Shelby Owen, MPH; Maria DeNunzio, PhD, MS

Introduction

In 2020, Americans age 65 or older accounted for about 17% of the population, yet accounted for about 37% of health care spending, nearly 2.5 times higher than working-age adults and more than five times higher than children (Centers for Medicare and Medicaid Services, n.d.). By 2050, the percentage of Americans age 65 and older is expected to rise to 23% (US Census Bureau, n.d.). While many older Americans can meet their daily care needs in part from advancements in supports available to them, it is estimated that almost 70% of adults 65 and older will need some form of long-term care services at some point in their remaining years (Administration for Community Living, n.d.; Scommegna, 2021). This support may come from nursing facilities, home health systems, or family caregivers. In conjunction with the aging population and their utilization of health care services, the health care system is declining as physicians and nurses age out of their professions and the current workforce experiences burnout and attrition (American Association of Colleges of Nursing, 2024; Boyle, 2021). While many aging Americans are likely to feel the impact of a declining health care workforce as long term care becomes less accessible due to demand and cost, their children may take an even bigger hit.

In the United States, approximately one in four adults (23%) is considered part of the “sandwich generation,” meaning individuals who are raising a child under 18 or providing financial support to an adult child while also having a parent 65 years or older (Horowitz, 2022). Adults in their 40s are especially affected, with more than half (54%) navigating responsibilities for both an aging parent and at least one child. These overlapping caregiving roles can be both time-consuming and financially straining. Almost one‑third of U.S. family caregivers are sandwich generation caregivers, many of whom provide 20 or more hours of care per week while remaining active in the workforce (Wynn, 2025). Research consistently shows that these compounded responsibilities are associated with elevated stress which can lead to burnout and poor mental health, underscoring the growing public health and workforce implications of multigenerational caregiving in the U.S. (Pashazade et al., 2024). Given the aging population, their need for health care services, and the evolving health care workforce, it is pertinent to document perspectives of those using the health care system—especially middle-aged adults who may be taking on the burden of caring for their parents alongside their children while also navigating their own health care needs.

CHESS Background

The Healthcare Value Hub conducted 45 Consumer Health Care Experience State Surveys (CHESS) across 36 states between 2018 and 2025, with some states participating multiple times. CHESS is designed to provide reliable, state-level estimates of respondents’ views on a wide range of health system issues: confidence in using the health system, the financial burden and tradeoffs that respondents have experienced, their worries about needing and affording health care now and in the future, and the policy fixes that might be needed to address these issues. The purpose of this brief is to present key findings around the health care affordability burdens and worry about affording health care services for the “sandwich generation” and their aging family.

CHESS has been administered in 36 states and Washington DC since 2018. While the purpose of the survey remained consistent to measure U.S. adults’ perceptions of the health care system, the instrument was edited each year based on funding priorities and national context. As a result of additional methodological limitations related to population weighting, data were not aggregated for this report. Rather, findings are presented individually by year. This brief presents a core set of variables that were measured consistently from 2021-2025 in most states surveyed.

Key Concerns about Aging and Healthcare Affordability

Health Care Affordability

Across all five survey years, the median percentage of CHESS respondents who reported experiencing at least one affordability burden fell between 59% and 71%. The percentage of respondents who reported that they or a family member who lived with them had overdue medical bills fell between 24% and 29%. While a large percentage of respondents reported that they did not have any major financial burdens due to medical bills, 12% or more of respondents in 39 of 43 states surveyed across five years reported that they used up all or most of their savings due to medical bills in the past 12 months. In 27 of 44 states surveyed, 12% or more of respondents reported they were unable to pay for basic necessities like food, heat, or housing due to medical bills. In 36 of 44 states, 12% or more respondents reported being contacted by collections agencies regarding medical bills in the year preceding the survey.

