manager or care navigator based in the area should be able to do so as well, for an hourly fee. To find one in your area, ask the local Agency on Aging, geriatric medical professional or ombudsman.

Rule of thumb: Nonprofit nursing homes tend to provide better staffing and care than for-profit ones…and for-profit nursing homes owned by “private equity” investors tend to be the worst. In 2021, researchers at University of Pennsylvania, New York University and University of Chicago concluded that mortality rates at private-equity–owned nursing homes were so much higher that they were responsible for 20,000 excess deaths over the 12-year period examined.

Challenge #3: Personal care and home health aides often are poorly trained—if they’re trained at all. Hiring in-home assistance is an alternative for some who can afford it—costs average upward of $60,000 per year. But there are no federal standards for most home health aides, and around half the states don’t require training…and the majority of states don’t conduct in-home reviews of home health aides or do any skills testing. Agencies that supply home health aides might provide some training and perform background checks—but not necessarily.

What to do: Take your time searching for the right home health aide rather than just calling an agency and accepting the first person the agency sends. An aide should seem trustworthy and have training and experience—ask for and then contact references…and have a background check done if you’re not working through an agency that has conducted one. There are reputable background search services online such as Intelius, USSearch and TruthFinder. The aide also should be compatible with the care recipient.

Problem: Home health aides often are hired in emergency situations—such as when a parent is being discharged from the hospital after a fall or other health problem and requires help immediately. In cases such as these, reach out to family members, friends, neighbors, religious congregations and other local groups…explain the situation and ask for volunteers to help out until the right aide can be hired. Also ask these people and groups if they can recommend a home health aide or agency—word of mouth often is how great home health aides are found. Other potential places to search for a home health aide: Eldercare Locator (…your local Area Agency on Aging…the National Association for Homecare & Hospice’s National Agency Location Service (……or a local geriatric care manager or care navigator.

Is it better to work through an agency or hire a home health aide directly? There’s no reliable data about which produces better results. An agency might have done background checks and training…but many excellent home health aides work directly for clients. They have more flexibility and avoid paying agency fees, which take a significant slice.

Challenge #4: Some assisted-living facilities have little oversight—and their contracts sometimes contain hidden traps. Assisted living has a better reputation than nursing home care—but the closer you look, the less clear it is that they’re any more trustworthy. Elder neglect tends to be less of an issue in assisted-living facilities because residents don’t depend on nursing care to the same degree. But the CMS provides no rating system or oversight of these facilities, and oversight by states varies greatly.

What’s more, the contracts signed by the residents of assisted-living facilities sometimes contain clauses that can increase costs in unexpected ways…or allow the facility to kick out the resident with little notice. Examples: A facility might be able to force a resident to leave by claiming that he/she has behavior problems or broke some obscure rule. In reality, the facility might want the resident out because that person needs more assistance than he previously did, which is cutting into its profits.

What to do: Contact your state’s long-term-care ombudsman program to ask what, if anything, the state does to inspect and monitor assisted-living facilities and how you can obtain information about the facilities you’re considering. Seek insight from an experienced geriatric care manager or care navigator as well or an elder-law attorney. (Legal services offer help for low-income seniors.) Before signing an assisted-living facility’s contract, have it examined by a knowledgeable elderlaw attorney. One question to ask this attorney is, “What can the facility kick my loved one out for?”

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