The Cost of Growing Old in America

CHRISTIANE AMANPOUR: So, what does it mean to age in America when basic tasks like bathing, grocery shopping, paying bills become just too difficult? Who can the elderly turn to for help? Professional assistance and nursing facilities are expensive. So, more than 80 percent of Americans over 65 rely on family and friends. And as author Lucy Schiller knows well, it is no small task. Her new book, “Aging Out,” draws on her personal experience caring for her own grandmother during the COVID-19 pandemic. And she speaks to Hari Sreenivasan about realities of elder care today.

HARI SREENIVASAN: Christiane, thanks. Lucy Schiller, thanks so much for joining us. You’ve written a book recently. It’s called, “Aging Out: An Exploration of Caregiving, Community and How Americans Grow Old.” Now it takes a good deep dive into what I would call the elder care industry in this country, but it was personal. Why’d you start this?

LUCY SCHILLER: It’s a great question. One of the reasons I started it was because I realized that I knew almost nothing about the daily realities of what it’s like to be an older person in this country. And the main way that I kind of realized that level of ignorance in myself was by taking care of, or helping to take care of, one of my grandmothers at the beginning of the COVID pandemic. We took her out of an assisted living facility because we were nervous about the spread of COVID inside. And I moved up — kind of the only person in my family without a job, so very convenient. I moved up and lived with her for a few months and really kind of saw firsthand some of the realities of what it’s like to be an older person in this country. And I also kind of realized I knew nothing about the inner workings of where she had been living for the past 10 or so years, you know. I would visit this assisted living facility on occasion. But that’s a far cry, you know, from actually residing inside of it.

SREENIVASAN: You write, “In the language of elder care, she needed help with her ‘ADLs’ — her activities of daily life. She needed someone to massage her arthritic feet with arnica cream, to help put on her shoes, to make her food, to do her laundry, to keep the place clean, to go get groceries, to stay on top of the many medications and health needs, to make doctors’ appointments and get her to them.”

And this was your first experience with this. You know, and it’s interesting — so many people just reading that list alone would say, wow, that’s a lot. That’s a full-time job. And yet the people who are caring for so many of their loved ones in this country are doing that in addition to a full-time job.

SCHILLER: Yeah. Very often, and maybe in addition to raising their own kids or any number of obligations, you know, that they may have. So it’s a huge amount of work. It’s also, I would say a huge amount of work just being an older person and needing that level of help or even just kind of wanting you know, family close by or a loved one of some kind close by to connect with and talk through this really interesting and complex phase of life with.

SREENIVASAN: Yeah. You also point out that culturally we still — I mean, while we say we respect our elders and we want their wisdom as a part of society, we still see them as a cost, you know, not necessarily as a benefit.

SCHILLER: Yeah, absolutely. I, you know, we could even just look at the word “entitlements.” And I put that in quotes in my book, but that’s a way in which people, you know, refer to social security and Medicare. And I know that it is technically an entitlement, but that word does have kind of a double meaning, which can sometimes feel a little bit nasty, you know, or point towards the idea or the sense that older people are somehow a drain on society.

That was something I was really interested in when starting to write this book, because I felt like not only was I kind of coming to this topic from my own experiences with my grandmothers, but I also felt like all of a sudden there was this really, I would say virulent, anti-old person sentiment in the air. And I couldn’t totally understand it, you know. So there’s obviously this anti-Boomer rhetoric, which has been around now for a while. And I, I’m remembering too, in the beginning of the pandemic, people would talk about the so-called “Boomer remover” that COVID was.

But also, you know, just this idea, which is actually quite an old kind of current in American life of older people being a drain on society and specifically taking resources away from younger people. There’s actually like a long history of this type of argument in American culture and American politics. You can trace it, you know, to the eighties and to attempted cuts at Social Security programs and Medicare programs.

And I think it very often has been used actually to fight against social programs and social welfare programs in general.

SREENIVASAN: You know, there’s a stat that’s in here. It says the national median cost for a semi-private room in a nursing home was $110,000 a year in 2025. And that is staggering.