Across the five years, CHESS respondents were also asked to report if they had skipped or foregone health care due to cost; the median percentage of those who reported that they had foregone care due to cost fell between 52% and 69%. The most frequently reported types of delayed care included delaying going to the doctor or having a procedure done (26-35%), skipping needed dental care (26-38%), or avoiding going to the doctor having a procedure done altogether (15-30%). While skipping care in the moment may provide temporary financial relief, avoiding routine screenings and medical and dental check-ups may lead to larger health and financial issues over time (Select Health, 2026). In 2023, 76% of U.S. adults reported having one or more chronic conditions such as heart disease cancer, stroke, and diabetes (Watson et al., 2025). Chronic disease is costly and early intervention can slow disease progression and improve quality of life as individuals age.

CHESS respondents were asked to rate their level of worry for a range of health care concerns. Across each survey year, CHESS respondents were worried about health care access and affordability, regardless of age, income, race, and insurance coverage. When asked to rate their level of worry about incurring unexpected medical costs in the event of a serious illness or accident, the median proportion of respondents who were worried or very worried was consistently equal to or more than 53% from 2021-2025. Unexpected medical costs can prove to be difficult financially for households. A 2022 Kaiser Family Foundation survey found that about half of adults say they would be unable to pay a $500 unexpected medical bill without borrowing money (Sparks, Lopes, et al., 2025). Unexpected medical costs are often more expensive than $500, with the U.S. Centers for Medicare and Medicaid Services estimating that care for a broken bone costs $30,000 and the average cost for a three-day hospital stay is $30,000. Fear over unexpected medical costs deepen when factoring in the rising costs of aging. While many respondents reported being worried about losing their health insurance, a greater proportion of respondents indicated that they were worried about their health insurance becoming too expensive, illustrating that respondents do not feel protected from medical expenses even when they have access to health insurance.

Worry about the Cost of Aging

When asked to rate how worried they were that they or a family member living with them would not be able to pay medical costs when they were an older adult, 55% or more of CHESS respondents reported they were worried or very worried in each state from 2021 to 2025. Similarly, 55% or more of respondents reported they were worried or very worried about affording nursing home and home health care services in each state from 2021 to 2025.

Middle-aged CHESS respondents exhibited the greatest worry around the cost of aging. Those aged 35 to 54 years old had the highest proportion of respondents who were worried or very worried about the medical costs associated with aging, while those aged 45 to 54 years old had the highest proportion of respondents who were worried or very worried about the medical costs associated with nursing home and home care services. Median percentages can be seen in Exhibit 1 and 2. Income does not seem to be protective of worry around aging costs. Respondents earning less than $100,000 were similarly worried about the medical costs associated with aging while those with incomes of $100,000 or more were slightly less worried. See Exhibit 1. Results were similar for CHESS respondents who worried about affording nursing home and home care services as they aged. See Exhibit 2.

Exhibit 1. Median Percentage of CHESS Respondents who Reported Worry About Cost of Aging Being Too Expensive by Age and Income (2021-2025)

Exhibit 2. Median Percentage of CHESS Respondents who Reported Worry About Cost of Nursing Home and Home Care Services Being Too Expensive by Age and Income (2021-2025)

Policy

Researchers have highlighted a number of key themes that policymakers, health care workers, and families should keep in mind as the population ages.

• U.S. life expectancy is stalling, and many Americans are living with costly chronic diseases such as heart disease, obesity, and diabetes as they age (Khan et al., 2024; Scommegna & Mather, 2025). According to the CDC, 93% of adults age 65 and older have at least one condition, while 79% have two or more (Watson et al., 2025).
  
• With the passing of H.R. 1, changes to Medicare and Medicaid may impact aging adults, especially low-income Americans who are dually eligible for Medicare and Medicaid. In turn, this may place financial strain on the family (Center for Medicare Advocacy, 2025). Long term care is incredibly expensive, and many nursing home residents (63%) utilize Medicaid to cover daily care (American Health Care Association, 2025).
  
  • Starting in January 2027, the Medicaid retroactive eligibility period will be shortened from three months to two months for Medicaid applicants. Retroactive coverage is essential for older adults needing long term care as it gives them time to submit their applications while still receiving services or getting placement in nursing home facilities (Carlson, 2026).
    
