In 1965, the United States made a generational promise. Standing beside Harry Truman, Lyndon Johnson signed Medicare and Medicaid into law and declared that “no longer will older Americans be denied the healing miracle of modern medicine… no longer will illness crush and destroy the savings they have carefully put away… no longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations.” These programs weren’t just policy—they were a commitment to institutionalized dignity. And for a time, they worked.
But that promise is unraveling—not because we’ve lost the will to care, but because we’ve failed to build the infrastructure that care requires. America’s fastest-growing care need—home-based long-term support—is on the brink of collapse. Providers are underfunded. Medicaid reimbursement rates hover near break-even. Caregiver turnover exceeds 60% annually. For every caregiver available, five patients wait. In many parts of the country, families are told it will be weeks—sometimes months—before someone can come help.
When the state fails to care, the burden falls back on the family. A daughter steps back from her job to care for her mother. A son starts dipping into savings to cover private-pay aides. A couple decides to put off having a second child—because they’re already caring for an aging parent. And slowly, silently, the load adds up. Dual-income households fracture. Women exit the workforce. Siblings fight over who will take on more hours. Young people, watching all this, start to wonder whether they can afford to have kids of their own.
A recent study published in Demography found that caregiving burdens significantly reduce fertility intent among adults in their peak childbearing years. The OECD reports that countries with high eldercare demands and low institutional support—like the U.S.—consistently see lower birth rates, greater family stress, and rising mental health burdens. In Japan, where eldercare has similarly overwhelmed the household, the government has identified aging care as a key barrier to national fertility recovery. A society that can’t care for its elders makes it harder to imagine creating the next generation.
And yet, economists call this a “labor shortage.” As if the only problem were a missing headcount. But the truth is deeper—and more dangerous.
At the bottom of the demand curve are not price-sensitive consumers. They are the elderly, the disabled, the poor. Classical economics tells us the invisible hand will resolve this. When demand rises, so too should wages—until the market clears. But that logic breaks down in home care. If providers raise wages to attract workers, patients who rely on fixed Medicaid reimbursements are priced out of the system. The labor supply doesn’t grow—it just shifts toward wealthier, private-pay clients. And the public safety net quietly fails.
It fails not only due to underfunding, but because the infrastructure required to deliver care is fundamentally broken. Today’s home care providers operate with vanishingly thin margins—not because care is too expensive, but because it is built on manual coordination. Scheduling, compliance, shift replacements, documentation, and payroll are stitched together by humans working across spreadsheets, texts, and brittle workflows. The result is a model where every dollar is eaten by complexity before it reaches the caregiver’s paycheck.
This is where technology must intervene—not to replace humans, but to unburden them. A typical home care provider might serve 300 clients with a back office of 15 staff. That means one coordinator for every 20 to 50 caregivers—each one juggling shift coverage, compliance tasks, payroll, and constant crisis management. That ratio should look more like one admin per 1,000 caregivers. That’s not a fantasy—that’s the level of operational leverage already achieved by modern platforms like Uber, which coordinates over 33 million trips per day with just 30,000 employees.
If we can bring that level of software-driven efficiency to home care, the economics shift meaningfully. Today, a typical Medicaid reimbursement of $25 an hour breaks down into $15 for the caregiver, $3 to $4 for administrative overhead, and $1 to $2 in agency margin—leaving little room for stability or growth. But with automation compressing overhead by up to 80 percent, agencies could preserve their margins while redirecting $2 to $3 an hour back into caregiver wages. That’s a 15 to 20 percent raise—without increasing what the system pays.
This isn’t just an economic adjustment. It’s behavioral leverage. Turnover in home care exceeds 65 percent per year, but studies show that even a one-dollar wage increase can reduce churn by up to 20 percent. If we can consistently raise caregiver pay from $15 to $18 an hour, we change the decision calculus for millions of workers—making caregiving a competitive alternative to retail, warehouse, or gig work. In doing so, we not only stabilize the workforce, we begin to grow it.
But the potential goes beyond margin recovery. If we get the operational layer right, we can also expand the clinical scope—and the strategic role—of home care itself.
Today, home care is often treated as glorified nannying: help with meals, light housekeeping, companionship. It’s seen as soft, non-clinical, and low-skilled—which is exactly why reimbursement rates remain so low. But this perception is shaped less by the nature of the work than by the limits of the system that delivers it. When care is fragmented, undocumented, and manually coordinated, it’s easy for policymakers to underfund it and for clinicians to ignore it.
With the right software infrastructure, home care becomes a platform. It becomes the connective tissue between daily living and clinical insight: a place where remote patient monitoring feeds into real-time interventions, where in-home aides are supported by intelligent workflows, where telehealth, vitals tracking, medication adherence, and caregiver observations flow into one continuous stream of context-rich care.
This is the same transformation we’ve seen across other service industries. DoorDash didn’t just digitize food delivery—it redefined the restaurant. Amazon didn’t just optimize shopping—it redefined distribution. Zoom didn’t just replace meetings—it rewired the geography of work. In each case, technology didn’t serve the legacy system—it replaced the coordination layer, and in doing so, changed the nature of the service.
Home care is next. With an intelligent, AI-driven operating system, the home is no longer the periphery of care. It becomes the center—the first line of observation, the earliest site of intervention, and the most stable setting for long-term health.
If we treat the home as the center of care—not just a setting for support, but a site of coordination—then the economic logic changes too. Suddenly, we’re not just talking about lowering costs through efficiency. We’re talking about unlocking a reallocation of the $1.5 trillion the U.S. spends annually on hospital and institutional care.
Acute care settings—hospitals, nursing homes, rehab facilities—absorb the majority of healthcare spending. But much of that spending is reactive: managing crises that could have been prevented with earlier intervention. One in five Medicare patients is readmitted to the hospital within 30 days. Chronic conditions like diabetes, heart failure, and COPD account for the majority of admissions—and nearly all of them are daily-life-sensitive.
If we can shift just a fraction of that spend upstream—toward smarter home-based monitoring, proactive check-ins, and consistent care delivered by trained aides—we don’t just lower costs. We improve outcomes. We catch problems earlier. We avoid hospitalizations entirely. A 2022 CMS pilot found that enhanced home care with remote monitoring reduced hospitalizations by 30 percent and emergency room visits by 40 percent in high-risk populations. If even a modest share of Medicare and Medicaid budgets were redirected toward this kind of integrated home care, it would represent a doubling or tripling of current home care reimbursement rates—without increasing total spend.
This is the opportunity in front of us—not just to fix a broken system, but to finish the work that was started generations ago. When Lyndon Johnson signed Medicare and Medicaid into law, he wasn’t just solving a policy problem; he was laying the foundation for a functional society—a system that recognized care not as a luxury or a handout, but as a condition for national vitality. We don’t need new slogans or new entitlements. We need to rebuild the Great Society with the tools of this century. That means applying AI not as a novelty, but as institutional infrastructure: software that replaces manual coordination, stabilizes agency margins, and turns caregiving into a job worth doing.