So help our audience understand kind of the lay of the land here. How did this become a for-profit industry? Who owns it, who’s profiting? Just gimme an idea of when people get old in this country, in general, what is happening to them? Where are they going?

SCHILLER: Yeah. So, you know, Medicare was passed in the late sixties, and with the passage of Medicare there was a huge sudden springing up of nursing homes and the nursing home industry. A lot has changed — kind of like cliff notes version — a lot has changed in those kind of decades. There was a movement particularly in the seventies in response to conditions in these early nursing homes to make sure that nursing homes were actually places that offered good quality care and didn’t in fact, maybe even get people more sick than they were when they entered and were you know, solid places in which an older person or a person with a disability could receive quality care.

Since then, there’s also been assisted living facilities and the rise of assisted living facilities. Which — so with nursing homes, generally you pay for those via Medicaid, and you hear all of these stories, right, about people having to “spend down” in order to qualify for Medicaid in order to enter a nursing home. So what that might mean is, you know, you have to maybe even sell your house in order to get into a nursing home. Nursing homes can be for-profit, they can be non-profit. There’s a whole range of them. They’re not, you know, uniformly bad or uniformly good. Some of them are excellent, some of them are maybe not so much.

There are huge kind of conglomerates behind a lot of nursing homes. You know, there’s private equity now in that space. Assisted living is another part of that landscape. And with assisted living, you have to go what’s called private pay. So if you’re entering an assisted living, generally speaking — it’s not always the case, but very much the majority of the case of the time — you’re paying out of your own pocket in order to enter an assisted living facility. And these places can be exorbitantly expensive. And so —

SREENIVASAN: Give me an idea of how much.

SCHILLER: Anywhere from probably lower end, like $5,000 a month to way, way, way higher than that.

There’s also what are called continuing care retirement communities, which that’s the type of thing that sometimes people think of, you know, when they think of aging in a really nice place. You enter, you pay a lot of money, you enter at a certain age that you’ve agreed upon kind of contractually with this place. And then you kind of age there through whatever your body decides to do. Maybe you end up needing to go into their memory care facility. Maybe you need a, you know maybe you don’t need too much help, but either way you’re kind of surrounded by all sorts of people with all sorts of kind of experiences of oldness in there.

And then finally there’s aging in place. What that term tends to mean is, you know, that you’re at home and that you’re not in a “facility” of some kind. You’re aging in a place of your own kind of desire and maybe familiarity. There’s been an increase in kind of state support in some ways for that option. There are certain places that, you know, help you, you know, install, grab bars in your bathroom if that’s something that you need, or provide you with reimbursement for caretaking — caregiving services people coming into your home.

SREENIVASAN: There is Medicare, and that is, you know, the option that so many people get because they’re not, they don’t qualify. They don’t have low enough income for Medicaid. And within Medicare, there’s this big fork in, in the road of Medicare and Medicare Advantage plans. For most people, again, that are not in that part of life yet, haven’t done the homework. What’s the big difference and what’s happened to this?

SCHILLER: That’s a great question. So first of all, I’ll just note that Medicare does not cover long-term care. And this is something that very often surprises even older people themselves when they get to a moment of needing to suddenly pay for long-term care. So that’s a really kind of important basic fact here.

Medicare Advantage is what I would call the privatized arm of Medicare. So Medicare, as you said, it’s a public program. There’s one Medicare. There are about 4,000 Medicare Advantage plans. And what these are, are insurance company brokered private plans that still bill Medicare, the public you know, insurance option for people, for their services. Medicare Advantage plans have been reported, you know, to be draining the Medicare fund particularly by — and I think is coming from a New York Times report on it — insurance companies that are using and selling Medicare Advantage plans developing these kind of systems to make patients appear as sick as possible and then bill accordingly.

So denials of care in Medicare Advantage plans are relatively high. Often Medicare Advantage plans are heavily marketed to people and particularly I saw a study that underlined that they’re very often marketed to Black and Hispanic patients. They also are very often involving what we’re all probably familiar with at this point, this term prior authorization, right? That you need to be authorized by your doctor or your insurance company, rather, for a particular procedure before they decide whether or not they’re going to reimburse you.