  • Starting in January 2027, eligibility will also be redetermined every six months instead of every 12 months which may lead to older adults losing coverage more frequently (Center for Medicare Advocacy, 2025).
    
  • Aging immigrants dually eligible for Medicare and Medicaid may lose both sources of coverage, leaving them with limited options for health care. Without consistent coverage, older immigrants will likely not have access to preventative or ongoing care and prescription medications unless they pay out of pocket, potentially leading to medical debt (Justice in Aging, 2026).
    
• The United States is facing a caregiving crisis, especially for older Americans with low incomes and dementia. Demand for elder care is expected to increase, and the number of Americans living with Alzheimer’s disease could more than double by 2050 (Scommegna & Mather, 2025).
  
• The health care workforce is shifting due to:
  
  • High labor and supply costs at hospitals and long-term care facilities;
    
  • Nursing shortage caused by decline in nursing school enrollment and a shortage of nursing school faculty; and
    
  • The health care workforce reaching retirement age (American Association of Colleges of Nursing, 2024).

Public policy decisions over the next few decades will play a central role in shaping health care affordability and access for adults age 65 and older, as well as their families. Research shows that the aging population is the primary driver of long‑term Medicare spending growth, increasing pressure on program sustainability and beneficiary cost sharing (Centers for Medicare and Medicaid Services, n.d.). To counter health care spending, recent reforms like the Inflation Reduction Act (IRA) allow Medicare to negotiate prescription drug prices and cap out‑of‑pocket drug spending; this is a significant policy for many CHESS respondents (Rep. Yarmuth, 2022). Between 2021 and 2025, CHESS respondents were asked to rate their level of agreement with the government enacting certain policies that would influence health care. Most respondents (89-92%) agreed that state or federal government should enact policies that cap out-of-pocket costs for life-saving medications, such as insulin. The IRA is expected to reduce medication costs and improve financial protection for older adults, particularly those with chronic conditions like diabetes.

Alongside rising costs in prescription drugs, rising long‑term care costs and limited insurance coverage continue to shift financial and caregiving responsibility onto families and Medicaid, as most older adults lack sufficient resources to pay for private care. To combat the financial impact of long-term care, the state of Washington is preparing to launch WA Cares, the nation’s first public, worker‑funded long‑term care insurance program, with benefits scheduled to begin July 1, 2026. Enacted in 2019 and funded through a 0.58% payroll tax, the program is designed to help workers pay for long‑term services and supports as they age, including in‑home care, family caregiver respite, assistive equipment, meals, and other supports (Cornfield, 2025). Other states may consider implementing similar policies to support individuals and families as they age.

Looking Ahead

As the U.S. population ages, rising health and long‑term care costs are increasingly intertwined with health care workforce shortages and growing stress among middle-aged working‑age adults, particularly those in the sandwich generation. National health expenditures reached $5.3 trillion in 2024 and are projected to continue outpacing economic growth, driven in part by higher per‑capita spending among adults age 65 and older, who incur more than twice the health care costs of working‑age adults (Centers for Medicare and Medicaid Services, n.d.; Rakshit et al., 2026). At the same time, persistent shortages of nurses, direct care workers, and other health professionals are contributing to higher labor costs and reduced availability of formal care, especially in long‑term care and home‑based settings (American Association of Colleges of Nursing, 2024; Boyle, 2021).

These pressures have coincided with sharp increases in the cost of care, with prices for home care, assisted living, and nursing home services rising 25–50% between 2019 and 2024 (Wynn, 2026). As care becomes less affordable and harder to access, more responsibility is shifting to families, often children of aging parents. Caregivers often experience elevated stress and burnout, with middle-aged or sandwich generation caregivers more likely than other adults to report being emotionally exhausted, financially strained, and lacking the time to juggle competing responsibilities between work and caring for children and parents. While it is critical to focus on the impacts of the aging population, especially as the last of the Boomer generation enters their 60s, it is imperative to also keep the sandwich generation in mind as they fill in the gaps of an unstable health care system.

References

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