Bigbee Labs

U.S. healthcare is in the midst of a massive shift – moving complex, long-term care out of expensive institutions and into the home. The shift is driven by sheer necessity:

• As we know, our population is aging. The number of Americans ages 65 and older is projected to increase from 58 million in 2022 to 82 million by 2050 (a 42% increase), and the 65-and-older age group’s share of the total population is projected to rise from 17% to 23%. By 2050, more than 30 million U.S. residents will be age 80 or older, and the proportion of the older adult population age 80 and older is projected to climb from 27 to 37 percent

• This aging population is creating enormous healthcare demand. And we can’t meet the demand through institutional care because it’s simply too costly. Clinical professionals are in short supply. And most older adults want to be home – not in a facility.

Successfully shifting care into the home depends almost entirely on one group: informal caregivers – family and friends doing the work of care. To be clear, shifting care into the home is not new:

• Today, 53 million Americans – 1 in 4 adults – are providing ongoing care for older adults, people with serious illnesses, or those with disabilities. That’s a jaw-dropping 20 million increase since 2015.

• Caregivers in the US are performing the equivalent of an estimated $873.5 billion worth of labor each year – or 3.2% of the U.S. GDP.

• If family caregiving was a business entity it would be the largest revenue-generating company in the world – exceeding the revenue of Apple (+126%), Amazon (+45%) and Walmart (+31%)

But the informal caregiver system is fragile. Demographic shifts mean there are fewer potential family caregivers available per older adult compared to previous generations (the “caregiver support ratio” is declining) – from 2010 to 2040, the percentage of frail older adults without a living child will increase from 14 to 21 percent. And informal caregiving causes extreme stress and strain – physically, emotionally, and economically. The system is particularly vulnerable when an individual caregiver’s capacity is overwhelmed by the specific demands they face. 

An under-resourced system relying on millions of individuals who may or may not have the ability to take on the work is inherently unstable.

And herein lies the Big Bet: that we’ll figure out how to support and enable caregivers at scale before the whole system collapses. If informal caregiving fails, institutional care can’t absorb the demand – not financially, not logistically. That collapse would ripple through Medicare, Medicaid, hospitals, and families, triggering a healthcare and social crisis of potentially historic proportions. 

Moving care into the home and onto caregivers is Plan A. And Plan B? There is no Plan B.

Up to this point, I’ve been talking a lot about the numbers. And the numbers matter. But, this is about much more than just the numbers. At its heart, caregiving is an act of profound love. When a daughter cares for her aging mother, when a spouse tends to their partner through illness, when a family gathers around someone at the end of life – these should be moments marked by presence, connection, and grace. There is beauty in this work: in the small dignities preserved, in the stories shared, in simply being together through hard times. But too often, that love gets crushed under the weight of everything else – the overwhelming logistics, the endless details, the financial strain, the physical exhaustion. What should be sacred becomes a grinding burden that breaks people. We can do better. We must do better – not just to prevent system collapse, but to restore the humanity and meaning that caregiving deserves.

When it comes to supporting caregivers, we know what helps: a combination of respite, financial relief, training, and coordination. Important groundwork has been laid through legislation like the RAISE Family Caregivers Act and programs like the National Family Caregiver Support Program. 

However, these efforts are built on a professional-driven model that, while effective, cannot scale to meet the national demand. The model is constrained by two factors: the high cost of deploying trained professionals like social workers and nurses to millions of families, and the chronic scarcity of those very professionals (we face shortages in the aggregate and maldistribution also creates acute regional shortages). 

We know what helps. But the delivery mechanism doesn’t scale.

While informal caregivers working in the home setting are the linchpin, the focus (policy, funding, technology) is almost entirely on clinicians working in the institutional setting. There are a range of reasons why this is true: from reimbursement models (“follow the money”) to cultural biases (“doctors matter, caregivers don’t”). Yet no amount of institutional process improvement will absorb the on-coming demand. 

We must shift our focus to caregivers if we want to shift care into the home and avoid a national healthcare crisis.