And a lot of reporting has been done on this, that Medicare Advantage plans, there are many stories out there about people suddenly realizing that their surgery isn’t going to be covered by this plan that has offered them all of these wonderful freebies.

They can be anything from incredibly affordable and cheap to incredibly expensive. They’re, I would say, the personalized, privatized version of Medicare. And so you can really kind of choose almost an a la carte option type option, like what you want from your insurance plan. Whether or not it’s gonna work for you down the road, you know, fingers crossed.

SREENIVASAN: How does aging and the options that you have in America differ based on your race or your income level or your gender?

SCHILLER: Well, statistically the people who tend to make it to old age are white women. So that’s a pretty important fact to consider. And in my book, a reviewer just pointed this out, which I thought was a really smart point, that a lot of my subjects — or the people who I’m speaking with in the book — are women.

But your class really, really, really influences your experience as an older person. So, you know, for instance if you’re on Medicaid, that is going to really kind of whittle your options in a very particular direction. When it comes to long-term care certainly, you know, that means you’re eligible to get into a nursing home, but that doesn’t necessarily mean that you’re gonna be going into an assisted living facility or a continuing care retirement community, both of which are kind of the province of more moneyed people.

And it’s part of my book, you know, I toured some of these places and I had this strange emotional experience in a continuing care retirement community because I just felt like no one I know is gonna be able to experience something like this. This is amazing. It’s beautiful. It’s like all of these older people – there was a woodworking shop, there was a swimming pool, there were people maintaining the gardens outside. It’s a place where residents really, like, run the place. It’s like very insistent on resident autonomy and self-direction. And I thought this is like, this is the ideal, you know, if you’re deciding to live in a community rather than necessarily age in place inside your own home. And yet, you know, it would be financially out of reach for nearly everyone that I know, myself included.

SREENIVASAN: You know, I wonder if, did you figure out why we don’t want to talk about aging as much, or why? Why it is that we just don’t talk about it more that it’s not part of the social conversation.

SCHILLER: I think a reluctance to talk about disability in public life. You know, aging very often includes some level of disability. And that’s something that a lot of people still in this country feel unsure about how to talk about for themselves, you know, or maybe for a loved one. I think, you know, a lot has, a lot of ink has been spilled about how kind of youth obsessed we are in this country, which I think is, is true. There’s also a productivity obsession in this country, think there’s a real American discomfort with relaxing and with stopping work and with how to feel like a member of society when you’re no longer in the workforce. And so I think that’s, and maybe, you know, you’re no longer in the workforce because you have a disability and you’re not, you know, a part of the workplace that you once were, or maybe maybe you’re retired or maybe you’re just in a different life phase.

SREENIVASAN: You know, when you look at this uniquely American problem in some ways, is there a format that we can adopt? Are there countries that are doing it better? What can we, what’s a good idea that we can steal?

SCHILLER: Well, to be honest, I would just say universal healthcare across the spectrum would be a wonderful place to start. You know, one of the things that I really wish that we could do in general is just have more intergenerational connection.

A person who I looked at in the book, who’s the famous elder activist, Maggie Kuhn, and she was a huge advocate for intergenerational housing and lived with younger people as an older woman for decades. And I spoke with some of them who remembered what that experience was like for them, so many years, you know, after the fact. And they found it to be totally life changing. So I think that’s something a lot of other countries have that we all, we actually already do have small versions of that happening in the United States in various cities.

But I think in general, you know, maybe if we could talk about it on an individual level for a second. Like, you know, thinking of yourself as someone who ideally — and I’m speaking here as a young-ish person — is going to grow old, like, I don’t wanna preclude connections with older people currently in my life. I want to learn from them, I wanna connect with them. I want to be surprised and changed and moved by them in the same way that hopefully I can do the same for them. And I think more than anything, like trying to think about dissolving walls between older people and younger is something to really think through, particularly as younger people who have really been steeped in, I would say, a lot of anti-old person rhetoric for many years now.

SREENIVASAN: The book is called “Aging Out.” Author Lucy Schiller. Thanks so much for your time.

SCHILLER: Thanks for having me.